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Mesraoua B, Brigo F, Lattanzi S, Perucca E, Ali M, Asadi-Pooya AA. Safe delivery, perinatal outcomes and breastfeeding in women with epilepsy. Epilepsy Behav 2024; 156:109827. [PMID: 38759429 DOI: 10.1016/j.yebeh.2024.109827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024]
Abstract
Safe delivery and optimal peripartum and postpartum care in women with epilepsy (WWE) is a major concern which has received limited attention in recent years. A diagnosis of epilepsy per se is not an indication for a planned cesarean section or induction of labor, even though epidemiological studies indicate that cesarean delivery is more common among WWE compared to the general population. Pregnancy in WWE is associated with an increased risk of obstetrical complications and increased perinatal morbidity and mortality, and these risks may be greater among WWE taking ASMs. Wherever feasible, pregnant WWE should be directed to specialist care. Risk minimization includes, when appropriate, dose adjustment to compensate for pregnancy-related changes in the pharmacokinetics of some ASMs. With respect to postpartum management, WWE should be advised that the benefits of breastfeeding outweigh the small risk of adverse drug reactions in the infant.
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Affiliation(s)
- Boulenouar Mesraoua
- Neurosciences Department, Hamad Medical Corporation and Weill Cornell Medical College, Doha, Qatar.
| | - Francesco Brigo
- Research Area Innovation, Research and Teaching Service (SABES- ASDAA), Bolzano-Bozen, Italy.
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
| | - Emilio Perucca
- Department of Medicine (Austin Health), University of Melbourne, and Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Musab Ali
- Neurosciences Department, Hamad Medical Corporation, Doha, Qatar.
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
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Smolinski NE, Sarayani A, Thai TN, Jugl S, Ewig CLY, Winterstein AG. Prenatal Exposure to Valproic Acid Across Various Indications for Use. JAMA Netw Open 2024; 7:e2412680. [PMID: 38776082 PMCID: PMC11112441 DOI: 10.1001/jamanetworkopen.2024.12680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/21/2024] [Indexed: 05/25/2024] Open
Abstract
Importance Teratogenic outcomes associated with valproic acid use represent a substantial concern for persons of childbearing age. Regulatory agencies worldwide have enhanced warnings or implemented risk minimization programs to reduce exposure during pregnancy. Objectives To determine pregnancy rates during valproic acid use and concomitant contraception use across indications. Design, Setting, and Participants This retrospective cohort study used data from the Merative MarketScan commercial claims databases from January 1, 2005, to December 31, 2020, to identify female patients aged 12 to 44 years who initiated valproic acid treatment and had continuous insurance enrollment 6 months before initiation and 9 months after treatment end. A treatment episode included consecutive prescription fills that occurred within 7 days from the end of the days' supply of the previous dispensing. Data were analyzed from March 1 to September 10, 2023. Main Outcomes and Measures Treatment episodes were categorized by inferred indication using diagnoses preceding treatment initiation, including epilepsy, migraine or headache, mood disorders, and unknown or off-label uses. Pregnancy incidence rate ratios (IRRs) were calculated and were adjusted for age and calendar year. Contraceptive use (prescription contraceptives, intrauterine devices, and implants) during treatment was examined. Results The cohort included 165 772 valproic acid treatment episodes among 69 390 women (mean [SD] age, 29.8 [10.0] years). Mood disorders (42.5%) were the most common indication, followed by migraine or headache (20.1%), with epilepsy playing a minor role (14.9%). Pregnancy incidence rates during valproic acid use remained unchanged, with a rate of 1.74 (95% CI, 1.14-2.53) per 100 person-years in 2005 and a rate of 1.90 (95% CI, 1.16-3.12) per 100 person-years in 2019. Compared with epilepsy, pregnancy rates were more than double for mood disorder (IRR, 2.16 [95% CI, 1.93-2.42]) and migraine or headache (IRR, 2.01 [95% CI, 1.92-2.09]). Few treatment episodes coincided with contraceptive use (37 012 [22.3%]), and oral dosage forms were the most common (27 069 [73.1%]). Conclusions and Relevance In this cohort study of patients of childbearing age who used valproic acid, pregnancy rates during valproic acid use did not decrease despite enhanced US Food and Drug Administration safety communications, and contraception use remained low. Patients with migraine and mood disorders accounted for the largest proportion of valproic acid use and had the highest pregnancy rates, while patients with epilepsy had the lowest. These findings suggest a need to enhance efforts to mitigate prenatal exposure to valproic acid, especially for indications where the risk of use during pregnancy outweighs the benefit.
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Affiliation(s)
- Nicole E. Smolinski
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Amir Sarayani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
- Now with Janssen Research & Development, LLC, Raritan, New Jersey
| | - Thuy N. Thai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
- Faculty of Pharmacy, HUTECH University (Ho Chi Minh City University of Technology), Ho Chi Minh City, Vietnam
| | - Sebastian Jugl
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Celeste L. Y. Ewig
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
- Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville
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Smith Malm C, Klecki J, Lisovska K, Zelano J. Survey of an online system for information to women with epilepsy of childbearing age and management during pregnancy: A 3-year evaluation. Epilepsia Open 2024; 9:558-567. [PMID: 38135910 PMCID: PMC10984308 DOI: 10.1002/epi4.12893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 11/16/2023] [Accepted: 12/10/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVE We developed an online tool for women with epilepsy consisting of two modules: one with information on pregnancy-related issues (information module) and one for reminders about blood test and communication about dose changes (pregnancy module). Our aim was to assess perceived value, user-friendliness and improvement of patient knowledge in users. METHODS The system was launched in 2019 and patients invited by epilepsy nurses were asked to participate in a survey 1 month after the invitation for the information module, and 1 month postnatally for the pregnancy module. RESULTS By November 2022, the system had been used by 96 individuals out of 100 invited in the pregnancy module, in a total of 114 pregnancies. One hundred and eleven women had been invited to the information module, and 70 of these accessed it. The survey received 96 answers (44 information, 52 pregnancy). User-friendliness was rated as good or very good by a little over half of the users; 55% in the information module and 52% in the pregnancy module. Among pregnant women, 83% found the TDM part useful and most would prefer a similar system in future pregnancies. Sixty-four percent of users of the information module and 48% of the pregnancy module found that the system had increased their knowledge. Two knowledge questions were answered correctly by a significantly higher proportion of those that had accessed the online information. SIGNIFICANCE There was great demand for online communication during pregnancy and our experiences of implementation can hopefully assist digitalization of epilepsy care elsewhere. Online information also seems to increase knowledge about pregnancy-related issues, but our invitation-only method of inclusion was not effective for widespread dissemination. Patient-initiated access with optional epilepsy-team contact if questions arise could be an alternative. PLAIN LANGUAGE SUMMARY We have performed a survey of users of a new Internet-based tool for information to women of childbearing age and communication about dose changes during pregnancy. Users were overall satisfied with the tool and answered some knowledge questions more accurately after accessing the information.
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Affiliation(s)
| | - Judith Klecki
- Department of NeurologySahlgrenska university hospitalGothenburgSweden
| | - Kristina Lisovska
- Department of NeurologySahlgrenska university hospitalGothenburgSweden
| | - Johan Zelano
- Department of NeurologySahlgrenska university hospitalGothenburgSweden
- Institute of neuroscience and physiology, Department of clinical neuroscience, Sahlgrenska AcademyGothenburg UniversityGothenburgSweden
- Wallenberg Center of Molecular and Translational MedicineGothenburg UniversityGothenburgSweden
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Askew MA, Smaldone AM, Gold MA, Smith-Whitley K, Strouse JJ, Jin Z, Green NS. Pediatric hematology providers' contraceptive practices for female adolescents and young adults with sickle cell disease: A national survey. Pediatr Blood Cancer 2022; 69:e29877. [PMID: 35856776 PMCID: PMC9623811 DOI: 10.1002/pbc.29877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/25/2022] [Accepted: 06/15/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adolescent and young adult (AYA) women with sickle cell disease (SCD) have increased pregnancy-related health risks and are prescribed potentially teratogenic medications, yet limited data are available regarding pediatric SCD provider contraceptive practices. We aimed to assess pediatric hematology providers' beliefs, practices, motivators, and barriers for providing contraceptive care to female AYAs with SCD. METHODS Guided by the Health Belief Model (HBM), we developed a 25-question, web-based survey to assess practices. Survey links were distributed nationwide to pediatric SCD and/or general hematology providers through their publicly available emails and by request to directors of U.S.-accredited Pediatric Hematology-Oncology fellowship programs for distribution to their SCD providers. Data analysis included descriptive statistics, chi-square analysis, and logistic regression. RESULTS Of 177 respondents, 160 surveys meeting inclusion criteria were analyzed. Most providers reported counseling (77.5%) and referring female AYA patients for contraception (90.8%), but fewer reported prescribing contraception (41.8%). Proportionally fewer trainees provided counseling compared with established providers (54% vs. 85%, p < .001), with a similar trend for prescribing (p = .05). Prescription practices did not differ significantly by provider beliefs regarding potential teratogenicity of hydroxyurea. Key motivators included patient request and disclosure of sexual activity. Key barriers included inadequate provider training, limited visit time, and perceived patient/parent interest. CONCLUSION Provider contraceptive practices for female AYAs with SCD varied, especially by provider status. Health beliefs regarding teratogenic potential of hydroxyurea did not correlate with contraceptive practices. Clinical guidelines, provider training, and patient/parent decision-making tools may be tested to assess whether provider contraceptive practices could be improved.
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Affiliation(s)
- Megan A Askew
- Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA
| | - Arlene M Smaldone
- Department of Scholarship and Research, School of Nursing and College of Dental Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Melanie A Gold
- Department of Pediatrics, Division of Child and Adolescent Health, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA
| | - Kim Smith-Whitley
- Division of Hematology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John J Strouse
- Division of Hematology, Department of Medicine, Duke University, Durham, North Carolina, USA
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Nancy S Green
- Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA
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Ershadi F, Mousavi Mirzaei SM, Tabrizi N, Roshanravan B, Sahebnasagh A, Avan R. Evaluation of family planning methods in married women with epilepsy. Epilepsy Behav 2022; 129:108618. [PMID: 35257991 DOI: 10.1016/j.yebeh.2022.108618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/13/2022] [Accepted: 02/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epilepsy is one of the most common neurologic unit diseases that have different prevalence in different parts of the world. Antiepileptic drugs (AEDs) are associated with major fertility risks for women of childbearing age. Due to the fact that studies on family planning methods in married women with epilepsy (WWE) have not been conducted in Iran, the aim of this study was to evaluate the family planning methods in married WWE in Birjand, Iran. METHODS An analytical-descriptive study was performed on 126 married WWE hospitalized in the neurology ward or referred to Vali-e-Asr specialized and sub-specialized clinic in Birjand. Demographic information of patients as well as data on the type of used AED, and various methods of family planning were collected in a questionnaire. Data analysis was performed using Chi-square and Fisher tests. All of the above analyses were considered at a significance level of less than 5% by SPSS v.19 software. RESULTS The mean age of the patients was 33.41 ± 9.15 years. The mean age of experiencing the first seizure and the onset of menstruation were 24.82 and 13.79 years, respectively. Fifty (35.5%), 38 (27%), 15 (10.6%), 14 (9.9%), and 14 (9.9%) patients used sodium valproate, carbamazepine, phenytoin, levetiracetam, and lamotrigine, respectively. The results showed that 72 sexually active patients (70.6%) used family planning methods, of which 43 patients (59.7%) used withdrawal method, 20 patients (27.8%) used condoms, and 6 patients (8.3%) used oral contraceptive pills (OCP). Eight patients (9.6%) had a history of unintended pregnancy and 3 patients (3.6%) had a history of abortion. CONCLUSION It is recommended to apply effective family planning methods in married WWE to prevent unintended pregnancies and the subsequent adverse effects in the fetus, considering the fact that a significant percentage of WWE did not use effective family planning methods and 8 cases of unintended pregnancies were reported. Because of high consumption of valproate in women of childbearing age in our study and concerning issue about its fetal malformation, it is recommended to reduce the administration of valproate in this population. Moreover, regarding the low consumption of folic acid, especially for women of childbearing age and pregnant WWE who are taking AED, the necessary recommendations should be made by our physicians.
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Affiliation(s)
- Faranak Ershadi
- Medical Student, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Nasim Tabrizi
- Department of Neurology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Babak Roshanravan
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Razieh Avan
- Department of Clinical Pharmacy, School of Pharmacy, Medical Toxicology and Drug Abuse Research Center, Birjand University of Medical Sciences, Birjand, Iran.
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Patel T, Grindrod KA. Antiseizure drugs and women: Challenges with contraception and pregnancy. Can Pharm J (Ott) 2020; 153:357-360. [PMID: 33282026 PMCID: PMC7689629 DOI: 10.1177/1715163520959735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tejal Patel
- School of Pharmacy, University of Waterloo, Kitchener, Ontario
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Shroukh WA, Steinke DT, Willis SC. Risk management of teratogenic medicines: A systematic review. Birth Defects Res 2020; 112:1755-1786. [DOI: 10.1002/bdr2.1799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Wejdan A. Shroukh
- Division of Pharmacy and Optometry, School of Health Sciences The University of Manchester Manchester UK
| | - Douglas T. Steinke
- Division of Pharmacy and Optometry, School of Health Sciences The University of Manchester Manchester UK
| | - Sarah C. Willis
- Division of Pharmacy and Optometry, School of Health Sciences The University of Manchester Manchester UK
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Knowledge of pregnancy and procreation in women with epilepsy of childbearing age: A 16-year comparative study in Poland. Epilepsy Res 2020; 164:106372. [PMID: 32480232 DOI: 10.1016/j.eplepsyres.2020.106372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 11/23/2022]
Abstract
Studies across countries and time periods have demonstrated insufficient pregnancy-related knowledge in women with epilepsy (WWE) of childbearing age. To assess the current state of such knowledge as well as the relevant time-related changes over 16 years in Poland, we conducted a study of WWE using a questionnaire developed in 2003. The participants were 656 WWE of childbearing age who completed online and paper-based questionnaires. The results were compared with those obtained in 2003. Overall, pregnancy-related knowledge improved significantly over 16 years. This improved knowledge was most evident in preconception use of folic acid and breastfeeding. However, even now, less than 40% of WWE believe that breastfeeding is possible in most cases. In 2019, pregnancy-related knowledge was positively correlated with participants' educational level and hometown size and negatively correlated with the frequency of generalized tonic-clonic seizures. Women completing the online survey had better knowledge than those who completed the paper-based survey. Indications for cesarean section, the possibility of using oral contraception and breastfeeding are the areas where knowledge in WWE remains inadequate, necessitating targeted educational activities.
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Alhamdan W, Moukaddem A, AlOtaibi N, Aledrees A, Alhatem N, Alshehri N, Alfaraj S, Aladham M. Knowledge regarding teratogens among women of childbearing age at a large tertiary care center in Saudi Arabia. J Family Med Prim Care 2020; 9:3088-3093. [PMID: 32984178 PMCID: PMC7491822 DOI: 10.4103/jfmpc.jfmpc_173_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 11/16/2022] Open
Abstract
AIM To investigate the knowledge of Saudi women regarding the teratogenic effects of environmental agents such as fever, some chronic conditions and medications and its association with certain socio-demographic factors. MATERIALS AND METHODS A survey based cross-sectional study was conducted on 315 Saudi women of childbearing age visiting OB/GYN clinics at a large tertiary care centre in Riyadh, Saudi Arabia. Knowledge of subjects on teratogenic risk of common entities was measured and nonparametric Mann-Whitney and Kruskal-Wallis tests were used to associate knowledge score with various predictors. RESULTS The response rate was 75%. Most of the participants were between 28 and 37 years. Knowledge on teratogenic risk was generally poor with specifically higher knowledge regarding insulin intake and isotretinoin. Older age, higher education, being employed, and having a high monthly income were significantly associated with a higher knowledge score (P < 0.05). CONCLUSION Women's knowledge regarding teratogenic risks is crucial in ensuring a safe pregnancy and a healthy fetus. Our study revealed inadequate knowledge of teratogens among the participants which implies an urgent need to increase awareness of mothers regarding the harmful effects of common teratogens.
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Affiliation(s)
- Wejdan Alhamdan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Afaf Moukaddem
- Department of Medical Education, Research Unit, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nourh AlOtaibi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adibah Aledrees
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nada Alhatem
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nada Alshehri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Samaher Alfaraj
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- In Vitro Fertilization Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Maysoon Aladham
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Obstetrics and Gynecology Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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López-Escobar B, Fernández-Torres R, Vargas-López V, Villar-Navarro M, Rybkina T, Rivas-Infante E, Hernández-Viñas A, Álvarez Del Vayo C, Caro-Vega J, Sánchez-Alcázar JA, González-Meneses A, Carrión MÁ, Ybot-González P. Lacosamide intake during pregnancy increases the incidence of foetal malformations and symptoms associated with schizophrenia in the offspring of mice. Sci Rep 2020; 10:7615. [PMID: 32376856 PMCID: PMC7203245 DOI: 10.1038/s41598-020-64626-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/08/2020] [Indexed: 01/01/2023] Open
Abstract
The use of first and second generation antiepileptic drugs during pregnancy doubles the risk of major congenital malformations and other teratogenic defects. Lacosamide (LCM) is a third-generation antiepileptic drug that interacts with collapsing response mediator protein 2, a protein that has been associated with neurodevelopmental diseases like schizophrenia. The aim of this study was to test the potential teratogenic effects of LCM on developing embryos and its effects on behavioural/histological alterations in adult mice. We administered LCM to pregnant mice, assessing its presence, and that of related compounds, in the mothers’ serum and in embryonic tissues using liquid chromatography coupled to quadrupole/time of flight mass spectrometry detection. Embryo morphology was evaluated, and immunohistochemistry was performed on adult offspring. Behavioural studies were carried out during the first two postnatal weeks and on adult mice. We found a high incidence of embryonic lethality and malformations in mice exposed to LCM during embryonic development. Neonatal mice born to dams treated with LCM during gestation displayed clear psychomotor delay and behavioural and morphological alterations in the prefrontal cortex, hippocampus and amygdala that were associated with behaviours associated with schizophrenia spectrum disorders in adulthood. We conclude that LCM and its metabolites may have teratogenic effects on the developing embryos, reflected in embryonic lethality and malformations, as well as behavioural and histological alterations in adult mice that resemble those presented by patients with schizophrenia.
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Affiliation(s)
- Beatriz López-Escobar
- Grupo de Neurodesarrollo, Hospital Universitario Virgen del Rocio/Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Sevilla, 41013, Spain
| | - Rut Fernández-Torres
- Departamento de Química Analítica, Facultad Química, Universidad Sevilla, Sevilla, Spain.,Centro de Investigación en Salud y Medio Ambiente (CYSMA), Universidad de Huelva, Huelva, Spain
| | - Viviana Vargas-López
- Departamento de Fisiología, Anatomía y Biología Celular, Universidad Pablo de Olavide, 41013, Sevilla, Spain.,Behavioral Neurophysiology Laboratory, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | | | - Tatyana Rybkina
- Departamento de Fisiología, Anatomía y Biología Celular, Universidad Pablo de Olavide, 41013, Sevilla, Spain
| | - Eloy Rivas-Infante
- Unidad de Gestión Clínica de Anatomía Patología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ayleen Hernández-Viñas
- Grupo de Neurodesarrollo, Hospital Universitario Virgen del Rocio/Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Sevilla, 41013, Spain
| | - Concepción Álvarez Del Vayo
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío and Universidad de Sevilla, Sevilla, Spain
| | - José Caro-Vega
- Grupo de Neurodesarrollo, Hospital Universitario Virgen del Rocio/Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Sevilla, 41013, Spain
| | - José A Sánchez-Alcázar
- Centro Andaluz de Biología del Desarrollo (CABD), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, CSIC, Universidad Pablo de Olavide, 41013, Sevilla, Spain
| | - Antonio González-Meneses
- Unidad de Gestión Clínica de Pediatría, Hospital Universitario Virgen del Rocío and Universidad de Sevilla, Sevilla, Spain
| | - M Ángel Carrión
- Departamento de Fisiología, Anatomía y Biología Celular, Universidad Pablo de Olavide, 41013, Sevilla, Spain.
| | - Patricia Ybot-González
- Grupo de Neurodesarrollo, Hospital Universitario Virgen del Rocio/Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Sevilla, 41013, Spain. .,Unidad de Gestión Clínica de Neurología y Neurofisiología, Hospital Universitario Virgen Macarena, Sevilla, 41009, Spain.
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Bosak M, Słowik A, Turaj W. Why do some women with epilepsy use valproic acid despite current guidelines? A single-center cohort study. Epilepsy Behav 2019; 98:1-5. [PMID: 31299525 DOI: 10.1016/j.yebeh.2019.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Current guidelines and regulations strongly discourage the use of valproic acid (VPA) in women of childbearing age because of the risk of congenital malformations and neurodevelopmental disability in children exposed to VPA in utero. Our goal was to establish the reasons for continued use of VPA in a cohort of women with epilepsy (WWE) and to characterize the subgroup of WWE who do not consent to withdraw VPA despite potential risks. MATERIAL AND METHODS The study included consecutive adult premenopausal WWE who visited an outpatient epilepsy clinic between April 2017 and March 2018. Data on demographics (age, age at onset of epilepsy), characteristics of epilepsy (types and frequency of seizures), and its treatment were collected from medical records and seizure diaries. All WWE taking VPA were regularly informed about VPA-related risks and had the opportunity to discuss the withdrawal of VPA. RESULTS The study involved 353 WWE (mean age: 31.7 years). Focal epilepsy was diagnosed in 244 (69.1%) patients; 180 (51.0%) women had no seizures during last 12 months before the study visit, and 228 patients (64.6%) were on monotherapy. A total of 146 (41.3%) patients used VPA in the past, and 98 (27.8%) never used VPA. Of women who were currently on VPA (n = 109, 30.9%), 30 had concurrent severe disabilities that would make future pregnancy extremely unlikely, in further 15 patients, VPA was recommenced because of failure of alternative treatment and 64 women did not accept the plan of VPA withdrawal. Women currently on VPA were more likely to have genetic generalized epilepsy and to be on monotherapy (both p ≪ 0.001). Among 64 WWE who decided to continue therapy with VPA, 35 (55.5%) had generalized epilepsy and 35 (55.5%) were in remission, 27 (42.2%) had at least one child, 9 (14.1%) planned to have a child in the near future but only 15 (23.4%) used effective contraception. CONCLUSION Treatment with VPA is unavoidable in many WWE of childbearing age despite recent regulations. About 60% of WWE currently treated with VPA do not consent to withdraw VPA treatment after thorough consideration of potential risks and other 40% use VPA because pregnancy is highly unlikely and/or other treatments failed.
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Affiliation(s)
- Magdalena Bosak
- Dept. of Neurology, Jagiellonian University Medical College, Krakow, Poland.
| | - Agnieszka Słowik
- Dept. of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Turaj
- Dept. of Neurology, Jagiellonian University Medical College, Krakow, Poland
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12
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Herzog AG, Mandle HB, MacEachern DB. Prevalence of highly effective contraception use by women with epilepsy. Neurology 2019; 92:e2815-e2821. [PMID: 31101739 DOI: 10.1212/wnl.0000000000007581] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 02/08/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine (1) the proportion of women with epilepsy (WWE) at risk of unintended pregnancy who use highly effective contraception, (2) demographic predictors, and (3) folic acid (FA) use. METHODS These cross-sectional data come from 311 US WWE, 18-47 years, who participated in the Epilepsy Birth Control Registry (EBCR) web-based survey in 2017. They provided demographic, epilepsy, antiepileptic drug (AED), contraceptive, and FA data. We report frequencies of highly effective contraception use and use logistic regression to determine demographic predictors. We report the proportion who take FA. RESULTS A total of 186 (59.8%) of the 311 WWE were at risk of unintended pregnancy. A total of 131 (70.4%) used a highly effective contraceptive category; 55 (29.6%) did not. An additional 13 (7.0%) used a combination of generally effective hormonal contraception with an enzyme-inducing AED, which poses increased risk of unintended pregnancy. Overall, 68 (36.6%) of the 186 WWE at risk did not use highly effective contraception. Increasing income (p = 0.004) and having insurance (p = 0.048) were predictors of highly effective contraception. A total of 50.0% took FA supplement. There was no significant difference in relation to the use or lack of use of highly effective contraception. CONCLUSION A total of 36.6% of WWE in the EBCR did not use highly effective contraception and 50.0% did not take FA in 2017 despite the important negative consequences of unintended pregnancy on pregnancy outcomes. There is a need for more readily available information and counseling on safe and effective contraception and FA use for this community.
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Affiliation(s)
- Andrew G Herzog
- From the Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Hannah B Mandle
- From the Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, MA
| | - Devon B MacEachern
- From the Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, MA
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13
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Management of epilepsy in women. Lancet Neurol 2019; 18:481-491. [DOI: 10.1016/s1474-4422(18)30495-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 11/19/2018] [Accepted: 12/10/2018] [Indexed: 01/01/2023]
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14
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Abdullah NL, Gunasekaran R, Mohd-Zin SW, Lim BH, Maniam P, Mohd-Salleh AS, Thong MK, Chik Z, Nordin N, Omar Z, Engkasan JP, Ganesan D, Aiezzah ZN, Ahmad-Annuar A, Abdul-Aziz NM. Cranial neural tube defect after trimethoprim exposure. BMC Res Notes 2018; 11:475. [PMID: 30012199 PMCID: PMC6048906 DOI: 10.1186/s13104-018-3593-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/12/2018] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES The Neural Tube Defects Research Group of University of Malaya was approached to analyze a tablet named TELSE, which may have resulted in a baby born with central nervous system malformation at the University of Malaya Medical Centre. In this animal experimental study, we investigated the content of TELSE and exposure of its contents that resulted in failure of primary neurulation. RESULTS Liquid Chromatography Tandem Mass spectrophotometry analysis of the TELSE tablet confirmed the presence of trimethoprim as the active compound. The TELSE tablet-treated females produced significant numbers of embryos with exencephaly (n = 8, 36.4%, *P < 0.0001), in all litters. The TELSE tablet-treated females subsequently given folic acid did not result in pregnancies despite there being evidence of possible resorption. Furthermore, after multiple rounds of mating which did not yield viable pregnancies, eventually, 2 embryos with exencephaly were harvested in a litter of 6 at 0.05% w/v pure trimethoprim once. The use of trimethoprim, a folic acid antagonist, peri-conceptionally increased the risk of exencephaly in the mouse.
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Affiliation(s)
- Nor Linda Abdullah
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
- Molecular Pathology Unit, Cancer Research Centre, Institute for Medical Research, Jalan Pahang, 50588 Kuala Lumpur, Malaysia
| | - Renuka Gunasekaran
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Siti Waheeda Mohd-Zin
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Bee-Hui Lim
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
- Perdana University Graduate School of Medicine, Block B and D1, MAEPS Building, MARDI Complex, Jalan MAEPS, 43400 Serdang, Selangor, Malaysia
| | - Pramila Maniam
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Anis Shuhada Mohd-Salleh
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Meow-Keong Thong
- Department of Paediatrics, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Zamri Chik
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
- Department of Pharmacology, Faculty of Medicine, University of Malaya Bioequivalence and Testing Centre (UBAT), University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Noreena Nordin
- Department of Pharmacology, Faculty of Medicine, University of Malaya Bioequivalence and Testing Centre (UBAT), University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Zaliha Omar
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Julia Patrick Engkasan
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Dharmendra Ganesan
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Zakaria Nurul Aiezzah
- Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
- Unit of Pathology & Transfusion, Hospital Parit Buntar, Jalan Sempadan, 34200 Parit Buntar, Perak, Malaysia
| | - Azlina Ahmad-Annuar
- Department of Biomedical Science, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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15
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Rezaallah B, Lewis DJ, Zeilhofer HF, Berg BI. Risk of Cleft Lip and/or Palate Associated With Antiepileptic Drugs: Postmarketing Safety Signal Detection and Evaluation of Information Presented to Prescribers and Patients. Ther Innov Regul Sci 2018; 53:110-119. [PMID: 29714593 DOI: 10.1177/2168479018761638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The aim was to analyze safety data associated with the maternal use of antiepileptic drugs in pregnancy and to assess the risk of cleft lip and/or palate (CL/P) as an outcome in the neonate. A parallel objective was to assess the completeness of the safety information concerning pregnancy exposures in the Summary of Product Characteristics (SmPCs) and the Patient Information (PI) in the USA and the UK. METHODS We analyzed individual case safety reports of CL/P associated with antiepileptic drugs in the FDA Adverse Event Reporting System. For the antiepileptic drugs with signals (EB05 ≥ 2), we reviewed Drug Analysis Prints for CL/P cases in the UK Medicines and Healthcare products Regulatory Agency (MHRA). We performed descriptive analyses of relevant SmPCs and PIs in the UK and the USA using a checklist of recommendations collected from the literature. RESULTS In total 817 CL/P reports were identified for 12 antiepileptic drugs in the FDA Adverse Event Reporting System. Ten of the 12 antiepileptic drugs were associated with 156 CL/P cases in the MHRA Sentinel. Safety information concerning pregnancy was found to be more comprehensive in UK SmPCs than in the US equivalents. CONCLUSIONS There is statistical disproportionality in individual case safety reports indicative of an increased risk of CL/P with 12 antiepileptic drugs studied. More studies are required to explore the association between in utero exposure to antiepileptic drugs and the risk of CL/P. There are inconsistencies between the UK and US safety labels. CL/P associated with antiepileptic drugs is an important topic and requires providing inclusive, unbiased, up-to-date information to prescribers and women of childbearing age.
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Affiliation(s)
- Bita Rezaallah
- 1 Department of Clinical Research, University of Basel, Basel, Switzerland.,2 Patient Safety, Novartis Global Drug Development, Novartis Pharma Basel, Switzerland
| | - David John Lewis
- 2 Patient Safety, Novartis Global Drug Development, Novartis Pharma Basel, Switzerland.,3 School of Health and Human Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Hans-Florian Zeilhofer
- 4 Department of Cranio-Maxillofacial Surgery, University Hospital Basel, Basel, Switzerland.,5 Hightech Research Center of Cranio-Maxillofacial Surgery, University of Basel, Basel, Switzerland
| | - Britt-Isabelle Berg
- 4 Department of Cranio-Maxillofacial Surgery, University Hospital Basel, Basel, Switzerland.,5 Hightech Research Center of Cranio-Maxillofacial Surgery, University of Basel, Basel, Switzerland.,6 Division of Oral and Maxillofacial Radiology, Columbia University Medical Center, New York City, NY, USA
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16
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Women with epilepsy in childbearing age: Pregnancy-related knowledge, information sources, and antiepileptic drugs. Epilepsy Behav 2018; 80:122-128. [PMID: 29414541 DOI: 10.1016/j.yebeh.2018.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 11/21/2022]
Abstract
Pregnancy-related issues in epilepsy (PRIE) are essential for management of epilepsy in women. We conducted a study among women with epilepsy (WWE) aged 15-45years about their knowledge, sources, and needs for information regarding PRIE, which included their current antiepileptic drugs (AEDs) usage. Women with epilepsy, visitors of Croatian Association for Epilepsy webpage, were offered an online questionnaire, and 200 responses were analyzed. The mean number of correct answers about PRIE was 3.5 out of 5. Main predictors of knowledge on PRIE were a prior consultation with a neurologist and higher usage of books/brochures. A prior neurologist consultation on PRIE was stated by 45% of subjects. As the preferred future mode of being informed on PRIE, majority of women (61%) chooses their neurologist, 22% written materials distributed by a neurologist, and only 13% Internet. Levetiracetam was the most commonly used AED (34.5%). Valproate was used by 26%, and of those 59% stated no previous consultation on PRIE with their neurologist. In summary, we believe our study shows that knowledge of PRIE among WWE in their childbearing age is unsatisfactory, as are the neurologist consultation rates about PRIE. Our results demonstrate that, despite modern technologies, educational activities should be based on neurologist consultations and providing the patients with appropriate written materials. This is especially true for the relatively large proportion of women still taking valproate.
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Affiliation(s)
- Kimford J Meador
- From the Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, Palo Alto, CA; Department of Genetics (D.L.), University Medical Center Utrecht; and Stichting Epilepsie Instellingen Nederland (SEIN) (D.L.), Heemstede/Zwolle, the Netherlands.
| | - Dick Lindhout
- From the Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, Palo Alto, CA; Department of Genetics (D.L.), University Medical Center Utrecht; and Stichting Epilepsie Instellingen Nederland (SEIN) (D.L.), Heemstede/Zwolle, the Netherlands
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18
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Toimela T, Huttala O, Sabell E, Mannerström M, Sarkanen JR, Ylikomi T, Heinonen T. Intra-laboratory validated human cell-based in vitro vasculogenesis/angiogenesis test with serum-free medium. Reprod Toxicol 2016; 70:116-125. [PMID: 27915012 DOI: 10.1016/j.reprotox.2016.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/11/2016] [Accepted: 11/28/2016] [Indexed: 01/27/2023]
Abstract
Vasculogenesis and angiogenesis are the processes by which new blood vessels are formed. We have developed a serum-free human adipose stromal cell and umbilical cord vein endothelial cell based vasculogenesis/angiogenesis test. In this study, the test was validated in our GLP laboratory following the OECD Guidance Document 34 [1] using erlotinib, acetylic salicylic acid, levamisole, 2-methoxyestradiol, anti-VEGF, methimazole, and D-mannitol to show its reproducibility, repeatability, and predictivity for humans. The results were obtained from immunostained tubule structures and cytotoxicity assessment. The performance of the test was evaluated using 26 suspected teratogens and non-teratogens. The positive predictive value was 71.4% and the negative predictive value was 50.0%, indicating that inhibition of vasculogenesis is a significant mechanism behind teratogenesis. In conclusion, this test has great potential to be a screening test for prioritization purposes of chemicals and to be a test in a battery to predict developmental hazards in a regulatory context.
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Affiliation(s)
- T Toimela
- FICAM, University of Tampere, Finland.
| | - O Huttala
- FICAM, University of Tampere, Finland
| | - E Sabell
- FICAM, University of Tampere, Finland
| | | | - J R Sarkanen
- Cell Biology, University of Tampere, Finland; Science Center, Tampere University Hospital, Finland
| | - T Ylikomi
- Cell Biology, University of Tampere, Finland; Science Center, Tampere University Hospital, Finland
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Effects of lacosamide "a novel antiepileptic drug" in the early stages of chicken embryo development. Childs Nerv Syst 2016; 32:1715-9. [PMID: 27473858 DOI: 10.1007/s00381-016-3181-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Antiepileptic drugs (AEDs) are teratogens and confer a risk of congenital malformation. The estimated prevalence of major congenital malformations such as cardiac defects, facial clefts, hypospadias, and neural tube defects in epileptic women is 4-10 %, which represents a two- to fourfold increase in pregnant women compared to the general population. However, there are no clear data for newer drugs. Lacosamide (LCM), a novel AED, is the first of the third-generation AEDs to be approved as adjunctive therapy for the treatment of partial-onset seizures. There are no data on the pharmacokinetics of LCM during pregnancy, and only some published data have reported on its effects during pregnancy. METHODS In this study, three different doses of LCM (0.12, 0.5, and 1.60 mg in 0.18 mL) were applied under the embryonic disks of specific pathogen-free Leghorn chicken embryos after a 30-h incubation. Incubation was continued for 80 h, at which time all embryos were evaluated macroscopically and microscopically. RESULTS There was growth retardation in all of the LCM-treated groups. Major malformations increased in a dose-dependent manner and were mostly observed in the supratherapeutic group. CONCLUSION Based on our data, LCM may cause growth retardation or major congenital malformations. Nevertheless, more extensive investigations of its reliability are needed.
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Abstract
Approximately 50% of all pregnancies in women with epilepsy (WWE) occur unplanned. This is worrying, given the increased occurrence of obstetrical complications in WWE, including the risk of seizures and their possible consequences for both the mother and the unborn child. Hormonal contraception is usually regarded as highly effective, but it is subject to numerous bidirectional drug interactions with several antiepileptic drugs. These interactions may lead to loss of seizure control or contraceptive failure. Further concerns are loss of bone mineral density and increased seizure activity due to hormonal effects. Many physicians lack sufficient knowledge regarding these issues, and most WWE have never received adequate counseling. Moreover, several studies show that a large proportion of WWE do not take their medicines regularly. This article reviews all of these issues and offers practical recommendations for the management of contraception in WWE.
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Affiliation(s)
- Arne Reimers
- Department of Clinical Pharmacology, St Olavs University Hospital.,Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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