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Alshogran OY, Dodeja P, Albukhaytan H, Laffey T, Chaphekar N, Caritis S, Shaik IH, Venkataramanan R. Drugs in Human Milk Part 1: Practical and Analytical Considerations in Measuring Drugs and Metabolites in Human Milk. Clin Pharmacokinet 2024; 63:561-588. [PMID: 38748090 DOI: 10.1007/s40262-024-01374-3] [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] [Accepted: 02/11/2024] [Indexed: 05/22/2024]
Abstract
Human milk is a remarkable biofluid that provides essential nutrients and immune protection to newborns. Breastfeeding women consuming medications could pass the drug through their milk to neonates. Drugs can be transferred to human milk by passive diffusion or active transport. The physicochemical properties of the drug largely impact the extent of drug transfer into human milk. A comprehensive understanding of the physiology of human milk formation, composition of milk, mechanisms of drug transfer, and factors influencing drug transfer into human milk is critical for appropriate selection and use of medications in lactating women. Quantification of drugs in the milk is essential for assessing the safety of pharmacotherapy during lactation. This can be achieved by developing specific, sensitive, and reproducible analytical methods using techniques such as liquid chromatography coupled with mass spectrometry. The present review briefly discusses the physiology of human milk formation, composition of human milk, mechanisms of drug transfer into human milk, and factors influencing transfer of drugs from blood to milk. We further expand upon and critically evaluate the existing analytical approaches/assays used for the quantification of drugs in human milk.
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Affiliation(s)
- Osama Y Alshogran
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Prerna Dodeja
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hamdan Albukhaytan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Taylor Laffey
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nupur Chaphekar
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, UPMC Magee-Women's Hospital, Pittsburgh, PA, USA
| | - Imam H Shaik
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, 3501 Terrace Street, Room 7406, Salk Hall, Pittsburgh, PA, 15261, USA.
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Gallitelli V, Franco R, Guidi S, Puri L, Parasiliti M, Vidiri A, Eleftheriou G, Perelli F, Cavaliere AF. Depression Treatment in Pregnancy: Is It Safe, or Is It Not? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:404. [PMID: 38673317 PMCID: PMC11049910 DOI: 10.3390/ijerph21040404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
Prenatal depression carries substantial risks for maternal and fetal health and increases susceptibility to postpartum depression. Untreated depression in pregnancy is correlated with adverse outcomes such as an increased risk of suicidal ideation, miscarriage and neonatal growth problems. Notwithstanding concerns about the use of antidepressants, the available treatment options emphasize the importance of specialized medical supervision during gestation. The purpose of this paper is to conduct a brief literature review on the main antidepressant drugs and their effects on pregnancy, assessing their risks and benefits. The analysis of the literature shows that it is essential that pregnancy be followed by specialized doctors and multidisciplinary teams (obstetricians, psychiatrists and psychologists) who attend to the woman's needs. Depression can now be treated safely during pregnancy by choosing drugs that have no teratogenic effects and fewer side effects for both mother and child. Comprehensive strategies involving increased awareness, early diagnosis, clear guidelines and effective treatment are essential to mitigate the impact of perinatal depression.
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Affiliation(s)
- Vitalba Gallitelli
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | - Rita Franco
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | - Sofia Guidi
- Division of Gynecology and Obstetrics, IRCSS Azienda Ospedaliera-Universitaria of Bologna, 40138 Bologna, Italy;
| | - Ludovica Puri
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | - Marco Parasiliti
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | - Annalisa Vidiri
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | | | - Federica Perelli
- Azienda USL Toscana Centro, Gynecology and Obstetrics Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy;
| | - Anna Franca Cavaliere
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
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Nasr El-Din WA, Potu BK, Fadel RA, Salem AH, Sequeira RP, Almarabheh A, El-Fark MMO. Impact of maternal topiramate ingestion on ossification of skull and appendicular bones in rat fetuses. Morphologie 2024; 108:100702. [PMID: 37890283 DOI: 10.1016/j.morpho.2023.100702] [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: 05/18/2023] [Revised: 07/16/2023] [Accepted: 07/16/2023] [Indexed: 10/29/2023]
Abstract
The skull and appendicular bones are derived from different embryological sources during their development. The impact of prenatal exposure of topiramate on ossification of these bones is not adequately studied. The goal of this study was to assess the ossification patterns of the craniofacial bones and bones of the forelimbs and hindlimbs in 20-day-old rat fetuses after maternal exposure to topiramate at doses equivalent to human therapeutic doses. Three groups of Sprague-Dawley pregnant rats were used: control, topiramate 50mg/kg/day (T50) and topiramate 100mg/kg/day (T100). Topiramate was given by oral gavage from day 6 to day19 of gestation. Ossification was evaluated in the bones of 20 days fetuses after staining with Alizarin red. Results showed a significant reduction in complete ossified centers of the metacarpal, metatarsal and craniofacial bones in topiramate-exposed fetuses at both doses when compared to the control group. Also, a significant decrease in the length of ossified part of the long bones of the forelimbs and hindlimbs in topiramate-exposed fetuses at both doses was noted when compared to the control group. Crown-rump length and fetal weight were significantly decreased in topiramate treated groups compared to the control group. In all examined groups, there was a positive correlation between the crown-rump length and the lengths of humerus and femur. No abnormalities in the ossified bones and no significant changes in their ossification pattern were observed between the treated groups. In conclusion, prenatal administration of topiramate in doses equivalent to human therapeutic doses delayed ossification and development of craniofacial and appendicular bones in rat fetuses and their effects are not dose dependent at doses investigated. The implications of these findings in women who require topiramate therapy in pregnancy merit further evaluation.
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Affiliation(s)
- W A Nasr El-Din
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain; Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - B K Potu
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain.
| | - R A Fadel
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain; Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - A H Salem
- Department of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain; Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - R P Sequeira
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - A Almarabheh
- Department of Family and Community Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - M M O El-Fark
- Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Berman E, Erenburg N, Beloosesky R, Eyal S, Kovo M. Placental disposition of cannabidiol: An ex vivo perfusion study. Epilepsia 2023; 64:3354-3364. [PMID: 37777821 DOI: 10.1111/epi.17778] [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: 06/08/2023] [Revised: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE In the absence of safety data in humans, the use of cannabidiol (CBD) is not recommended during pregnancy. Yet >50% of pregnancies in women with epilepsy are unintended, making fetal exposure to CBD possible. As a small-molecule, highly lipid-soluble drug, CBD is likely to be distributed into the placenta and cross it. To estimate the placental distribution profile of CBD and its potential short-term placental effects, we conducted an ex vivo perfusion study in human placentas. METHODS Placentas were obtained from healthy women undergoing cesarean deliveries. Selected cotyledons were cannulated and perfused for 180 min with a CBD-containing medium (250 ng/mL, .796 μmol·L-1 ; representative of a low therapeutic concentration; n = 8). CBD concentrations were determined at 180 min in the medium and placental tissue using liquid chromatography-tandem mass spectrometry. A customized gene panel array was used to analyze the expression of selected genes in the perfused placental cotyledons as well as in placentas perfused with 1000 ng/mL CBD (3.18 μmol·L-1 ; high therapeutic concentration; n = 8) and in those exposed to the vehicle. RESULTS CBD was sequestered in the placental tissue, exhibiting significant variability across samples (median = 5342 ng/g tissue, range = 1066-9351 ng/g tissue). CBD concentrations in the fetal compartment were one fifth of those measured in the maternal compartment (median = 59 ng/mL, range = 48-72 ng/mL vs. 280 = ng/mL, range = 159-388 ng/mL, respectively; p < .01). Placental gene expression was not significantly altered by CBD. SIGNIFICANCE The placenta acts as a depot compartment for CBD, slowing down its distribution to the fetus. This phenomenon might yield flatter but prolonged fetal CBD levels in vivo. The attenuated transplacental CBD transfer does not imply that its use by pregnant women is safe for the fetus. Only pregnancy registries and neurocognitive assessments would establish the risk of being antenatally exposed to CBD.
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Affiliation(s)
- Erez Berman
- Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Natalia Erenburg
- Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Sara Eyal
- Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
- Multidisciplinary Center for Cannabinoid Research, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Schmidt CT, Deligiannidis KM, Kittel-Schneider S, Frodl T, Spigset O, Paulzen M, Schoretsanitis G. Transfer of anticonvulsants and lithium into amniotic fluid, umbilical cord blood & breast milk: A systematic review & combined analysis. Prog Neuropsychopharmacol Biol Psychiatry 2023; 124:110733. [PMID: 36805301 DOI: 10.1016/j.pnpbp.2023.110733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/21/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Data on the ability of anticonvulsants and lithium to enter fetal and newborn circulation has become increasingly available; here we estimated penetration ratios in a series of matrices from combined samples of pregnant/breastfeeding women treated with anticonvulsants or lithium. METHODS We conducted a systematic literature search in PubMed/EMBASE for studies with concentrations of anticonvulsants/lithium from maternal blood, amniotic fluid, umbilical cord blood and/or breast milk. Penetration ratios were calculated by dividing the concentrations in amniotic fluid, umbilical cord plasma or breast milk by the maternal concentrations. When data from multiple studies were available, we calculated combined penetration ratios, weighting studies' mean by study size. RESULTS Ninety-one eligible studies for brivaracetam, carbamazepine, clonazepam, ethosuximide, gabapentin, lacosamide, lamotrigine, levetiracetam, lithium, oxcarbazepine, perampanel, phenobarbital, phenytoin, pregabalin, primidone, topiramate, valproate, vigabatrin and zonisamide were identified. For amniotic fluid, the highest penetration ratios were estimated for levetiracetam (mean 3.56, range 1.27-5.85, n = 2) and lowest for valproate (mean 0.11, range 0.02-1.02, n = 57). For umbilical cord plasma, oxcarbazepine had the highest ratio (mean 1.59, range 0.11-4.33, n = 12) with clonazepam having the lowest (mean 0.55, range 0.52-0.59, n = 2). For breast milk, the highest ratios were observed for oxcarbazepine (mean 3.75, range 0.5-7.0, n = 2), whereas the lowest were observed for valproate (mean 0.04, range 0.01-0.22, n = 121). DISCUSSION We observed substantial variability between anticonvulsants and lithium regarding their ability to enter fetal/newborn circulation. Assessing concentrations of anticonvulsants and lithium in maternal samples can provide a surrogate of fetal/infant exposure, although patterns of concentration-dependent effects for maternal/neonatal safety are lacking.
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Affiliation(s)
- Chiara Theresa Schmidt
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, JARA - Translational Brain Medicine, Aachen, Germany
| | - Kristina M Deligiannidis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry at the Donald and Barbara Zucker, School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; The Departments of Obstetrics & Gynecology and Molecular Medicine at the Zucker, School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sarah Kittel-Schneider
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Thomas Frodl
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, JARA - Translational Brain Medicine, Aachen, Germany
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, JARA - Translational Brain Medicine, Aachen, Germany; Alexianer Hospital Aachen, Aachen, Germany
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry at the Donald and Barbara Zucker, School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland.
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Arabia G, De Martino A, Moro E. Sex and gender differences in movement disorders: Parkinson's disease, essential tremor, dystonia and chorea. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:101-128. [PMID: 36038202 DOI: 10.1016/bs.irn.2022.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Sex and gender-based differences in epidemiology, clinical features and therapeutical responses are emerging in several movement disorders, even though they are still not widely recognized. In this chapter, we summarize the most relevant evidence concerning these differences in Parkinson's disease, essential tremor, dystonia and chorea. Indeed, both sex-related biological (hormonal levels fluctuations) and gender-related variables (socio-cultural and environmental factors) may differently impact symptoms manifestation and severity, phenotype and disease progression of movement disorders on men and women. Moreover, sex differences in treatment responses should be taken into account in any therapeutical planning. Physicians need to be aware of these major differences between men and women that will eventually have a major impact on better tailoring prevention, treatment, or even delaying progression of the most common movement disorders.
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Affiliation(s)
- Gennarina Arabia
- Magna Graecia University, Movement Disorders Center, Neurology Unit, Catanzaro, Italy.
| | - Antonio De Martino
- Magna Graecia University, Movement Disorders Center, Neurology Unit, Catanzaro, Italy
| | - Elena Moro
- Grenoble Alpes University, CHU of Grenoble, Division of Neurology, Grenoble Institute of Neurosciences, Grenoble, France
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Nucera B, Brigo F, Trinka E, Kalss G. Treatment and care of women with epilepsy before, during, and after pregnancy: a practical guide. Ther Adv Neurol Disord 2022; 15:17562864221101687. [PMID: 35706844 PMCID: PMC9189531 DOI: 10.1177/17562864221101687] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/03/2022] [Indexed: 01/16/2023] Open
Abstract
Women with epilepsy (WWE) wishing for a child represent a highly relevant subgroup of epilepsy patients. The treating epileptologist needs to delineate the epilepsy syndrome and choose the appropriate anti-seizure medication (ASM) considering the main goal of seizure freedom, teratogenic risks, changes in drug metabolism during pregnancy and postpartum, demanding for up-titration during and down-titration after pregnancy. Folic acid or vitamin K supplements and breastfeeding are also discussed in this review. Lamotrigine and levetiracetam have the lowest teratogenic potential. Data on teratogenic risks are also favorable for oxcarbazepine, whereas topiramate tends to have an unfavorable profile. Valproate needs special emphasis. It is most effective in generalized seizures but should be avoided whenever possible due to its teratogenic effects and the negative impact on neuropsychological development of in utero-exposed children. Valproate still has its justification in patients not achieving seizure freedom with other ASMs or if a woman decides to or cannot become pregnant for any reason. When valproate is the most appropriate treatment option, the patient and caregiver must be fully informed of the risks associated with its use during pregnancies. Folate supplementation is recommended to reduce the risk of major congenital malformations. However, there is insufficient information to address the optimal dose and it is unclear whether higher doses offer greater protection. There is currently no general recommendation for a peripartum vitamin K prophylaxis. During pregnancy most ASMs (e.g. lamotrigine, oxcarbazepine, and levetiracetam) need to be increased to compensate for the decline in serum levels; exceptions are valproate and carbamazepine. Postpartum, baseline levels are reached relatively fast, and down-titration is performed empirically. Many ASMs in monotherapy are (moderately) safe for breastfeeding and women should be encouraged to do so. This review provides a practically oriented overview of the complex management of WWE before, during, and after pregnancy.
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Affiliation(s)
- Bruna Nucera
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria
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Koishikawa M, Furugen A, Ohyama N, Narumi K, Ishikawa S, Kobayashi M. Uptake of antiepileptic drugs in forskolin-induced differentiated BeWo cells: Alteration of gabapentin transport. Xenobiotica 2022; 52:405-412. [PMID: 35642749 DOI: 10.1080/00498254.2022.2085635] [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: 10/18/2022]
Abstract
Previous studies have indicated that the expression levels of several transporters are altered during placental trophoblast differentiation. However, changes in the transport activities of therapeutic agents during differentiation must be comprehensively characterised. Antiepileptic drugs, including gabapentin (GBP), lamotrigine (LTG), topiramate, and levetiracetam, are increasingly prescribed during pregnancy. The objective of this study was to elucidate differences in the uptake of antiepileptic drugs during the differentiation process.Human placental choriocarcinoma BeWo cells were used as trophoblast models. For differentiation into syncytiotrophoblast-like cells, cells were treated with forskolin.The uptake of GBP and LTG was lower in differentiated BeWo cells than in undifferentiated cells. In particular, the maximum uptake rate of GBP transport was decreased in differentiated BeWo cells. Furthermore, GBP transport was trans-stimulated by the amino acids His and Met. We investigated the profiles of amino acids in undifferentiated and differentiated BeWo cells. Supplementation with His and Met, which demonstrated trans-stimulatory effects on GBP uptake, restored GBP uptake in differentiated cells. The findings of this study suggest that drug transport in BeWo cells can be altered before and after differentiation, and that the altered GBP uptake could be mediated by the intracellular amino acid status.
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Affiliation(s)
- Mai Koishikawa
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University
| | - Ayako Furugen
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University
| | - Nanami Ohyama
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University
| | - Katsuya Narumi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University
| | | | - Masaki Kobayashi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University
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Shawahna R, Zaid L. Concentrations of antiseizure medications in breast milk of lactating women with epilepsy: A systematic review with qualitative synthesis. Seizure 2022; 98:57-70. [PMID: 35427849 DOI: 10.1016/j.seizure.2022.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/20/2022] [Accepted: 03/25/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Recent position papers and guidelines encourage women with epilepsy (WWE) to exclusively breastfeed their infants because the benefits to their infants outweigh the potential adverse effects caused by exposure to antiseizure medications (ASMs). OBJECTIVE The objectives of this review were: to evaluate concentrations of ASMs in breastmilk of lactating WWE, qualitatively synthesize evidence that can be used to estimate theoretical doses as estimated daily intake (EDI) and relative infant dose (RID) of ASMs, and to evaluate potential risks to infants as a result of exposure to ASMs from breastmilk. METHODS This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42020223645. The databases: MEDLINE/PubMed, EMBASE, CINAHL/EBSCO, COCHRANE, SpringerLink, ScienceDirect, Summon, WHO International Clinical Trials Registry Platform, and SCOPUS were systematically searched. A qualitative synthesis was adopted in this study. RESULTS A total of 15 records were included in this systematic review. The included studies reported levels of 8 ASMs in the breastmilk of WWE. The highest RIDs of carbamazepine, lamotrigine, primidone, phenobarbital, gabapentin, valproic acid, ethosuximide, levetiracetam, and topiramate were 3.70%, 36.33%, 4.96%, 3.15%, 4.37%, 1.90%, 31.49%, 12.50%, and 12.18%, respectively. Breastfeeding might be limited or even discontinued when signs of excessive sedation/drowsiness and/or poor weight gain are evident on infants exposed to primidone and phenobarbital, ethosuximide/primidone, or ethosuximide/phenobarbital. CONCLUSIONS Concentrations of ASMs can be detected in breastmilk of WWE and plasma/serum of infants exposed via breastmilk. Healthcare providers and WWE might use the findings of this study to make informed decisions on the safety of breastfeeding while taking ASMs.
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Rayhill M. Headache in Pregnancy and Lactation. Continuum (Minneap Minn) 2022; 28:72-92. [DOI: 10.1212/con.0000000000001070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Lai W, He S, Zhou D, Chen L. Managing reproductive problems in women with epilepsy of childbearing age. ACTA EPILEPTOLOGICA 2021. [DOI: 10.1186/s42494-021-00062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractGirls and women constitute nearly 50% of all epilepsy cases. Apart from the disease symptoms, epilepsy and antiseizure medications (ASMs) may also affect the reproductive function, pregnancy and even the health of their offspring. Therefore, it is very important to identify and summarize the problems and risks for women with epilepsy (WWE) of childbearing age, and offer internationally recognized methods through multidisciplinary collaboration. In this review, we summarize the reproduction-related problems with WWE and propose multidisciplinary management by epileptologists, gynecologists and obstetricians, as well as other experts, from preconception to delivery. Large, multicenter registries are needed to advance our knowledge on new ASMs and their effects on WWE and their offspring.
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12
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Monitoring topiramate concentrations at delivery and during lactation. Biomed Pharmacother 2021; 138:111446. [PMID: 33676308 DOI: 10.1016/j.biopha.2021.111446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine transplacental passage of topiramate and its transport to colostrum, mature maternal milk and breastfed infants, we examined data from 27 women treated with topiramate from 2004 to 2020. METHODS In this cohort study, maternal serum, umbilical cord serum, milk and infant serum levels were measured by gas chromatography in the delivery subgroup, the colostrum subgroup (3-4 days postpartum) and the mature milk subgroup (7-30 days postpartum). Paired umbilical cord serum, maternal serum, breastfed infant serum, and milk levels were used to assess the ratios of umbilical cord/maternal serum, milk/maternal serum and infant/maternal serum levels. RESULTS Topiramate levels varied from 1.0 to 7.1 mg/L in maternal serum and from 0.8 to 6.2 mg/L in umbilical cord serum, and the mean umbilical cord/maternal serum ratio was 0.93 ± 0.11. At 3-4 days after delivery, topiramate concentrations were 1.4-8.4 mg/L in maternal serum, 1.5-8.6 mg/L in milk and 0.3-4.4 mg/L in infant serum. The mean milk/maternal serum ratio was 0.99 ± 0.45, and the mean infant/maternal serum ratio was 0.25 ± 0.15. At 7-30 days after delivery, maternal serum levels varied from 1.9 to 9.7 mg/L, milk levels ranged from 2.3 to 10.6 mg/L and infant serum levels ranged from 0.3 to 6.5 mg/L. The mean milk/maternal serum ratio was 1.07 ± 0.31, and the mean infant/maternal serum ratio was 0.51 ± 0.27. CONCLUSIONS We extended information about free transplacental passage of topiramate and its extensive transport to maternal milk with lower serum concentrations in breastfed infants in the largest group of patients ever reported to our knowledge. DATA AVAILABILITY STATEMENT Authors declare that take full responsibility for the data, the analyses and interpretation, and the conduct of the research; that they have full access to all of the data; and that they have the right to publish all data. Authors were not participations in industry-sponsored research and corporate activities for evaluation of a manuscript.
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Johannessen Landmark C, Johannessen SI, Patsalos PN. Therapeutic drug monitoring of antiepileptic drugs: current status and future prospects. Expert Opin Drug Metab Toxicol 2020; 16:227-238. [DOI: 10.1080/17425255.2020.1724956] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Cecilie Johannessen Landmark
- Program for Pharmacy, Department of Life Sciences and Health, Faculty of Health Sciences, Metropolitan University, Oslo, Norway
- The National Center for Epilepsy, Sandvika, Oslo University Hospital, Oslo, Norway
- Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Svein I. Johannessen
- The National Center for Epilepsy, Sandvika, Oslo University Hospital, Oslo, Norway
- Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Philip N. Patsalos
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
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Abstract
The management of epilepsy during pregnancy involves optimizing seizure control for the mother, while ensuring the best outcome for the developing fetus. Preconception counseling regarding contraception, folic acid, and antiseizure medications (ASMs) will maximize positive outcomes. Folic acid supplementation is recommended to decrease risk of neural tube defects, similar to the general population, and has been associated with improved cognitive outcomes and decreased risk of autistic traits in offspring. Efforts should be made to optimize the ASM regimen before pregnancy to the fewest number of ASMs, lowest effective doses, with avoidance of more teratogenic agents such as valproic acid. Valproic acid is associated with the highest increased risk of major congenital malformations, as well as reduced cognitive outcomes and neurodevelopmental disorders. Decreasing or changing ASMs during pregnancy should be done with caution, as convulsive seizures have been associated with adverse fetal outcomes including cognitive impairment. Physiologic changes during pregnancy affect ASM levels and in turn, risk for seizures, necessitating frequent monitoring of ASM serum concentrations. Mothers should also be counseled postpartum about how the benefits of breastfeeding outweigh the transmission of medication into breast milk. Communication between providers (obstetrics and neurology) and pregnant women with epilepsy is essential.
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Affiliation(s)
- Rachael Benson
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States
| | - Alison Pack
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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van Casteren DS, van den Brink AM, Terwindt GM. Migraine and other headache disorders in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:187-199. [PMID: 32768088 DOI: 10.1016/b978-0-444-64240-0.00011-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Migraine prevalence is three times higher in women than in men during fertile years, which is mainly due to sex hormone differences. The majority of women suffering from migraine without aura report improvement of their migraine attacks during pregnancy. Migraine attacks with aura can also improve during pregnancy, but more often remain the same or worsen. Anovulation caused by lactation is generally associated with a decrease in migraine attacks in breastfeeding women. This chapter describes the current knowledge on acute and prophylactic treatment options of migraine and other primary headache disorders during pregnancy and lactation. Further, clinical profiles of secondary headaches during pregnancy and the postpartum period are summarized.
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Affiliation(s)
- Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
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Abstract
Movement disorders in women during pregnancy are uncommon. Therefore, high quality studies are limited, and guidelines are lacking for the treatment of movement disorders in pregnancy, thus posing a significant therapeutic challenge for the treating physicians. In this chapter, we discuss movement disorders that arise during pregnancy and the preexisting movement disorders during pregnancy. Common conditions encountered in pregnancy include but are not limited to restless legs syndrome, chorea gravidarum, Parkinson disease, essential tremor, and Huntington disease as well as more rare movement disorders (Wilson's disease, dystonia, etc.). This chapter summarizes the published literature on movement disorders and pharmacologic and surgical considerations for neurologists and physicians in other specialties caring for patients who are pregnant or considering pregnancy.
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Affiliation(s)
- Fang Ba
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Janis M Miyasaki
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Marmura MJ, Kumpinsky AS. Refining the Benefit/Risk Profile of Anti-Epileptic Drugs in Headache Disorders. CNS Drugs 2018; 32:735-746. [PMID: 30073584 DOI: 10.1007/s40263-018-0555-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Anti-epileptic drugs are among the most effective drugs for migraine prophylaxis, and will likely continue to have a role even as new therapies emerge. Topiramate and valproate are effective for the preventive treatment of migraine, and other medications such as gabapentin or lamotrigine may have a role in the treatment of those with allodynia or frequent aura, respectively. Oxcarbazepine, carbamazepine, phenytoin, gabapentin, and others may alleviate pain in trigeminal neuralgia. While many anti-epileptic drugs can be effective in those with migraine or other headaches, most of these agents can potentially cause serious side effects. In particular, valproate, topiramate, carbamazepine, and phenytoin may lead to adverse outcomes for infants of exposed mothers. Valproate should not be given to women of childbearing potential for migraine prevention.
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Affiliation(s)
- Michael J Marmura
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut ST #200, Philadelphia, PA, 19107, USA.
| | - Aliza S Kumpinsky
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut ST #200, Philadelphia, PA, 19107, USA
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Crettenand M, Rossetti AO, Buclin T, Winterfeld U. [Use of antiepileptic drugs during breastfeeding : What do we tell the mother?]. DER NERVENARZT 2018; 89:913-921. [PMID: 29487964 DOI: 10.1007/s00115-018-0496-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Knowledge about the passage of various antiepileptic drugs into breast milk and its consequences for the infant is limited. Faced with this uncertainty, breastfeeding is often discouraged for these patients. The aim of this study was to comprehensively review the available data regarding antiepileptic drugs during breastfeeding, to compare these data with information provided by the summary of product characteristics (SmPCs), and to provide recommendations for the use of these drugs in breastfeeding women. MATERIAL AND METHODS We performed a systematic literature review on breastfeeding data for 23 antiepileptic drugs. A breastfeeding compatibility score was developed and validated. The estimated score based on the literature review was compared with the estimated score based on recommendations provided by the SmPCs. RESULTS We identified 75 articles containing exposure and safety data for 15 antiepileptic agents during breastfeeding. The comparison between the score values based on the literature review and on the SmPCs revealed a very low degree of concordance (weighted kappa: 0.08). CONCLUSION Phenobarbital, primidone, carbamazepine, valproate and levetiracetam are probably compatible with breastfeeding. Treatment with phenytoin, ethosuximide, clonazepam, oxcarbazepine, vigabatrin, topiramate, gabapentin, pregabalin, lamotrigine and zonisamide can be authorized during breastfeeding, provided breastfed infants are carefully monitored for side effects. Since data on the use of mesuximide, clobazam, rufinamide, felbamate, lacosamide, sultiame, perampanel and retigabine are insufficient to adequately assess the risk for breastfed infants, use in breastfeeding women is in principle not recommended and should be carefully evaluated on a case by case basis. In practice, a risk-benefit analysis should be performed for each mother under antiepileptic treatment wishing to breastfeed her child, so that individual risk factors can adequately be taken into account when counseling the patient.
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Affiliation(s)
- M Crettenand
- Faculté de biologie et de médecine, Ecole de médecine, Université de Lausanne, Lausanne, Schweiz
| | - A O Rossetti
- Département des Neurosciences Cliniques, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Schweiz
| | - T Buclin
- Swiss Teratogen Information Service, Service de pharmacologie clinique, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Schweiz
| | - U Winterfeld
- Swiss Teratogen Information Service, Service de pharmacologie clinique, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Schweiz.
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Ornoy A, Weinstein-Fudim L, Ergaz Z. Antidepressants, Antipsychotics, and Mood Stabilizers in Pregnancy: What Do We Know and How Should We Treat Pregnant Women with Depression. Birth Defects Res 2017; 109:933-956. [DOI: 10.1002/bdr2.1079] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/02/2017] [Accepted: 06/06/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Asher Ornoy
- Laboratory of Teratology, Department of Medical Neurobiology; Hebrew University Hadassah Medical School; Jerusalem Israel
| | - Liza Weinstein-Fudim
- Laboratory of Teratology, Department of Medical Neurobiology; Hebrew University Hadassah Medical School; Jerusalem Israel
| | - Zivanit Ergaz
- Laboratory of Teratology, Department of Medical Neurobiology; Hebrew University Hadassah Medical School; Jerusalem Israel
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21
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Bank AM, Stowe ZN, Newport DJ, Ritchie JC, Pennell PB. Placental passage of antiepileptic drugs at delivery and neonatal outcomes. Epilepsia 2017; 58:e82-e86. [PMID: 28387929 DOI: 10.1111/epi.13733] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2017] [Indexed: 11/29/2022]
Abstract
Children of women treated with antiepileptic drugs (AEDs) are at increased risk of adverse outcomes detectable in the neonatal period, which may be associated with the amount of AEDs in the fetal circulation. Placental passage of AEDs can be measured by calculating the ratio of umbilical cord to maternal AED concentrations collected at delivery. The aims of this study were to determine the umbilical cord concentrations and umbilical-to-maternal ratios for AEDs, and whether higher cord concentrations are associated with increased risk of neonatal complications. AED cord and maternal blood concentrations from 70 mother-newborn dyads and neonatal complications were recorded. Logistic regressions were performed to determine the association between AED concentrations and complications. Mean umbilical-to-maternal ratios for total concentrations ranged from 0.79 for carbamazepine to 1.20 for valproic acid, and mean umbilical-to-maternal ratios for free concentrations ranged from 0.86 for valproic acid to 1.42 for carbamazepine, indicating complete placental passage. Neither umbilical cord concentrations nor umbilical-to-maternal ratios were associated with adverse neonatal outcomes. Additional investigations are warranted to delineate the relationship between quantified fetal AED exposure and neonatal complications.
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Affiliation(s)
- Anna M Bank
- Brigham and Women's Hospital, Boston, Massachusetts, U.S.A.,Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Zachary N Stowe
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A.,Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, U.S.A
| | - D Jeffrey Newport
- University of Miami Miller School of Medicine, Miami, Florida, U.S.A
| | - James C Ritchie
- Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Page B Pennell
- Brigham and Women's Hospital, Boston, Massachusetts, U.S.A.,Harvard Medical School, Boston, Massachusetts, U.S.A
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22
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McNally MA, Johnson J, Huisman TA, Poretti A, Baranano KW, Baschat AA, Stafstrom CE. SCN8A Epileptic Encephalopathy: Detection of Fetal Seizures Guides Multidisciplinary Approach to Diagnosis and Treatment. Pediatr Neurol 2016; 64:87-91. [PMID: 27659738 DOI: 10.1016/j.pediatrneurol.2016.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/30/2016] [Accepted: 08/07/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND SCN8A mutations are rare and cause a phenotypically heterogeneous early onset epilepsy known as early infantile epileptic encephalopathy type 13 (EIEE13, OMIM #614558). There are currently no clear genotype-phenotype correlations to help guide patient counseling and management. PATIENT DESCRIPTION We describe a patient with EIEE13 (de novo heterozygous pathogenic mutation in SCN8A - p.Ile240Val (ATT>GTT)) who presented prenatally with maternally reported intermittent, rhythmic movements that, when observed on ultrasound, were concerning for fetal seizures. Ultrasound also revealed abnormal developmental states. With maternal administration of levetiracetam, the rhythmic fetal movements stopped. After birth, the patient developed treatment-refractory multi-focal epilepsy confirmed by electroencephalogram. Neuroimaging revealed restricted diffusion in the superior cerebellar peduncles, a finding not reported previously in EIEE13. CONCLUSION This is the first report of EIEE13 associated with clinical prenatal-onset seizures. Ultrasonography can be useful for identifying fetal seizures, which may be treatable in utero. Ideally, the clinical approach to fetal seizures should involve a multidisciplinary team spanning the pre- and postnatal course to expedite early diagnosis and optimize management, as illustrated by this patient.
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Affiliation(s)
- Melanie A McNally
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thierry A Huisman
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrea Poretti
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin W Baranano
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet A Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carl E Stafstrom
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Rovnack MB, Gromelski JS. Medications and Breast-Feeding: A Guide for Pharmacists, Pharmacy Technicians, and other Healthcare Professionals Part III. J Pharm Technol 2016. [DOI: 10.1177/875512250402000304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective:To provide a guide for practicing pharmacists, pharmacy technicians, and other healthcare professionals so that they are able to counsel and advise breast-feeding mothers and fellow healthcare professionals on the safety and use of antiinfectives, vaccines, antiepileptics, benzodiazepines, psychotherapeutic drugs, and radiopharmaceuticals during breast-feeding.Data Sources:Primary texts used by the breast-feeding community ( Medications and Mothers' Milk, Drugs in Pregnancy and Lactation, Drugs and Human Lactation) were searched, as well as Micromedex, MEDLINE, PubMed, EMBASE, and EMBASE2 (1984–February 2004).Study Selection/Data Extraction:Multiple sources were used wherever available to validate the data, and primary articles were used to verify all tertiary source information. Search terms included breast-feeding, lactation, nursing, and medications, as well as specific drug names.Data Synthesis:Concerns regarding medication use during breast-feeding have caused mothers to either discontinue nursing or not take necessary medications. Complete avoidance of medications or cessation of breast-feeding is often unnecessary. Although there are drugs that can be harmful to nursing infants, breast-milk concentrations of most drugs are insufficient to cause any harm.Conclusions:Having objective and reliable information on medications enables pharmacists, pharmacy technicians, other healthcare providers, and mothers to make educated decisions regarding drug therapy and breast-feeding.
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Affiliation(s)
- Frank J Nice
- FRANK J NICE MS MPA DPA CPHP, Assistant Director, Clinical Neurosciences Program (CNP), National Institutes of Health (NIH), Bethesda, MD
| | - Deborah DeEugenio
- DEBORAH DeEUGENIO PharmD, at time of writing, Pharmacy Student (USP), CNP, NIH; now, Assistant Professor, School of Pharmacy, Temple University, Philadelphia, PA; Clinical Pharmacist, Jefferson Antithrombotics Therapy Service, Jefferson Heart Institute, Philadelphia
| | - Traci A DiMino
- TRACI A DiMINO PharmD, at time of writing, Pharmacy Student (USP), CNP, NIH; now, Adverse Event Specialist, Global Safety Surveillance & Epidemiology, Wyeth, Collegeville, PA
| | - Ingrid C Freeny
- INGRID C FREENY PharmD, at time of writing, Pharmacy Student (USP), CNP, NIH; now, Medical Student, Drexel University College of Medicine, Philadelphia
| | - Marissa B Rovnack
- MARISSA B ROVNACK PharmD, at time of writing, Pharmacy Student (Wilkes University), CNP, NIH; now, Clinical Staff Pharmacist, Lehigh Valley Hospital and Health Network, Allentown, PA
| | - Joseph S Gromelski
- JOSEPH S GROMELSKI PharmD, at time of writing, Pharmacy Student (Wilkes University), CNP, NIH; now, Pharmacist, Walmart, Baltimore, MD; Law Student, University of Maryland, Baltimore
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Amundsen S, Nordeng H, Nezvalová-Henriksen K, Stovner LJ, Spigset O. Pharmacological treatment of migraine during pregnancy and breastfeeding. Nat Rev Neurol 2016; 11:209-19. [PMID: 25776823 DOI: 10.1038/nrneurol.2015.29] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Migraine affects up to 25% of women of reproductive age. In the majority of these women, migraine improves progressively during pregnancy, but symptoms generally recur shortly after delivery. As suboptimally treated migraine in pregnancy could have negative consequences for both mother and fetus, the primary aim of clinicians should be to provide optimal treatment according to stage of pregnancy, while minimising possible risks related to drug therapy. Nonpharmacological approaches are always first-line treatment, and should also be used to complement any required drug treatment. Paracetamol is the preferred drug for acute treatment throughout pregnancy. If paracetamol is not sufficiently effective, sporadic use of sumatriptan can be considered. NSAIDs such as ibuprofen can also be used under certain circumstances, though their intake in the first and third trimesters is associated with specific risks and contraindications. Preventive treatment should only be considered in the most severe cases. In women contemplating pregnancy, counselling is essential to promote a safe and healthy pregnancy and postpartum period for the mother and child, and should involve a dialogue addressing maternal concerns and expectations about drug treatment. This Review summarizes current evidence of the safety of the most common antimigraine medications during pregnancy and breastfeeding, and provides treatment recommendations for use in clinical practice.
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Abstract
BACKGROUND Migraine is a chronic debilitating disorder. Selected antiepileptic drugs (AEDs) are proposed as preventives for migraine. Clinical efficacy and side effects of these AEDs are discussed. SUMMARY OF REVIEW The American Academy of Neurology and the American Society of Headache classify topiramate (TPM) and divalproex sodium (DVPX) as Level-A medications and recommend offering them to patients for migraine prophylaxis. Their mechanism(s) of actions remains not entirely known. Their recognized action as sodium channel blockers may affect the neural component of migraine pain. TPM or DVPX can be considered an obvious choice for those patients with a concomitant seizure disorder. Care must be taken to plan their treatment with their psychiatrist if a mood disorder is present. DVPX tends not to be prescribed as first/second choice due to its potential for weight gain and hepatotoxicity. TPM is generally first choice, but bears severe contraindications. Both medications require education on teratogenesis in childbearing women. Consideration of gabapentin, acetazolamide, leviteracetam, zonisamide, and carbamazipine may be given later as empiric options and in selected patients. Patients must be made aware that there is insufficient scientific support for their use in migraine. CONCLUSIONS Available AEDs to prophylactically treat migraine are few but of robust clinical efficacy. Special care needs to be exerted with respect to their side effects. Future research is needed for a better understanding of their mechanisms of action in migraine. Such research has the potential of providing some insight into the pathophysiology of migraine.
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Affiliation(s)
| | - Janine Good
- Department of Neurology, University of Vanderbilt, Nashville, TN, USA
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Laganà AS, Triolo O, D’Amico V, Cartella SM, Sofo V, Salmeri FM, Vrtačnik Bokal E, Spina E. Management of women with epilepsy: from preconception to post-partum. Arch Gynecol Obstet 2015; 293:493-503. [DOI: 10.1007/s00404-015-3968-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 11/16/2015] [Indexed: 02/07/2023]
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Alsaad AM, Chaudhry SA, Koren G. First trimester exposure to topiramate and the risk of oral clefts in the offspring: A systematic review and meta-analysis. Reprod Toxicol 2015; 53:45-50. [DOI: 10.1016/j.reprotox.2015.03.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 02/16/2015] [Accepted: 03/11/2015] [Indexed: 11/16/2022]
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Epilepsy and recommendations for breastfeeding. Seizure 2015; 28:57-65. [DOI: 10.1016/j.seizure.2015.02.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/27/2015] [Accepted: 02/10/2015] [Indexed: 02/08/2023] Open
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van der Meer DH, Wieringa A, Wegner I, Wilffert B, Ter Horst PGJ. Lactation studies of anticonvulsants: a quality review. Br J Clin Pharmacol 2015; 79:558-65. [PMID: 25291358 PMCID: PMC4386941 DOI: 10.1111/bcp.12524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 09/25/2014] [Indexed: 12/21/2022] Open
Abstract
AIM The aim of this review was to investigate the quality of the current literature on the transfer of anticonvulsants to breast milk to provide an overview of which anticonvulsants are in need of further research. METHODS We reviewed the quality of the available lactation studies for 19 anticonvulsants against the guidelines of the Food and Drug Administration (FDA) and the International Lactation Consultant Association (ILCA). RESULTS Except for one study on lamotrigine and one case report on gabapentin, no study on anticonvulsants had both the absolute infant dose (AID) and milk to plasma ratio (M : P) correctly assessed. Only one study on carbamazepine, phenytoin and vigabatrin was found that correctly assessed the AID. The main cause for this low number is the lack of essential details in published studies, since 25 of 62 studies were case reports, letters or abstracts. Other major shortcomings were the lack of information on sampling methods, the number of samples in a particular dose interval as well as the low number of study participants. CONCLUSION The quality of the current literature on the transfer of anticonvulsants to breast milk is low, except for lamotrigine, which makes it hard to draw conclusions about the safety of the use of anticonvulsants during the lactation period. Therefore, further research is needed.
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Affiliation(s)
- Douwe H van der Meer
- Department of Clinical Pharmacy, Isala Medical Centre, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
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Abstract
This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in breastfeeding women. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, the article reviews common medical conditions (eg, depression, hypertension, infections) in breastfeeding women and their appropriate treatment.
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Affiliation(s)
- Hilary Rowe
- Department of Pharmacy, Fraser Health Authority, Surrey, British Columbia, Canada
| | - Teresa Baker
- Texas Tech University School of Medicine, 1400 Coulter Street, Amarillo, Texas 79106, USA
| | - Thomas W Hale
- Texas Tech University School of Medicine, 1400 Coulter Street, Amarillo, Texas 79106, USA.
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Davanzo R, Bua J, Paloni G, Facchina G. Breastfeeding and migraine drugs. Eur J Clin Pharmacol 2014; 70:1313-24. [PMID: 25217187 DOI: 10.1007/s00228-014-1748-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 08/31/2014] [Indexed: 01/16/2023]
Abstract
PURPOSE Breastfeeding women may suffer from migraine. While we have many drugs for its treatment and prophylaxis, the majority are poorly studied in breastfeeding women. We conducted a review of the most common anti-migraine drugs (AMDs) and we determined their lactation risk. METHODS For each AMD, we collected all retrievable data from Hale's Medications and Mother Milk (2012), from the LactMed database (2014) of the National Library of Medicine, and from a MedLine Search of relevant studies published in the last 10 years. RESULTS According to our review, AMDs safe during breastfeeding are as follows: low-dose acetylsalicylic acid (ASA), ibuprofen, sumatriptan, metoprolol, propranolol, verapamil, amitriptyline, escitalopram, paroxetine, sertraline, acetaminophen, caffeine, and metoclopramide. AMDs compatible with breastfeeding but warranting caution are as follows: diclofenac, ketoprofen, naproxen, most new triptans, topiramate, valproate, venlafaxine, and cyproheptadine. Finally, high-dose ASA, atenolol, nadolol, cinnarizine, flunarizine, ergotamine, methysergide, and pizotifen are contraindicated. CONCLUSIONS According to our review, the majority of the revised AMDs were assessed to be compatible with breastfeeding.
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Affiliation(s)
- Riccardo Davanzo
- Division of Neonatology, Institute for Maternal and Child Health, IRCCS "BurloGarofolo", Trieste, Italy
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New antiepileptic drugs and women. Seizure 2014; 23:585-91. [DOI: 10.1016/j.seizure.2014.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 05/08/2014] [Accepted: 05/10/2014] [Indexed: 12/26/2022] Open
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Abstract
INTRODUCTION Migraine is a very common medical disorder characterized by attacks of moderate-severe headache, nausea and disability. Topiramate is an effective, popular prophylactic migraine treatment, which is approved for use in adults and adolescents. Due to its multiple mechanisms of action, topiramate has multiple potential safety issues, including systemic and CNS adverse events, which may complicate therapy. AREAS COVERED This review evaluates common adverse events as seen in the pivotal trials of topiramate for migraine as well as those observed in postmarketing studies. These include weight loss, metabolic acidosis, renal calculi, acute angle closure glaucoma, visual distortions and cognitive slowing. Topiramate use during pregnancy is associated with an increased risk of cleft lip. This review highlights both common and unusual safety issues associated with topiramate use, including important drug interactions and a comparison with other migraine prophylactic agents. EXPERT OPINION Topiramate is highly effective in migraine prophylaxis but clinicians using the drug need to be aware of the potential for bothersome or serious adverse events. When treating with topiramate, use a slow titration to the goal dose of 100 mg or the lowest dose, which helps prevent migraine.
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Affiliation(s)
- Michael J Marmura
- Thomas Jefferson University, Jefferson Headache Center, Department of Neurology , 900 Walnut Street, Suite 200, PA 19107 , USA +1 215 955 2243 ; +1 215 955 2060 ;
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Verrotti A, Scaparrotta A, Cofini M, Chiarelli F, Tiboni GM. Developmental neurotoxicity and anticonvulsant drugs: a possible link. Reprod Toxicol 2014; 48:72-80. [PMID: 24803404 DOI: 10.1016/j.reprotox.2014.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 04/05/2014] [Accepted: 04/18/2014] [Indexed: 01/16/2023]
Abstract
In utero exposure to antiepileptic drugs (AEDs) may affect neurodevelopment causing postnatal cognitive and behavioral alterations. Phenytoin and phenobarbital may lead to motor and learning dysfunctions in the pre-exposed children. These disorders may reflect the interference of these AEDs with the development of hippocampal and cerebellar neurons, as suggested by animal studies. Exposure to valproic acid may result in inhibition of neural stem cell proliferation and/or immature neuron migration in the cerebral cortex with consequent increased risk of neurodevelopmental impairment, such as autistic spectrum disorders. A central issue in the prevention of AED-mediated developmental effects is the identification of drugs that should be avoided in women of child-bearing potential and during pregnancy. The aim of this review is to explore the possible link between AEDs and neurodevelopmental dysfunctions both in human and in animal studies. The possible mechanisms underlying this association are also discussed.
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Affiliation(s)
- A Verrotti
- Department of Pediatrics, University of Perugia, Italy
| | - A Scaparrotta
- Department of Medicine and Aging Sciences, University "G. d'Annunzio" of Chieti-Pescara, Italy
| | - M Cofini
- Department of Pediatrics, University of Perugia, Italy
| | - F Chiarelli
- Department of Medicine and Aging Sciences, University "G. d'Annunzio" of Chieti-Pescara, Italy
| | - G M Tiboni
- Department of Medicine and Aging Sciences, University "G. d'Annunzio" of Chieti-Pescara, Italy.
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Italiano D, Perucca E. Clinical pharmacokinetics of new-generation antiepileptic drugs at the extremes of age: an update. Clin Pharmacokinet 2014; 52:627-45. [PMID: 23640503 DOI: 10.1007/s40262-013-0067-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Epilepsies occur across the entire age range, and their incidence peaks in the first years of life and in the elderly. Therefore, antiepileptic drugs (AEDs) are commonly used at the extremes of age. Rational prescribing in these age groups requires not only an understanding of the drugs' pharmacodynamic properties, but also careful consideration of potential age-related changes in their pharmacokinetic profile. The present article, which updates a review published in 2006 in this journal, focuses on recent findings on the pharmacokinetics of new-generation AEDs in neonates, infants, children, and the elderly. Significant new information on the pharmacokinetics of new AEDs in the perinatal period has been acquired, particularly for lamotrigine and levetiracetam. As a result of slow maturation of the enzymes involved in glucuronide conjugation, lamotrigine elimination occurs at a particularly slow rate in neonates, and becomes gradually more efficient during the first months of life. In the case of levetiracetam, elimination occurs primarily by renal excretion and is also slow at birth, but drug clearance increases rapidly thereafter and can even double within 1 week. In general, infants older than 2-3 months and children show higher drug clearance (normalized for body weight) than adults. This pattern was confirmed in recent studies that investigated the pediatric pharmacokinetics of several new AEDs, including levetiracetam, rufinamide, stiripentol, and eslicarbazepine acetate. At the other extreme of age, in the elderly, drug clearance is generally reduced compared with younger adults because of less efficient drug-metabolizing activity, decreased renal function, or both. This general pattern, described previously for several AEDs, was confirmed in recent studies on the effect of old age on the clearance of felbamate, levetiracetam, pregabalin, lacosamide, and retigabine. For those drugs which are predominantly eliminated by renal excretion, aging-related pharmacokinetic changes could be predicted by measuring creatinine clearance (CLCR). Overall, most recent findings confirm that age is a major factor influencing the pharmacokinetic profile of AEDs. However, pharmacokinetic variability at any age can be considerable, and the importance of other factors should not be disregarded. These include genetic factors, co-morbidities, and drug interactions, particularly those caused by concomitantly administered AEDs which induce or inhibit drug-metabolizing enzymes.
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Affiliation(s)
- Domenico Italiano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Probable topiramate-induced diarrhea in a 2-month-old breast-fed child - A case report. EPILEPSY & BEHAVIOR CASE REPORTS 2014; 2:22-3. [PMID: 25667861 PMCID: PMC4307966 DOI: 10.1016/j.ebcr.2013.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 12/20/2013] [Accepted: 12/23/2013] [Indexed: 11/20/2022]
Abstract
An infant developed a severe condition of recurrent and persistent watery diarrhea at 40 days of age. The child had been partially breast-fed, and the mother used topiramate for epilepsy. Hospital examination excluded a viral or bacterial infection and failed to identify any other potential cause. After two weeks, topiramate exposure was suspected to be the cause, and breast-feeding was suspended. The diarrhea ceased within 2 days. Analysis of the breast milk showed a topiramate concentration of 15.7 μmol/L (5.3 μg/mL). There is little information on the use of topiramate in breast-feeding women. The potential effects on the children are not known. Topiramate passes into breast milk, and the concentration may equal the therapeutic plasma concentration. In this case, the infant may have ingested up to 40% of the mother's weight-adjusted dose. Diarrhea is a well-known adverse reaction to topiramate and has the potential to cause serious electrolyte disturbances in neonates and infants. The condition improved rapidly after suspension of breast-feeding. Topiramate in breast milk may reach levels that cause adverse effects in infants. Based on the adverse reaction profile of topiramate and the milk concentration, the diarrhea was assessed as a probable adverse drug reaction in the infant.
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Sabers A, Petrenaite V. Pharmacokinetics of antiepileptic drugs in pregnancy. Expert Rev Clin Pharmacol 2014; 1:129-36. [DOI: 10.1586/17512433.1.1.129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Davanzo R, Dal Bo S, Bua J, Copertino M, Zanelli E, Matarazzo L. Antiepileptic drugs and breastfeeding. Ital J Pediatr 2013; 39:50. [PMID: 23985170 PMCID: PMC3844381 DOI: 10.1186/1824-7288-39-50] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 08/10/2013] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION This review provides a synopsis for clinicians on the use of antiepileptic drugs (AEDs) in the breastfeeding mother. METHODS For each AED, we collected all retrievable data from Hale's "Medications and Mother Milk" (2012), from the LactMed database (2013) of the National Library of Medicine, and from a MedLine Search of relevant studies in the past 10 years. RESULTS Older AEDs, such as carbamazepine, valproic acid, phenytoin, phenobarbital, primidone are considered to have a good level of safety during lactation, due to the long term clinical experience and the consequent amount of available data from the scientific literature. On the contrary, fewer data are available on the use of new AEDs. Therefore, gabapentin, lamotrigine, oxcarbazepine, vigabatrin, tiagabine, pregabalin, leviracetam and topiramate are compatible with breastfeeding with a less documented safety profile. Ethosuximide, zonisamide and the continue use of clonazepam and diazepam are contraindicated during breastfeeding. CONCLUSIONS Although the current available advice on the use of AEDs during breastfeeding, given by different accredited sources, present some contradictions, most AEDs can be considered safe according to our review.
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Affiliation(s)
- Riccardo Davanzo
- Division of Neonatology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Via dell'Istria 65/1, Trieste 34100, Italy.
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Abstract
Seizures during pregnancy complicate <1% of all gestations; however, they are associated with increased adverse maternal and perinatal outcomes (acute and long term). The differential diagnosis of seizures in pregnancy is extensive. Determining the underlying etiology is crucial in the management of these patients. Medical providers caring for pregnant women should be educated about possible etiologies of seizures during pregnancy and the importance of prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach with other specialties such as neurology. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of pregnancies complicated by seizures.
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Affiliation(s)
- Laura A Hart
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Reimers A, Brodtkorb E. Second-generation antiepileptic drugs and pregnancy: a guide for clinicians. Expert Rev Neurother 2013; 12:707-17. [PMID: 22650173 DOI: 10.1586/ern.12.32] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
When treating pregnant women with antiepileptic drugs (AEDs), clinicians have to balance potential fetal adverse effects against the risks of uncontrolled maternal disease. Only recently have emerging scientic data provided a rational basis for treatment decisions considering both aspects. The focus of research is currently moving from the first to the second AED generation. Lamotrigine is relatively well studied, and data on other novel AEDs, such as levetiracetam, oxcarbazepine, topiramate, zonisamide, gabapentin and pregabalin, are in progress. Safety issues appear to be favorable for lamotrigine, and preliminary results are also promising for levetiracetam and oxcarbazepine. Drugs metabolized by uridine-diphospate glucuronosyl transferase or excreted unchanged by the kidneys are particularly susceptible to increased body clearance during pregnancy. Lamotrigine is subject to both mechanisms, and therapeutic serum levels may sometimes be difficult to maintain. The authors review the recommendations and clinical research on modern AED treatment during pregnancy, highlighting current experience with second-generation drugs.
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Affiliation(s)
- Arne Reimers
- Department of Clinical Pharmacology, St. Olavs University Hospital, 7006 Trondheim, Norway
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Hutchinson S, Marmura MJ, Calhoun A, Lucas S, Silberstein S, Peterlin BL. Use of common migraine treatments in breast-feeding women: a summary of recommendations. Headache 2013; 53:614-27. [PMID: 23465038 PMCID: PMC3974500 DOI: 10.1111/head.12064] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Breast-feeding has important health and emotional benefits for both mother and infant, and should be encouraged. While there are some data to suggest migraine may improve during breast-feeding, more than half of women experience migraine recurrence with 1 month of delivery. Thus, a thorough knowledge base of the safety and recommended use of common acute and preventive migraine drugs during breast-feeding is vital to clinicians treating migraine sufferers. Choice of treatment should take into account the balance of benefit and risk of medication. For some of the medications commonly used during breast-feeding, there is not good evidence about benefits. METHODS A list of commonly used migraine medications was agreed upon by the 6 authors, who treat migraine and other headaches on a regular basis and are members of the Women's Special Interest Section of the American Headache Society. Each medication was researched by the first author utilizing widely accepted data sources, such as the American Academy of Pediatrics publication "The Transfer of Drugs and Other Chemicals Into Human Milk; Thomas Hale's manual Medications and Mothers Milk; Briggs, Freeman, and Yaffe's reference book Drugs in Pregnancy and Lactation; and the National Library of Medicine's Drugs and Lactation Database (LactMed) - a peer-reviewed and fully referenced database available online. RESULTS Many commonly used migraine medications may be compatible with breast-feeding based on expert recommendations. Ibuprofen, diclofenac, and eletriptan are among acute medications with low levels in breast milk, but studies of triptans are limited. Toxicity is a concern with aspirin due to an association with Reye's syndrome; sedation or apnea is a concern with opioids. Finally, preventive medications not recommended include zonisamide, atenolol, and tizanidine. CONCLUSIONS Several excellent resources are available for clinicians making treatment decisions in breast-feeding women. Clinicians treating migraine should discuss both acute and preventive treatment options shortly before and within a few months after delivery, keeping in mind the clinical features of the individual patient, and in consultation with their obstetrician and pediatrician. An awareness of the pharmacological data that are currently available and how to access that data may be helpful in making treatment decisions in this population.
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Affiliation(s)
- Susan Hutchinson
- Orange County Migraine and Headache Center, Irvine, CA 92604, USA
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Abstract
This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in women who are breastfeeding. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, common medical conditions and suitable treatments of depression, hypertension, infections and so forth for women who are breastfeeding are also reviewed.
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Affiliation(s)
- Hilary Rowe
- Maternal Fetal Medicine, Fraser Health, Surrey, British Columbia, Canada
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Tomson T, Landmark CJ, Battino D. Antiepileptic drug treatment in pregnancy: Changes in drug disposition and their clinical implications. Epilepsia 2013; 54:405-14. [DOI: 10.1111/epi.12109] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Torbjörn Tomson
- Department of Clinical Neuroscience; Karolinska Institutet; Stockholm; Sweden
| | - Cecilie Johannessen Landmark
- Department of Pharmacy and Biomedical Science; Faculty of Health Sciences; Oslo and Akershus University College of Applied Sciences; Oslo; Norway
| | - Dina Battino
- Epilepsy Center; Department of Neurophysiology; IRCCS Foundation Carlo Besta Neurological Institute; Milan; Italy
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Krishnamurthy KB. Managing epilepsy during pregnancy: assessing risk and optimizing care. Curr Treat Options Neurol 2012; 14:348-55. [PMID: 22711429 DOI: 10.1007/s11940-012-0184-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OPINION STATEMENT Epilepsy is the most common neurologic condition found in pregnancy. As such, all neurologists, internists, and obstetricians should know how to counsel women with epilepsy as they are considering pregnancy. While all of the usual recommendations for women of childbearing potential apply, including preconceptual and ongoing use of folic acid, calcium, and vitamin D, additional consideration must be given to the need for adjustment or change of anticonvulsant therapy. Monotherapy with the lowest dose of medication needed to control seizures should be prescribed prior to conception. Most anticonvulsants have a favorable profile when used in pregnancy; older anticonvulsants such as valproate and carbamazepine should be avoided, as they are associated with higher rates of fetal malformation, and in the case of valproate, with proven cognitive deficits in children exposed to this medication in utero. With use of any anticonvulsant medication, dosing throughout pregnancy will need to be adjusted to maintain an appropriate serum concentration. Dosing of anticonvulsants needs to be decreased after delivery to avoid medication-related toxicity, although sleep deprivation and hormonal fluctuation can increase the risk of seizures in postpartum women. With proper management, the majority of women with epilepsy can have uneventful pregnancies and healthy babies.
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Effects of Levetiracetam on neural tube development and closure of the chick embryos in ovo. Childs Nerv Syst 2012; 28:969-76. [PMID: 22570165 DOI: 10.1007/s00381-012-1758-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Effects of Levetiracetam (LEV) within its therapeutic range at a 50 mg/kg dose for the chick embryo in ovo has been studied in order to demonstrate whether LEV would effect neural tube closure at the macroscopic morphology or LEV administered embryos still encounter neuroglial detrimental effects at the histological level. METHODS Embryos were randomly seperated into control (n = 20) and study (n = 20) groups. The eggshell was windowed at specifically 24 h of incubation, and area underlying the membrane was excised to allow injection with 4.5 μl LEV in the study group, while physiologic saline (0.045 ml) were injected in the control group and each egg were re-incubated for 48 h more. Then, histological and immunohistochemical evaluation of the subjects were done. RESULTS Macroscopic evaluation revealed immaturity of the placental vessel network in number and width for the study group in comparison to the controls. Defects of migration, decrease in the crista neuralis content, delay of the basal plates structures in the formation of the usual configuration, and delay in the cellular proliferation and the delay of development for the central nervous system were determined in the LEV-exposed group. Immunostaining of S100 proteins in this study has clearly demonstrated increased expression patterns of both neuroglial and neuronal cell populations. Toluidine blue stainings revealed mostly bipolar, differentiating neurons and crista neuralis cells which is concordant with active migration and differentiation. CONCLUSIONS LEV found that delay in the closure of the neural tube and microcephalic fetuses disturb further morphological, biochemical, and functional development.
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Johannessen Landmark C, Johannessen SI, Tomson T. Host factors affecting antiepileptic drug delivery-pharmacokinetic variability. Adv Drug Deliv Rev 2012; 64:896-910. [PMID: 22063021 DOI: 10.1016/j.addr.2011.10.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 10/11/2011] [Accepted: 10/14/2011] [Indexed: 01/16/2023]
Abstract
Antiepileptic drugs (AEDs) are the mainstay in the treatment of epilepsy, one of the most common serious chronic neurological disorders. AEDs display extensive pharmacological variability between and within patients, and a major determinant of differences in response to treatment is pharmacokinetic variability. Host factors affecting AED delivery may be defined as the pharmacokinetic characteristics that determine the AED delivery to the site of action, the epileptic focus. Individual differences may occur in absorption, distribution, metabolism and excretion. These differences can be determined by genetic factors including gender and ethnicity, but the pharmacokinetics of AEDs can also be affected by age, specific physiological states in life, such as pregnancy, or pathological conditions including hepatic and renal insufficiency. Pharmacokinetic interactions with other drugs are another important source of variability in response to AEDs. Pharmacokinetic characteristics of the presently available AEDs are discussed in this review as well as their clinical implications.
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Metcalfe A, Roberts JI, Abdulla F, Wiebe S, Hanson A, Federico P, Jette N. Patient knowledge about issues related to pregnancy in epilepsy: a cross-sectional study. Epilepsy Behav 2012; 24:65-9. [PMID: 22481038 DOI: 10.1016/j.yebeh.2012.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 03/01/2012] [Accepted: 03/02/2012] [Indexed: 11/18/2022]
Abstract
In 2009, new guidelines were established by the American Academy of Neurology regarding pregnancy in women with epilepsy. A questionnaire was developed to assess patient knowledge of current guidelines related to epilepsy and pregnancy. Patients were recruited from a single outpatient clinic in a large Canadian tertiary care center. Patients were eligible to participate if they were female, of reproductive age, had active epilepsy for at least 6 months and were not cognitively impaired. One hundred women completed the survey (response rate 87%) with a median score of 40%. A significant association was found between total score and years of education (p<0.001). Significant associations were not found between total score and epilepsy duration (p=0.37), previously being pregnant (p=0.22), and polytherapy (p=0.31). Patient knowledge of the impact of epilepsy on pregnancy is low. More knowledge translation efforts are required to increase knowledge of issues related to pregnancy for women with epilepsy.
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Affiliation(s)
- Amy Metcalfe
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
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Craig JJ. Do lamotrigine and levetiracetam solve the problem of using sodium valproate in women with epilepsy? Obstet Med 2012; 5:6-13. [PMID: 27579124 PMCID: PMC4989683 DOI: 10.1258/om.2011.110071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2011] [Indexed: 05/30/2024] Open
Abstract
Women with epilepsy, especially those of child-bearing age, are faced with difficult choices when it comes to choosing the most suitable antiepileptic drug (AED). This is particularly so for those with idiopathic generalized epilepsies, or those for whom seizure syndrome is not immediately apparent, where sodium valproate is still considered the drug of choice. While with treatment most might expect to become seizure free, without any adverse effects, other considerations for women mean that valproate is usually initially avoided, with other AEDs such as lamotrigine or levetiracetam being chosen in preference. Based on current information, this article attempts to provide an overview on whether or not the availability of these and other broad-spectrum AEDs have solved the difficulties of using valproate in women of child-bearing age.
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Affiliation(s)
- John J Craig
- Department of Neurology, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, Antrim BT12 6BA, UK
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Landmark CJ, Johannessen SI. Safety aspects of antiepileptic drugs-focus on pharmacovigilance. Pharmacoepidemiol Drug Saf 2011; 21:11-20. [DOI: 10.1002/pds.2269] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 08/22/2011] [Accepted: 09/19/2011] [Indexed: 11/10/2022]
Affiliation(s)
- Cecilie Johannessen Landmark
- Institute of Pharmacy and Biomedical Sciences; Faculty of Health Sciences; Oslo Norway
- Akershus University; College of Applied Sciences; Oslo Norway
| | - Svein I. Johannessen
- The National Center for Epilepsy; Sandvika Norway
- Department of Pharmacology; Oslo University Hospital; Oslo Norway
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