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Mbizvo GK, Bucci T, Lip GYH, Marson AG. Morbidity and mortality risks associated with valproate withdrawal in young adults with epilepsy. Brain 2024; 147:3426-3441. [PMID: 38657115 PMCID: PMC11449131 DOI: 10.1093/brain/awae128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/19/2024] [Accepted: 03/13/2024] [Indexed: 04/26/2024] Open
Abstract
Valproate is the most effective treatment for idiopathic generalized epilepsy. Current guidance precludes its use in females of childbearing potential, unless other treatments are ineffective or not tolerated, because of high teratogenicity. This risk was recently extended to males. New guidance will limit use both in males and females aged <55 years, resulting in withdrawal of valproate from males already taking it, as occurs for females. Whether there are risks of personal harm (including injury or death) associated with valproate withdrawal has not yet been quantified for males or females ON valproate, meaning clinicians cannot reliably counsel either sex when discussing valproate withdrawal with them, despite that this concern may be at the forefront of patients' and clinicians' minds. We assessed whether there are any morbidity or mortality risks associated with valproate withdrawal in young males and females. We performed a retrospective cohort study of internationally derived electronic health data within the TriNetX Global Collaborative Network. Included were males and females aged 16-54 years with ≥1 epilepsy disease or symptom code between 1 December 2017 and 1 December 2018, and ≥2 valproate prescriptions over the preceding 2 years (1 January 2015-30 November 2017). Five-year propensity-matched risks of mortality and a range of morbidity outcomes were compared between those remaining ON versus withdrawn from valproate during the 1 December 2017-1 December 2018 recruitment period, regardless of whether switched to another antiseizure medication. Survival analysis was undertaken using Cox-proportional hazard models, generating hazard ratios (HRs) with 95% confidence intervals (CIs). In total, 8991 males and 5243 females taking valproate were recruited. Twenty-eight per cent of males and 36% of females were subsequently withdrawn from valproate. Valproate withdrawal was associated with significantly increased risks of emergency department attendance [HRs overall: 1.236 (CI 1.159-1.319), males: 1.181 (CI 1.083-1.288), females: 1.242 (CI 1.125-1.371)], hospital admission [HRs overall: 1.160 (CI 1.081-1.246), males: 1.132 (CI 1.027-1.249), females: 1.147 (CI 1.033-1.274)], falls [HRs overall: 1.179 (CI 1.041-1.336), males: 1.298 (CI 1.090-1.546)], injuries [HRs overall: 1.095 (CI 1.021-1.174), males: 1.129 (CI 1.029-1.239)], burns [HRs overall: 1.592 (CI 1.084-2.337)] and new-onset depression [HRs overall 1.323 (CI 1.119-1.565), females: 1.359 (CI 1.074-1.720)]. The risk of these outcomes occurring was 1%-7% higher in those withdrawn from valproate than in those remaining ON valproate. Overall, valproate withdrawal was not associated with increased mortality. These results may help patients and clinicians have a more informed discussion about personal safety when considering valproate withdrawal.
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Affiliation(s)
- Gashirai K Mbizvo
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, L69 7TX, UK
- Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 7BE, UK
- Neurology Service, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, L69 7TX, UK
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, 00185, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, L69 7TX, UK
- Department of Clinical Medicine, Danish Centre for Health Services Research, Aalborg University, Aalborg, 9220, Denmark
| | - Anthony G Marson
- Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, L69 7BE, UK
- Neurology Service, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
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Raine SP. Legal and Ethical Issues in the Neurology of Reproductive Health. Neurol Clin 2023; 41:533-541. [PMID: 37407105 DOI: 10.1016/j.ncl.2023.03.003] [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: 07/07/2023]
Abstract
Women may acquire neurologic conditions during their reproductive years. As a result, the potential for pregnancy must be considered when selecting appropriate treatment of these women. Physicians who adhere to the standard of care through sound clinical judgment, use of shared decision-making, provide appropriate and timely consultation and follow-up, and clearly document all aspects of patient care minimize legal liability in the event of an unanticipated pregnancy resulting in fetal harm due to treatment with a teratogenic medication.
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Affiliation(s)
- Susan P Raine
- Baylor College of Medicine, One Baylor Plaza, Suite N104, Houston, TX 77030, USA
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3
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Wójcik K, Franciszek Kołek M, Dec-Ćwiek M, Słowik A, Bosak M. Trends in antiseizure medications utilization among women of childbearing age with epilepsy in Poland between 2015 and 2019. Epilepsy Behav 2023; 139:109091. [PMID: 36682232 DOI: 10.1016/j.yebeh.2023.109091] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/01/2023] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
PURPOSE To determine trends in the use of antiseizure medications (ASMs) among women of childbearing age (WOCA) and girls aged 12-14 years with epilepsy between 2015 and 2019 in Poland. METHODS The study used data from the Pex database, which captures information on prescriptions dispensed from 85% of community pharmacies in Poland. The prescriptions issued by neurologists who provide epilepsy care in Poland were studied. Six of the most commonly prescribed ASMs were analyzed: carbamazepine, lamotrigine, levetiracetam, oxcarbazepine, topiramate, and valproate. RESULTS The use of valproate and carbamazepine decreased in all age groups. Among the newer ASMs, the use of lamotrigine, levetiracetam, and topiramate increased and oxcarbazepine decreased significantly in WOCA. The only subgroup with statistically significant changes in all ASMs prescriptions were women aged 19-34 years. For girls aged 12-14 years, significant changes were found only for valproate and carbamazepine. In the last year of observation (2019) valproate and lamotrigine accounted for two-thirds of ASMs units prescribed to WOCA. Valproate accounted for half of the prescribed drug units in girls aged 12-14 years. The lowest rates of VPA prescriptions were found in women aged 19-34 years. CONCLUSIONS There is a change in prescribing habits in WOCA with epilepsy in Poland with trends toward using less teratogenic ASMs. However, many WOCAs are treated with valproate and topiramate despite their known teratogenicity risk. Valproate is still the most commonly prescribed ASM in WOCA and girls aged 12-14 years. Educational interventions for healthcare professionals are needed to improve prescribing practices in WOCA with epilepsy in Poland.
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Affiliation(s)
| | | | - Małgorzata Dec-Ćwiek
- University Hospital in Kraków, Poland; Jagiellonian University, Faculty of Medicine, Department of Neurology, Poland
| | - Agnieszka Słowik
- University Hospital in Kraków, Poland; Jagiellonian University, Faculty of Medicine, Department of Neurology, Poland
| | - Magdalena Bosak
- University Hospital in Kraków, Poland; Jagiellonian University, Faculty of Medicine, Department of Neurology, Poland.
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Biosensors modern technology in determination of anti-epileptic drugs (AEDs). Clin Chim Acta 2022; 533:175-182. [PMID: 35798056 DOI: 10.1016/j.cca.2022.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/19/2022] [Accepted: 06/24/2022] [Indexed: 12/17/2022]
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Shawahna R, Zaid L. Caring for women with epilepsy in Palestine: A qualitative study of the current status. Epilepsy Behav 2022; 130:108689. [PMID: 35398722 DOI: 10.1016/j.yebeh.2022.108689] [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: 01/01/2022] [Revised: 03/26/2022] [Accepted: 03/26/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This qualitative study was conducted to explore the current status of caring for women with epilepsy (WWE) in the Palestinian healthcare system. METHODS This study used an explorative qualitative design. A purposive sampling technique was used to recruit the participants. Semi-structured in-depth interviews were conducted with neurologists (n = 6), gynecologists (n = 5), psychiatrists (n = 3), an internist (n = 1), and clinical pharmacists (n = 5). The interpretive description methodology was used to thematically analyze the qualitative data. RESULTS A total of 745 min (12.4 h) of interview time were analyzed. The qualitative data collected in this study were categorized under 3 major themes and multiple subthemes. The 3 major themes were: (1) diagnosis and care for patients with epilepsy, (2) general issues in caring for patients with epilepsy, and (3) consideration of women's issues in the pharmacotherapy of epilepsy. Formally adopted protocols/criteria for the diagnosis and care for WWE were lacking. CONCLUSION Findings of this qualitative study showed a need to formally adopt uniform guidelines that can guide the diagnosis and care of WWE in the Palestinian healthcare system. The findings of this study might be informative to healthcare providers, decision-makers in healthcare authorities, WWE, and patient advocacy groups who could be interested in improving and benchmarking healthcare services provided to WWE. Future studies are still needed to quantitatively measure adherence to the international guidelines in caring for WWE.
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Affiliation(s)
- Ramzi Shawahna
- Department of Physiology, Pharmacology and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine; An-Najah BioSciences Unit, Centre for Poisons Control, Chemical and Biological Analyses, An-Najah National University, Nablus, Palestine.
| | - Lina Zaid
- Master of Pharmacology Program, Faculty of Graduate Studies, An-Najah National University, Nablus, Palestine
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Acar S, Kapucu A, Akgün-Dar K. The effects of regular swimming exercise during sodium valproate treatment on seizure behaviors and EEG recordings in pentylenetetrazole-kindled rats. Epilepsy Res 2022; 179:106830. [PMID: 34894619 DOI: 10.1016/j.eplepsyres.2021.106830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/02/2021] [Accepted: 11/27/2021] [Indexed: 11/08/2022]
Abstract
We investigated the effects of alone/combined regular swimming exercise and sodium valproate on epileptic seizure behaviors and EEG recordings, anti-oxidative mechanism, learning, and memory in pentylenetetrazole (PTZ)-kindled rats. Forty-eight healthy rats were randomly divided into eight equal groups as control (CONT), swimming exercise (EX), sodium valproate (SV), SV+EX, PTZ, EX+PTZ, SV+PTZ and SV+EX+PTZ. The rats were forced to regular swimming exercise for 60 min every other day, 13 doses of PTZ (40 mg/kg) were given to induce epileptic seizures and 200 mg/kg SV was given for 28 days. Epileptic seizures were evaluated by visual observation and EEG recordings (total spike numbers and number of epileptiform discharges). Memory and learning skills were assessed with passive avoidance test. According to our visual seizure observations, seizure latency was prolonged only in SV+EX+PTZ (p < 0.001) group, seizure severity score decreased in SV+PTZ (p < 0.05) and SV+EX+PTZ (p < 0.001) groups and seizure frequency was reduced in SV+PTZ (p < 0,001), EX+PTZ (p < 0,001), and SV+EX+PTZ (p < 0,001) groups. Total spike numbers and number of epileptiform discharges highly increased in PTZ group, whereas they decreased in swimming exercise and/or SV treatment groups. The most effective result was seen in the combined therapy group. Memory deficit was observed in PTZ -kindling group, but it didn't change with exercise or SV. Based on our results, regular swimming exercise had positive effects on PTZ-induced seizure frequency, and combined therapy of regular swimming exercise and SV is the most effective way to ameliorate visual seizure behaviors and decrease spike numbers and number of epileptiform discharges according to EEG recordings. Regular swimming exercise could be an alternative option to reduce the dose of SV and the side effects of SV can be avoided in clinical aspects.
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Affiliation(s)
- Samet Acar
- Department of Biology, Faculty of Science, Istanbul University, Istanbul, Turkey.
| | - Ayşegul Kapucu
- Department of Biology, Faculty of Science, Istanbul University, Istanbul, Turkey
| | - Kadriye Akgün-Dar
- Department of Biology, Faculty of Science, Istanbul University, Istanbul, Turkey
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Müffelmann B, Hagemann A, Knaak N, Bien CG. [Women with epilepsy before and during pregnancy: a case series of outpatient counseling in a tertiary epilepsy center]. DER NERVENARZT 2021; 93:566-574. [PMID: 34608536 DOI: 10.1007/s00115-021-01198-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Data of large pregnancy registries have improved the recommendations for women with epilepsy before pregnancy. Monotherapy containing antiepileptic drugs with a low malformation rate (lamotrigine or levetiracetam) is recommended as well as preconceptional folic acid supplementation, while valproic acid should be avoided. The practicability of these recommendations remains controversial. METHODS Retrospective case series of 160 women with epilepsy over a period of 5 years who were advised in our outpatient department before and during pregnancy. RESULTS Only 18.9% of women presented with valproic acid. Even without valproic acid, complications or emergency admissions rarely occurred under specialist supervision. In our case series, lamotrigine proved to be less effective and less controllable than other drugs during pregnancy. Levetiracetam also has a low malformation rate, but showed a better effect on seizure outcome during pregnancy than lamotrigine. Only 12% of women who wanted to have children took folic acid. CONCLUSION This case series comes from a tertiary center; the referred women were mainly accompanied by neurologists with special expertise in epileptology. In this group valproate could be avoided in most cases. Lamotrigine is probably less effective due to the drop in blood levels during pregnancy. Levetiracetam seems to be a good alternative, working well against focal and generalized seizures. Folic acid may be taken later than recommended.
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Affiliation(s)
- Birgitt Müffelmann
- Krankenhaus Mara, Epilepsie-Zentrum Bethel, Universitätsklinik für Epileptologie, Maraweg 17-21, 33617, Bielefeld, Deutschland.
| | - Anne Hagemann
- Epilepsie-Zentrum Bethel, Gesellschaft für Epilepsieforschung, Bielefeld, Deutschland
| | - Niklas Knaak
- Campus Kiel, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Christian G Bien
- Krankenhaus Mara, Epilepsie-Zentrum Bethel, Universitätsklinik für Epileptologie, Maraweg 17-21, 33617, Bielefeld, Deutschland
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Steinbart D, Gaus V, Kowski AB, Holtkamp M. Valproic acid use in fertile women with genetic generalized epilepsies. Acta Neurol Scand 2021; 144:288-295. [PMID: 33977526 DOI: 10.1111/ane.13446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/18/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In genetic generalized epilepsies (GGE), valproic acid (VPA) is the most efficacious compound. However, due to teratogenicity and increased risk for impaired cognitive development after intrauterine exposure, its use in women of fertile age is strictly regulated but sometimes unavoidable. METHODS All patients with GGE treated at the outpatient clinic of a tertiary epilepsy center with at least one visit between January 2015 and April 2020 were included in this retrospective study. The rate of women aged 18 to 49 years taking VPA was compared to that of men of the same age group and to women > 49 years. Furthermore, in each group, clinical variables associated with VPA use were sought. RESULTS Twenty-eight out of 125 women of fertile age (22%) were treated with VPA, compared to 28 out of 56 men ≤ 49 years (50%; p = .002) and to 22 out of 40 female patients > 49 years (55%; p < .001). VPA dose was lower in fertile women compared to men, with no difference in seizure freedom rates. In women ≤ 49 years, multivariate analysis demonstrated age as the only variable independently associated with VPA use (OR 1.095; 95% CI 1.036-1.159). In the other two groups, no associated variables were identified. CONCLUSIONS Despite warnings with respect to teratogenicity and impaired cognitive development with VPA, from 2015 to 2020, almost every fourth women of fertile age with GGE received this compound. Inevitably lower VPA doses in these women seem sufficient for favorable seizure freedom rates.
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Affiliation(s)
- David Steinbart
- Department of Neurology Epilepsy‐Center Berlin‐Brandenburg Charité – Universitätsmedizin Berlin Berlin Germany
| | - Verena Gaus
- Department of Neurology Epilepsy‐Center Berlin‐Brandenburg Charité – Universitätsmedizin Berlin Berlin Germany
| | - Alexander B. Kowski
- Department of Neurology Epilepsy‐Center Berlin‐Brandenburg Charité – Universitätsmedizin Berlin Berlin Germany
| | - Martin Holtkamp
- Department of Neurology Epilepsy‐Center Berlin‐Brandenburg Charité – Universitätsmedizin Berlin Berlin Germany
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Atalar AÇ, Şirin NG, Bebek N, Baykan B. Predictors of successful valproate withdrawal in women with epilepsy. Epilepsy Behav 2021; 119:107980. [PMID: 33957390 DOI: 10.1016/j.yebeh.2021.107980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/05/2021] [Accepted: 04/05/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Valproate (VPA) use was restricted due to its teratogenic risks in women with epilepsy (WWE). We aimed to assess the outcome and predictors of treatment decisions of withdrawal/switch or continuation of VPA in WWE. METHODS We included 214 consecutive WWE with a follow-up time of 9.57 ± 7.04 years, who have used (n = 142) or are still using VPA (n = 72) during their reproductive ages. The demographic, clinical, and electroencephalography (EEG) properties of WWE who could withdraw (successful withdrawal; n = 142) and could not withdraw VPA (unsuccessful withdrawal; n = 36) were compared statistically. RESULTS The main reasons for still using VPA were high risk of seizure recurrence (63.9%), cognitive impairment (27.8%), and no pregnancy prospect (8.3%). In the successful withdrawal group, 67 (47.1%) patients maintained remission after VPA withdrawal and 26 of them (38.8%) had relapse during the follow-up. The rate of side effects related to the new drugs (levetiracetam and lamotrigine) was 52/142 (36.6%). The unsuccessful withdrawal rate was 13.9% in focal epilepsy whereas it was 86.1% in generalized epilepsy (p = 0.002). Co-occurrence of three types of seizures and anti-seizure medication (ASM)-resistance was related to unsuccessful withdrawal in genetic generalized epilepsy (GGE) (p = 0.02 for both). CONCLUSIONS Although women with focal epilepsies are more ASM-resistant and more likely to have continuing seizures, they do not usually deteriorate after VPA discontinuation, therefore posing them to teratogenic risk is often unnecessary. In GGE, certain predictors such as previous ASM-resistance and the presence of three seizure types must be taken into account, before a withdrawal attempt of VPA treatment.
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Affiliation(s)
- Arife Çimen Atalar
- Istanbul University, Istanbul Faculty of Medicine, Departments of Neurology and Clinica Neurophysiology, Istanbul, Turkey; Istanbul Education and Research Hospital, Department of Neurology, Istanbul, Turkey
| | - Nermin Görkem Şirin
- Istanbul University, Istanbul Faculty of Medicine, Departments of Neurology and Clinica Neurophysiology, Istanbul, Turkey.
| | - Nerses Bebek
- Istanbul University, Istanbul Faculty of Medicine, Departments of Neurology and Clinica Neurophysiology, Istanbul, Turkey
| | - Betül Baykan
- Istanbul University, Istanbul Faculty of Medicine, Departments of Neurology and Clinica Neurophysiology, Istanbul, Turkey
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Mermi Dibek D, Öztura İ, Baklan B. Our reasons for converting to valproic acid treatment in female patients with genetic generalized epilepsy: a retrospective, single-centre study. Neurol Sci 2021; 43:517-523. [PMID: 33890162 DOI: 10.1007/s10072-021-05261-8] [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: 01/11/2021] [Accepted: 04/16/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIM Valproic acid (Na valproate) is a broad-spectrum anti-seizure medication used in children and adolescents. It is thought to have fewer adverse effects; however, recent studies have restricted its use in women of reproductive age due to the teratogenic impacts on cognition. Although alternative drugs have been used to treat patients in clinical follow-up, some patients have to return to using valproic acid. Our study aimed to determine the rate of return to valproic acid treatment in female patients with follow-up in our centre and the reasons for the return. MATERIALS AND METHODS Female patients with genetic generalized epilepsy who were followed up in our centre were included in the study. Patient data were retrospectively obtained from file records. The patients were grouped by seizure subgroups, antiepileptic treatment used, electroencephalography characteristics, and seizure treatment response. RESULTS Sixty-three (31.7%) of the 199 patients had to return to VPA treatment. When the reasons for the discontinuation of other drugs were examined, non-response to treatment was found in 80.0% of patients, adverse medication effects in 18.3%, and 1.7% continued voluntarily. Patients who are JAE subtypes were more likely to return to VPA treatment than GTCS alone subtypes. A total of 7.4% of patients converted to VPA therapy had continued myoclonic seizures compared with 20.4% of patients treated with alternative drugs. CONCLUSION VPA treatment is not used as the first choice in females of reproductive age; however, some patients will only achieve seizure control with valproate, especially those with myoclonic seizures and JAE.
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Affiliation(s)
- Dilara Mermi Dibek
- Department of Neurology, Clinical Neurophysiology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey.
| | - İbrahim Öztura
- Department of Neurology, Clinical Neurophysiology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Barış Baklan
- Department of Neurology, Clinical Neurophysiology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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Li S, Zhang L, Wei N, Tai Z, Yu C, Xu Z. Research Progress on the Effect of Epilepsy and Antiseizure Medications on PCOS Through HPO Axis. Front Endocrinol (Lausanne) 2021; 12:787854. [PMID: 34992582 PMCID: PMC8726549 DOI: 10.3389/fendo.2021.787854] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/23/2021] [Indexed: 12/14/2022] Open
Abstract
Epilepsy is a common chronic neurological disease that manifests as recurrent seizures. The incidence and prevalence of epilepsy in women are slightly lower than those in men. Polycystic ovary syndrome (PCOS), a reproductive endocrine system disease, is a complication that women with epilepsy are susceptible to, and its total prevalence is 8%-13% in the female population and sometimes as high as 26% in female epilepsy patients. The rate of PCOS increased markedly in female patients who chose valproate (VPA), to 1.95 times higher than that of other drugs. In addition, patients receiving other anti-seizure medications (ASMs), such as lamotrigine (LTG), oxcarbazepine (OXC), and carbamazepine (CBZ), also have reproductive endocrine abnormalities. Some scholars believe that the increase in incidence is related not only to epilepsy itself but also to ASMs. Epileptiform discharges can affect the activity of the pulse generator and then interfere with the reproductive endocrine system by breaking the balance of the hypothalamic-pituitary-ovarian (HPO) axis. ASMs may also cause PCOS-like disorders of the reproductive endocrine system through the HPO axis. Moreover, other factors such as hormone metabolism and related signalling pathways also play a role in it.
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Affiliation(s)
| | | | | | | | | | - Zucai Xu
- *Correspondence: Changyin Yu, ; Zucai Xu,
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Haki C, Akdogan O, Bora IH. DIAGNOSTIC DIFFICULTIES IN PATIENTS WITH JUVENILE MYOCLONIC EPILEPSY. SANAMED 2020. [DOI: 10.24125/sanamed.v15i3.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Samalin L, Godin O, Olié E, Etain B, Henry C, Pelletier A, Poinso F, Encely L, Mazer N, Roux P, Loftus J, Gard S, Bennabi D, Polosan M, Schwitzer T, Aubin V, Schwan R, Passerieux C, Bougerol T, Dubertret C, Aouizerate B, Haffen E, Courtet P, Bellivier F, Leboyer M, Llorca PM, Belzeaux R. Evolution and characteristics of the use of valproate in women of childbearing age with bipolar disorder: Results from the FACE-BD cohort. J Affect Disord 2020; 276:963-969. [PMID: 32745833 DOI: 10.1016/j.jad.2020.07.078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/19/2020] [Accepted: 07/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Valproate is associated with teratogenic and neurodevelopmental effects. Several agencies have restricted the conditions of its prescription in bipolar disorders (BD). We aimed to assess the evolution of valproate prescription and the clinical profile of BD women of childbearing age receiving valproate. METHODS Based on a large national cohort, we included all BD women 16-50 years old. Sociodemographic, clinical and pharmacological data were recorded. Logistic regression analyses were used to describe variables associated with valproate prescription. RESULTS Of the 1018 included women 16-50 years old, 26.9% were treated with valproate with a mean daily dosage of 968 mg. The prevalence of BD women using valproate was 32.6% before May 2015 and 17.3% after May 2015 (p<0.001), the date of French regulatory publication of restriction of valproate prescription. The multivariate analysis revealed that the inclusion period after May 2015 (OR=0.54, CI 95% 0.37-0.78, p=0.001), the age lower than 40 years (OR=0.65, CI 95% 0.43-0.98, p=0.040) and the number of lifetime mood episodes (OR=0.98, CI 95% 0.95-0.99, p=0.040) were the variables negatively associated with the use of valproate. LIMITATIONS Study could be underpowered to determine a clinical profile associated with valproate prescription. CONCLUSIONS The regulatory change in BD women of childbearing age had a significant impact on valproate prescription, even if the prescription rate remains high. Important efforts are needed to help clinicians and patients to improve quality of care in BD women of childbearing age.
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Affiliation(s)
- L Samalin
- Fondation Fondamental, Créteil, France; Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, EA 7280, Clermont-Ferrand, France.
| | - O Godin
- Fondation Fondamental, Créteil, France; INSERM U955, Équipe de Psychiatrie Translationnelle, Université Paris-Est Créteil, DHU Pe-PSY, Pôle de Psychiatrie des Hôpitaux Universitaires H Mondor, Créteil, France
| | - E Olié
- Fondation Fondamental, Créteil, France; Department of Emergency Psychiatry and Acute Care, CHU de Montpellier, PSNREC, University Montpellier, INSERM, Montpellier, France
| | - B Etain
- Fondation Fondamental, Créteil, France; AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences Tête et Cou, Département de Psychiatrie et de Médecine Addictologique, INSERM UMRS 1144, Université de Paris, Paris, France
| | - C Henry
- Department of Psychiatry, Service Hospitalo-Universitaire, GHU Paris Psychiatrie and Neurosciences, Université Descartes, Paris, France
| | - A Pelletier
- Fondation Fondamental, Créteil, France; AP-HP, DMU IMPACT, Psychiatry and Addictology of Mondor University Hospital, University Paris-Est-Créteil, Créteil, France
| | - F Poinso
- Pôle de Psychiatrie, APHM, Marseille, France; INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
| | - L Encely
- Pôle de Psychiatrie, APHM, Marseille, France; INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
| | - N Mazer
- Fondation Fondamental, Créteil, France; AP-HP, Groupe Hospitalo-universitaire AP-HP Nord, DMU ESPRIT, Service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Colombes, Inserm U1266, Faculté de Médecine, Université de Paris, France
| | - P Roux
- Fondation Fondamental, Créteil, France; Centre Hospitalier de Versailles, Service Universitaire de psychiatrie d'adulte et d'addictologie, Le Chesnay, EA 4047 HANDIReSP, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin-en-Yvelines, Equipe « PsyDev », CESP, Université Paris-Saclay, Inserm, 94807 Villejuif, France
| | - J Loftus
- Fondation Fondamental, Créteil, France; Department of Psychiatry, Princess-Grace Hospital, Monaco, Monaco
| | - S Gard
- Fondation Fondamental, Créteil, France; Department of Psychiatry, Princess-Grace Hospital, Monaco, Monaco
| | - D Bennabi
- Fondation Fondamental, Créteil, France; Department of Clinical Psychiatry, CIC-1431 INSERM, CHU de Besançon, EA481 Neurosciences, University Bourgogne Franche-Comté, France
| | - M Polosan
- Fondation Fondamental, Créteil, France; CHU Grenoble Alpes, Grenoble Institut Neurosciences, Inserm, U1216, University of Grenoble Alpes, Grenoble, France
| | - T Schwitzer
- Fondation Fondamental, Créteil, France; Centre Psychothérapique de Nancy, Pôle Hospitalo-universitaire de Psychiatrie d'Adultes du Grand Nancy, Laxou F-54520, France
| | - V Aubin
- Fondation Fondamental, Créteil, France; Department of Psychiatry, Princess-Grace Hospital, Monaco, Monaco
| | - R Schwan
- Fondation Fondamental, Créteil, France; Centre Psychothérapique de Nancy, Pôle Hospitalo-universitaire de Psychiatrie d'Adultes du Grand Nancy, Laxou F-54520, France
| | - C Passerieux
- Fondation Fondamental, Créteil, France; Centre Hospitalier de Versailles, Service Universitaire de psychiatrie d'adulte et d'addictologie, Le Chesnay, EA 4047 HANDIReSP, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin-en-Yvelines, Equipe « PsyDev », CESP, Université Paris-Saclay, Inserm, 94807 Villejuif, France
| | - T Bougerol
- Fondation Fondamental, Créteil, France; CHU Grenoble Alpes, Grenoble Institut Neurosciences, Inserm, U1216, University of Grenoble Alpes, Grenoble, France
| | - C Dubertret
- Fondation Fondamental, Créteil, France; AP-HP, Groupe Hospitalo-universitaire AP-HP Nord, DMU ESPRIT, Service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Colombes, Inserm U1266, Faculté de Médecine, Université de Paris, France
| | - B Aouizerate
- Fondation Fondamental, Créteil, France; Department of Clinical and Academic Psychiatry, Charles-Perrens Hospital, Bordeaux, France; NutriNeuro, UMR INRA 1286, University of Bordeaux, Bordeaux, France
| | - E Haffen
- Fondation Fondamental, Créteil, France; Department of Clinical Psychiatry, CIC-1431 INSERM, CHU de Besançon, EA481 Neurosciences, University Bourgogne Franche-Comté, France
| | - P Courtet
- Fondation Fondamental, Créteil, France; Department of Emergency Psychiatry and Acute Care, CHU de Montpellier, PSNREC, University Montpellier, INSERM, Montpellier, France
| | - F Bellivier
- Fondation Fondamental, Créteil, France; AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences Tête et Cou, Département de Psychiatrie et de Médecine Addictologique, INSERM UMRS 1144, Université de Paris, Paris, France
| | - M Leboyer
- Fondation Fondamental, Créteil, France; AP-HP, DMU IMPACT, Psychiatry and Addictology of Mondor University Hospital, University Paris-Est-Créteil, Créteil, France
| | | | - P M Llorca
- Fondation Fondamental, Créteil, France; Department of Psychiatry, CHU Clermont-Ferrand, University of Clermont Auvergne, EA 7280, Clermont-Ferrand, France
| | - R Belzeaux
- Fondation Fondamental, Créteil, France; Pôle de Psychiatrie, APHM, Marseille, France; INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
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14
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Quílez A, Baraldés-Rovira M, Gallego Y, Sanahuja J, Mauri-Capdevila G, Purroy F. Risk-benefit assessment of treatment of epileptic women of childbearing age with valproic acid. Seizure 2020; 82:27-30. [PMID: 32979602 DOI: 10.1016/j.seizure.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 01/31/2023] Open
Abstract
AIM Valproic acid (VPA) is a widely used anti-epileptic drug (AED) of demonstrated efficacy. However, its teratogenic effects have resulted in many regulatory agencies recommending that it should not be administered to women of childbearing age unless they are taking contraceptives. The aim of this study was to determine the willingness of candidate patients to change their treatment and to monitor the evolution of their attitude. METHODS We identified patients aged between 15 and 45 years old who had been diagnosed with epilepsy and were being treated with VPA. A shared decision-making visit was arranged, during which variables related to their epilepsy were recorded. The patients were informed about the teratogenic effects of VPA and the risks/benefits of a change in treatment. The patient, or legal guardian, then freely chose the course of treatment that they wished to follow. On a follow-up visit, six months later, seizure control and tolerance to the chosen treatment were recorded. The variables related to each patient's willingness to their change treatment were analysed. RESULTS A total of 60 patients, with a median age of 32.7 years, were included in the study. Of these, 25 (41.7%) suffered some form of intellectual disability. Only one (1.7%) had poor seizure control. After the initial visit, 41 patients (68%) opted to continue with the VPA treatment, six opted to stop receiving VPA, and 13 decided to switch to another AED. The median age of the patients who opted to change treatment was significantly lower than that of those who opted to continue with the VPA treatment (29.1 vs. 34.4, p = 0.024). The absence of intellectual disability (p = 0.047) and a length of treatment of less than five years (0.016) were both significantly associated with the decision to change treatment. Of the 19 patients who changed treatment, nine (47%) returned to the initial treatment with VPA. CONCLUSIONS Despite being informed of the teratogenic risk associated with VPA, a significant number of patients and legal guardians opted to continue with this treatment; the reasons given for this were the low possibility of pregnancy and the risk of breakthrough seizures. In almost half the cases studied, the pharmacological alternatives to VPA were poorly tolerated and did not provide a good level of seizure control.
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Affiliation(s)
- Alejandro Quílez
- Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain; Clinical Neurosciences group, Institut de Recerca Biomèdica (IRBLleida), UdL, Lleida, Spain
| | | | - Yhovany Gallego
- Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
| | - Jordi Sanahuja
- Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain; Clinical Neurosciences group, Institut de Recerca Biomèdica (IRBLleida), UdL, Lleida, Spain
| | - Gerard Mauri-Capdevila
- Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain; Clinical Neurosciences group, Institut de Recerca Biomèdica (IRBLleida), UdL, Lleida, Spain
| | - Francisco Purroy
- Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain; Clinical Neurosciences group, Institut de Recerca Biomèdica (IRBLleida), UdL, Lleida, Spain.
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15
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Understanding and Responding to Prescribing Patterns of Sodium Valproate-Containing Medicines in Pregnant Women and Women of Childbearing Age in Western Cape, South Africa. Drug Saf 2020; 44:41-51. [PMID: 32844313 PMCID: PMC7813724 DOI: 10.1007/s40264-020-00987-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Growing evidence of the teratogenic potential of sodium valproate (VPA) has changed prescribing practices across the globe; however, the impact of this research and the consequent dissemination of a Dear Health Care Professional Letter (DHCPL) in December 2015, recommending avoidance of the teratogen VPA in women of childbearing age (WOCBA) and pregnant women in South Africa, is unknown. We explored trends and reasons for VPA use among pregnant women and WOCBA in the public sector in Western Cape Province from 1 January 2015 to 31 December 2017. METHODS Using the provincial health information exchange that collates routine electronic health data via unique patient identifiers, we analysed clinical and pharmacy records from 2015 to 2017 to determine prescription patterns of VPA and other antiepileptic drug (AED) and mood-stabilising medicine (MSM) use in WOCBA and pregnant women. Senior clinicians and policy makers were consulted to understand the determinants of VPA use. RESULTS At least one VPA prescription was dispensed to between 8205 (0.79%) and 9425 (0.94%) WOBCA from a cohort of approximately 1 million WOCBA attending provincial health care facilities per year. Prescriptions were more likely in HIV-infected women compared with HIV-uninfected women (1.1-1.3% vs. 0.7-0.9%; p < 0.001). VPA use in WOCBA remained stable at 0.8-0.9% over the review period despite the 2016 DHCPL. VPA was the most prescribed AED/MSM, constituting 43.2-45.5% of all WOCBA taking at least one such agent, while lamotrigine, the other recommended first-line agent, was only prescribed in 7.8-8.9% of WOCBA. Over 3 years, approximately 663 pregnancies were exposed to VPA, with a steady rise in the number of exposures each year (n = 204, 214 and 245, respectively). CONCLUSION Despite warnings, VPA remained the most frequently prescribed AED or MSM in WOCBA. Contributing factors are described.
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Angus‐Leppan H, Moghim MM, Cock H, Kinton L, Synnott Wells M, Shankar R. Valproate risk form-Surveying 215 clinicians involving 4775 encounters. Acta Neurol Scand 2020; 141:483-490. [PMID: 32072612 DOI: 10.1111/ane.13231] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/17/2020] [Accepted: 02/11/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Annual completion of a Valproate Risk Acknowledgement Form (RAF) is mandated in the United Kingdom due to neurodevelopmental risks of in utero valproate exposure. The number of women of childbearing potential taking valproate, the uptake of the RAF within this population and their clinical outcomes is not known or monitored. This study surveyed responses of clinicians administering the RAF to women of childbearing potential taking valproate medications. MATERIALS AND METHODS Study design-national online survey distributed to clinical specialists throughout the United Kingdom via their national organizations. Participants-clinicians qualified to counsel and administer the valproate RAF (as defined by the Medicines and Healthcare products Regulatory Agency). Main outcome measures-quantitative and qualitative responses regarding identification, uptake, effects and reactions to the RAF. Trial registration-registered at the Clinical Governance and Audit Committee at Royal Free London NHS Foundation Trust Hospital. RESULTS 215 respondents covering more than 4775 patient encounters were captured. Most patients continued on valproate, 90% with epilepsy as the indication. Respondents reported that seizure control deteriorated when switched to levetiracetam (33%) and lamotrigine (43%), compared to 7% when continuing valproate (P < .001). CONCLUSIONS 33%-43% of clinicians reported seizure control deterioration in women changed to alternatives to valproate. Informed consent requires women considering a change are given this information. Systematic capture of data automated through online RAFs and linked to patient outcomes is needed. There remains little data on valproate given for indications other than epilepsy.
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Affiliation(s)
- Heather Angus‐Leppan
- Epilepsy Initiative Group Clinical Neurosciences Royal Free London NHS Foundation Trust London UK
- UCL Queen Square Institute of Neurology London UK
| | - Melika M. Moghim
- University College London Medical School University College London London UK
| | - Hannah Cock
- Institute of Molecular & Clinical Sciences St George's University of London London UK
- Atkinson Morley Regional Epilepsy Network St George's University Hospitals NHS Foundation Trust London UK
| | - Lucy Kinton
- Wessex Neurological Centre University Hospitals Southampton Southampton UK
| | - Marie Synnott Wells
- Department of Neurophysiology Guy's and St Thomas' NHS Foundation Trust London UK
| | - Rohit Shankar
- Cornwall Partnership NHS Foundation Trust Truro UK
- University of Exeter Medical School Exeter UK
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Kouremenos E, Arvaniti C, Constantinidis TS, Giannouli E, Fakas N, Kalamatas T, Kararizou E, Naoumis D, Mitsikostas DD. Consensus of the Hellenic Headache Society on the diagnosis and treatment of migraine. J Headache Pain 2019; 20:113. [PMID: 31835997 PMCID: PMC6911284 DOI: 10.1186/s10194-019-1060-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/18/2019] [Indexed: 01/03/2023] Open
Abstract
More than 0.6 million people suffer from disabling migraines in Greece causing a dramatic work loss, but only a small proportion of migraineurs attend headache centres, most of them being treated by non-experts. On behalf of the Hellenic Headache Society, we report here a consensus on the diagnosis and treatment of adult migraine that is based on the recent guidelines of the European Headache Federation, on the principles of Good Clinical Practice and on the Greek regulatory affairs. The purposes are three-fold: (1) to increase awareness for migraine in Greece; (2) to support Greek practitioners who are treating migraineurs; and (3) to help Greek migraineurs to get the most appropriate treatment. For mild migraine, symptomatic treatment with high dose simple analgesics is suggested, while for moderate to severe migraines triptans or non-steroidal anti-inflammatory drugs, or both, should be administered following an individually tailored therapeutic strategy. A rescue acute treatment option should always be advised. For episodic migraine prevention, metoprolol (50–200 mg/d), propranolol (40–240 mg/d), flunarizine (5–10 mg/d), valproate (500–1800 mg/d), topiramate (25–100 mg/d) and candesartan (16–32 mg/d) are the drugs of first choice. For chronic migraine prevention topiramate (100-200 mg/d), valproate (500–1800 mg/d), flunarizine (5–10 mg/d) and venlafaxine (150 mg/d) may be used, but the evidence is very limited. Botulinum toxin type A and monoclonal antibodies targeting the CGRP pathway (anti-CGRP mAbs) are recommended for patients suffering from chronic migraine (with or without medication overuse) who failed or did not tolerate two previous treatments. Anti-CGRP mAbs are also suggested for patients suffering from high frequency episodic migraine (≥8 migraine days per month and less than 14) who failed or did not tolerate two previous treatments.
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Affiliation(s)
| | - Chrysa Arvaniti
- Second Neurology Department, School of Medicine, National & Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | | | | | - Nikolaos Fakas
- Neurology Department, 401 Military General Hospital, Athens, Greece
| | | | - Evangelia Kararizou
- First Neurology Department, School of Medicine, National & Kapodistrian University of Athens, Aeginition Hospital, 72-74 Vl Sofia's Avenue, 11528, Athens, Greece
| | - Dimitrios Naoumis
- Neurology Department, 251 Air Force General Hospital, Athens, Greece
| | - Dimos D Mitsikostas
- First Neurology Department, School of Medicine, National & Kapodistrian University of Athens, Aeginition Hospital, 72-74 Vl Sofia's Avenue, 11528, Athens, Greece.
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Kostev K, Osina G, Rider F, Guekht A. Prevalence of valproate prescriptions in women of childbearing age in certain regions of Russia. Epilepsy Behav 2019; 101:106584. [PMID: 31675601 DOI: 10.1016/j.yebeh.2019.106584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 11/30/2022]
Abstract
AIM The goal of this retrospective study was to analyze the proportion of women with epilepsy who had received valproate (VPA) prescriptions in certain regions of Russia in 2018. METHODS This retrospective cross-sectional study was based on the IQVIA Russia longitudinal prescriptions (LRx) database and included all individuals with a documented epilepsy code (International Classification of Diseases, Tenth Revision [ICD-10]: G.40) from 13 regions in Russia who had received at least one prescription of an antiepileptic drug (AED). The prevalence of VPA prescriptions in female patients with epilepsy aged 16-45 years was analyzed by age group and epilepsy diagnosis code. A multivariate logistic regression model was used to study the association between predefined variables and the probability of having received a VPA prescription. RESULTS We found a total of 15,412 patients with epilepsy aged 16-45 who had received AED prescriptions in 2018 in the LRx database; 4488 (29.1%) of those patients were women. Of those, 64% had received at least one VPA prescription in 2018. The highest prevalence of VPA prescriptions was found in the age group 16-20 years (69%). This prevalence decreased with age. When compared with women aged 41-45 years, the 16-20-year-old age group was associated with a 1.6-fold increased probability of having receiving a VPA prescription (odds ratio [OR]: 1.60; p < 0.001), followed by the 21-25-year-old age group (OR: 1.46; p < 0.001). Nevertheless, the majority of women received VPA in low dosages (below 700 MG per day). CONCLUSIONS The prevalence of VPA prescriptions in women of childbearing age was quite high in Russia. The therapeutic doses were in line with international guidelines and had low teratogenic potential. Further research is needed to gain a better understanding of the reasons for prescribing VPA to women with epilepsy who are of childbearing age.
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Affiliation(s)
| | | | - Flora Rider
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia
| | - Alla Guekht
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
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