Sexual problems in people with refractory epilepsy

New valproate regulations, informed choice and seizure risk

Valproate is the most effective medication for generalised epilepsies, and several specific epilepsy syndromes. For some people, it will be the only medication to establish seizure remission, and withdrawing it carries risks of seizure recurrence and Sudden Unexpected Death in Epilepsy (SUDEP). It is also of proven efficacy for bipolar disorder and migraine prevention. Guidelines based on observational and epidemiological studies stress that maternal valproate related teratogenicity and neurodevelopmental effects are significantly higher than for other antiseizure medications (ASMs). It should, therefore, only be used if other medications are ineffective and after balancing the teratogenicity risk. Regulatory restrictions have changed prescribing practices and reduced valproate use. The number of other medications that must be trialled in the different conditions for which valproate has effectiveness and the consequences of the lack of efficacy of those drugs leading to significant harm including death remains unexplored. Risk minimisation measures (RMMs) for valproate, chiefly Pregnancy Prevention practices (PPP), consider foetal risk and not risk to people living with epilepsy. In the United Kingdom (UK), limitations relating to valproate use in all people < 55 years commenced in January 2024. While the evidence in child-bearing women is not disputed, the data in males are based on animal models, case reports, and one commissioned, unpublished, non-peer reviewed report unavailable to the UK public, stakeholder charities or professionals. Evidence suggests that 30-40% of people switching from valproate have breakthrough seizures. Thus, an estimated 21,000-28000 people in the UK will imminently be exposed to the potential hazards of breakthrough seizures, including death. There is little government investment in monitoring the effects of these changes to valproate prescribing on patient health and quality of life. This review summarises the history of valproate regulation, evidence underpinning it and argues how the latest regulations in the UK do not align with the country's medical regulatory bodies ethical principles nor with the Montgomery principles of informed patient choice and autonomy. It dissects how such regulations infringe Common Law principles, nor give due regard for patient outcomes beyond reproduction. The paper looks to provide recommendations to redress these concerns while appreciating the core need for such governance to emerge in the first place.

Use of screening tools to assess comorbidities and adverse events in patients with epilepsy. A European Reference Network for Rare and Complex Epilepsies (EpiCARE) survey

PURPOSE

As comorbidities can affect treatment decisions, quality of life, and prognosis in epilepsy, it is important that they are detected and addressed as soon as possible. Screening tools can help by rapidly assessing various additional challenges in epilepsy.

METHODS

To map the use and perceived benefit of different screening instruments for quality of life, psychiatric comorbidity, and cognition, along with side effects from anti-seizure medication in Europe, we sent an online questionnaire to dedicated epilepsy centres departments within the European Reference Network for Rare and Complex Epilepsies (EpiCARE).

RESULTS

Among the 40 hospitals in the EpiCARE network, we received responses from 25 (63%), with 28 individual respondents. Most respondents reported using screening for quality of life (86%) and psychiatric comorbidity (82%), but relatively few (14%) screen for sexual problems. Many (47) different tools were used for evaluation of cognitive dysfunction, but just a few (5) different tools were used to screen for adverse events. The optimization of individual patient care was one main reason given for using screening tools (58%-100% - depending on purpose of tool), another was research (50% - 88% - depending on purpose of tool). A major benefit of using screening tools perceived by the respondents is the detection of "hidden" comorbidity (67% - 90% - depending on purpose of tool).

CONCLUSION

In the absence of a broad consensus regarding use of screening tools, practices vary considerably among epilepsy centres. Greater emphasis should be directed towards harmonizing use of screening tools. Future research should address how screening results influence treatment choices, and how these might affect clinical care.

The Quality of Life in Patients with Epilepsy in the Context of Sleep Problems and Sexual Satisfaction

Epilepsy influences the quality of patient functioning in almost all aspects of life. This study aimed to assess the quality of difficulties with sleep initiation and those concerning sexual function, and to assess whether sleep disorders are associated with selected aspects of sexual function and quality of life. The study involved completing a quality-of-life questionnaire for persons with epilepsy: a QOLIE-31 questionnaire, and the present authors' questionnaire, including 20 questions. A total of 170 questionnaires were completed by 89 men and 81 women. Sleep problems of various frequency were reported by 98 participants (57.6%). Only 41% of patients were definitely satisfied with their sex life. The respondents who declared dissatisfaction with their sex life more often reported difficulties with sleep initiation (χ2 = 10.20; p ≤ 0.001). Moreover, those who claimed that epilepsy might contribute to sex life problems more commonly declared dissatisfaction with their sex life (χ2 = 20.01; p ≤ 0.001) and more frequently, reported difficulties with sleep initiation (χ2 = 6.30; p ≤ 0.012). The issues should constitute the constant element of medical history taking, as improvement in these areas of functioning may promote better quality of life in patients with epilepsy.

The impact of medications and medical comorbidities on sexual function in people with epilepsy

OBJECTIVE

People with epilepsy experience increased rates of sexual dysfunction, often affecting quality of life. Sexual dysfunction may result from the underlying disorder, antiseizure or other medications, or comorbid psychosocial factors. This study evaluated the incidence and clinical associations of sexual dysfunction in adult epilepsy patients.

METHODS

89 epilepsy patients 18 years and older admitted to the New York University Comprehensive Epilepsy Center epilepsy monitoring unit between 2016 and 2018 completed a survey on sexual functioning. The survey included demographic, clinical, and sexual functioning information with a validated measure of sexual function (the Arizona Sexual Experiences Scale (ASEX).

RESULTS

Of 89 surveys completed, 15 (16.9 %) patients had discussed sexual functioning with a medical professional and 20 (22.5 %) reported sexual dysfunction. For the group, the mean ASEX score was 13.6 (SD 4.8). 59 (66.3 %) participants reported not being asked about sexual health by their doctor or nurse practitioner in the last year. The two independent predictors of sexual dysfunction were self-identifying as overweight/obese (OR 6.1, CI 1.4-26.5, P = 0.02) or taking strong enzyme-inducing antiseizure medications (OR 7.8, CI 1.4-44.9, P = 0.02). Other factors such as age, relationship status, duration of epilepsy, the presence of depression or anxiety, cardiovascular risk factors, and opioid/stimulant use, did not predict sexual dysfunction.

SIGNIFICANCE

Our study showed that sexual dysfunction is common in epilepsy patients but infrequently discussed by medical professionals. Two modifiable risk factors, being overweight or taking strong enzyme-inducing antiseizure medications, were independently associated with sexual dysfunction, suggesting interventions to potentially improve sexual health.

Valproate, sexual health, and men: A narrative review

OBJECTIVE

This article explores current evidence about the effects of valproate (VPA) medicines on sexual health in men, how to monitor symptoms, communicate with patients, and improve clinical outcomes. There has been a lot of focus on VPA use in women of childbearing age following recent changes to prescribing regulations owing to the well-established and significant teratogenic risk. Concerns have been raised by patients and clinicians as to the risk of adverse sexual effects of VPA use in men.

RESULTS

The evidence base for the effect of VPA on sexual function compared with other antiepileptic drugs (AEDs) in men is limited with no randomized controlled trials. Sexual function in men with epilepsy is complex, and there is no direct relationship between objective measures of sexual function and sexual satisfaction. Epilepsy, comorbidities, psychosocial factors, and most AEDs including VPA may cause sexual dysfunction in men, including reduced sexual desire, erectile dysfunction, and fertility problems. Sexual and reproductive function should be discussed with men prior to treatment with AEDs including VPA.

CONCLUSION

Early and proactive discussion of sexual and reproductive functioning mitigates, rather than increases, the risk of sexual problems and potentially improves adherence. Sexual dysfunction in men with cognitive impairment [such as intellectual disability (ID) and dementia] may present with behavioral disturbance. Identification of sexual adverse effects of medication could significantly change treatment plans which is of particular importance for individuals with treatment resistance. We provide an information fact sheet for men to help guide prescribing discussions.

Sexual dysfunction and mental health in patients with multiple sclerosis and epilepsy

BACKGROUND

Epilepsy and multiple sclerosis (MS) are two neurological diseases known to greatly influence a patient's life. The primary aim of this study was to describe the prevalence of sexual dysfunction in patients with epilepsy and MS and investigate whether there is an association between disease, sexual function, and physical and mental health. A secondary aim was to investigate whether there is a difference in sexual function between patients with MS and epilepsy.

METHODS

A total of 414 patients were included in this descriptive cross-sectional study. Three patient report questionnaires were used for measurements: the Changes in Sexual Function Questionnaire (CSFQ) cut-off score; the Short Form 36 Health Survey (SF-36) divided into the Physical Component Summary (PCS) and Mental Component Summary (MCS), and the Life Satisfaction-11 (LiSat-11).

RESULTS

Patients with MS constituted 62% (n = 258) of the participants and patients with epilepsy 38% (n = 156). The prevalence of sexual dysfunction was 68% in women and 77% in men. No differences were found between patients with MS and epilepsy (p = 0.184), except for the CSFQ desire domain, as patients with epilepsy more often had a desire problem (p = 0.029). On the SF-36, patients with MS scored significantly worse on the PCS (p = 0.000). Patients with epilepsy scored significantly worse on the MCS (p = 0.002). No significant differences were found on the LiSat-11. Regression analysis with CSFQ as the dependent variable showed an association with the PCS in men and an association with both PCS and MCS in women.

CONCLUSIONS

In this study, the cohort of patients with MS and epilepsy had negatively affected sexual function. The only significant difference between patients with MS and epilepsy in sexual function measured by the CSFQ-14, was found in the frequency of desire, in which a larger number of patients with epilepsy reported sexual dysfunction. In the studied cohort, sexual function in women is associated with both physical and mental health, and in men with physical health. These results should be considered when caring for patients with epilepsy and MS.

Sexual dysfunction in people with epilepsy

Sexual dysfunction is a common comorbidity in people with epilepsy (PWE) that adversely affects their quality of life. Nearly one-half of men and women with epilepsy have sexual dysfunction, but in the majority, this often goes unnoticed. The wide variation in the reported prevalence of sexual dysfunction in PWE is due to the significant heterogeneity among the studies with regard to patient population, type and severity of epilepsy, number and type of antiseizure drugs (ASDs) used, and the tools used for assessing sexual dysfunction. Generally, patients with uncontrolled epilepsy, longer duration of epilepsy, focal epilepsy, higher seizure frequency, and those receiving enzyme-inducing and multiple ASDs are more likely to have sexual dysfunction. Women generally have dysfunction in the domains of desire, while males usually have arousal disorders such as erectile dysfunction and premature ejaculation. There is limited evidence to indicate that sexual function improves in patients rendered seizure-free following epilepsy surgery. Multiple mechanisms including direct effects of epilepsy, effects of ASDs, and psychosocial factors contribute to sexual dysfunction in epilepsy. Circumstantial evidence indicates that seizures and interictal epileptiform discharges can directly affect the hypothalamic-pituitary axis as well as production of gonadal steroids. Enzyme-inducing ASDs cause sexual dysfunction by affecting the metabolism of gonadal steroids. Limited data suggest that newer ASDs including oxcarbazepine, lamotrigine, and levetiracetam cause no or minimal sexual dysfunction. Depression and anxiety significantly contribute to sexual dysfunction in PWE. A multipronged and multidisciplinary approach is essential for optimizing the sexual functions. Every effort should be made to identify and treat reversible causes including changing to nonenzyme-inducing ASDs and to provide symptomatic relief. Large, prospective studies are required to improve our understanding on prevalence and mechanisms of sexual dysfunction in PWE.

Challenges in epilepsy-The perspective of Norwegian epilepsy patients

OBJECTIVES

For most people with epilepsy (PWE), problems that are not directly related to seizures may constitute major challenges in everyday life. The purpose of this study was to determine the extent of these challenges and any risk factors for their occurrence among PWE in Norway, based on the patients' own perspective.

MATERIALS AND METHODS

We used a web-based survey to ask PWE visiting the homepage of the Norwegian Epilepsy Association about different everyday challenges. A link to the survey was accessible via the members' homepage for a 4-month period during 2017.

RESULTS

One thousand one hundred eighty-two PWE responded to the questionnaire. Although more than 40% of the cohort reported that they had been seizure free for at least 1 year, the majority reported that tiredness (71%), memory problems (70%), concentration problems (68%), headache or vertigo (51%), and feeling depressed (59%) continued to represent challenges. In addition, fear of being alone, sexual problems or difficulties in social settings were reported by about one-third of the patients. Reporting having these challenges was significantly associated with female gender, polytherapy, experiencing seizures during the previous 12 months and feeling blue or depressed.

CONCLUSIONS

The results of this study, reflecting a self-selected Norwegian population, provide insights into the challenges not directly associated with seizures that impact on the quality of life of PWE. The impacts of such challenges may be underestimated as components of the entire burden of epilepsy.

Lamotrigine-induced sexual dysfunction and non-adherence: case analysis with literature review

BACKGROUND

Optimal anti-epileptic drug (AED) treatment maximises therapeutic response and minimises adverse effects (AEs). Key to therapeutic AED treatment is adherence. Non-adherence is often related to severity of AEs. Frequently, patients do not spontaneously report, and clinicians do not specifically query, critical AEs that lead to non-adherence, including sexual dysfunction. Sexual dysfunction prevalence in patients with epilepsy ranges from 40 to 70%, often related to AEDs, epilepsy or mood states. This case reports lamotrigine-induced sexual dysfunction leading to periodic non-adherence.

AIMS

To report lamotrigine-induced sexual dysfunction leading to periodic lamotrigine non-adherence in the context of multiple comorbidities and concurrent antidepressant and antihypertensive pharmacotherapy.

METHOD

Case analysis with PubMed literature review.

RESULTS

A 56-year-old male patient with major depression, panic disorder without agoraphobia and post-traumatic stress disorder was well-controlled with escitalopram 20 mg bid, mirtazapine 22.5 mg qhs and alprazolam 1 mg tid prn. Comorbid conditions included complex partial seizures, psychogenic non-epileptic seizures (PNES), hypertension, gastroesophageal reflux disease and hydrocephalus with patent ventriculoperitoneal shunt that were effectively treated with lamotrigine 100 mg tid, enalapril 20 mg qam and lansoprazole 30 mg qam. He acknowledged non-adherence with lamotrigine secondary to sexual dysfunction. With lamotrigine 300 mg total daily dose, he described no libido with impotence/anejaculation/anorgasmia. When off lamotrigine for 48 h, he described becoming libidinous with decreased erectile dysfunction but persistent anejaculation/anorgasmia. When off lamotrigine for 72 h to maximise sexual functioning, he developed auras. Family confirmed patient's consistent monthly non-adherence for 2-3 days during the past year.

CONCLUSIONS

Sexual dysfunction is a key AE leading to AED non-adherence. This case describes dose-dependent lamotrigine-induced sexual dysfunction with episodic non-adherence for 12 months. Patient/clinician education regarding AED-induced sexual dysfunction is warranted as are routine sexual histories to ensure adherence.

DECLARATION OF INTEREST

No financial interests. K.R.K. is Editor of BJPsych Open; he took no part in the peer-review of this work.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Topiramate-associated sexual dysfunction: A systematic review

INTRODUCTION

Sexual pharmacotoxicity renders patients with epilepsy at a risk for sexual dysfunction (SD). This study is aimed to analyze the relationship between sexual function and topiramate to avoid topiramate-associated SD.

METHODS

A systematic review following the PRISMA guidelines was performed to elucidate any SD occurrence in patients receiving topiramate.

RESULTS

A total of 17 publications were reviewed. Based on limited polytherapy observational studies, the frequency of self-reported topiramate-associated SD, libido disorder, and orgasmic disorder in patients with polytherapy was 9.0%, 9.0%, and 2.6%, respectively (grade C evidence). Female patients mainly had anorgasmia, whereas male patients principally had erectile dysfunction. The daily dose of topiramate in patients with SD was within the recommended dose. Sexual adversity usually occurred from 4weeks after topiramate use but favorably subsided without eventful complications after topiramate substitution or dose reduction in all patients.

CONCLUSIONS

Topiramate can elicit different patterns of SD, especially anorgasmia in women and erectile dysfunction in men, even with a therapeutic dose. Detailed drug education and careful monitoring are necessary to maximize sexual health, especially in persons undergoing polytherapy and with other risks for SD. Moreover, a rapid response, such as substitution or reduction of the dose, is suggested when SD occurs during its use.

Erectile Dysfunction in Wistar Audiogenic Rats Is Associated With Increased Cavernosal Contraction and Decreased Neuronal Nitric Oxide Synthase Protein Expression

OBJECTIVE

To test the hypothesis that naive Wistar audiogenic rats (WARs) display erectile dysfunction (ED), which is associated with increased sympathetic-mediated contractile tone and decreased nitric oxide-mediated relaxation responses of the cavernous tissue.

METHODS

Changes in the ratio of the maximal intracavernosal pressure-mean arterial pressure after the electrical stimulation of the right major pelvic ganglion were determined in vivo. Cavernosal contractility was induced by electrical field stimulation and phenylephrine. In addition, nonadrenergic-noncholinergic (NANC)-induced relaxation was determined. Rho-kinase (ROCK) pathway proteins, neuronal nitric oxide synthase (nNOS) protein expression, and endothelial nitric oxide synthase (eNOS) and extracellular signal-regulated kinase 1/2 activities were determined by Western blot.

RESULTS

WARs display a significant decrease in maximal intracavernosal pressure-mean arterial pressure responses suggesting ED in this strain. Sympathetic-mediated contractile responses were increased in WARs and contractile responses to phenylephrine were not changed. The increased sympathetic-mediated contractile responses were not associated with changes in the ROCK pathway. On the other hand, NANC-mediated relaxation responses were significantly reduced in WARs. This functional response was accompanied by decreased nNOS and total eNOS protein expressions, augmented phosphorylated eNOS, and decreased extracellular signal-regulated kinase 1/2 phosphorylation levels.

CONCLUSION

Our data have demonstrated that naive WARs display ED in vivo that is associated with increased sympathetic-mediated contractile responses and decreased NANC-mediated relaxation responses. The increase in contractile responses is independent of the ROCK pathway, and the changes in relaxation responses are associated with a decrease in nNOS protein expression, which may activate compensatory mechanisms in the cavernous tissue.