1
|
Wan X, Wu Y, Zou Q, Yuan B, Huang L, Hu M. Seizure control and adverse outcomes of lamotrigine use during pregnancy: A systematic review and meta-analysis. Epilepsy Behav 2024; 157:109924. [PMID: 38945077 DOI: 10.1016/j.yebeh.2024.109924] [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: 04/07/2024] [Revised: 06/01/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE This review aims to summarize existing evidence on the adverse pregnancy outcomes and seizure control effects of using lamotrigine (LTG) monotherapy in pregnancy women with epilepsy (WWE) during pregnancy. METHODS A comprehensive search was conducted in various databases including Cochrane, Web of Science, CBM, PubMed, Embase, CNKI, and Pregnancy Registration Center databases to identify relevant studies. The search was concluded up to January 2024. Studies comparing LTG with other antiseizure medications (ASMs) for treating epilepsy in pregnant women were included, with no language or regional restrictions. RESULTS A total of 19 studies were included for analysis, with 16 studies reporting adverse pregnancy outcomes and 6 studies reporting seizure control outcomes. Meta-analysis showed that compared to monotherapy with carbamazepine (CBZ), sodium valproate (VPA), and levetiracetam (LEV), LTG monotherapy had a slightly weaker ability to control seizures during pregnancy, with ORs and 95 %CIs of 0.65 (0.57-0.75; CBZ), 0.50 (0.32-0.79; VPA), and 0.55 (0.36-0.84; LEV). Regarding adverse pregnancy outcomes, the occurrence rate of LTG monotherapy was significantly lower than that of CBZ, VPA, phenytoin (PHT), and phenobarbital (PHB), with ORs and 95 %CIs ranging from 0.30 (0.25-0.35; VPA) to 0.68 (0.56-0.81; CBZ). CONCLUSION Based on meta-analysis, LTG and LEV appear to be preferred medications for controlling seizures during pregnancy. This review provides further support for the use of LTG monotherapy in pregnant WWE, building upon existing evidence for clinical practitioners.
Collapse
Affiliation(s)
- Xin Wan
- First School of Clinical Medicine, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yunhong Wu
- First School of Clinical Medicine, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Qing Zou
- Department of Psychosomatic Medicine, The 1(st) Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Bin Yuan
- Department of Child and Adolescent Psychology, Third Fuzhou Jiangxi Hospital, Fuzhou, China
| | - Liping Huang
- Department of Psychosomatic Medicine, The 1(st) Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Maorong Hu
- First School of Clinical Medicine, Jiangxi Medical College, Nanchang University, Nanchang, China; Department of Psychosomatic Medicine, The 1(st) Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
| |
Collapse
|
2
|
Li D, Franco S, Pennell PB. The impact of pregnancy-related hormonal and physiological changes on antiseizure medications: expert perspective. Expert Rev Clin Pharmacol 2024; 17:655-663. [PMID: 38748860 DOI: 10.1080/17512433.2024.2356617] [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: 03/14/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Epilepsy is a disorder of recurrent, unprovoked seizures affecting approximately 15 million individuals of childbearing potential worldwide. Patients with epilepsy rely on regular daily therapy with antiseizure medications (ASMs). Furthermore, ASMs are also prescribed for other neuropsychiatric indications (e.g. bipolar disorder, pain, migraines) with over 2% of the pregnancies in the United States involving prenatal exposure to ASMs. AREAS COVERED ASM concentrations are affected by hormonal and physiological changes in pregnancy, including increases in renal and hepatic blood flow, decreased protein binding, and changes in enzyme activity. Clearance changes typically reverse within a few weeks after delivery. During pregnancy, many ASMs, such as lamotrigine, levetiracetam, and oxcarbazepine, should have serum concentrations monitored and doses increased to maintain the individualized target range for seizure control. ASMs metabolized via glucuronidation, primarily lamotrigine, undergo marked increases in clearance throughout pregnancy, requiring about 3-fold the pre-pregnancy daily dose by delivery. Postpartum, ASM doses are usually decreased over several weeks to prevent drug toxicity. EXPERT OPINION In the future, the development of a physiologically-based pharmacokinetic model for various ASMs may enable empiric dose adjustments in pregnancy without the difficulties of frequent therapeutic drug monitoring.
Collapse
Affiliation(s)
- Denise Li
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Susannah Franco
- Department of Pharmacy, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Page B Pennell
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
3
|
Sha L, Cao Z, Fu Y, Duan Y, Xia Y, Feng X, Tomson T, Xie X, Chen L. Global burden and management of women with epilepsy in pregnancy: A modeling study. MED 2024:S2666-6340(24)00264-2. [PMID: 39053463 DOI: 10.1016/j.medj.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/10/2024] [Accepted: 07/02/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Most pregnant women with epilepsy do not receive proper medical care, which creates a special burden worldwide. We aimed to qualify this special global burden and assess the impact of different clinical management strategies to reduce it. METHODS The data used in this study were extracted from articles published between 2005 and 2022. We calculated the economic costs associated with major burdens experienced by pregnant women with epilepsy. We developed a microsimulation model to estimate the different effects of various interventions and their combinations as integrated strategies for pregnant women with epilepsy and related burden reduction. We also compared the regional differences in disease burden and interventions. FINDINGS The total economic burden for pregnant women with epilepsy is estimated to reach $1.8 billion globally annually, which is more than three times the burden for epilepsy alone. Folic acid supplementation is projected to be the most effective intervention, with a 9.1% reduction in major congenital malformations, a 14.9% reduction in autism spectrum disorder, and a 10.8% reduction in offspring-related economic burden globally annually. Integrated strategies are associated with a reduced economic burden of up to $37.7 million annually globally. Folic acid supplementation is the most effective intervention in high- and upper-middle-income countries, whereas changes in antiseizure medication prescriptions are more effective in lower-middle- and low-income countries. CONCLUSION This study highlights the huge burden for pregnant women with epilepsy and actions that must be taken to improve their quality of life. FUNDING This work was supported by the Sichuan Science and Technology Program (2023YFS0047).
Collapse
Affiliation(s)
- Leihao Sha
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ze Cao
- Department of Industrial Engineering, Tsinghua University, Beijing 100084, China
| | - Yutong Fu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yifei Duan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yilin Xia
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xiaoru Feng
- School of Medicine, Tsinghua University, Beijing 100084, China
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, 11351 Stockholm, Sweden
| | - Xiaolei Xie
- Department of Industrial Engineering, Tsinghua University, Beijing 100084, China.
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
| |
Collapse
|
4
|
Meador KJ, Cohen MJ, Loring DW, Matthews AG, Brown CA, Robalino C, Carmack A, Sumners S, Birnbaum AK, Kalayjian LA, Gedzelman E, Voinescu PE, Gerard EE, Hanna J, Cavitt J, Sam M, Hwang ST, Pack AM, Tsai JJ, Pennell PB. Association of Prenatal Exposure to Antiseizure Medications With Creative and Executive Function at Age 4.5 Years. Neurology 2024; 102:e209448. [PMID: 38810172 PMCID: PMC11226309 DOI: 10.1212/wnl.0000000000209448] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/08/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neurodevelopmental effects of fetal antiseizure medication (ASM) exposure on creativity and executive functions are poorly understood. We previously found fetal valproate exposure to adversely affect measures of creativity and executive functions. In this study, we examine fetal exposure of newer ASMs on these functions in children of women with epilepsy (WWE) compared with children of healthy women (HW). METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs study is a multicenter NIH-funded prospective observational cohort study of WWE and HW enrolled in pregnancy and their offsprings. This report examines blindly assessed creativity and executive functions in 4.5-year-old children of WWE vs HW. In addition, exposure-dependent ASM effects during the third trimester were examined in children of WWE, using a ratio of maximum observed ASM concentrations and ratio of defined daily dose (ratio DDD). For polytherapy, ratios were summed across ASMs. Linear regression models adjusted for multiple potential confounding factors were conducted for all analyses. The primary outcome for 4.5-year-old children was the Torrance Test of Creative Thinking-Figural Creativity Index. Secondary outcomes included the Global Executive Composite Score from the Behavior Rating Inventory of Executive Function-Preschool Version and subscales and other indexes of both measures. RESULTS The primary analysis included 251 children of WWE and 73 of HW. No differences in creativity or executive function were found between children of WWE vs HW. No ASM exposure-dependent effects were found for the creativity measures, but exposure-dependent effects for executive function were present for ratio ASM concentration and ratio DDD. DISCUSSION Our findings at 4.5 years show no differences in creative thinking between children of WWE vs HW (-3.2 [-9.0 to 2.7], p = 0.286) or associations with fetal exposure to ASMs (-2.6 [-11.0 to 5.7], p = 0.530). Secondary analyses revealed fetal exposure-dependent effects for executive function in children of WWE (7.0 [2.9-11.2], p = 0.001), which are most marked for levetiracetam (12.9 [4.2-21.6], p = 0.004). Our findings suggest that even for relatively safe ASMs, dosing needs to be adjusted to concentrations that prevent seizures, but balance risks to the fetus that high concentrations may pose. TRIAL REGISTRATION INFORMATION The study is registered at ClinicalTrials.gov as NCT01730170.
Collapse
Affiliation(s)
- Kimford J Meador
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Morris J Cohen
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - David W Loring
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Abigail G Matthews
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Carrie A Brown
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Chelsea Robalino
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Andrea Carmack
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Sarah Sumners
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Angela K Birnbaum
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Laura A Kalayjian
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Evan Gedzelman
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Paula E Voinescu
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Elizabeth E Gerard
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Julie Hanna
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Jennifer Cavitt
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Maria Sam
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Sean T Hwang
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Alison M Pack
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Jeffrey J Tsai
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| | - Page B Pennell
- From the Stanford University (K.J.M.), Palo Alto, CA; Pediatric Neuropsychology International (M.J.C.), Augusta; Emory University School of Medicine (D.W.L., E.G.), Atlanta, GA; The Emmes Company (A.G.M., C.A.B., C.R., A.C.), Rockville, MD; Piedmont University (S.S.), Athens, GA; University of Minnesota (A.K.B.), Minneapolis; University of Southern California (L.A.K.), Los Angeles; Brigham and Women's Hospital (P.E.V.), Harvard Medical School, Boston, MA; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (J.H.), Roseville; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; Northwell Health (S.T.H.), Great Neck; Columbia University (A.M.P.), New York, NY; University of Washington (J.J.T.), Seattle; and University of Pittsburgh (P.B.P.), PA
| |
Collapse
|
5
|
Johnson EL. Valproate: Weighing the Unique Risks. Neurology 2024; 102:e209325. [PMID: 38569129 DOI: 10.1212/wnl.0000000000209325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/21/2024] [Indexed: 04/05/2024] Open
Affiliation(s)
- Emily L Johnson
- From the Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
6
|
Kobayashi E. Step Climb Dosing Guidance From Simulation Studies on Lamotrigine Concentration Changes During Pregnancy. Epilepsy Curr 2024; 24:177-179. [PMID: 38898917 PMCID: PMC11185212 DOI: 10.1177/15357597241237373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Empiric Dosing Strategies to Predict Lamotrigine Concentrations During Pregnancy Barry JM, French JA, Pennell PB, Karanam A, Harden CL, Birnbaum AK. Pharmacotherapy . 2023;43(10):998-1006. doi:10.1002/phar.2856 . PMID: 37475496 Introduction: Maintaining seizure control with lamotrigine is complicated by altered pharmacokinetics and existence of subpopulations in whom clearance increases or remains constant during pregnancy. Objective: Our objective was to characterize the potential for particular dosing scenarios to lead to increased seizure risk or toxicity. Methods: Lamotrigine pharmacokinetic parameters obtained from our previous study were applied to a one-compartment model structure with subpopulations (75:25%) exhibiting different clearance changes. A single-patient simulation was conducted with typical pharmacokinetic parameter values from each subpopulation. Population-level simulations (N = 48,000) included six dosing scenarios and considered four preconception doses using the R package mrgsolve (Metrum Research Group). Thresholds for efficacy and toxicity were selected as drug concentration that are 65% lower than preconception concentrations and doubling of preconception concentrations, respectively. Results: Individual simulation results demonstrated that without dose increases, concentrations fell below 0.65 at 6-8 weeks in the high clearance change (HC) subpopulation, depending on preconception clearance. While no simulated dosing regimen allowed all women in both subpopulations to maintain preconception concentrations, some regimens provided a more balanced risk profile than others. Predicted concentrations suggested potential increased seizure risk for 7%-100% of women in the HC group depending on preconception dose and subpopulation. Additionally, in 63% of dosing scenarios for women with low clearance change (LC), there was an increased risk of toxicity (34%-100% of women). Significance: A substantial percentage of simulated individuals had concentrations low enough to potentially increase seizure risk or high enough to create toxicity. Early clearance changes indicate possible subpopulation categorization if therapeutic drug monitoring is conducted in the first trimester. An arbitrary “one-size-fits-all” philosophy may not work well for lamotrigine dosing adjustments during pregnancy and reinforces the need for therapeutic drug monitoring until a patient is determined to be in the LC or HC group.
Collapse
Affiliation(s)
- Eliane Kobayashi
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, Faculty of Medicine and Health Sciences, McGill University
| |
Collapse
|
7
|
Goo Y, der Nederlanden AM, Bleasel A, Alffenaar JW, Kim HY. Dose Monitoring of Lamotrigine Monotherapy in Pregnancy: Are Pregnant Women with Epilepsy Currently Optimally Managed? A Systematic Review. Ther Drug Monit 2024; 46:181-194. [PMID: 38366344 DOI: 10.1097/ftd.0000000000001186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Lamotrigine monotherapy is the first-line treatment for epilepsy in pregnant women. However, altered pharmacokinetics during pregnancy can lead to suboptimal drug levels and increased seizure risk. This systematic review aimed to evaluate current therapeutic drug monitoring (TDM) strategies for lamotrigine monotherapy in pregnant women with epilepsy and provide guidance for monitoring and dose adjustments. METHODS A systematic search was performed using the Ovid-MEDLINE, Ovid-EMBASE, and Ovid-Cochrane Central Register of Controlled Trials databases. Studies were included if data on lamotrigine dosing, concentration, TDM strategies, efficacy, or safety were available. RESULTS Eleven studies were analyzed, revealing heterogeneity in outcomes with selective reporting of TDM strategies; however, clear similarities were observed. Blood samples were collected every 1-3 months during pregnancy to maintain prepregnancy baseline drug levels. Lamotrigine's apparent and relative clearance increased across trimesters, particularly in the second and third trimesters, coinciding with a period of increased seizure frequency and required dose adjustments. Details on dose adjustments were limited. Some studies have proposed using the threshold of the ratio to the target concentration to predict increased seizure risk. No distinct association was observed between adverse newborn outcomes and lamotrigine dose or serum concentration. Few maternal adverse effects have been reported after delivery, confirming the necessity of empirical postpartum tapering. CONCLUSIONS Further studies are required to establish evidence-based standardized protocols encompassing all aspects of TDM. Early interventions, such as empirical dose increases during pregnancy and postpartum tapering, and routine monitoring from preconception to the postpartum period may enhance seizure control, reducing the risk of breakthrough seizures for the mother and unborn child.
Collapse
Affiliation(s)
- Yeonkyung Goo
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Andrew Bleasel
- Neurology Department, Westmead Hospital, Westmead, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia ; and
| | - Jan-Willem Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Hannah Yejin Kim
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| |
Collapse
|
8
|
Gandelman-Marton R, Theitler J. Trends in enzyme-inducing antiseizure medication use: A retrospective analysis among adults with epilepsy. Epilepsy Behav 2024; 152:109662. [PMID: 38277853 DOI: 10.1016/j.yebeh.2024.109662] [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: 10/26/2023] [Revised: 01/20/2024] [Accepted: 01/21/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Enzyme-inducing antiseizure medications (EIASMs) were associated with drug interactions and long-term adverse effects. Therefore, it was suggested that epilepsy treatment should be started with non-EIASMs, and in patients treated with EIASMs, replacement with non-EIASMs should be evaluated OBJECTIVE: To assess potent EIASM use among patients with epilepsy at their first visit in our epilepsy outpatient clinic. METHODS We retrospectively reviewed the computerized database and the medical records of all the patients who had their first visit in our outpatient epilepsy clinic during a 10-year period (2012-2021). Of 730 patients with ASM treated epilepsy, 243 (33%) were receiving potent EIASMs. RESULTS The annual potent EIASM use decreased from 35.1 % in 2012 to 11.8 % in 2021. Most of the patients who received potent EIASM had their first visit during 2012-2015 compared to the following years (56.8 % vs 43.2 %) (p = 0.0001). Patients with epilepsy receiving potent EIASMs were older (44.3 vs 34.7) (p = 0.0001), more likely men (60.9 % vs 47.2 %) (p = 0.001), with longer disease duration (13 vs 9.3 y) (p = 0.0001), higher rate of neuropsychiatric comorbidity (37 % vs 27.9 %) (p = 0.014), and were treated with more ASMs (1.6 vs 1.3) (p = 0.0001) compared to patients receiving non-EIASMs. CONCLUSIONS Potent EIASM use has been declining over the past decade. Additional efforts to further decrease EIASM use should be exerted among all patients with ASM-treated epilepsy, with emphasis on men with focal epilepsy and epilepsy duration > 10 years.
Collapse
Affiliation(s)
- Revital Gandelman-Marton
- Neurology Department, Shamir-Assaf Harofeh Medical Center, Zerifin, Israel; Faculty of Medicine, Tel Aviv University, Israel.
| | - Jacques Theitler
- Neurology Department, Shamir-Assaf Harofeh Medical Center, Zerifin, Israel; Faculty of Medicine, Tel Aviv University, Israel
| |
Collapse
|
9
|
Kumaravel J, Sarma P, Suri V, Singh P, Prakash A, Medhi B. Therapeutic Drug Monitoring of Levetiracetam in Different Trimesters of Pregnant Women with Epilepsy in a Tertiary Care Center: A Prospective Study. Neurol India 2024; 72:358-363. [PMID: 38691482 DOI: 10.4103/ni.ni_439_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 04/16/2023] [Indexed: 05/03/2024]
Abstract
BACKGROUND Levetiracetam is the most commonly used antiepileptic drug in pregnant women due to its low teratogenic risk profile, favorable pharmacokinetic characteristics, and safety profile. Serum levels of levetiracetam vary in epilepsy during pregnancy. Therefore, the aim of the study was to evaluate the serum levels of levetiracetam during different trimesters of pregnancy by using therapeutic drug monitoring (TDM). MATERIALS AND METHODS This was a single-center, prospective study. Pregnant women with epilepsy on levetiracetam were enrolled after getting written informed consent from them. Serum trough levels of levetiracetam were estimated at all trimesters by high-performance liquid chromatography (HPLC). RESULTS The study included 16 participants with mean ± standard deviation (SD) age of 27.75 ± 4 years. There were nine (56.2%) participants with generalized seizure disorder and seven (43.8%) participants of focal seizure disorder. Among 16 patients, 10 (62.5%) participants were on levetiracetam alone and six (37.5%) participants were on levetiracetam combined with other antiepileptic drugs. In a total of 48 trough samples, 45 sample concentrations were below the therapeutic range of 12-46 mg/l and three sample concentrations were within the therapeutic range. There was a statistically significant difference in the concentration-dose ratio (CDR) of levetiracetam between the third and first trimesters (P-value 0.018). CONCLUSION There was a statistically significant difference in serum levetiracetam concentration between the third and first trimesters. A well-conducted, intensive pharmacokinetic sampling study in PWWE with a control group is needed in future to evaluate the whole pharmacokinetic profile of levetiracetam and to correlate the clinical outcome.
Collapse
Affiliation(s)
- J Kumaravel
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Phulen Sarma
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Parampreet Singh
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Prakash
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
10
|
Wójcik K, Kruk M, Koń B, Słowik A, Bosak M. Treatment patterns in women of childbearing age and pregnant women with epilepsy in Poland between the years 2019 and 2022-A nationwide population-based cohort study. Seizure 2024; 115:75-80. [PMID: 38232647 DOI: 10.1016/j.seizure.2024.01.007] [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: 11/01/2023] [Revised: 12/25/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024] Open
Abstract
AIM To describe the antiseizure medications (ASMs) prescription pattern in women of childbearing age (WOCA) and pregnant women with epilepsy in the 2019-2022 period in Poland MATERIALS AND METHODS: The National Health Fund (NHF) databases were analyzed. Women aged 15-49 years were considered as being of childbearing age, while exposure during pregnancy was estimated taking into account 15 months before delivery. ASMs belonging to the N03A subgroup of the Anatomical Therapeutic Chemical Classification System, reimbursed by NHF were analyzed. RESULTS During 2019, 36 784 WOCA and 921 pregnant women filled at least 1 ASM prescription. In 2022, these numbers were 32 304 and 594, respectively. Valproate was the most widely used ASM in WOCA (38.4 %) in 2019, followed by levetiracetam (35.6 %), lamotrigine (30.1 %), and carbamazepine (20.0 %). The percentage of ASM users decreased in 2022 for valproate (32.1 %; p < 0.001) and carbamazepine (17 %; p < 0.001) and increased for levetiracetam (40.8 %; p < 0.001) and lamotrigine (32.7 %; p < 0.001). In 2019 lamotrigine (42.1 %) and levetiracetam (41.5 %) were the most frequently prescribed ASMs to pregnant women. During the study period, a significant increase in prescriptions for levetiracetam was observed (49.5 %; p = 0.003). The proportion of ASMs exposed pregnancies declined for valproate (from 24.7 to 16 %; p < 0.001) and topiramate (from 6.6 to 3.2 %; p = 0.005). The percentage of polytherapy regimens remained stable over the years, both for WOCA (39 %) and pregnant women (32 %). CONCLUSION Despite the decline in valproate usage, the drug was still among the most commonly prescribed ASMs in women of childbearing age and pregnant women with epilepsy. The awareness of teratogenic risks and new treatment guidelines should be improved in Poland.
Collapse
Affiliation(s)
| | | | - Beata Koń
- National Health Fund, Warszawa, Poland
| | - Agnieszka Słowik
- Jagiellonian University, Medical College, Department of Neurology, Kraków, Poland
| | - Magdalena Bosak
- Jagiellonian University, Medical College, Department of Neurology, Kraków, Poland.
| |
Collapse
|
11
|
Cohen MJ, Meador KJ, Loring DW, Matthews AG, Brown C, Robalino CP, Birnbaum AK, Voinescu PE, Kalayjian LA, Gerard EE, Gedzelman ER, Hanna J, Cavitt J, Sam MC, French JA, Hwang ST, Pack AM, Pennell PB. Behavioral Outcomes and Neurodevelopmental Disorders Among Children of Women With Epilepsy. JAMA Neurol 2024; 81:19-29. [PMID: 37983058 PMCID: PMC10660252 DOI: 10.1001/jamaneurol.2023.4315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/21/2023] [Indexed: 11/21/2023]
Abstract
Importance The association of fetal exposure to antiseizure medications (ASMs) with outcomes in childhood are not well delineated. Objective To examine the association of fetal ASM exposure with subsequent adaptive, behavioral or emotional, and neurodevelopmental disorder outcomes at 2, 3, and 4.5 years of age. Design, Setting, and Participants The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational cohort study conducted at 20 epilepsy centers in the US. A total of 456 pregnant women with epilepsy or without epilepsy were enrolled from December 19, 2012, to January 13, 2016. Children of enrolled women were followed up with formal assessments at 2, 3, 4.5, and 6 years of age. Statistical analysis took place from August 2022 to May 2023. Exposures Exposures included mother's epilepsy status as well as mother's ASM blood concentration in the third trimester (for children of women with epilepsy). Women with epilepsy were enrolled regardless of ASM regimen. Main Outcomes and Measures The primary outcome was the Adaptive Behavior Assessment System, Third Edition (ABAS-3) General Adaptive Composite (GAC) score among children at 4.5 years of age. Children of women with epilepsy and children of women without epilepsy were compared, and the associations of ASM exposures with outcomes among exposed children were assessed. Secondary outcomes involved similar analyses of other related measures. Results Primary analysis included 302 children of women with epilepsy (143 boys [47.4%]) and 84 children of women without epilepsy (45 boys [53.6%]). Overall adaptive functioning (ABAS-3 GAC score at 4.5 years) did not significantly differ between children of women with epilepsy and children of women without epilepsy (parameter estimate [PE], 0.4 [95% CI, -2.5 to 3.4]; P = .77). However, in adjusted analyses, a significant decrease in functioning was seen with increasing third-trimester maximum ASM blood concentrations (PE, -7.8 [95% CI, -12.6 to -3.1]; P = .001). This decrease in functioning was evident for levetiracetam (PE, -18.9 [95% CI, -26.8 to -10.9]; P < .001) and lamotrigine (PE, -12.0 [95% CI, -23.7 to -0.3]; P = .04), the ASMs with sample sizes large enough for analysis. Results were similar with third-trimester maximum daily dose. Conclusions and Relevance This study suggests that adaptive functioning of children of women with epilepsy taking commonly used ASMs did not significantly differ from that of children of women without epilepsy, but there was an exposure-dependent association of ASMs with functioning. Thus, psychiatric or psychological screening and referral of women with epilepsy and their offspring are recommended when appropriate. Additional research is needed to confirm these findings.
Collapse
Affiliation(s)
- Morris J. Cohen
- Pediatric Neuropsychology International LLC, Augusta, Georgia
| | - Kimford J. Meador
- Department of Neurology & Neurological Sciences, Stanford University, Palo Alto, California
| | - David W. Loring
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Abigail G. Matthews
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Carrie Brown
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Chelsea P. Robalino
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Angela K. Birnbaum
- Epilepsy Research and Education Program, Experimental & Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis
| | - Paula E. Voinescu
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Elizabeth E. Gerard
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Evan R. Gedzelman
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Julie Hanna
- Adult Epilepsy, Minnesota Epilepsy Group, St Paul
| | - Jennifer Cavitt
- Division of Epilepsy, Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Maria C. Sam
- Department of Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Jacqueline A. French
- Department of Neurology and Comprehensive Epilepsy Center, New York University Comprehensive Epilepsy Center, New York
| | - Sean T. Hwang
- Department of Neurology, Northwell Health, Great Neck, New York
| | - Alison M. Pack
- Department of Neurology, Columbia University, New York, New York
| | - Page B. Pennell
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
12
|
Lee SK. Issues of Women with Epilepsy and Suitable Antiseizure Drugs. J Epilepsy Res 2023; 13:23-35. [PMID: 38223363 PMCID: PMC10783964 DOI: 10.14581/jer.23005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/12/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Seizure aggravation in women with epilepsy (WWE) tends to occur at two specific times during the menstrual cycle: the perimenstrual phase and the ovulation period. Antiseizure drugs (ASDs), especially those that induce enzymes, can accelerate the metabolism of hormones in oral contraceptives, rendering them less effective. Estrogen in contraceptive pills increases the metabolism of lamotrigine. Physiological changes during pregnancy can significantly impact the pharmacokinetics of ASDs, potentially necessitating adjustments in dosage for women with epilepsy to maintain seizure control. The use of valproate in pregnant women is associated with the highest risk of major congenital malformations among ASDs. Risks of major congenital malformations associated with lamotrigine, levetiracetam, and oxcarbazepine were within the range reported in the general population. Exposure to valproate can lead to lower IQ in offspring. Reduced folic acid levels are linked to orofacial clefts, cardiovascular malformations, and urogenital and limb anomalies in WWE. Decreased folate levels are expected with the use of enzyme-inducing ASDs. However, a high dose of folate was associated with an increased risk of cancer in children of mothers with epilepsy. Most ASDs are generally considered safe for breastfeeding and should be encouraged. However, no single ASD is considered ideal for childbearing WWE. Lamotrigine and levetiracetam are relatively more suitable options for this situation.
Collapse
Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
13
|
Lopez MR, VanCott AC, Amuan ME, Panahi S, Henion A, Pugh MJ. Prescribing Trends of Antiseizure Drugs in Women Veterans With Epilepsy. Mil Med 2023; 188:e3628-e3634. [PMID: 37283266 PMCID: PMC11022647 DOI: 10.1093/milmed/usad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/21/2023] [Accepted: 05/12/2023] [Indexed: 06/08/2023] Open
Abstract
OBJECTIVE Antiseizure medications (ASMs) are frequently used for other indications, such as migraine, pain syndromes, and psychiatric disorders. Possible teratogenic effects are therefore of wide concern and the risks imposed by the medications must be weighed against the risk with the disorder treated. It is our objective to update family practitioners on the implications of starting ASM for women with epilepsy during childbearing age. We hypothesized that clinicians would prescribe ASM based on avoiding teratogenesis and treating associated comorbidities simultaneously. METHODS The study cohort was derived from women veterans with epilepsy (WVWE) prescribed ASM who received Veterans Health Administration care for at least 3 years in Veterans Health Administration between fiscal years (FY)01 and FY19. Regimens were classified as monotherapy or polytherapy. Multivariant logistic regression examined the association between demographics, military characteristics, physical/psychiatric comorbidities, neurological care, and use of each ASM. RESULTS Among 2,283 WVWE, in ages between 17 and 45, the majority (61%) received monotherapy in FY19. Commonly prescribed ASM included 29% gabapentin, 27% topiramate, 20% lamotrigine, 16% levetiracetam, and 8% valproate (VPA). Comorbid diagnosis of headache predicted use of topiramate and VPA, bipolar disease predicted use of LMT and VPA, pain predicted gabapentin, and schizophrenia was associated with VPAs use. Women receiving levetiracetam and lamotrigine were significantly more likely to receive neurology care previously. CONCLUSION The presence of medical comorbidities influences the selection of ASM. VPAs use in WVWE during childbearing age continues, despite the high teratogenic risk, especially in women with bipolar disorder and headaches. Multidisciplinary care integrating family practice doctors, mental health, and neurology can prevent the enduring problem of teratogenesis in women taking ASM.
Collapse
Affiliation(s)
- Maria Raquel Lopez
- VA Epilepsy Centers of Excellence, Miami Veterans Health Care System, Miami, FL 33125, USA
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL 33125, USA
| | - Anne C VanCott
- VA Pittsburgh Healthcare System, University of Pittsburgh, University Drive C, Pittsburgh, PA 15240, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15240, USA
| | - Megan E Amuan
- Department of Medicine, Texas A&M Health Science Center, Bryan, TX 78229, USA
- Center for Health Quality, Outcomes and Economic Research, Bedford VA Medical Center, Bedford, MA 01730, USA
| | - Samin Panahi
- Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84132, USA
| | - Amy Henion
- Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84132, USA
| | - Mary Jo Pugh
- Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84132, USA
- Internal Medicine, Division of Epidemiology, Research Career Scientist VA, Salt Lake City, UT 84132, USA
| |
Collapse
|
14
|
Reitan Riibe S, Heitmann K, Schjøtt J, Riedel B. Healthcare professionals' information need related to antiseizure medication use in breastfeeding patients with epilepsy. Retrospective analysis of enquiries to Norwegian medicines information and pharmacovigilance centers. Epilepsy Behav Rep 2023; 24:100629. [PMID: 37954010 PMCID: PMC10632412 DOI: 10.1016/j.ebr.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023] Open
Abstract
Background Safety information of antiseizure medication (ASM) during breastfeeding is scarce and conflicting. We aimed to identify characteristic traits of safety concerns among healthcare professionals by reviewing enquiries to the Norwegian Regional Medicines Information and Pharmacovigilance Centres (RELIS). Method Enquiries related to breastfeeding, epilepsy, and ASM identified by their ATC-numbers were retrieved from the RELIS database of question-and-answer pairs (QAPs) by combining indexed and Boolean database searches and manual inspection. 112 QAPs were analyzed retrospectively using descriptive statistics. Results Hospital-employed physicians and nurses were puzzled by ambiguous or conflicting drug information advice and called for general information about the compatibility of an ASM with breastfeeding, mainly related to lamotrigine and levetiracetam. Other enquiries were related to co-medication with other drugs, mainly antidepressants. Half of the enquiries were posed after birth, 12 of these motivated by suspected adverse events in the infants. Conclusion Healthcare professionals with acknowledged high competence in the topic were uncertain about the prevailing safety information of ASM during breastfeeding. The fear to harm the infant may lead to the decision not to recommend breastfeeding. Future information strategies should aim to reach these professions, and support their information need on this topic.
Collapse
Affiliation(s)
- Sunniva Reitan Riibe
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Sandnessjøen Helgeland Hospital, Prestmarkveien 1, 8800 Sandnessjøen, Norway
| | - Kristine Heitmann
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Haukeland University Hospital, 5021 Bergen, Norway
| | - Jan Schjøtt
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Haukeland University Hospital, 5021 Bergen, Norway
| | - Bettina Riedel
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
| |
Collapse
|
15
|
Lawal OD, Meador KJ, Hume AL, Wen X. Utilization of Antiseizure Medications in Women of Childbearing Age With Epilepsy and Nonepilepsy Indications: A Retrospective Cohort Study. Neurology 2023; 101:e1083-e1096. [PMID: 37407266 PMCID: PMC10491435 DOI: 10.1212/wnl.0000000000207580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 05/10/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Antiseizure medications (ASMs) are among the most commonly prescribed teratogenic drugs in women of childbearing age. Limited data exist on utilization patterns across different indications for therapy and for the newer-generation ASMs in this population. Thus, we assessed the pattern of ASM use in women of childbearing age with epilepsy and nonepilepsy indications (pain and psychiatric disorders). METHODS We conducted a retrospective analysis of deidentified administrative data submitted to the Optum Clinformatics database. Eligible participants included women aged 12-50 years who filled ASMs between year 2011 and 2017. Participants were followed from date of index prescription filled to study end or insurance disenrollment, whichever came first. For the overall cohort and potential therapy indications, we assessed the type and frequency of ASMs filled; proportion of participants on monotherapy, polytherapy, or treatment switching; and duration of continuous use. Trends were characterized using annual percent change from study start to study end. RESULTS Our analysis included 465,131 participants who filled 603,916 distinct ASM prescriptions. At baseline, most of the participants had chronic pain (51.0%) and psychiatric disorders (32.7%), with epilepsy the least common (0.9%). The most frequently dispensed were diazepam (24.3%), lorazepam (20.1%), gabapentin (17.4%), clonazepam (12.7%), topiramate (11.3%), and lamotrigine (4.6%). Significant linear increase in trends were observed with gabapentin (annual percent change [95% CI]: 8.4 [7.3-9.4]; p < 0.001) and levetiracetam (3.4 [0.7-6.2]; p = 0.022) and decreasing trends for diazepam (-3.5 [-2.4 to 4.5]; p < 0.001) and clonazepam (-3.4 [-2.3 to 4.5]; p = 0.001). No significant change in trend was observed with valproate (-0.4 [-2.7 to 1.9]; p = 0.651), while nonlinear changes in trends were observed with lorazepam, topiramate, lamotrigine, and pregabalin. DISCUSSION Decreasing trends were observed with older ASMs in the overall cohort and across the potential indications for therapy. Conversely, increasing trends were seen with the newer ASMs. Considering the risk of teratogenicity associated with the newer medications largely unknown, counseling and education in addition to a careful consideration of the benefits vs potential risks should remain pivotal when prescribing ASMs for women of childbearing age.
Collapse
Affiliation(s)
- Oluwadolapo D Lawal
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Kimford J Meador
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Anne L Hume
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Xuerong Wen
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA.
| |
Collapse
|
16
|
Ohyama N, Furugen A, Sawada R, Aoyagi R, Nishimura A, Umazume T, Narumi K, Kobayashi M. Effects of valproic acid on syncytialization in human placental trophoblast cell lines. Toxicol Appl Pharmacol 2023; 474:116611. [PMID: 37385477 DOI: 10.1016/j.taap.2023.116611] [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: 03/19/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/01/2023]
Abstract
The placenta is a critical organ for fetal development and a healthy pregnancy, and has multifaceted functions (e.g., substance exchange and hormone secretion). Syncytialization of trophoblasts is important for maintaining placental functions. Epilepsy is one of the most common neurological conditions worldwide. Therefore, this study aimed to reveal the influence of antiepileptic drugs, including valproic acid (VPA), carbamazepine, lamotrigine, gabapentin, levetiracetam, topiramate, lacosamide, and clobazam, at clinically relevant concentrations on syncytialization using in vitro models of trophoblasts. To induce differentiation into syncytiotrophoblast-like cells, BeWo cells were treated with forskolin. Exposure to VPA was found to dose-dependently influence syncytialization-associated genes (ERVW-1, ERVFRD-1, GJA1, CGB, CSH, SLC1A5, and ABCC4) in differentiated BeWo cells. Herein, the biomarkers between differentiated BeWo cells and the human trophoblast stem model (TSCT) were compared. In particular, MFSD2A levels were low in BeWo cells but abundant in TSCT cells. VPA exposure affected the expression of ERVW-1, ERVFRD-1, GJA1, CSH, MFSD2A, and ABCC4 in differentiated cells (ST-TSCT). Furthermore, VPA exposure attenuated BeWo and TSCT cell fusion. Finally, the relationships between neonatal/placental parameters and the expression of syncytialization markers in human term placentas were analyzed. MFSD2A expression was positively correlated with neonatal body weight, head circumference, chest circumference, and placental weight. Our findings have important implications for better understanding the mechanisms of toxicity of antiepileptic drugs and predicting the risks to placental and fetal development.
Collapse
Affiliation(s)
- Nanami Ohyama
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan
| | - Ayako Furugen
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan.
| | - Riko Sawada
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan
| | - Ryoichi Aoyagi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan
| | | | - Takeshi Umazume
- Department of Obstetrics, Hokkaido University Hospital, Japan
| | - Katsuya Narumi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan
| | - Masaki Kobayashi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan.
| |
Collapse
|
17
|
Mazzone PP, Hogg KM, Weir CJ, Stephen J, Bhattacharya S, Chin RFM. Comparison of Perinatal Outcomes for Women With and Without Epilepsy: A Systematic Review and Meta-analysis. JAMA Neurol 2023; 80:484-494. [PMID: 36912826 PMCID: PMC10012044 DOI: 10.1001/jamaneurol.2023.0148] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/12/2023] [Indexed: 03/14/2023]
Abstract
Importance Pregnant women who have epilepsy need adequate engagement, information, and pregnancy planning and management to improve pregnancy outcomes. Objective To investigate perinatal outcomes in women with epilepsy compared with women without epilepsy. Data Sources Ovid MEDLINE, Embase, CINAHL, and PsycINFO were searched with no language or date restrictions (database inception through December 6, 2022). Searches also included OpenGrey and Google Scholar and manual searching in journals and reference lists of included studies. Study Selection All observational studies comparing women with and without epilepsy were included. Data Extraction and Synthesis The PRISMA checklist was used for abstracting data and the Newcastle-Ottawa Scale for risk-of-bias assessment. Data extraction and risk-of-bias assessment were done independently by 2 authors with mediation conducted independently by a third author. Pooled unadjusted odds ratios (OR) or mean differences were reported with 95% CI from random-effects (I2 heterogeneity statistic >50%) or fixed-effects (I2 < 50%) meta-analyses. Main Outcomes and Measures Maternal, fetal, and neonatal complications. Results Of 8313 articles identified, 76 were included in the meta-analyses. Women with epilepsy had increased odds of miscarriage (12 articles, 25 478 pregnancies; OR, 1.62; 95% CI, 1.15-2.29), stillbirth (20 articles, 28 134 229 pregnancies; OR, 1.37; 95% CI, 1.29-1.47), preterm birth (37 articles, 29 268 866 pregnancies; OR, 1.41; 95% CI, 1.32-1.51) and maternal death (4 articles, 23 288 083 pregnancies; OR, 5.00; 95% CI, 1.38-18.04). Neonates born to women with epilepsy had increased odds of congenital conditions (29 articles, 24 238 334 pregnancies; OR, 1.88; 95% CI, 1.66-2.12), neonatal intensive care unit admission (8 articles, 1 204 428 pregnancies; OR, 1.99; 95% CI, 1.58-2.51), and neonatal or infant death (13 articles, 1 426 692 pregnancies; OR, 1.87; 95% CI, 1.56-2.24). The increased odds of poor outcomes was increased with greater use of antiseizure medication. Conclusions and Relevance This systematic review and meta-analysis found that women with epilepsy have worse perinatal outcomes compared with women without epilepsy. Women with epilepsy should receive pregnancy counseling from an epilepsy specialist who can also optimize their antiseizure medication regimen before and during pregnancy.
Collapse
Affiliation(s)
- Paolo Pierino Mazzone
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Christopher J. Weir
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Jacqueline Stephen
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
| | - Sohinee Bhattacharya
- The Institute of Applied Health Sciences, Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Richard F. M. Chin
- Muir Maxwell Epilepsy Centre, University of Edinburgh, Edinburgh, United Kingdom
- Royal Hospital for Children and Young People, Edinburgh, United Kingdom
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
18
|
Increasing use of newer antiseizure medication during pregnancy: An observational study with special focus on lacosamide. Seizure 2023; 107:107-113. [PMID: 37003184 DOI: 10.1016/j.seizure.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Epilepsy is a common neurological disease requiring long-term therapy also during pregnancy. Most studies on pregnancy outcomes in women with epilepsy are based on antiseizure medication (ASM) in monotherapy. However, about 20-30% of epilepsy patients require polytherapy and newer ASMs are an option, when seizure control is not achieved with first line ASMs. METHODS Observational study evaluating the use of newer ASMs with marketing authorization since 2005 reported to the Embryotox Center of Clinical Teratology and Drug Safety in Pregnancy between 2004 and 2019. In addition, course and outcome of lacosamide exposed pregnancies were analysed. RESULTS Our study confirms the increasing use of newer ASMs also in pregnant women. This is especially true for lacosamide, eslicarbazepine and brivaracetam with rising numbers of exposed pregnancies soon after marketing authorization. Analysis of 55 prospectively and 10 retrospectively ascertained lacosamide exposed pregnancies does not indicate increased risks of major birth defects or spontaneous abortion. However, bradycardia observed in 3 neonates might be related to prenatal lacosamide exposure. CONCLUSION Available data do not support the assumption of lacosamide being a major teratogen. The increasing use of newer ASMs during pregnancy underscores the need for more studies to guide preconception counselling, especially for lacosamide, eslicarbazepine and brivaracetam.
Collapse
|
19
|
McNulty ML. Gender Issues in Epileptic Patients. Neurol Clin 2023; 41:249-263. [PMID: 37030956 DOI: 10.1016/j.ncl.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Treatment approaches for epilepsy for both women and men are similar, however, there are special aspects that must be considered when caring for women with epilepsy. This includes how hormonal fluctuations may affect seizure frequency, contraception, and potential drug-drug interactions, and pregnancy planning to minimize and potentially mitigate any adverse neurodevelopmental outcomes and major congenital malformations. Adequate counseling for women across the lifespan can help prepare women for the future and optimize outcomes.
Collapse
Affiliation(s)
- Maggie L McNulty
- Department of Neurology, Rush University Medical Center, 1725 West Harrison Street Suite 885, Chicago, IL 60612, USA.
| |
Collapse
|
20
|
Avachat C, Birnbaum AK. Women of childbearing age: What antiseizure medications are they taking? Br J Clin Pharmacol 2023; 89:46-48. [PMID: 36261929 PMCID: PMC10134405 DOI: 10.1111/bcp.15555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 09/02/2022] [Accepted: 09/18/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Charul Avachat
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
21
|
Management of Anti-Seizure Medications during Pregnancy: Advancements in The Past Decade. Pharmaceutics 2022; 14:pharmaceutics14122733. [PMID: 36559227 PMCID: PMC9788450 DOI: 10.3390/pharmaceutics14122733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/24/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Management of seizures often involves continuous medication use throughout a patient's life, including when a patient is pregnant. The physiological changes during pregnancy can lead to altered drug exposure to anti-seizure medications, increasing patient response variability. In addition, subtherapeutic anti-seizure medication concentrations in the mother may increase seizure frequency, raising the risk of miscarriage and preterm labor. On the other hand, drug exposure increases can lead to differences in neurodevelopmental outcomes in the developing fetus. Established pregnancy registries provide insight into the teratogenicity potential of anti-seizure medication use. In addition, some anti-seizure medications are associated with an increased risk of major congenital malformations, and their use has declined over the last decade. Although newer anti-seizure medications are thought to have more favorable pharmacokinetics in general, they are not without risk, as they may undergo significant pharmacokinetic changes when an individual becomes pregnant. With known changes in metabolism and kidney function during pregnancy, therapeutic monitoring of drug concentrations helps to determine if and when doses should be changed to maintain similar seizure control as observed pre-pregnancy. This review concentrates on the results from research in the past decade (2010-2022) regarding risks of major congenital malformations, changes in prescribing patterns, and pharmacokinetics of the anti-seizure medications that are prescribed to pregnant patients with epilepsy.
Collapse
|
22
|
Toprani S, Meador KJ, Robalino CP, Brown CA, Matthews AG, Gerard EE, Penovich P, Gedzelman E, Cavitt J, Hwang ST, Kalayjian LA, Sam M, Pack A, Pennell PB. Effect of Epilepsy on Sleep Quality During Pregnancy and Postpartum. Neurology 2022; 99:e1584-e1597. [PMID: 35853745 PMCID: PMC9559942 DOI: 10.1212/wnl.0000000000200959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/25/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study seeks to understand how sleep is affected in pregnant women with epilepsy (WWE) relative to healthy pregnant women during pregnancy and postpartum and to nonpregnant WWE during comparative periods. Sleep affects maternal health and mood during pregnancy. Maternal sleep disturbances are related to poor fetal growth and increased fetal deaths. Epilepsy is the most common neurologic condition in pregnancy. Sleep disruption can worsen epileptic seizures. The interplay between epilepsy, pregnancy, and sleep is poorly understood. METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an NIH-funded, prospective, observational, multicenter study, enrolling women from December 2012 through January 2016. Sleep quality was assessed using the average Pittsburgh Sleep Quality Index collected during pregnancy, postpartum, or analogous periods. Sleep scores range from 0 to 21 with higher scores indicating worse sleep quality; scores >5 are associated with poor sleep quality. RESULTS Of 351 pregnant WWE, 105 healthy pregnant women, and 109 nonpregnant WWE enrolled in the MONEAD study, data from 241 pregnant WWE, 74 healthy pregnant women, and 84 nonpregnant WWE were analyzed. Pregnant WWE had worse sleep (a higher mean sleep score) during pregnancy compared with healthy pregnant women in unadjusted analysis (p = 0.006), but no longer significant in adjusted analysis (p = 0.062); pregnant WWE (least square mean sleep score [95% CI] = 5.8 [5.5-6.1]) vs healthy pregnant women (5.1 [4.6-5.7]). During postpartum period, WWE (5.6 [5.4-5.9]) had similarly impaired sleep compared with healthy women (5.7 [5.2-6.2]; adjusted p = 0.838). Sleep was significantly worse in pregnant WWE vs nonpregnant WWE (for comparable period) in pregnancy and postpartum in unadjusted and adjusted analyses; adjusted scores for pregnant WWE in pregnancy (5.7 [5.4-6.0]) and those in postpartum (5.7 [5.4-6.0]) compared with those for nonpregnant WWE (4.7 [4.2-5.3]; p = 0.002) and (4.1 [3.6-4.7]; p < 0.001), respectively. Sleep quality between pregnancy and postpartum varied only in healthy pregnant women (change in mean score = 0.8 [0.2-1.3]; p = 0.01), whose sleep was worse in postpartum. DISCUSSION Pregnant WWE had worse sleep during pregnancy and postpartum period than nonpregnant WWE during comparable periods in the adjusted analysis. TRIAL REGISTRATION INFORMATION The study is registered at ClinicalTrials.gov as NCT01730170.
Collapse
Affiliation(s)
- Sheela Toprani
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA.
| | - Kimford J Meador
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Chelsea P Robalino
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Carrie Anne Brown
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Abigail G Matthews
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Elizabeth E Gerard
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Patricia Penovich
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Evan Gedzelman
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Jennifer Cavitt
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Sean T Hwang
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Laura A Kalayjian
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Maria Sam
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Alison Pack
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Page B Pennell
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| |
Collapse
|
23
|
Epilepsy Complicating Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00344-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
24
|
Pennell PB, Karanam A, Meador KJ, Gerard E, Kalayjian L, Penovich P, Matthews A, McElrath TM, Birnbaum AK. Antiseizure Medication Concentrations During Pregnancy: Results From the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) Study. JAMA Neurol 2022; 79:370-379. [PMID: 35157004 PMCID: PMC8845026 DOI: 10.1001/jamaneurol.2021.5487] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE During pregnancy in women with epilepsy, lower blood concentrations of antiseizure medications can have adverse clinical consequences. OBJECTIVE To characterize pregnancy-associated concentration changes for several antiseizure medications among women with epilepsy. DESIGN, SETTING, AND PARTICIPANTS Enrollment in this prospective, observational cohort study, Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD), occurred from December 19, 2012, to February 11, 2016, at 20 US sites. Enrolled cohorts included pregnant women with epilepsy and nonpregnant control participants with epilepsy. Inclusion criteria were women aged 14 to 45 years, an intelligence quotient greater than 70 points, and, for the cohort of pregnant women, a fetal gestational age younger than 20 weeks. A total of 1087 women were assessed for eligibility; 397 were excluded and 230 declined. Data were analyzed from May 1, 2014, to June 30, 2021. EXPOSURE Medication plasma concentrations in women taking monotherapy or in combination with noninteracting medications. The cohort of pregnant women was monitored through 9 months post partum, with similar time points for control participants. MAIN OUTCOMES AND MEASURES Dose-normalized concentrations were calculated as total or unbound plasma medication concentrations divided by total daily dose. Phlebotomy was performed during 4 pregnancy study visits and 3 postpartum visits for the pregnant women and 7 visits over 18 months for control participants. The primary hypothesis was to test pregnancy changes of dose-normalized concentrations from nonpregnant postpartum samples compared with those of control participants. RESULTS Of the 351 pregnant women and 109 control participants enrolled in MONEAD, 326 pregnant women (median [range] age, 29 [19-43] years) and 104 control participants (median [range] age, 29 [16-43] years) met eligibility criteria for this analysis. Compared with postpartum values, dose-normalized concentrations during pregnancy were decreased by up to 56.1% for lamotrigine (15.60 μg/L/mg to 6.85 μg/L/mg; P < .001), 36.8% for levetiracetam (11.33 μg/L/mg to 7.16 μg/L/mg; P < .001), 17.3% for carbamazepine (11.56 μg/L/mg to 7.97 μg/L/mg; P = .03), 32.6% for oxcarbazepine (11.55 μg/L/mg to 7.79 μg/L/mg; P < .001), 30.6% for unbound oxcarbazepine (6.15 μg/L/mg to 4.27 μg/L/mg; P < .001), 39.9% for lacosamide (26.14 μg/L/mg to 15.71 μg/L/mg; P < .001), and 29.8% for zonisamide (40.12 μg/L/mg to 28.15 μg/L/mg; P < .001). No significant changes occurred for unbound carbamazepine, carbamazepine-10,11-epoxide, and topiramate, although a decrease was observed for topiramate (29.83 μg/L/mg to 13.77 μg/L/mg; P = .18). Additionally, compared with dose-normalized concentrations from control participants, pregnancy dose-normalized median (SE) concentrations decreased significantly by week of gestational age: carbamazepine, -0.14 (0.06) μg/L/mg (P = .02); carbamazepine unbound, -0.04 (0.01) μg/L/mg (P = .01); lacosamide, -0.23 (0.07) μg/L/mg (P < .001); lamotrigine, -0.20 (0.02) μg/L/mg (P < .001); levetiracetam, -0.06 (0.03) μg/L/mg (P = .01); oxcarbazepine, -0.14 (0.04) μg/L/mg (P < .001); oxcarbazepine unbound, -0.11 (0.03) μg/L/mg (P < .001); and zonisamide, -0.53 (0.14) μg/L/mg (P < .001) except for topiramate (-0.35 [0.20] μg/L/mg per week) and carbamazepine-10,11-epoxide (0.02 [0.01] μg/L/mg). CONCLUSIONS AND RELEVANCE Study results suggest that therapeutic drug monitoring should begin early in pregnancy and that increasing doses of these anticonvulsants may be needed throughout the course of pregnancy.
Collapse
Affiliation(s)
- Page B Pennell
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashwin Karanam
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis
| | - Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Gerard
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Laura Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | - Thomas M McElrath
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis
| | | |
Collapse
|
25
|
Kohn E, Dinavitser N, Berlin M, Brandriss N, Bar-Chaim A, Gueta I, Keidar R, Livne A, Stepensky D, Berkovitch M, Masarwi M. Magnitude of Lamotrigine Exposure Through Breastfeeding. Breastfeed Med 2022; 17:341-348. [PMID: 35049332 DOI: 10.1089/bfm.2021.0304] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Importance: Lamotrigine use during breastfeeding has significantly increased in the recent years, whereas breast milk lamotrigine pharmacokinetics data are still sparse. Objectives: To assess lamotrigine exposure in breastfed infants by monitoring maternal serum and breast milk concentrations. Methods: Breastfeeding women treated with lamotrigine were recruited to this study. Maternal trough breast milk and serum samples were collected, and additional breast milk samples were collected 1, 3, 6, 9, 12 hours after lamotrigine consumption. Trough breast milk/serum ratios (M/S ratio) and breast milk area under the curve (AUC) values were calculated. Results: Twenty-one breastfeeding women were recruited to this study, and the final dataset was based on the samples collected from 17 women. Lamotrigine trough serum and mother's milk concentrations were 5.1 ± 3.3 mg/L and 3.1 ± 1.9 mg/L, respectively (mean ± standard deviation). The trough M/S ratio of lamotrigine was 0.66 ± 0.22. The lamotrigine breast milk average AUC was 41.7 ± 24.6 mg·h/L. The estimated infant dose of lamotrigine was 0.52 ± 0.31 mg/kg/day and 0.26 ± 0.15 mg/kg/day for fully and partially breastfed infants, respectively. Significant correlation was found between the maternal lamotrigine serum trough concentrations and the breast milk parameters: trough breast milk concentrations (Spearman's rho = 0.986, p < 0.0001) and breast milk AUC values (Spearman's rho = 0.941, p < 0.0001). No significant correlation was found between the maternal lamotrigine daily dose and serum trough concentrations, breast milk trough concentrations, and breast milk AUC values (Spearman's rho = 0.294, 0.285, and 0.438, p = 0.252, 0.396, and 0.078, respectively). Conclusion and Relevance: High correlation between the maternal lamotrigine trough serum concentrations and the breast milk AUC values was found, implying that monitoring the maternal lamotrigine serum concentrations can be useful for prediction of exposure of infants to lamotrigine through the breast milk. The trial was registered in the Israeli trials registry MOH_2021-09-05_010243 at September 5, 2021 Retrospectively registered https://my.health.gov.il/CliniTrials.
Collapse
Affiliation(s)
- Elkana Kohn
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Natalie Dinavitser
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Maya Berlin
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Nurit Brandriss
- Biochemistry Laboratory, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Adina Bar-Chaim
- Biochemistry Laboratory, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Itai Gueta
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine A, Sheba Medical Center, Tel Hashomer, Israel
| | - Rimona Keidar
- Neonatal Intensive Care Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Ayelet Livne
- Neonatal Intensive Care Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - David Stepensky
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Majdi Masarwi
- Pharmacy Department, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| |
Collapse
|
26
|
Abstract
PURPOSE OF REVIEW Issues pertaining to women with epilepsy have advanced with a better understanding of multidirectional influences among hormones, seizures, and antiseizure medications, as well as pregnancy-related concerns around fertility, seizure destabilization, and antiseizure medication-associated teratogenicity. This article highlights important developments in this field and reviews best practices in the management of women with epilepsy. RECENT FINDINGS Important external hormonal influences may impact women with epilepsy particularly in the context of gender-affirming medications, hormonal replacement therapy, and fertility therapies. Fertility for women with epilepsy is influenced by multiple variables; however, in the absence of preexisting fertility issues, epilepsy per se is not associated with significantly impaired fertility. Once women with epilepsy are pregnant, the majority have a stable course. Antiseizure medication use in pregnancy is associated with major congenital malformations 2 to 5 times that of the general population and is highest with high-dose (≥1500 mg or greater total daily) valproate. Carefully considered changes in drug choice and dose may mitigate these risks. Therapeutic drug monitoring plays an important role in pregnancy care, and under expert supervision, women with epilepsy in pregnancy have similar seizure risks as women with epilepsy who are not pregnant. As women with epilepsy age, bone health and menopause may further be impacted by seizures and antiseizure medications. SUMMARY The care of women with epilepsy is a multifaceted discipline that recognizes the life-long impact of sex and gender influences on epilepsy care.
Collapse
|
27
|
Alsfouk BA. Neurodevelopmental outcomes in children exposed prenatally to levetiracetam. Ther Adv Drug Saf 2022; 13:20420986221088419. [PMID: 35387387 PMCID: PMC8977694 DOI: 10.1177/20420986221088419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 03/02/2022] [Indexed: 11/15/2022] Open
Abstract
Some old antiseizure medications (ASMs) pose teratogenic risks, including major
congenital malformations and neurodevelopmental delay. Therefore, the use of new
ASMs in pregnancy is increasing, particularly lamotrigine and levetiracetam.
This is likely due to evidence of low risk of anatomical teratogenicity for both
lamotrigine and levetiracetam. Regarding neurodevelopmental effects, lamotrigine
is the most frequently investigated new ASM with information available for
children up to 14 years of age. However, fewer data are available for the
effects of levetiracetam on cognitive and behavioral development, with smaller
cohorts and shorter follow-up. The aim of the present review was to explicate
neurodevelopmental outcomes in children exposed prenatally to levetiracetam to
support clinical decision-making. The available data do not indicate an
increased risk of abnormal neurodevelopmental outcomes in children exposed
prenatally to levetiracetam. Findings demonstrated comparable outcomes for
levetiracetam versus controls and favorable outcomes for
levetiracetam versus valproate on global and specific cognitive
abilities, and behavioral problems. In addition, the available evidence shows no
significant dose-effect association for levetiracetam on neurodevelopmental
outcomes. However, this evidence cannot be determined definitively due to the
limited numbers of exposures with relatively short follow-up. Therefore, further
research is required.
Collapse
Affiliation(s)
- Bshra A. Alsfouk
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O Box 84428, Riyadh 11671, Saudi Arabia
| |
Collapse
|
28
|
Kang L, Duan Y, Chen C, Li S, Li M, Chen L, Wen Z. Structure-Activity Relationship (SAR) Model for Predicting Teratogenic Risk of Antiseizure Medications in Pregnancy by Using Support Vector Machine. Front Pharmacol 2022; 13:747935. [PMID: 35281912 PMCID: PMC8914116 DOI: 10.3389/fphar.2022.747935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/26/2022] [Indexed: 12/03/2022] Open
Abstract
Teratogenicity is one of the main concerns in clinical medications of pregnant women. Prescription of antiseizure medications (ASMs) in women with epilepsy during pregnancy may cause teratogenic effects on the fetus. Although large scale epilepsy pregnancy registries played an important role in evaluating the teratogenic risk of ASMs, for most ASMs, especially the newly approved ones, the potential teratogenic risk cannot be effectively assessed due to the lack of evidence. In this study, the analyses are performed on any medication, with a focus on ASMs. We curated a list containing the drugs with potential teratogenicity based on the US Food and Drug Administration (FDA)-approved drug labeling, and established a support vector machine (SVM) model for detecting drugs with high teratogenic risk. The model was validated by using the post-marketing surveillance data from US FDA Spontaneous Adverse Events Reporting System (FAERS) and applied to the prediction of potential teratogenic risk of ASMs. Our results showed that our proposed model outperformed the state-of-art approaches, including logistic regression (LR), random forest (RF) and extreme gradient boosting (XGBoost), when detecting the high teratogenic risk of drugs (MCC and recall rate were 0.312 and 0.851, respectively). Among 196 drugs with teratogenic potential reported by FAERS, 136 (69.4%) drugs were correctly predicted. For the eight commonly used ASMs, 4 of them were predicted as high teratogenic risk drugs, including topiramate, phenobarbital, valproate and phenytoin (predicted probabilities of teratogenic risk were 0.69, 0.60 0.59, and 0.56, respectively), which were consistent with the statement in FDA-approved drug labeling and the high reported prevalence of teratogenicity in epilepsy pregnancy registries. In addition, the structural alerts in ASMs that related to the genotoxic carcinogenicity and mutagenicity, idiosyncratic adverse reaction, potential electrophilic agents and endocrine disruption were identified and discussed. Our findings can be a good complementary for the teratogenic risk assessment in drug development and facilitate the determination of pharmacological therapies during pregnancy.
Collapse
Affiliation(s)
- Liyuan Kang
- College of Chemistry, Sichuan University, Chengdu, China
| | - Yifei Duan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Chen
- College of Chemistry, Sichuan University, Chengdu, China
| | - Shihai Li
- College of Chemistry, Sichuan University, Chengdu, China
| | - Menglong Li
- College of Chemistry, Sichuan University, Chengdu, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhining Wen
- College of Chemistry, Sichuan University, Chengdu, China
- Medical Big Data Center, Sichuan University, Chengdu, China
| |
Collapse
|
29
|
Adams J, Janulewicz PA, Macklin EA, Dhillon R, Phillips C, Schomer DL, Tosches WA, Carlson JM, Holmes LB. Neuropsychological effects in children exposed to anticonvulsant monotherapy during gestation: Phenobarbital, carbamazepine, and phenytoin. Epilepsy Behav 2022; 127:108533. [PMID: 35042158 DOI: 10.1016/j.yebeh.2021.108533] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/27/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Usage during pregnancy of the antiseizure medication (ASM), phenobarbital (PB), carbamazepine (CBZ), and phenytoin (PHT), has been associated with adverse pregnancy outcomes. While morphological effects on offspring are well-documented, inconsistent findings have been reported on neuropsychological development, possibly due to differences in attention to maternal demographics, and other design characteristics. Herein, we report the results of a carefully designed protocol used to examine the effects of gestational monotherapy with PB, CBZ, or PHT upon children's general mental abilities, when compared to age- and gender- matched children born to unexposed women of similar age, education, and socioeconomic status. METHODS For each ASM, we selected qualifying cases from children born to PB, CBZ, or PHT monotherapy-exposed and unexposed women. Following the application of inclusion, exclusion, and matching criteria, our sample included 34 PB-exposed, 40 PHT-exposed, and 41 CBZ-exposed children along with matched unexposed children for each drug group. Criteria were applied through examination of maternal medical and educational histories, parental socioeconomic characteristics, and child's age and gender. Each child's physical and neuropsychological characteristics were examined, using standardized protocols. We report on the cognitive performance of the children as assessed by the Wechsler Intelligence Scale for Children - III (WISC-III), the leading measure of mental ability in the U.S. RESULTS An overall mixed model ANOVA of the adjusted performance of the children across all groups controlling for maternal IQ revealed significant effects on verbal IQ, but not full-scale IQ or performance IQ. In the individual drug and unexposed group comparisons, only reduced verbal and full-scale IQ scores in PB-exposed versus matched unexposed children were found. Comparisons between drug groups revealed a significant reduction in verbal IQ and full-scale IQ in PB-exposed versus PHT-exposed children, but not in other drug-drug comparisons. SIGNIFICANCE These results demonstrate effects on children's mental ability due to prenatal PB exposure, such that analyses adjusted for maternal IQ scores, revealed reduced verbal mental abilities and reduced full-scale IQ scores when scores in exposed children were compared to scores from children of the same age and sex born to demographically similar, healthy unexposed women. When comparisons were made between drug groups, children exposed prenatally to PB performed significantly worse than prenatally PHT-exposed children, but CBZ-exposed children's scores were not significantly different from those of PB or PHT-exposed groups. In light of shared effects on structural teratogenicity, these findings suggest that use of PB monotherapy for the management of seizures during pregnancy may be associated with increased risk in comparison to PHT when neurobehavioral functioning is considered, and that only PB-exposed children have reduced performance compared to matched controls. Attention to these effects is critical in the developing world where use of these older medications remains predominant, and prudent choices can be made to reduce impact on cognitive development.
Collapse
Affiliation(s)
- Jane Adams
- University of Massachusetts Boston, Psychology Department, Boston, MA, United States.
| | - Patricia Ann Janulewicz
- Boston University School of Public Health, Environmental Health Department, Boston, MA, United States
| | - Eric A Macklin
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Biostatistics, Boston, MA, United States
| | - Ruby Dhillon
- Boston University School of Public Health, Environmental Health Department, Boston, MA, United States
| | - Catherine Phillips
- UMass Memorial Medical Center, Department of Neurology, Worcester, MA, United States
| | - Donald L Schomer
- Beth Israel Deaconess Medical Center, Department of Neurology, Boston, MA, United States
| | - William A Tosches
- Beth Israel Deaconess Medical Center, Department of Neurology, Hopedale, MA, United States
| | - Jeffrey M Carlson
- Boston University School of Public Health, Environmental Health Department, Boston, MA, United States
| | - Lewis B Holmes
- MassGeneral Hospital for Children, Medical Genetics Unit, Boston, MA, United States
| |
Collapse
|
30
|
Twenty-year trends in the use of anti-seizure medication among pregnant women in the Netherlands. Epilepsy Behav 2022; 127:108549. [PMID: 35042161 DOI: 10.1016/j.yebeh.2021.108549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/30/2021] [Accepted: 12/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anti-seizure medications (ASMs) are used to treat conditions such as epilepsy and bipolar disorder. Some of these drugs are associated with an increased risk of congenital malformations and adverse developmental outcomes. OBJECTIVES To examine trends in use of ASMs among pregnant women in the Netherlands according to medication safety profile. METHODS Using population-based data from the PHARMO Perinatal Research Network, we assessed trends in use of ASMs among pregnant women in the Netherlands between 1999 and 2019, stratified by medication safety profile. Individual treatment patterns were also assessed. RESULTS In total, 671,709 pregnancies among 446,169 women were selected, of which 2405 (3.6 per 1000) were ASM-exposed. Over the study period, a significant increase was observed for use of known safest ASMs (0.7-18.0 per 10,000 pregnancies) as well as for those with uncertain risk (5.3-13.4 per 10,000 pregnancies). Use of ASMs with higher risk of congenital malformations decreased significantly (24.8-14.5 per 10,000 pregnancies), except for topiramate (0-6.7 per 10,000 pregnancies). Switches between ASM safety risk categories before and during pregnancy were uncommon; women rather discontinued treatment or switched within the same category. There was no clear change for the proportion using polytherapy during pregnancy (12% overall), however a non-significant trend toward inclusion of known safest ASMs was observed over time (1.9-3.6%). CONCLUSIONS Over the last two decades, there has been an increase in use of known safest ASMs among pregnant women, together with a trend toward newer ASMs with uncertain risk. Only a small proportion of women switched to a safer alternative before or during pregnancy. Altogether, this highlights the need for an expansion of ASM risk knowledge and communication to healthcare providers and women of reproductive age to improve preconception counseling.
Collapse
|
31
|
Alsfouk BA, Almarzouqi MR, Alageel S, Alsfouk AA, Alsemari A. Patterns of antiseizure medication prescription in pregnancy and maternal complications in women with epilepsy: A retrospective study in Saudi Arabia. Saudi Pharm J 2022; 30:205-211. [PMID: 35498221 PMCID: PMC9051954 DOI: 10.1016/j.jsps.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/27/2021] [Indexed: 11/29/2022] Open
Abstract
Aim To evaluate patterns of antiseizure medication (ASM) prescription in pregnancy and changes over a 16-year period: 2005–2020, and to investigate maternal complications in pregnant women with epilepsy (WWE). Method Data of pregnant WWE was retrospectively reviewed at the King Faisal Specialist Hospital and Research Centre, Riyadh and Jeddah, Saudi Arabia. Results Out of 162 pregnancies, 81.5% were prescribed ASMs. During the study period, the prescription rate increased from 68.8% to 93.5%. Between 2005 and 2020, the use of new ASMs increased from 15.4% to 75.5% (p < 0.0001). Furthermore, valproate use markedly decreased from 23.08% to 2.04%. The rate of maternal and delivery complications was 29.6%; the most frequent was gestational diabetes (5.6%), followed by bleeding during pregnancy (4.9%). Furthermore, preeclampsia and eclampsia were documented in 3.7% and 1.8%, respectively. ASMs use and other factors were not found to be associated with maternal complications (p > 0.05). However, first generation ASMs, i.e. carbamazepine (38.71%) and valproate (41.67%), were associated with higher maternal complication rates than new ASMs, i.e. levetiracetam (25%) and lamotrigine (20%), but the difference was not statistically significant (p = 0.4403). Conclusion ASM prescription in pregnancy is increasing as is the use of new ASMs. The rate of maternal and delivery complications was relatively low, particularly preeclampsia and eclampsia. ASMs use was not found to associated with these complications. However, exposure to first generation ASMs seemed to be a predictor of adverse pregnancy outcomes.
Collapse
|
32
|
Panelli DM, Leonard SA, Kan P, Meador KJ, McElrath TF, Darmawan KF, Carmichael SL, Lyell DJ, El-Sayed YY, Druzin ML, Herrero TC. Association of Epilepsy and Severe Maternal Morbidity. Obstet Gynecol 2021; 138:747-754. [PMID: 34619720 PMCID: PMC8542621 DOI: 10.1097/aog.0000000000004562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy. METHODS We retrospectively examined SMM using linked birth certificate and maternal hospital discharge records in California between 2007 and 2012. Epilepsy present at delivery admission was the exposure and was subtyped into generalized, focal and other less specified, or unspecified. The outcomes were SMM and nontransfusion SMM from delivery up to 42 days' postpartum, identified using Centers for Disease Control and Prevention indicators. Multivariable logistic regression models were used to adjust for confounders, which were selected a priori. We also estimated the association between epilepsy and SMM independent of comorbidities by using a validated obstetric comorbidity score. Severe maternal morbidity indicators were then compared using the same multivariable logistic regression models. RESULTS Of 2,668,442 births, 8,145 (0.3%) were to patients with epilepsy; 637 (7.8%) had generalized, 6,250 (76.7%) had focal or other less specified, and 1,258 (15.4%) had unspecified subtypes. Compared with patients without epilepsy, patients with epilepsy had greater odds of SMM (4.3% vs 1.4%, adjusted odds ratio [aOR] 2.91, 95% CI 2.61-3.24) and nontransfusion SMM (2.9% vs 0.7%, aOR 4.16, 95% CI 3.65-4.75). Epilepsy remained significantly associated with increased SMM and nontransfusion SMM after additional adjustment for the obstetric comorbidity score, though the effects were attenuated. When grouped by organ system, all SMM indicators were significantly more common among patients with epilepsy-most notably those related to hemorrhage and transfusion. CONCLUSION Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.
Collapse
Affiliation(s)
- Danielle M. Panelli
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie A. Leonard
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Peiyi Kan
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Kimford J. Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas F. McElrath
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelly F. Darmawan
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Suzan L. Carmichael
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Deirdre J. Lyell
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yasser Y. El-Sayed
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maurice L. Druzin
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tiffany C. Herrero
- Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
33
|
Kamitaki BK, Janmohamed M, Kandula P, Elder C, Mani R, Wong S, Perucca P, O'Brien TJ, Lin H, Heiman GA, Choi H. Clinical and EEG factors associated with antiseizure medication resistance in idiopathic generalized epilepsy. Epilepsia 2021; 63:150-161. [PMID: 34705264 DOI: 10.1111/epi.17104] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/18/2021] [Accepted: 10/08/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE We sought to determine which combination of clinical and electroencephalography (EEG) characteristics differentiate between an antiseizure medication (ASM)-resistant vs ASM-responsive outcome for patients with idiopathic generalized epilepsy (IGE). METHODS This was a case-control study of ASM-resistant cases and ASM-responsive controls with IGE treated at five epilepsy centers in the United States and Australia between 2002 and 2018. We recorded clinical characteristics and findings from the first available EEG study for each patient. We then compared characteristics of cases vs controls using multivariable logistic regression to develop a predictive model of ASM-resistant IGE. RESULTS We identified 118 ASM-resistant cases and 114 ASM-responsive controls with IGE. First, we confirmed our recent finding that catamenial epilepsy is associated with ASM-resistant IGE (odds ratio [OR] 3.53, 95% confidence interval [CI] 1.32-10.41, for all study subjects) after covariate adjustment. Other independent factors seen with ASM resistance include certain seizure-type combinations (absence, myoclonic, and generalized tonic-clonic seizures [OR 7.06, 95% CI 2.55-20.96]; absence and generalized tonic-clonic seizures [OR 4.45, 95% CI 1.84-11.34]), as well as EEG markers of increased generalized spike-wave discharges (GSWs) in sleep (OR 3.43, 95% CI 1.12-11.36 for frequent and OR 7.21, 95% CI 1.50-54.07 for abundant discharges in sleep) and the presence of generalized polyspike trains (GPTs; OR 5.49, 95% CI 1.27-38.69). The discriminative ability of our final multivariable model, as measured by area under the receiver-operating characteristic curve, was 0.80. SIGNIFICANCE Multiple clinical and EEG characteristics independently predict ASM resistance in IGE. To improve understanding of a patient's prognosis, clinicians could consider asking about specific seizure-type combinations and track whether they experience catamenial epilepsy. Obtaining prolonged EEG studies to record the burden of GSWs in sleep and assessing for the presence of GPTs may provide additional predictive value.
Collapse
Affiliation(s)
- Brad K Kamitaki
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Mubeen Janmohamed
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Neurology Department, Alfred Hospital, Melbourne, Victoria, Australia.,Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Padmaja Kandula
- Department of Neurology, Cornell University, New York, NY, USA
| | - Christopher Elder
- Department of Neurology, Columbia University, New York, New York, USA
| | - Ram Mani
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Stephen Wong
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Piero Perucca
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Neurology Department, Alfred Hospital, Melbourne, Victoria, Australia.,Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, The University of Melbourne, and Comprehensive Epilepsy Program, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Neurology Department, Alfred Hospital, Melbourne, Victoria, Australia.,Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Haiqun Lin
- School of Nursing, Rutgers, the State University of New Jersey, Newark, New Jersey, USA
| | - Gary A Heiman
- Department of Genetics, Human Genetics Institute of New Jersey, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Hyunmi Choi
- Department of Neurology, Columbia University, New York, New York, USA
| |
Collapse
|
34
|
Bermeo-Ovalle A. Like Mother, Like Child. Keeping Control of Seizures During Pregnancy. Epilepsy Curr 2021; 21:252-254. [PMID: 34690559 PMCID: PMC8512916 DOI: 10.1177/15357597211012026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Changes in Seizure Frequency and Antiepileptic Therapy During Pregnancy Pennell PB, French JA, May RC, et al. N Engl J Med.
2020;383(26):2547-2556. doi:10.1056/NEJMoa2008663 Background: Among women with epilepsy, studies regarding changes in seizure frequency during
pregnancy have been limited by the lack of an appropriate nonpregnant comparator
group to provide data on the natural course of seizure frequency in both groups. Methods: In this prospective, observational, multicenter cohort study, we compared the
frequency of seizures during pregnancy through the peripartum period (the first 6
weeks after birth) (epoch 1) with the frequency during the postpartum period (the
following 7.5 months after pregnancy; epoch 2). Nonpregnant women with epilepsy were
enrolled as controls and had similar follow-up during an 18-month period. The
primary outcome was the percentage of women who had a higher frequency of seizures
that impaired awareness during epoch 1 than during epoch 2. We also compared changes
in the doses of antiepileptic drugs that were administered in the 2 groups during
the first 9 months of epoch 1. Results: We enrolled 351 pregnant women and 109 controls with epilepsy. Among the 299
pregnant women and 93 controls who had a history of seizures that impaired awareness
and who had available data for the 2 epochs, seizure frequency was higher during
epoch 1 than during epoch 2 in 70 (23%) pregnant women and in 23 (25%) controls
(odds ratio, 0.93; 95% CI, 0.54-1.60). During pregnancy, the dose of an
antiepileptic drug was changed at least once in 74% of pregnant women and in 31% of
controls (odds ratio, 6.36; 95% CI, 3.82-10.59). Conclusions: Among women with epilepsy, the percentage who had a higher incidence of seizures
during pregnancy than during the postpartum period was similar to that in women who
were not pregnant during the corresponding epochs. Changes in doses of antiepileptic
drugs occurred more frequently in pregnant women than in nonpregnant women during
similar time periods. (Funded by the National Institutes of Health; MONEAD ClinicalTrials.gov number, NCT01730170.).
Collapse
|
35
|
Eyal S. Exploring the Cognitive Outcomes of Children Prenatally Exposed to Antiseizure Medications: Mind the Lab. Epilepsy Curr 2021; 22:25-27. [PMID: 35233192 PMCID: PMC8832358 DOI: 10.1177/15357597211051942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
36
|
Meador KJ, Cohen MJ, Loring DW, May RC, Brown C, Robalino CP, Matthews AG, Kalayjian LA, Gerard EE, Gedzelman ER, Penovich PE, Cavitt J, Hwang S, Sam M, Pack AM, French J, Tsai JJ, Pennell PB. Two-Year-Old Cognitive Outcomes in Children of Pregnant Women With Epilepsy in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. JAMA Neurol 2021; 78:927-936. [PMID: 34096986 DOI: 10.1001/jamaneurol.2021.1583] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The neurodevelopmental risks of fetal exposure are uncertain for many antiseizure medications (ASMs). Objective To compare children at 2 years of age who were born to women with epilepsy (WWE) vs healthy women and assess the association of maximum ASM exposure in the third trimester and subsequent cognitive abilities among children of WWE. Design, Setting, and Participants The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational, multicenter investigation of pregnancy outcomes that enrolled women from December 19, 2012, to January 13, 2016, at 20 US epilepsy centers. Children are followed up from birth to 6 years of age, with assessment at 2 years of age for this study. Of 1123 pregnant women assessed, 456 were enrolled; 426 did not meet criteria, and 241 chose not to participate. Data were analyzed from February 20 to December 4, 2020. Main Outcomes and Measures Language domain score according to the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), which incorporates 5 domain scores (language, motor, cognitive, social-emotional, and general adaptive), and association between BSID-III language domain and ASM blood levels in the third trimester in children of WWE. Analyses were adjusted for multiple potential confounding factors, and measures of ASM exposure were assessed. Results The BSID-III assessments were analyzed in 292 children of WWE (median age, 2.1 [range, 1.9-2.5] years; 155 female [53.1%] and 137 male [46.9%]) and 90 children of healthy women (median age, 2.1 [range, 2.0-2.4] years; 43 female [47.8%] and 47 male [52.2%]). No differences were found between groups on the primary outcome of language domain (-0.5; 95% CI, -4.1 to 3.2). None of the other 4 BSID-III domains differed between children of WWE vs healthy women. Most WWE were taking lamotrigine and/or levetiracetam. Exposure to ASMs in children of WWE showed no association with the language domain. However, secondary analyses revealed that higher maximum observed ASM levels in the third trimester were associated with lower BSID-III scores for the motor domain (-5.6; 95% CI, -10.7 to -0.5), and higher maximum ASM doses in the third trimester were associated with lower scores in the general adaptive domain (-1.4; 95% CI, -2.8 to -0.05). Conclusions and Relevance Outcomes of children at 2 years of age did not differ between children of WWE taking ASMs and children of healthy women. Trial Registration ClinicalTrials.gov Identifier: NCT01730170.
Collapse
Affiliation(s)
- Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Morris J Cohen
- Pediatric Neuropsychology International, Augusta, Georgia
| | - David W Loring
- Department of Neurology, Emory University, Atlanta, Georgia
| | | | | | | | | | - Laura A Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | | | - Jennifer Cavitt
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Maria Sam
- Department of Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Alison M Pack
- Department of Neurology, Columbia University, New York, New York
| | | | - Jeffrey J Tsai
- Department of Neurology, University of Washington, Seattle
| | - Page B Pennell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
37
|
Marxer CA, Rüegg S, Rauch MS, Panchaud A, Meier CR, Spoendlin J. A review of the evidence on the risk of congenital malformations and neurodevelopmental disorders in association with antiseizure medications during pregnancy. Expert Opin Drug Saf 2021; 20:1487-1499. [PMID: 34128743 DOI: 10.1080/14740338.2021.1943355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The majority of women with epilepsy require treatment with antiseizure medications (ASM) throughout pregnancy. However, in utero exposure to several ASM has been associated with an increased risk of congenital malformations and/or neurodevelopmental disorders (CM/NDD) in the child, but observational evidence is methodologically heterogeneous.Areas covered: We critically evaluate current evidence on the risk of CM/NDD in children of women with epilepsy after in utero exposure to different ASM. We highlight characteristics of different data sources and discuss their benefits and drawbacks. This review includes evidence published before December 2020.Expert opinion: Given the lack of randomized controlled trials, evidence on in utero safety of ASM originates from methodologically heterogeneous post-marketing observational studies based on registries, prospective cohorts, and large electronic health databases. It has been clearly demonstrated that valproate is associated with a high risk of CM/NDD, whereas lamotrigine and levetiracetam are relatively safe. However, evidence is less explicit for other ASM. Reported risks vary depending on the size and origin of the underlying study population, the definition of exposure and outcomes, and other aspects of the study design. Increased collaboration between data sources to increase sample size is desirable.
Collapse
Affiliation(s)
- Carole A Marxer
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marlene S Rauch
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute for Pharmaceutical Sciences of Western Switzerland, Switzerland
| | - Christoph R Meier
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.,Boston Collaborative Drug Surveillance Program, Lexington, MA, United States
| | - Julia Spoendlin
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| |
Collapse
|
38
|
Knight R, Wittkowski A, Bromley RL. Neurodevelopmental outcomes in children exposed to newer antiseizure medications: A systematic review. Epilepsia 2021; 62:1765-1779. [PMID: 34128227 DOI: 10.1111/epi.16953] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 01/16/2023]
Abstract
As prenatal exposure to certain older antiseizure medications (ASMs) has been linked with poorer neurodevelopmental outcomes in children, the use of newer ASMs throughout pregnancy has increased. The current review aimed to delineate the impact of in utero exposure to these newer ASMs on child neurodevelopment. A systematic search of MEDLINE, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature Plus, and PsycINFO was conducted, limiting results to articles available in English and published after the year 2000. Studies investigating neurodevelopmental outcomes following in utero exposure to the following ASMs were eligible for inclusion in the review: eslicarbazepine, gabapentin, lacosamide, lamotrigine, levetiracetam, oxcarbazepine, perampanel, topiramate, and zonisamide. Thirty-five publications were identified, and a narrative synthesis was undertaken. Methodological quality was variable, with distinct patterns of strengths/weaknesses attributable to design. Most studies examined lamotrigine exposure and reported nonsignificant effects on child neurodevelopment. Comparatively fewer high-quality studies were available for levetiracetam, limiting conclusions regarding findings to date. Data for topiramate, gabapentin, and oxcarbazepine were so limited that firm conclusions could not be drawn. Concerningly, no studies investigated eslicarbazepine, lacosamide, perampanel, or zonisamide. Exposure to certain newer ASMs, such as lamotrigine and levetiracetam, does not thus far appear to impact certain aspects of neurodevelopment, but further delineation across the different neurodevelopmental domains and dosage levels is required. A lack of data cannot be inferred to represent safety of newer ASMs, which are yet to be investigated.
Collapse
Affiliation(s)
- Rebecca Knight
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, UK
| | - Anja Wittkowski
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, UK
| | - Rebecca Louise Bromley
- Division of Evolution and Genomic Science, University of Manchester, Manchester, UK.,Royal Manchester Children's Hospital, Manchester Academic Health Sciences, Manchester, UK
| |
Collapse
|
39
|
Ajinkya S, Fox J, Lekoubou A. Contemporary trends in antiepileptic drug treatment among women of childbearing age with epilepsy in the United States: 2004-2015. J Neurol Sci 2021; 427:117500. [PMID: 34087566 DOI: 10.1016/j.jns.2021.117500] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/18/2021] [Accepted: 05/15/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Certain antiepileptic drugs are associated with an increased risk for major congenital malformations (MCM). However, little is known regarding recent patterns of antiepileptic drug (ASM) prescriptions to women of childbearing age with epilepsy (WCE) in the United States. METHODS Data from the Medical Expenditure Panel Survey was analyzed between the years 2004-2015 to determine trends in national antiepileptic drug prescriptions for WCE. Analysis of associations between demographic covariates and prescription of ASMs with MCM rate > 5% (topiramate, valproate, or phenobarbital) was performed with logistic regression. RESULTS There was a weighted total of 395,292 WCE. 29.1% (23.2%-35.8%) of WCE were prescribed an AED with MCM rate > 5%. The odds of a LEV prescription significantly increased in the 2010-2012 (OR 2.91, 95% CI 1.09-7.79) and 2013-2015 (OR 5.06, 95% CI 2.02-12.67) intervals compared to 2004-2006. Conversely, the odds of PB prescriptions significantly decreased in 2010-2012 (OR 0.13, 95% CI 0.02-0.83) and 2013-2015 (OR 0.13, 95% CI 0.02-0.93) compared to 2004-2006. WCE between the ages of 25-34 (OR = 2.67, 95% CI = 1.32-5.41) and 35-44 years (OR = 2.59, 95% CI = 1.23-5.45), had lower odds of being prescribed ASMs with MCM rate > 5% compared to those between the ages of 15-24 years. SIGNIFICANCE Between 2004 and 2015, the prescriptions of ASMs given to WCE has changed. Regardless, nearly one third were prescribed potentially teratogenic medications despite available and affordable safer alternatives. Identifying factors associated with the prescription of teratogenic drugs to WCE is critical so that it may be further limited in the future.
Collapse
Affiliation(s)
- Shaun Ajinkya
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Jonah Fox
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alain Lekoubou
- Department of Neurology, Penn State University Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
40
|
Seshachala BB, Jose M, Lathikakumari AM, Murali S, Kumar AS, Thomas SV. Valproate usage in pregnancy: An audit from the Kerala Registry of Epilepsy and Pregnancy. Epilepsia 2021; 62:1141-1147. [PMID: 33782943 DOI: 10.1111/epi.16882] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This is an audit of the use of valproate (VPA) during pregnancy in women with epilepsy (WWE). METHODS We identified all pregnancies exposed to VPA in the Kerala Registry of Epilepsy and Pregnancy between January 2010 and December 2019. Subjects' past usage of antiepileptic drugs (AEDs), seizure count before and during pregnancy, fetal outcome, and major congenital malformations (MCMs) were abstracted from the registry records. The presumed reason for usage of VPA was deducted from the clinical records. RESULTS There were 221 pregnancies (17.75%) exposed to VPA (monotherapy, n = 149) during the audit period. The MCM rate for the completed pregnancies exposed to VPA was higher (n = 20, 10.36%) than that of VPA-unexposed pregnancies (n = 39, 4.96%). The relative risk for MCM with VPA exposure was 2.1 (95% confidence interval = 1.24-3.48, number needed to treat with VPA to result in MCM = 19). Reasons for using VPA during pregnancy (some women had more than one reason) were (1) VPA was the first AED prescribed and was effective (68, 29.06%), (2) other AEDs were ineffective (128, 54.70%), and (3) other AEDs were discontinued due to adverse effects (17, 7.28%). Other reasons (21, 8.97%) were (1) VPA was selected after the epilepsy classification was revised (3, 1.28%), (2) other AEDs were expensive (2, .85%), and (3) patient switched to VPA from other AEDs for unspecified reason (16, 6.83%). VPA was discontinued during pregnancy for 6 (2.71%) persons. Less than 10% of women were tried on lamotrigine or levetiracetam before switching to VPA. SIGNIFICANCE Nine MCMs per thousand pregnancies can be avoided if VPA is not used in WWE. Safe and effective AEDs as alternatives to VPA are the need of the hour. Professional bodies and regulatory authorities need to implement updated guidelines on AED usage in girls and women.
Collapse
Affiliation(s)
- Balaji B Seshachala
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Manna Jose
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Arya M Lathikakumari
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Sruthy Murali
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Arjun S Kumar
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Sanjeev V Thomas
- Kerala Registry of Epilepsy and Pregnancy, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| |
Collapse
|
41
|
Dupont S, Vercueil L. Epilepsy and pregnancy: What should the neurologists do? Rev Neurol (Paris) 2021; 177:168-179. [PMID: 33610349 DOI: 10.1016/j.neurol.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 02/08/2023]
Abstract
Epilepsy is one of the most common chronic disorders affecting women of childbearing age. Unfortunately, many women with epilepsy (WWE) still report not receiving key information about pregnancy. They obviously need information about epilepsy and pregnancy prior to conception with a particular emphasis on effective birth control (i.e. contraception), necessity to plan pregnancy, antiepileptic drugs optimization, and folate supplementation. The risks associated with use of antiepileptic drugs during pregnancy have to be balanced against fetal and maternal risks associated with uncontrolled seizures. This report reviews evidence-based counseling and management strategies concerning maternal and fetal risks associated with seizures, teratogenic risks associated with antiepileptic drug exposure with a special emphasis on developmental and behavioural outcomes of children exposed to intra utero antiepileptic drugs.
Collapse
Affiliation(s)
- S Dupont
- Epilepsy and Rehabilitation Unit, Hôpital de la Pitié-Salpêtrière, AP-HP, Paris, France; Centre de Recherche de l'Institut du Cerveau et de la Moëlle Épinière (ICM), UMPC-UMR 7225 CNRS-UMRS 975 INSERM, Paris, France; Université Paris Sorbonne, Paris, France.
| | - L Vercueil
- EFSN, University Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), 38000 Grenoble, France
| |
Collapse
|
42
|
Han SH, Lee H, Shin JY, Moon HJ, Lee SY. Real-world prescribing trends of valproate in women with epilepsy in Korea. Epilepsy Behav 2021; 115:107700. [PMID: 33421853 DOI: 10.1016/j.yebeh.2020.107700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
Avoiding valproate is recommended in women of childbearing age due to possible teratogenicity and infertility. We aimed to examine the recent trend of valproate prescriptions in Korea to review the adequacy of anticonvulsant prescriptions in women with epilepsy (WWE). Oral valproate utilization was assessed using nationwide and unselected data from the Korean National Health Insurance Service from 2009 to 2017. The temporal trends of the proportions of valproate prescriptions were analyzed using the Poisson regression model and expressed as average annual percentage change (AAPC). Among the WWE of childbearing age, valproate was prescribed in 37.0% overall and 29.4% as initial prescription in 2017. The proportion of valproate utilization showed a decreasing trend in overall prescription (AAPC = -1.10%) and initial prescription (AAPC = -2.63%). However, the proportion was static over time in the initial monotherapy group (AAPC = -0. 53%), while it was significantly decreasing in the initial polytherapy group (AAPC = -8.25%). A noticeable proportion of WWE was still being prescribed valproate in Korea. In particular, the use of valproate for initial monotherapy has not decreased over the past nine years. This result calls not only for reinforcement of education regarding anticonvulsant selection but also for monitoring the actual prescription.
Collapse
Affiliation(s)
- Su-Hyun Han
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyesung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Republic of Korea; Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Hye-Jin Moon
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea.
| | - Seo-Young Lee
- Department of Neurology, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
| |
Collapse
|
43
|
Neonatal Outcomes in the MONEAD Study of Pregnant Women with Epilepsy. THE JOURNAL OF PEDIATRICS: X 2021; 7. [DOI: 10.1016/j.ympdx.2021.100073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
44
|
Pennell PB, French JA, May RC, Gerard E, Kalayjian L, Penovich P, Gedzelman E, Cavitt J, Hwang S, Pack AM, Sam M, Miller JW, Wilson SH, Brown C, Birnbaum AK, Meador KJ. Changes in Seizure Frequency and Antiepileptic Therapy during Pregnancy. N Engl J Med 2020; 383:2547-2556. [PMID: 33369356 PMCID: PMC7919187 DOI: 10.1056/nejmoa2008663] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Among women with epilepsy, studies regarding changes in seizure frequency during pregnancy have been limited by the lack of an appropriate nonpregnant comparator group to provide data on the natural course of seizure frequency in both groups. METHODS In this prospective, observational, multicenter cohort study, we compared the frequency of seizures during pregnancy through the peripartum period (the first 6 weeks after birth) (epoch 1) with the frequency during the postpartum period (the following 7.5 months after pregnancy) (epoch 2). Nonpregnant women with epilepsy were enrolled as controls and had similar follow-up during an 18-month period. The primary outcome was the percentage of women who had a higher frequency of seizures that impaired awareness during epoch 1 than during epoch 2. We also compared changes in the doses of antiepileptic drugs that were administered in the two groups during the first 9 months of epoch 1. RESULTS We enrolled 351 pregnant women and 109 controls with epilepsy. Among the 299 pregnant women and 93 controls who had a history of seizures that impaired awareness and who had available data for the two epochs, seizure frequency was higher during epoch 1 than during epoch 2 in 70 pregnant women (23%) and in 23 controls (25%) (odds ratio, 0.93; 95% confidence interval [CI], 0.54 to 1.60). During pregnancy, the dose of an antiepileptic drug was changed at least once in 74% of pregnant women and in 31% of controls (odds ratio, 6.36; 95% CI, 3.82 to 10.59). CONCLUSIONS Among women with epilepsy, the percentage who had a higher incidence of seizures during pregnancy than during the postpartum period was similar to that in women who were not pregnant during the corresponding epochs. Changes in doses of antiepileptic drugs occurred more frequently in pregnant women than in nonpregnant women during similar time periods. (Funded by the National Institutes of Health; MONEAD ClinicalTrials.gov number, NCT01730170.).
Collapse
Affiliation(s)
- Page B Pennell
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Jacqueline A French
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Ryan C May
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Elizabeth Gerard
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Laura Kalayjian
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Patricia Penovich
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Evan Gedzelman
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Jennifer Cavitt
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Sean Hwang
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Alison M Pack
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Maria Sam
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - John W Miller
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Steffanie H Wilson
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Carrie Brown
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Angela K Birnbaum
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Kimford J Meador
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| |
Collapse
|
45
|
Cerebral cavernous malformation: Management and outcome during pregnancy and puerperium. A systematic review of literature. J Gynecol Obstet Hum Reprod 2020; 50:101927. [PMID: 33035718 DOI: 10.1016/j.jogoh.2020.101927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/12/2020] [Accepted: 09/28/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Cerebral cavernomas malformations (CCMs) are vascular malformations that occur with an incidence of 0,4-0,8 % in general population. The most feared complication is cerebral hemorrhage. Currently there are no guidelines for pregnant women with CCMs. Some authors claimed that many physiological changes related to pregnancy could be linked to an high risk of rupture and bleeding of the cerebral cavernoma. However, more recent studies highlight that the presence of cerebral cavernomatosis is not a contraindication for pregnancy and that the risk of bleeding is similar in pregnant and in non-pregnant women. AIM OF THE STUDY The purpose of our work is to analyze, through the study of controversial findings in literature, all the information currently available trying to establish a common approach for management of women with cerebral cavernomatosis in pregnancy, during childbirth and in the puerperium. FINDINGS In accordance with existing literature, pregnancy does not appear to be a significant risk factor for the worsening of clinical manifestations associated with the presence of CCMs. Vaginal delivery is not contraindicated in patients with CCMs and there is no indication to perform cesarean section to reduce the incidence of hemorrhage. The only indication for neurosurgery of CCMs in pregnancy is the presence of rapidly progressive symptoms and should be postponed to the puerperium if arises after 30 weeks. The puerperium is a critical time for the woman with cavernomas for the possibility of bleeding and clinical observation must be continued. CONCLUSION The patients with a diagnosis of a CCMs can have a pregnancy without any particular risk to themselves and the fetus but should be addressed to highly specialized obstetrics center to assesses the initial individual risk related to their pathology and to follow the pregnancy.
Collapse
|
46
|
Birnbaum AK, Meador KJ, Karanam A, Brown C, May RC, Gerard EE, Gedzelman ER, Penovich PE, Kalayjian LA, Cavitt J, Pack AM, Miller JW, Stowe ZN, Pennell PB. Antiepileptic Drug Exposure in Infants of Breastfeeding Mothers With Epilepsy. JAMA Neurol 2020; 77:441-450. [PMID: 31886825 DOI: 10.1001/jamaneurol.2019.4443] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance There is limited information on infant drug exposure via breastfeeding by mothers who are receiving antiepileptic drug therapy. Objective To provide direct, objective information on antiepileptic drug exposure through breast milk. Design, Setting, and Participants This prospective cohort study was conducted between December 2012 to October 2016, with follow-up in children until 6 years of age at 20 sites across the United States. Data were collected via an observational multicenter investigation (Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs [MONEAD]) of outcomes in pregnant mothers with epilepsy and their children. Pregnant women with epilepsy who were aged 14 to 45 years, had pregnancies that had progressed to less than 20 weeks' gestational age, and had measured IQ scores of more than 70 points were enrolled and followed up through pregnancy and 9 postpartum months. Their infants were enrolled at birth. Data were analyzed from May 2014 to August 2019. Exposures Antiepileptic drug exposure in infants who were breastfed. Main Outcomes and Measures The percentage of infant-to-mother concentration of antiepileptic drugs. Antiepileptic drug concentrations were quantified from blood samples collected from infants and mothers at the same visit, 5 to 20 weeks after birth. Concentrations of antiepileptic drugs in infants at less than the lower limit of quantification were assessed as half of the lower limit. Additional measures collected were the total duration of all daily breastfeeding sessions and/or the volume of pumped breast milk ingested from a bottle. Results A total of 351 women (of 865 screened and 503 eligible individuals) were enrolled, along with their 345 infants (179 female children [51.9%]; median [range] age, 13 [5-20] weeks). Of the 345 infants, 222 (64.3%) were breastfed; the data collection yielded 164 matching infant-mother concentration pairs from 138 infants. Approximately 49% of all antiepileptic drug concentrations in nursing infants were less than the lower limit of quantification. The median percentage of infant-to-mother concentration for all 7 antiepileptic drugs and 1 metabolite (carbamazepine, carbamazepine-10,11-epoxide, levetiracetam, lamotrigine, oxcarbazepine, topiramate, valproate, and zonisamide) ranged from 0.3% (range, 0.2%-0.9%) to 44.2% (range, 35.2%-125.3%). In multiple linear regression models, maternal concentration was a significant factor associated with lamotrigine concentration in infants (Pearson correlation coefficient, 0.58; P < .001) but not levetiracetam concentration in infants. Conclusions and Relevance Overall, antiepileptic drug concentrations in blood samples of infants who were breastfed were substantially lower than maternal blood concentrations. Given the well-known benefits of breastfeeding and the prior studies demonstrating no ill effects when the mother was receiving antiepileptic drugs, these findings support the breastfeeding of infants by mothers with epilepsy who are taking antiepileptic drug therapy.
Collapse
Affiliation(s)
- Angela K Birnbaum
- Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis
| | - Kimford J Meador
- Department of Neurology & Neurological Sciences, Stanford University, Stanford, California
| | - Ashwin Karanam
- Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis
| | | | - Ryan C May
- The Emmes Corporation, Rockville, Maryland
| | | | | | | | - Laura A Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | - John W Miller
- Department of Neurology, University of Washington, Seattle.,Department of Neurological Surgery, University of Washington, Seattle
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin at Madison, Madison
| | - Page B Pennell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
47
|
Kim H, Faught E, Thurman DJ, Fishman J, Kalilani L. Antiepileptic Drug Treatment Patterns in Women of Childbearing Age With Epilepsy. JAMA Neurol 2020; 76:783-790. [PMID: 30933252 DOI: 10.1001/jamaneurol.2019.0447] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Limited population-based data are available on antiepileptic drug (AED) treatment patterns in women of childbearing age with epilepsy; the current population risk is not clear. Objectives To examine the AED treatment patterns and identify differences in use of valproate sodium and topiramate by comorbidities among women of childbearing age with epilepsy. Design, Setting, and Participants A retrospective cohort study used a nationwide commercial database and supplemental Medicare as well as Medicaid insurance claims data to identify 46 767 women with epilepsy aged 15 to 44 years. The eligible study cohort was enrolled between January 1, 2009, and December 31, 2013. Data analysis was conducted from January 1, 2017, to February 22, 2018. Exposures Cases required an International Classification of Diseases, Ninth Revision, Clinical Modification-coded epilepsy diagnosis with continuous medical and pharmacy enrollment. Incident cases required a baseline of 2 or more years without an epilepsy diagnosis or AED prescription before the index date. For both incident and prevalent cases, focal and generalized epilepsy cohorts were matched by age, payer type, and enrollment period and then compared. Main Outcomes and Measures Antiepileptic drug treatment pattern according to seizure type and comorbidities. Results Of the 46 767 patients identified, there were 8003 incident cases (mean [SD] age, 27.3 [9.4] years) and 38 764 prevalent cases (mean [SD] age, 29.7 [9.0] years). Among 3219 women in the incident epilepsy group who received AEDs for 90 days or more, 3173 (98.6%) received monotherapy as first-line treatment; among 28 239 treated prevalent cases, 18 987 (67.2%) received monotherapy. In 3544 (44.3%) incident cases and 9480 (24.5%) prevalent cases, AED treatment was not documented during 180 days or more of follow-up after diagnosis. Valproate (incident: 35 [5.81%]; prevalent: 514 [13.1%]) and phenytoin (incident: 33 [5.48%]; prevalent: 178 [4.53%]) were more commonly used for generalized epilepsy and oxcarbazepine (incident: 53 [8.03%]; prevalent: 386 [9.89%]) was more often used for focal epilepsy. Levetiracetam (incident: focal, 267 [40.5%]; generalized, 271 [45.0%]; prevalent: focal, 794 [20.3%]; generalized, 871 [22.2%]), lamotrigine (incident: focal, 123 [18.6%]; generalized, 106 [17.6%]; prevalent: focal, 968 [24.8%]; generalized, 871 [22.2%]), and topiramate (incident: focal, 102 [15.5%]; generalized, 64 [10.6%]; prevalent: focal, 499 [12.8%]; generalized, 470 [12.0%]) were leading AEDs prescribed for both focal and generalized epilepsy. Valproate was more commonly prescribed for women with comorbid headache or migraine (incident: 53 of 1251 [4.2%]; prevalent: 839 of 8046 [10.4%]), mood disorder (incident: 63 of 860 [7.3%]; prevalent: 1110 of 6995 [15.9%]), and anxiety and dissociative disorders (incident: 57 of 881 [6.5%]; prevalent: 798 of 5912 [13.5%]). Topiramate was more likely prescribed for those with comorbid headache or migraine (incident: 335 of 1251 [26.8%]; prevalent: 2322 of 8046 [28.9%]). Conclusions and Relevance Many women appear to be treated with valproate and topiramate despite known teratogenicity risks. Comorbidities may affect selecting certain AEDs despite their teratogenicity risks.
Collapse
Affiliation(s)
- Hyunmi Kim
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California
| | - Edward Faught
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - David J Thurman
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | | | | |
Collapse
|
48
|
30 years of second-generation antiseizure medications: impact and future perspectives. Lancet Neurol 2020; 19:544-556. [DOI: 10.1016/s1474-4422(20)30035-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/30/2019] [Accepted: 11/28/2019] [Indexed: 01/31/2023]
|
49
|
Hixson JD, Braverman L. Digital tools for epilepsy: Opportunities and barriers. Epilepsy Res 2020; 162:106233. [DOI: 10.1016/j.eplepsyres.2019.106233] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/10/2019] [Accepted: 10/26/2019] [Indexed: 11/27/2022]
|
50
|
Meador KJ, Pennell PB, May RC, Van Marter L, McElrath TF, Brown C, Gerard E, Kalayjian L, Gedzelman E, Penovich P, Cavitt J, French J, Hwang S, Pack AM, Sam M, Birnbaum AK, Finnell R. Fetal loss and malformations in the MONEAD study of pregnant women with epilepsy. Neurology 2020; 94:e1502-e1511. [PMID: 31806691 PMCID: PMC7251524 DOI: 10.1212/wnl.0000000000008687] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/11/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine occurrence of severe adverse fetal outcomes (SAO), including fetal loss and major congenital malformations (MCMs), in pregnant women with epilepsy (PWWE) vs healthy pregnant women (HPW). METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an NIH-funded, prospective, observational, multicenter investigation of pregnancy outcomes for both mother and child, which enrolled women December 2012 through January 2016. RESULTS The 351 PWWE had 365 conceptions, and 105 HPW had 109 conceptions. SAOs occurred more often in PWWE (7.9%) vs HPW (1.9%) (p = 0.025) with odds ratio (OR) 4.45 (95% confidence intervals [CI] 1.04-19.01). There were no significant differences for fetal loss (2.8% vs 0%, p = 0.126) or MCMs (5.2% vs 1.9%, p = 0.185; OR 2.86, 95% CI 0.65-12.53) individually. No fetal losses in PWWE appeared to be related to acute seizures. Outcomes were not affected by periconceptional folate, unplanned/unwanted pregnancies, prior maternal pregnancy history, or antiepileptic drug (AED) blood levels, except for an AED level effect for fetal loss that appeared to be due to polytherapy. Combined maternal or paternal family history of MCM was marginally associated with increased SAOs (p = 0.046). CONCLUSIONS The findings provide additional information on risks of SAOs in PWWE, assessing effects of both AED levels and periconceptional folate. Group differences in average enrollment gestational age could have affected fetal loss results. Analyses are limited by small sample sizes as the MONEAD study was not powered for these secondary outcomes. The large majority of pregnancies in women with epilepsy do not have SOAs.
Collapse
Affiliation(s)
- Kimford J Meador
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX.
| | - Page B Pennell
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Ryan C May
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Linda Van Marter
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Thomas F McElrath
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Carrie Brown
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Elizabeth Gerard
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Laura Kalayjian
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Evan Gedzelman
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Patricia Penovich
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Jennifer Cavitt
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Jacqueline French
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Sean Hwang
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Alison M Pack
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Maria Sam
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Angela K Birnbaum
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Richard Finnell
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| |
Collapse
|