1
|
Gandelman-Marton R, Theitler J. Folic acid supplementation in women of childbearing age with epilepsy: No association with type or number of antiepileptic drugs. Birth Defects Res 2024; 116:e2283. [PMID: 38093463 DOI: 10.1002/bdr2.2283] [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: 08/05/2023] [Revised: 10/21/2023] [Accepted: 11/15/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND For over two decades, a daily folic acid (FA) supplementation has been recommended for women of childbearing age with epilepsy. This recommendation is based on evidence that FA administration before conception and during pregnancy can decrease the risk of fetal malformations in the general population, improve cognitive development, and reduce the risk of autistic traits in children exposed in utero to antiepileptic drugs (AEDs). OBJECTIVE The aim of this study was to evaluate FA supplementation rate in nonpregnant women of childbearing age with epilepsy and its relation to AED type and number. METHODS We retrospectively reviewed the computerized database and the medical records of all the women who had a first visit to our outpatient epilepsy clinic (Shamir-Assaf Harofeh Medical Center, Zerifin, Israel) during a 10-year period (2012-2021). RESULTS Only 61 (22%) of 282 nonpregnant women of childbearing age with epilepsy treated with AEDs received FA supplementation. Ninety-two (33%) of the women were treated with AED polytherapy, and 41 (15%) received valproic acid in monotherapy or polytherapy. FA supplementation rate was higher in women aged ≤40 versus >40 (25% vs. 8.5%) (p = .004). No correlation was found between FA supplementation and AED type or number. CONCLUSIONS FA supplementation rate was low and was unaffected by AED treatment. Patient and physician-targeted interventions should be implemented to increase FA prescription and patient adherence.
Collapse
Affiliation(s)
- Revital Gandelman-Marton
- Neurology Department, Shamir-Assaf Harofeh Medical Center, Zerifin, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacques Theitler
- Neurology Department, Shamir-Assaf Harofeh Medical Center, Zerifin, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
2
|
von Wrede R, Witt JA, Auvin S, Devlin A, Lagae L, Marson A, Meador KJ, O'Brien TJ, Park J, Surges R, Trinka E, Wiebe S, Helmstaedter C. Unjustified allegation on cancer risks in children of mothers with epilepsy taking high-dose folic acid during pregnancy-No proof of a causal relationship. Epilepsia 2023; 64:2239-2243. [PMID: 37309815 DOI: 10.1111/epi.17680] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Randi von Wrede
- Department of Epileptology, University Hospital Bonn, Member of the European Reference Network EpiCARE, Bonn, Germany
| | - Juri-Alexander Witt
- Department of Epileptology, University Hospital Bonn, Member of the European Reference Network EpiCARE, Bonn, Germany
| | - Stéphane Auvin
- Department of Pediatric Neurology, AP-HP, Robert-Debré University Hospital, CRMR Épilepsies Rares, EpiCARE Member, Paris, France
- Université Paris Cité, INSERM NeuroDiderot, Paris, France
- Institut Universitaire de France (IUF), Paris, France
| | - Anita Devlin
- Great North Children's Hospital, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute Newcastle University, Newcastle upon Tyne, UK
| | - Lieven Lagae
- Department Development and Regeneration, KU Leuven, Member of the European Reference Network EpiCARE, Leuven, Belgium
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- The Walton Centre, NHS Foundation Trust, Liverpool, UK
| | - Kimford J Meador
- Department of Neurology & Neurological Sciences, Stanford University, Palo Alto, California, USA
| | - Terence J O'Brien
- The Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jun Park
- UH Rainbow Babies & Children's Hospital/UH Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Member of the European Reference Network EpiCARE, Bonn, Germany
| | - Eugen Trinka
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
- Christian Doppler Medical Centre, Centre for Cognitive Neuroscience, Member of the European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Christian Doppler Medical Centre, Centre for Cognitive Neuroscience, Salzburg, Austria
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, UMIT, Hall in Tyrol, Austria
| | - Samuel Wiebe
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Christoph Helmstaedter
- Department of Epileptology, University Hospital Bonn, Member of the European Reference Network EpiCARE, Bonn, Germany
| |
Collapse
|
3
|
Lo CB, Conrad B, Debs A, Herbst J, Kulkarni N, Nelson DM, Wentzel E, Cohen DM, Patel AD. Counseling on the Need for Folic Acid in Adolescents With Epilepsy. Neurol Clin Pract 2023; 13:e200177. [PMID: 37529297 PMCID: PMC10389172 DOI: 10.1212/cpj.0000000000200177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 05/09/2023] [Indexed: 08/03/2023]
Abstract
Background and Objectives Folic acid is an important supplement to take for women with epilepsy on antiseizure medications (ASMs). Determination of baseline counseling given to women with epilepsy and the association with folic acid being recommended were evaluated. Factors surrounding the association were reviewed. Methods An exploratory retrospective review of women with epilepsy seen at a large Midwestern pediatric institution was performed between January 2018 and January 2020. Results Patients who received preconception counseling were more likely to be given a recommendation to take folic acid. Patients on more than 1 ASM were likely to receive counseling. Patient age and race were associated with having folic acid recommended. Discussion Providing preconception counseling for women with epilepsy is associated with an increased recommendation and prescription of folic acid. Further evaluation into possible disparities to receiving a folic acid recommendation is needed.
Collapse
Affiliation(s)
- Charmaine B Lo
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Bailey Conrad
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Andrea Debs
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - James Herbst
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Neil Kulkarni
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Dustin Mark Nelson
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Evelynne Wentzel
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Daniel M Cohen
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Anup D Patel
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| |
Collapse
|
4
|
Sokou R, Parastatidou S, Iliodromiti Z, Lampropoulou K, Vrachnis D, Boutsikou T, Konstantinidi A, Iacovidou N. Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases. Nutrients 2023; 15:2822. [PMID: 37447149 DOI: 10.3390/nu15132822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.
Collapse
Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Elena Venizelou" Maternity Hospital, 11521 Athens, Greece
| | - Zoi Iliodromiti
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Katerina Lampropoulou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45110 Ioannina, Greece
| | - Dionysios Vrachnis
- Endocrinology Unit, 2nd Department of Obstetrics and Gynecology, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Aikaterini Konstantinidi
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| |
Collapse
|
5
|
Lopes das Neves P, Ventura R, Sobral-Pinho A, Silva E, Morgadinho A, Vitor J, Miranda M, Madureira B, Moniz Dionísio J, Pinheiro R, Delgado S, Carapinha D, Rego A, S Á F, Pelejão MR, Antunes F, Marques I, Brito da Silva V, Castro Sousa S, Peres J, Martins A, Tojal R. [Evaluation of the Knowledge of Women of Childbearing Age with Epilepsy about the Impact of Their Disease in Contraception, Pregnancy and Breastfeeding: A Multicenter Cross-Sectional Study]. ACTA MEDICA PORT 2023. [PMID: 36977340 DOI: 10.20344/amp.19156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/31/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION The interaction of antiseizure medication with contraceptives, its potential teratogenicity and implications in pregnancy and breastfeeding are aspects to consider in the neurological care of women with epilepsy of childbearing age. To ensure the commitment in therapeutic decisions and the appropriate planning of maternity, it is essential that women are informed about the implications of their disease in these domains. The main aim of this study was to assess the knowledge of women of childbearing age with epilepsy concerning the impact of epilepsy in contraception, pregnancy and breastfeeding. As secondary aims we defined (1) the demographic, clinical and therapeutic characterization of this group of patients, (2) the identification of variables that correlated with the level of knowledge of women with epilepsy, and (3) the identification of preferential methods to acquire new knowledge about epilepsy. MATERIAL AND METHODS The study was observational, cross-sectional and multicentric, and was carried out in five hospitals of the Lisbon metropolitan area. After identifying all women of childbearing age with epilepsy followed in the epilepsy clinic of each center, we applied an electronic questionnaire based on a non-systematic review of the literature. RESULTS One hundred and fourteen participants were validated, with a median age of 33 years. Half of the participants were on monotherapy, and the majority had no seizures in the last six months. We identified important gaps in the participants' knowledge. Sections about complications and administration of antiseizure medication during pregnancy were the ones with the worst results. None of the clinical and demographic variables correlated with the final questionnaire score. Having had a previous pregnancy and the desire to breastfeed in a future pregnancy were positively correlated with the performance in breastfeeding section. Face-to-face discussion during medical outpatient visits was selected as the preferential method to learn about epilepsy, and the internet and social media were the least preferred ones. CONCLUSION The knowledge of women of childbearing age with epilepsy in the Lisbon metropolitan area concerning the impact of epilepsy in contraception, pregnancy and breastfeeding seems to have significant gaps. Medical teams should consider engaging in patient education particularly during outpatient clinics.
Collapse
Affiliation(s)
- Pedro Lopes das Neves
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Rita Ventura
- Serviço de Neurologia. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | - André Sobral-Pinho
- Serviço de Neurologia. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | - Elisa Silva
- Serviço de Neurologia. Hospital Garcia de Orta. Almada. Portugal
| | | | - Joana Vitor
- Serviço de Neurologia. Hospital Beatriz Ângelo. Loures. Portugal
| | - Miguel Miranda
- Serviço de Neurologia. Hospital de Cascais Dr. José de Almeida. Cascais. Portugal
| | - Beatriz Madureira
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Joana Moniz Dionísio
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Rita Pinheiro
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Sofia Delgado
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Duarte Carapinha
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - André Rego
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Francisca S Á
- Serviço de Neurologia. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | - Maria Rita Pelejão
- Serviço de Neurologia. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | | | - Inês Marques
- Serviço de Neurologia. Hospital Garcia de Orta. Almada. Portugal
| | | | - Sandra Castro Sousa
- Serviço de Neurologia. Hospital de Cascais Dr. José de Almeida. Cascais. Portugal
| | - João Peres
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - António Martins
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Raquel Tojal
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| |
Collapse
|
6
|
Ma X, Li Y, Li J, Zhou D, Yang R. Construction of nursing-sensitive quality indicators for epilepsy in China: A Delphi consensus study. Seizure 2023; 107:71-80. [PMID: 36989923 DOI: 10.1016/j.seizure.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2023] Open
Abstract
OBJECTIVE The quality and safety of epilepsy care are of great importance because seizures are unpredictable. The aim of this study was to develop a set of nursing-sensitive quality indicators (NSQIs) for assessing and improving the quality of epilepsy nursing care in China. METHODS An international literature review, a cross-sectional survey and a qualitative study were conducted to identify candidate NSQIs for epilepsy care and compile a questionnaire. Then, two rounds of electronic Delphi studies were conducted with a panel of 27 independent experts to identify the final NSQIs for epilepsy. RESULTS Thirty-nine candidate NSQIs were extracted for the Delphi process. The recovery rates in the first and second rounds of expert consultations were 92.6% and 96.2%, respectively. The experts' authority coefficients of the two rounds were 0.876 and 0.878, respectively. The Kendall W value of the two rounds ranged between 0.094 and 0.200 (p<0.001). Eight structure indicators, 9 process indicators and 7 outcome indicators that represented the following three domains were included in the set of NSQIs for epilepsy: nursing resource allocation, implementation of nursing care, and outcomes of patients with epilepsy. CONCLUSION These NSQIs for epilepsy provide a primary foundation for monitoring and improving the quality of epilepsy nursing care in China. However, the effects of these indicators on improvements in epilepsy care and outcomes in patients need to be verified in clinical practice.
Collapse
|
7
|
Yan R, Tuo J, Tai Z, Zhang H, Yang J, Yu C, Xu Z. Management of anti-seizure medications in lactating women with epilepsy. Front Neurol 2022; 13:1005890. [PMID: 36468043 PMCID: PMC9712755 DOI: 10.3389/fneur.2022.1005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/28/2022] [Indexed: 09/10/2024] Open
Abstract
Epilepsy is a common neurological disease. At present, there are about 70 million epilepsy patients in the world, half of them are women, and 30-40% of women with epilepsy are of childbearing potential. Patients with epilepsy who are of childbearing potential face more challenges, such as seizures caused by hormonal fluctuations and the risk of adverse effects on the mother and baby from taking anti-seizure medications (ASMs). Breast milk is one of the best gifts that a mother can give her baby, and breastfeeding can bring more benefits to the baby. Compared with healthy people, people with epilepsy have more concerns about breastfeeding because they are worried that ASMs in their milk will affect the growth and development of the baby, and they are always faced with the dilemma of whether to breastfeed after childbirth. Regarding, whether women with epilepsy can breastfeed while taking ASMs, and whether breastfeeding will adversely affect the baby is still an important topic of concern for patients and doctors. This article reviews the existing research on breastfeeding-related issues in women with epilepsy to guide clinical practice, and improve the breastfeeding compliance of women with epilepsy.
Collapse
Affiliation(s)
- Rong Yan
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jinmei Tuo
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhenzhen Tai
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Haiqing Zhang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Juan Yang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Changyin Yu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Zucai Xu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| |
Collapse
|
8
|
LoPinto-Khoury C. Long-Term Effects of Antiseizure Medications. Semin Neurol 2022; 42:583-593. [PMID: 36216358 DOI: 10.1055/a-1958-0802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Most patients with epilepsy will benefit from seizure control with one of an array of chronic antiseizure medications. Knowledge of the potential long-term effects of these medications is critical to prevent adverse consequences on overall health. Antiseizure medications vary in their capacities to affect the brain and peripheral nerves, hormones, bone mineralization, cardiovascular risk, renal health, hepatic, hematological, and dermatological systems. Understanding of pathophysiology and population risk has evolved, although most of the data available are still on older generation antiseizure medications such as phenytoin, carbamazepine, and valproic acid. The enzyme-inducing properties of some antiseizure medications make their effects on cardiovascular risk and bone health detrimental. Few clear guidelines exist for monitoring long-term effects of medication therapy for epilepsy. When selecting an antiseizure medication, consideration should be given to the individual patient's risks of adverse consequences on other organ systems. During monitoring of patients on chronic therapy, screening tools such as metabolic panels and bone density measurements can help stratify risk and guide management.
Collapse
Affiliation(s)
- Carla LoPinto-Khoury
- Department of Neurology, Lewis Katz Temple School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Pennell PB, Karanam A, Meador KJ, Gerard E, Kalayjian L, Penovich P, Matthews A, McElrath TM, Birnbaum AK. Antiseizure Medication Concentrations During Pregnancy: Results From the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) Study. JAMA Neurol 2022; 79:370-379. [PMID: 35157004 PMCID: PMC8845026 DOI: 10.1001/jamaneurol.2021.5487] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE During pregnancy in women with epilepsy, lower blood concentrations of antiseizure medications can have adverse clinical consequences. OBJECTIVE To characterize pregnancy-associated concentration changes for several antiseizure medications among women with epilepsy. DESIGN, SETTING, AND PARTICIPANTS Enrollment in this prospective, observational cohort study, Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD), occurred from December 19, 2012, to February 11, 2016, at 20 US sites. Enrolled cohorts included pregnant women with epilepsy and nonpregnant control participants with epilepsy. Inclusion criteria were women aged 14 to 45 years, an intelligence quotient greater than 70 points, and, for the cohort of pregnant women, a fetal gestational age younger than 20 weeks. A total of 1087 women were assessed for eligibility; 397 were excluded and 230 declined. Data were analyzed from May 1, 2014, to June 30, 2021. EXPOSURE Medication plasma concentrations in women taking monotherapy or in combination with noninteracting medications. The cohort of pregnant women was monitored through 9 months post partum, with similar time points for control participants. MAIN OUTCOMES AND MEASURES Dose-normalized concentrations were calculated as total or unbound plasma medication concentrations divided by total daily dose. Phlebotomy was performed during 4 pregnancy study visits and 3 postpartum visits for the pregnant women and 7 visits over 18 months for control participants. The primary hypothesis was to test pregnancy changes of dose-normalized concentrations from nonpregnant postpartum samples compared with those of control participants. RESULTS Of the 351 pregnant women and 109 control participants enrolled in MONEAD, 326 pregnant women (median [range] age, 29 [19-43] years) and 104 control participants (median [range] age, 29 [16-43] years) met eligibility criteria for this analysis. Compared with postpartum values, dose-normalized concentrations during pregnancy were decreased by up to 56.1% for lamotrigine (15.60 μg/L/mg to 6.85 μg/L/mg; P < .001), 36.8% for levetiracetam (11.33 μg/L/mg to 7.16 μg/L/mg; P < .001), 17.3% for carbamazepine (11.56 μg/L/mg to 7.97 μg/L/mg; P = .03), 32.6% for oxcarbazepine (11.55 μg/L/mg to 7.79 μg/L/mg; P < .001), 30.6% for unbound oxcarbazepine (6.15 μg/L/mg to 4.27 μg/L/mg; P < .001), 39.9% for lacosamide (26.14 μg/L/mg to 15.71 μg/L/mg; P < .001), and 29.8% for zonisamide (40.12 μg/L/mg to 28.15 μg/L/mg; P < .001). No significant changes occurred for unbound carbamazepine, carbamazepine-10,11-epoxide, and topiramate, although a decrease was observed for topiramate (29.83 μg/L/mg to 13.77 μg/L/mg; P = .18). Additionally, compared with dose-normalized concentrations from control participants, pregnancy dose-normalized median (SE) concentrations decreased significantly by week of gestational age: carbamazepine, -0.14 (0.06) μg/L/mg (P = .02); carbamazepine unbound, -0.04 (0.01) μg/L/mg (P = .01); lacosamide, -0.23 (0.07) μg/L/mg (P < .001); lamotrigine, -0.20 (0.02) μg/L/mg (P < .001); levetiracetam, -0.06 (0.03) μg/L/mg (P = .01); oxcarbazepine, -0.14 (0.04) μg/L/mg (P < .001); oxcarbazepine unbound, -0.11 (0.03) μg/L/mg (P < .001); and zonisamide, -0.53 (0.14) μg/L/mg (P < .001) except for topiramate (-0.35 [0.20] μg/L/mg per week) and carbamazepine-10,11-epoxide (0.02 [0.01] μg/L/mg). CONCLUSIONS AND RELEVANCE Study results suggest that therapeutic drug monitoring should begin early in pregnancy and that increasing doses of these anticonvulsants may be needed throughout the course of pregnancy.
Collapse
Affiliation(s)
- Page B Pennell
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashwin Karanam
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis
| | - Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Gerard
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Laura Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | - Thomas M McElrath
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis
| | | |
Collapse
|
11
|
Wilson R, O'Connor D. Maternal folic acid and multivitamin supplementation: International clinical evidence with considerations for the prevention of folate-sensitive birth defects. Prev Med Rep 2021; 24:101617. [PMID: 34976673 PMCID: PMC8684027 DOI: 10.1016/j.pmedr.2021.101617] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 12/17/2022] Open
Abstract
More evidence is available for maternal intake, absorption, distribution, tissue specific concentrations, and pregnancy outcomes with folic acid (fortification/supplementation) during preconception - first trimester. This Quality Improvement prevention review used expert guidelines/opinions, systematic reviews, randomized control trials/controlled clinical trials, and observational case control/case series studies, published in English, from 1990 to August 2021. Optimization for an oral maternal folic acid supplementation is difficult because it relies on folic acid dose, type of folate supplement, bio-availability of the folate from foods, timing of supplementation initiation, maternal metabolism/genetic factors, and many other factors. There is continued use of high dose pre-food fortification 'RCT evidenced-based' folic acid supplementation for NTD recurrence pregnancy prevention. Innovation requires preconception and pregnancy use of 'carbon one nutrient' supplements (folic acid, vitamin B12, B6, choline), using the appropriate evidence, need to be considered. The consideration and adoption of directed personalized approaches for maternal complex risk could use serum folate testing for supplementation dosing choice. Routine daily folic acid dosing for low-risk women should consider a multivitamin with 0.4 mg of folic acid starting 3 months prior to conception until completion of breastfeeding. Routine folic acid dosing or preconception measurement of maternal serum folate (after 4-6 weeks of folate supplementation) could be considered for maternal complex risk group with genetic/medical/surgical co-morbidities. These new approaches for folic acid oral supplementation are required to optimize benefit (decreasing folate sensitive congenital anomalies; childhood morbidity) and minimizing potential maternal and childhood risk.
Collapse
Affiliation(s)
- R.D. Wilson
- Cumming School of Medicine, Department of Obstetrics and Gynecology, University of Calgary, FMC NT 435, 1403 29 St NW, Calgary, Alberta, Canada
| | - D.L. O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Al-Faraj AO, Pandey S, Herlihy MM, Pang TD. Factors affecting breastfeeding in women with epilepsy. Epilepsia 2021; 62:2171-2179. [PMID: 34289107 DOI: 10.1111/epi.17003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE This study aimed to compare rates of breastfeeding initiation and maintenance in women with epilepsy (WWE) with those of the general population and to identify factors affecting breastfeeding patterns in WWE. METHODS We retrospectively reviewed data for the following variables in pregnant WWE (n = 102) and healthy women without epilepsy (n = 112): demographic characteristics (age, race, ethnicity), epilepsy type (focal or generalized onset), antiseizure medication(s), psychiatric comorbidities, postpartum seizure control, breastfeeding counseling, and lactation consultation. Fisher exact test and logistic regression analyses were performed to compare the rates of breastfeeding initiation and continuation in pregnant WWE with those of healthy pregnant women and to determine factors associated with rates of breastfeeding initiation and maintenance. RESULTS The rate of breastfeeding initiation in WWE was significantly lower than in healthy women without epilepsy (50.9% vs. 87.6%), and WWE were less likely to maintain breastfeeding at 6 weeks (38.2%) and 3 months (36%) postpartum. Nearly half (53%) of WWE received antepartum breastfeeding counseling by their neurologists, and these women had higher odds of breastfeeding initiation and continuation (odds ratio [OR] = 2.53, 95% confidence interval [CI] = 1.14-5.72, p = .02). Postpartum consultation with a board-certified lactation consultant was associated with higher odds of breastfeeding continuation at 6 weeks (OR = 5.43, 95% CI = 1.39-27.23, p = .02) and at 3 months (OR = 4.9, 95% CI = 1.34-20.87, p = .019). Women taking levetiracetam were more likely to initiate and continue breastfeeding than those taking lamotrigine (OR = 6.22, 95% CI = 2.15-20.20, p = .001). SIGNIFICANCE The initiation rate and duration of breastfeeding were significantly lower in WWE than in healthy women without epilepsy and were significantly associated with several factors. Identification of potential barriers to breastfeeding in WWE may lead to development of intervention strategies that can improve breastfeeding rates in WWE to maximize positive health outcomes for WWE and their infants.
Collapse
Affiliation(s)
- Abrar O Al-Faraj
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Samiksha Pandey
- Boston University School of Medicine, Boston, Massachusetts, USA.,Beaumont Health-Royal Oak, Royal Oak, Michigan, USA
| | - Mary M Herlihy
- Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Trudy D Pang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Aykan DA, Ergün Y. Cross-sectional evaluation of prescription of valproate and other antiepileptic drugs to pregnant women. Acta Neurol Belg 2021; 121:503-508. [PMID: 31659713 DOI: 10.1007/s13760-019-01231-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 10/20/2019] [Indexed: 10/25/2022]
Abstract
Drug counseling is important in women with epilepsy since data about the effects of maternal antiepileptics on the developing fetus are limited. Although pregnant patients on the most teratogenic drugs are treated in accordance to the European Medicines Agency guidelines, a large amount of them may be exposed to the teratogenic medications unintentionally. We performed a tertiary center observational study about medications of pregnant women who were consulted to Teratology Information Service (TIS) unit for evidence-based teratogenic risk analysis. The registration records of 134 pregnant women between 2014 and 2018 were examined. We evaluated the diagnoses, prescriptions, usage of antiepileptic drugs, and distribution of drug subtypes and investigated the drug-related congenital anomalies after delivery. Women were recontacted after delivery to obtain information about health status of infants. We found that 33 women were diagnosed with neurological disorders. A total number of 60 neurologic drugs was prescribed, including 13 antiepileptics. Antiepileptic drugs covered 38.4% valproate (n = 5), 15.4% pregabalin/gabapentin (n = 2), 15.4% levetiracetam (n = 2), 15.4% lamotrigine (n = 2), 7.7% phenytoin (n = 1), and 7.7% carbamazepine (n = 1). Delivery outcomes revealed that valproate exposure resulted in one baby with congenital cataracts, one postnatal exitus with cardiac dysfunction, and one therapeutic abortion. Various antiepileptic drugs were prescribed to pregnant women prenatally or at different times of pregnancy and valproate was the most common antiepileptic drug consulted to TIS for teratogenic risk analysis. Disseminating TIS units and reporting the outcomes to the teratogenesis literature provide proper evaluation of teratogenic risks of drugs accordingly.
Collapse
|
14
|
Vajda FJE, O'Brien TJ, Graham JE, Hitchcock AA, Perucca P, Lander CM, Eadie MJ. Folic acid dose, valproate, and fetal malformations. Epilepsy Behav 2021; 114:107569. [PMID: 33272896 DOI: 10.1016/j.yebeh.2020.107569] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/08/2020] [Accepted: 10/18/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether there is a relationship between folic acid dose and the degree of protection against valproate-associated and other antiepileptic drug (AED)-associated fetal structural malformations in women with AED-treated epilepsy. METHODS Statistical analysis of data from the Raoul Wallenberg Australian Register of Antiepileptic Drugs in Pregnancy involving 2104 folic acid-treated pregnancies in women with epilepsy. RESULTS Multiple variable logistic regression failed to demonstrate any statistically significant effect of folic acid dosage in reducing overall fetal malformation rates in women taking folic acid either before and during pregnancy (P = 0.640) or during early pregnancy only (P = 0.801), and in reducing spina bifida occurrence rates (P = 0.409). CONCLUSIONS In the present state of knowledge, it would seem misguided to hope that a folic acid dose of 5 mg/day taken before and during pregnancy would protect against the occurrence of valproate-associated and other AED-associated fetal structural malformations. Future studies are required to determine whether high-dose periconceptional folate use may decrease the risk of other valproate-associated adverse fetal outcomes, including impaired post-natal neurobehavioral development.
Collapse
Affiliation(s)
- Frank J E Vajda
- Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria 3004, Australia.
| | - Terence J O'Brien
- Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria 3004, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria 3000, Australia
| | - Janet E Graham
- Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia
| | - Alison A Hitchcock
- Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia
| | - Piero Perucca
- Departments of Medicine and Neurology, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia; Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria 3004, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria 3000, Australia
| | - Cecilie M Lander
- Royal Brisbane and Women's Hospital and School of Medicine and Biomedical Science, University of Queensland, Brisbane, Queensland 4027, Australia
| | - Mervyn J Eadie
- Royal Brisbane and Women's Hospital and School of Medicine and Biomedical Science, University of Queensland, Brisbane, Queensland 4027, Australia
| |
Collapse
|
15
|
Tomson T, Battino D, Bromley R, Kochen S, Meador KJ, Pennell PB, Thomas SV. Global Survey of Guidelines for the Management of Epilepsy in Pregnancy: A report from the International League Against Epilepsy Task Force on Women and Pregnancy. Epilepsia Open 2020; 5:366-370. [PMID: 32913945 PMCID: PMC7469854 DOI: 10.1002/epi4.12420] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/10/2020] [Accepted: 07/15/2020] [Indexed: 11/27/2022] Open
Abstract
The ILAE Task Force on Women and Pregnancy conducted a survey among ILAE Chapters of their use of guidelines or recommendations for the management of women with epilepsy during pregnancy. A web-based questionnaire including 10 questions was sent to the 118 ILAE Chapters in December 2017 with repeated reminders until the end of February 2018. In total, 77 chapters (65%) responded, although not to all questions. Out of those responding, 68% reported having guidelines or recommendations, 34% of which were from 2014 or earlier. At least 20% of the guidelines did not include information on possible risk to cognitive development, information regarding specific risks with specific antiepileptic drugs, nor recommendations regarding selection of antiepileptic drugs. Among those responding to the question, 91% reported that recommendations were made regarding folate supplementation, but the recommended dose ranged from 0.4 mg/d to 4 mg/d or more; 34% did not include recommendations regarding drug level monitoring during pregnancy, and 19% did not include guidelines on breastfeeding. Our survey demonstrates that there is a need for the development of up-to-date, globally applicable recommendations for the management of epilepsy during pregnancy.
Collapse
Affiliation(s)
- Torbjörn Tomson
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Dina Battino
- Epilepsy CenterDepartment of Neurophysiology and Experimental EpileptologyFondazione IRCCS Istituto Neurologico CARLO BESTAMilanItaly
| | - Rebecca Bromley
- Division of Evolution and Genomic ScienceSchool of Biological SciencesFaculty of Biology, Medicine and HealthManchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Royal Manchester Children's HospitalManchester Academic Health Science CentreCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
| | - Silvia Kochen
- Epilepsy CenterENyS, CONICET, Hosp. El Cruce, Hosp. R. MejíaUniv Buenos AiresBuenos AiresArgentina
| | - Kimford J. Meador
- Department of Neurology & Neurological SciencesStanford UniversityPalo AltoCAUSA
| | - Page B. Pennell
- Divisions of Epilepsy and Women's HealthDepartment of NeurologyHarvard Medical SchoolBrigham and Women's HospitalBostonMAUSA
| | - Sanjeev V. Thomas
- Department of NeurologySree Chitra Tirunal Institute of Medical Sciences and TechnologyTrivandrumKerala StateIndia
| |
Collapse
|
16
|
Ghoneim FM, Alrefai H, Elsamanoudy AZ, Abo El-khair SM, Khalaf HA. The Protective Role of Prenatal Alpha Lipoic Acid Supplementation against Pancreatic Oxidative Damage in Offspring of Valproic Acid-Treated Rats: Histological and Molecular Study. BIOLOGY 2020; 9:biology9090239. [PMID: 32825436 PMCID: PMC7564314 DOI: 10.3390/biology9090239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 01/21/2023]
Abstract
Background: Sodium valproate (VPA) is an antiepileptic drug (AED) licensed for epilepsy and used during pregnancy in various indications. Alpha-lipoic acid (ALA) is a natural compound inducing endogenous antioxidant production. Our study aimed to investigate the effect of prenatal administration of VPA on the pancreas of rat offspring and assess the potential protective role of ALA co-administration during pregnancy. Methods: Twenty-eight pregnant female albino rats were divided into four groups: group I (negative control), group II (positive control, ALA treated), group III (VPA-treated), and group IV (VPA-ALA-treated). The pancreases of the rat offspring were removed at the fourth week postpartum and prepared for histological, immune-histochemical, morphometric, molecular, and oxidative stress marker studies. Results: In group III, there were pyknotic nuclei, vacuolated cytoplasm with ballooning of acinar, α, and β cells of the pancreas. Ultrastructural degeneration of cytoplasmic organelles was detected. Additionally, there was a significant increase in oxidative stress, a decrease in insulin-positive cell percentage, and an increase in glucagon positive cells in comparison to control groups. Moreover, VPA increased the gene expression of an apoptotic marker, caspase-3, with a decrease in anti-apoptotic Bcl2 and nuclear factor erythroid 2-related factor 2 (Nrf2) transcriptional factor. Conversely, ALA improved oxidative stress and apoptosis in group VI, and a consequent improvement of the histological and ultrastructure picture was detected. Conclusion: ALA co-administration with VPA significantly improved the oxidative stress condition, histological and morphometric picture of the pancreas, and restored normal expression of related genes, including Nrf2, caspase-3, and Bcl-2. Administration of α-lipoic acid has a protective effect against VPA-induced pancreatic oxidative damage via its cytoprotective antioxidant effect.
Collapse
Affiliation(s)
- Fatma M. Ghoneim
- Histology and Cell Biology Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt; (F.M.G.); (H.A.K.)
| | - Hani Alrefai
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt; (A.Z.E.); (S.M.A.E.-k.)
- Department of Internal Medicine, Infectious Diseases Div., College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Correspondence: ; Tel.: +1-513-975-9195
| | - Ayman Z. Elsamanoudy
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt; (A.Z.E.); (S.M.A.E.-k.)
- Clinical Biochemistry Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21465, Saudi Arabia
| | - Salwa M. Abo El-khair
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt; (A.Z.E.); (S.M.A.E.-k.)
| | - Hanaa A. Khalaf
- Histology and Cell Biology Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt; (F.M.G.); (H.A.K.)
| |
Collapse
|
17
|
Noe K. Further Evidence Breastfeeding by Women With Epilepsy Is Safe: Are Mothers Getting the Message? Epilepsy Curr 2020; 20:141-143. [PMID: 32550833 PMCID: PMC7281906 DOI: 10.1177/1535759720917997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Antiepileptic Drug Exposure in Infants of Breastfeeding Mothers With Epilepsy Birnbaum AK, Meador KJ, Karanam A, Brown C, et al. JAMA Neurology , 2019; epub. doi:10.1001/jamaneurol.2019.4443 . There is limited information on infant drug exposure via breastfeeding by mothers who are receiving antiepileptic drug therapy. Objective: To provide direct, objective information on antiepileptic drug exposure through breast milk. Design, Setting, and Participants: This prospective cohort study was conducted between December 2012 and October 2016, with follow-up in children until 6 years of age at 20 sites across the United States. Data were collected via an observational multicenter investigation (Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs) of outcomes in pregnant mothers with epilepsy and their children. Pregnant women with epilepsy who were aged 14 to 45 years, had pregnancies that had progressed to less than 20 weeks’ gestational age, and had measured intelligence quotient (IQ) scores of more than 70 points were enrolled and followed up through pregnancy and 9 postpartum months. Their infants were enrolled at birth. Data were analyzed from May 2014 to August 2019. Exposures: Antiepileptic drug exposure in infants who were breastfed. Main Outcomes and Measures: The percentage of infant-to-mother concentration of antiepileptic drugs. Antiepileptic drug concentrations were quantified from blood samples collected from infants and mothers at the same visit, 5 to 20 weeks after birth. Concentrations of antiepileptic drugs in infants at less than the lower limit of quantification were assessed as half of the lower limit. Additional measures collected were the total duration of all daily breastfeeding sessions and/or the volume of pumped breast milk ingested from a bottle. Results: A total of 351 women (of 865 screened and 503 eligible individuals) were enrolled, along with their 345 infants (179 female children [51.9%]; median [range] age, 13 [5-20] weeks). Of the 345 infants, 222 (64.3%) were breastfed; the data collection yielded 164 matching infant–mother concentration pairs from 138 infants. Approximately 49% of all antiepileptic drug concentrations in nursing infants were less than the lower limit of quantification. The median percentage of infant-to-mother concentration for all 7 antiepileptic drugs and 1 metabolite (carbamazepine, carbamazepine-10,11-epoxide, levetiracetam, lamotrigine, oxcarbazepine, topiramate, valproate, and zonisamide) ranged from 0.3% (range: 0.2%-0.9%) to 44.2% (range: 35.2%-125.3%). In multiple linear regression models, maternal concentration was a significant factor associated with lamotrigine concentration in infants (Pearson correlation coefficient, 0.58; P < .001) but not levetiracetam concentration in infants. Conclusions and Relevance: Overall, antiepileptic drug concentrations in blood samples of infants who were breastfed were substantially lower than maternal blood concentrations. Given the well-known benefits of breastfeeding and the prior studies demonstrating no ill effects when the mother was receiving antiepileptic drugs, these findings support the breastfeeding of infants by mothers with epilepsy who are taking antiepileptic drug therapy.
Collapse
|
18
|
Meador KJ, Pennell PB, May RC, Van Marter L, McElrath TF, Brown C, Gerard E, Kalayjian L, Gedzelman E, Penovich P, Cavitt J, French J, Hwang S, Pack AM, Sam M, Birnbaum AK, Finnell R. Fetal loss and malformations in the MONEAD study of pregnant women with epilepsy. Neurology 2020; 94:e1502-e1511. [PMID: 31806691 PMCID: PMC7251524 DOI: 10.1212/wnl.0000000000008687] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/11/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine occurrence of severe adverse fetal outcomes (SAO), including fetal loss and major congenital malformations (MCMs), in pregnant women with epilepsy (PWWE) vs healthy pregnant women (HPW). METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an NIH-funded, prospective, observational, multicenter investigation of pregnancy outcomes for both mother and child, which enrolled women December 2012 through January 2016. RESULTS The 351 PWWE had 365 conceptions, and 105 HPW had 109 conceptions. SAOs occurred more often in PWWE (7.9%) vs HPW (1.9%) (p = 0.025) with odds ratio (OR) 4.45 (95% confidence intervals [CI] 1.04-19.01). There were no significant differences for fetal loss (2.8% vs 0%, p = 0.126) or MCMs (5.2% vs 1.9%, p = 0.185; OR 2.86, 95% CI 0.65-12.53) individually. No fetal losses in PWWE appeared to be related to acute seizures. Outcomes were not affected by periconceptional folate, unplanned/unwanted pregnancies, prior maternal pregnancy history, or antiepileptic drug (AED) blood levels, except for an AED level effect for fetal loss that appeared to be due to polytherapy. Combined maternal or paternal family history of MCM was marginally associated with increased SAOs (p = 0.046). CONCLUSIONS The findings provide additional information on risks of SAOs in PWWE, assessing effects of both AED levels and periconceptional folate. Group differences in average enrollment gestational age could have affected fetal loss results. Analyses are limited by small sample sizes as the MONEAD study was not powered for these secondary outcomes. The large majority of pregnancies in women with epilepsy do not have SOAs.
Collapse
Affiliation(s)
- Kimford J Meador
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX.
| | - Page B Pennell
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Ryan C May
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Linda Van Marter
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Thomas F McElrath
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Carrie Brown
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Elizabeth Gerard
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Laura Kalayjian
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Evan Gedzelman
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Patricia Penovich
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Jennifer Cavitt
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Jacqueline French
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Sean Hwang
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Alison M Pack
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Maria Sam
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Angela K Birnbaum
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| | - Richard Finnell
- From Stanford University (K.J.M.), CA; Brigham & Women's Hospital (P.B.P., L.V.M., T.F.M.), Harvard Medical School, Boston, MA; Emmes (R.C.M., C.B.), Rockville, MD; Northwestern University (E.G.), Evanston, IL; University of Southern California (L.K.), Los Angeles; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (P.P.), St. Paul; University of Cincinnati (J.C.), OH; New York University (J.F.); Northwell Heath (S.H.); Columbia University (A.M.P.), New York, NY; Wake Forest University (M.S.), Winston-Salem, NC; University of Minnesota (A.K.B.), Minneapolis; and Baylor College of Medicine (R.F.), Houston, TX
| |
Collapse
|
19
|
Bosak M, Mołek P, Słowik A. Use of dietary and herbal supplements in adult patients with epilepsy. Epilepsy Res 2019; 156:106168. [PMID: 31369960 DOI: 10.1016/j.eplepsyres.2019.106168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 07/08/2019] [Accepted: 07/13/2019] [Indexed: 11/08/2022]
Abstract
PURPOSE To study the extent and characteristics of dietary and herbal supplements use in a large cohort of adult patients with epilepsy. METHODS This prospective study included 490 patients receiving care at a university epilepsy clinic. A number of variables, including demographics, characteristics of epilepsy and its treatment, comedication as well as data related to supplements intake were collected from medical records and a dedicated questionnaire. RESULTS Overall 247 patients (50.4%) took at least one dietary supplement; nearly half (111, 44.9%) of this group took >1 products. Multivitamins and magnesium were the most prevalent supplements. Most of the patients used supplements for general health rather than their epilepsy condition. The average number of supplements and prescription medications used per person was 5.4. Ten percent (25 of 247) of subjects used dietary supplements which could have proconvulsive effect or potential for interaction with prescription medications. Multivariate analysis revealed two independent variables associated with supplements intake, younger age and female sex. CONCLUSION Dietary and herbal supplements use is common in patients with epilepsy, adding to the burden of overmedication. Concurrent use of supplements may potentially lead to interactions with prescription medications or loss of seizure control. Health care providers should routinely check for dietary supplements use to limit potential harm related to their intake.
Collapse
Affiliation(s)
- Magdalena Bosak
- Dept. of Neurology, Jagiellonian University Medical College, Krakow, Poland.
| | | | - Agnieszka Słowik
- Dept. of Neurology, Jagiellonian University Medical College, Krakow, Poland
| |
Collapse
|
20
|
Turgut U, Kazan S, Cakin H, Ozak A. Valproic acid effect on neural tube defects is not prevented by concomitant folic acid supplementation: Early chick embryo model pilot study. Int J Dev Neurosci 2019; 78:45-48. [DOI: 10.1016/j.ijdevneu.2019.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 04/17/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- U. Turgut
- Akdeniz UniversityB Block 2nd Floor07000AntalyaTurkey
| | - S. Kazan
- Akdeniz UniversityB Block 2nd Floor07000AntalyaTurkey
| | - H. Cakin
- Akdeniz UniversityB Block 2nd Floor07000AntalyaTurkey
| | - A. Ozak
- Akdeniz UniversityB Block 2nd Floor07000AntalyaTurkey
| |
Collapse
|
21
|
Clayton-Smith J, Bromley R, Dean J, Journel H, Odent S, Wood A, Williams J, Cuthbert V, Hackett L, Aslam N, Malm H, James G, Westbom L, Day R, Ladusans E, Jackson A, Bruce I, Walker R, Sidhu S, Dyer C, Ashworth J, Hindley D, Diaz GA, Rawson M, Turnpenny P. Diagnosis and management of individuals with Fetal Valproate Spectrum Disorder; a consensus statement from the European Reference Network for Congenital Malformations and Intellectual Disability. Orphanet J Rare Dis 2019; 14:180. [PMID: 31324220 PMCID: PMC6642533 DOI: 10.1186/s13023-019-1064-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/12/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A pattern of major and minor congenital anomalies, facial dysmorphic features, and neurodevelopmental difficulties, including cognitive and social impairments has been reported in some children exposed to sodium valproate (VPA) during pregnancy. Recognition of the increased risks of in utero exposure to VPA for congenital malformations, and for the neurodevelopmental effects in particular, has taken many years but these are now acknowledged following the publication of the outcomes of several prospective studies and registries. As with other teratogens, exposure to VPA can have variable effects, ranging from a characteristic pattern of major malformations and significant intellectual disability to the other end of the continuum, characterised by facial dysmorphism which is often difficult to discern and a more moderate effect on neurodevelopment and general health. It has become clear that some individuals with FVSD have complex needs requiring multidisciplinary care but information regarding management is currently lacking in the medical literature. METHODS An expert group was convened by ERN-ITHACA, the European Reference Network for Congenital Malformations and Intellectual Disability comprised of professionals involved in the care of individuals with FVSD and with patient representation. Review of published and unpublished literature concerning management of FVSD was undertaken and the level of evidence from these sources graded. Management recommendations were made based on strength of evidence and consensus expert opinion, in the setting of an expert consensus meeting. These were then refined using an iterative process and wider consultation. RESULTS Whilst there was strong evidence regarding the increase in risk for major congenital malformations and neurodevelopmental difficulties there was a lack of high level evidence in other areas and in particular in terms of optimal clinical management.. The expert consensus approach facilitated the formulation of management recommendations, based on literature evidence and best practice. The outcome of the review and group discussions leads us to propose the term Fetal Valproate Spectrum Disorder (FVSD) as we feel this better encompasses the broad range of effects seen following VPA exposure in utero. CONCLUSION The expert consensus approach can be used to define the best available clinical guidance for the diagnosis and management of rare disorders such as FVSD. FVSD can have medical, developmental and neuropsychological impacts with life-long consequences and affected individuals benefit from the input of a number of different health professionals.
Collapse
Affiliation(s)
- Jill Clayton-Smith
- Division of Evolution and Genomic Sciences School of Biological Sciences, University of Manchester, Manchester, UK
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Rebecca Bromley
- Division of Evolution and Genomic Sciences School of Biological Sciences, University of Manchester, Manchester, UK
- Paediatric Psychosocial Department, Royal Manchester Children’s Hospital, Manchester Academic Health Sciences Centre, Manchester, UK
| | - John Dean
- Clinical Genetics, Clinical Genetics Service, Ashgrove House, Foresterhill, Aberdeen, UK
| | - Hubert Journel
- Génétique Médicale – Consultation, CHBA Centre Hospitalier Bretagne Atlantique - CH Chubert, 20 boulevard du Général Maurice Guillaudot, BP 70555, 56017 Vannes Cedex, France
| | - Sylvie Odent
- Service de Génétique Clinique, CNRS UMR 6290, Université de Rennes, CHU de Rennes - Hôpital Sud, 16 Boulevard de Bulgarie, 35203 Rennes Cedex 2, France
| | - Amanda Wood
- Aston Brain Centre, School of Life and Health Sciences, Aston Triangle, Birmingham, UK
- Brain and Mind, Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Melbourne, Australia
| | - Janet Williams
- INFACT/FACSA, Independent Fetal Anti-Convulsant Trust & FACS Syndrome Association, Preston, UK
| | - Verna Cuthbert
- Department of Paediatric Rheumatology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Latha Hackett
- Child and Adolescent Mental Health Services (CAMHS), Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Neelo Aslam
- Child and Adolescent Mental Health Services (CAMHS), Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Heli Malm
- Teratology Information Service, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Tukholmankatu 17, 00029 HUS, Helsinki, Finland
| | - Gregory James
- Department of Neurosurgery, Great Ormond Street Hospital, Great Ormond Street, London, UK
- Craniofacial Unit, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH UK
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH UK
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG UK
| | - Lena Westbom
- Lund University, Barnmed klin, SUS, Lund, Sweden
| | - Ruth Day
- Guardian Medical Centre, Guardian Street, Warrington, UK
| | - Edmund Ladusans
- Department of Paediatric Cardiology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK
| | - Adam Jackson
- Department of Neurology, Salford Royal Hospital NHS Trust, Stott Lane, Salford, UK
| | - Iain Bruce
- Paediatric ENT Department, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Robert Walker
- Department of Paediatric Anaesthesia, Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Sangeet Sidhu
- Department of Paediatric Nephrology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK
| | - Catrina Dyer
- Cleft Lip and Palate Team, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK
| | - Jane Ashworth
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Daniel Hindley
- Community Paediatrics, Bolton NHS Foundation Trust, Breightmet Health Centre, Bolton, UK
| | - Gemma Arca Diaz
- Department of Neonatology, Hospital Clinic (Maternitat), Sabino Arana 1, 08028 Barcelona, Spain
| | - Myfanwy Rawson
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Peter Turnpenny
- Clinical Genetics, Royal Devon and Exeter NHS Foundation Trust, Gladstone Rd, Exeter, UK
| |
Collapse
|
22
|
George IC, Bartolini L, Ney J, Singhal D. Differences in treatment of epilepsy in pregnancy: A worldwide survey. Neurol Clin Pract 2019; 9:201-207. [PMID: 31341707 DOI: 10.1212/cpj.0000000000000642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/17/2019] [Indexed: 11/15/2022]
Abstract
Background How to safely treat pregnant women with epilepsy is a question for which there are guidelines, but variations in practice exist. Methods To better characterize how clinicians address this difficult clinical question, we distributed an anonymous survey to neurology practitioners across subspecialties and different levels of training via the Neurology®: Clinical Practice website. The survey was conducted from May 31 to December 3, 2017. We received responses from 642 participants representing 81 countries. We performed both descriptive and inferential analyses. For the inferential analysis, a multiple logistic regression model was used to analyze the effect of provider characteristics on the constructed binary outcome variables of interest. Results The results of this survey demonstrate a wide range in the amount of folic acid recommended and the frequency of checking levels of anti-epileptic drugs. Choice of first-line agent varied by the economic development status of the respondent's country, suggesting that access to medications plays an important role in clinical decision making in many parts of the world. Conclusion This survey highlights several areas where further research would be helpful in guiding practice.
Collapse
Affiliation(s)
- Ilena C George
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (ICG), Mount Sinai, New York, NY; Clinical Epilepsy Section (LB), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Center for Neuroscience (LB), George Washington University, Children's National Health System; Center for Healthcare Organization and Implementation Research (JN), Edith Nourse Rogers Memorial VA, Bedford, MA; and Department of Neurology (DS), University of Oklahoma
| | - Luca Bartolini
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (ICG), Mount Sinai, New York, NY; Clinical Epilepsy Section (LB), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Center for Neuroscience (LB), George Washington University, Children's National Health System; Center for Healthcare Organization and Implementation Research (JN), Edith Nourse Rogers Memorial VA, Bedford, MA; and Department of Neurology (DS), University of Oklahoma
| | - John Ney
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (ICG), Mount Sinai, New York, NY; Clinical Epilepsy Section (LB), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Center for Neuroscience (LB), George Washington University, Children's National Health System; Center for Healthcare Organization and Implementation Research (JN), Edith Nourse Rogers Memorial VA, Bedford, MA; and Department of Neurology (DS), University of Oklahoma
| | - Divya Singhal
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (ICG), Mount Sinai, New York, NY; Clinical Epilepsy Section (LB), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Center for Neuroscience (LB), George Washington University, Children's National Health System; Center for Healthcare Organization and Implementation Research (JN), Edith Nourse Rogers Memorial VA, Bedford, MA; and Department of Neurology (DS), University of Oklahoma
| |
Collapse
|
23
|
Aicua-Rapun I, André P, Novy J. Closed-loop Neuropharmacology for Epilepsy: Distant Dream or Future Reality? Curr Neuropharmacol 2019; 17:447-458. [PMID: 29521237 PMCID: PMC6520584 DOI: 10.2174/1570159x16666180308154646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/10/2017] [Accepted: 02/27/2018] [Indexed: 11/22/2022] Open
Abstract
Epilepsy is considered the most frequent severe neurological condition but most patients treated with medication become seizure free. The management of treatment, however, is highly empirical, mainly relying on observation. A closed-loop therapy for epilepsy would be very valuable for more efficient treatment regimens. Here we discuss monitoring treatment (therapeutic drug monitoring) and the potential developments in this field, as well as providing a review of potential biomarkers that could be used to monitor the disease activity. Finally, we consider the pharmacogenetic input in epilepsy treatment.
Collapse
Affiliation(s)
- Irene Aicua-Rapun
- Address correspondence to this author at the Department of Neuroscience, Neurology service. University Hospital of Lausanne BH07, Faculty of Biology and Medicine, University of Lausanne. Rue du Bugnon 46 CH 1011, Lausanne, Switzerland; Tel/Fax: +41213144552, +41213141290;, E-mail:
| | | | | |
Collapse
|
24
|
Yoshimura K, Hashimoto T, Sato Y, Sato A, Takeuchi T, Watanabe H, Terao T, Nakazato M, Iyo M. Survey of Anticonvulsant Drugs and Lithium Prescription in Women of Childbearing age in Japan Using a Public National Insurance Claims Database. ACTA ACUST UNITED AC 2018. [DOI: 10.5234/cnpt.9.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kensuke Yoshimura
- Department of Psychiatry, Graduate School of Medicine, Chiba University, Japan
| | - Tasuku Hashimoto
- Department of Psychiatry, Graduate School of Medicine, Chiba University, Japan
- Department of Psychiatry, Satsuki-kai Sodegaura-Satsukidai Hospital, Japan
| | - Yasunori Sato
- Department of Global Clinical Research, Graduate School of Medicine, Chiba University, Japan
- Department of Preventive Medicine and Public Health, School of Medicine, Keio University, Japan
| | - Aiko Sato
- Department of Psychiatry, Graduate School of Medicine, Chiba University, Japan
| | - Takashi Takeuchi
- Department of Psychiatry, Tokyo Medical and Dental University, Japan
| | - Hiroyuki Watanabe
- Division of Medical Treatment and Rehabilitation, Chiba University Center for Forensic Mental Health, Japan
- Department of Psychiatry, Gakuji-kai Kimura Hospital, Japan
| | - Takeshi Terao
- Department of Neuropsychiatry, Oita University Faculty of Medicine, Japan
| | - Michiko Nakazato
- Department of Psychiatry, Graduate School of Medicine, Chiba University, Japan
- Department of Psychiatry, International University of Health and Welfare Atami Hospital, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Graduate School of Medicine, Chiba University, Japan
| |
Collapse
|
25
|
Myers KA, Johnstone DL, Dyment DA. Epilepsy genetics: Current knowledge, applications, and future directions. Clin Genet 2018; 95:95-111. [PMID: 29992546 DOI: 10.1111/cge.13414] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/03/2018] [Accepted: 07/06/2018] [Indexed: 12/12/2022]
Abstract
The rapid pace of disease gene discovery has resulted in tremendous advances in the field of epilepsy genetics. Clinical testing with comprehensive gene panels, exomes, and genomes are now available and have led to higher diagnostic rates and insights into the underlying disease processes. As such, the contribution to the care of patients by medical geneticists, neurogeneticists and genetic counselors are significant; the dysmorphic examination, the necessary pre- and post-test counseling, the selection of the appropriate next-generation sequencing-based test(s), and the interpretation of sequencing results require a care provider to have a comprehensive working knowledge of the strengths and limitations of the available testing technologies. As the underlying mechanisms of the encephalopathies and epilepsies are better understood, there may be opportunities for the development of novel therapies based on an individual's own specific genotype. Drug screening with in vitro and in vivo models of epilepsy can potentially facilitate new treatment strategies. The future of epilepsy genetics will also probably include other-omic approaches such as transcriptomes, metabolomes, and the expanded use of whole genome sequencing to further improve our understanding of epilepsy and provide better care for those with the disease.
Collapse
Affiliation(s)
- K A Myers
- Department of Pediatrics, University of McGill, Montreal, Canada.,Research Institute of the McGill University Health Centre, Montreal, Canada
| | - D L Johnstone
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Canada
| | - D A Dyment
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Canada.,Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| |
Collapse
|
26
|
Panchaud A, Cohen JM, Patorno E, Huybrechts KF, Desai RJ, Gray KJ, Mogun H, Hernandez-Diaz S, Bateman BT. Anticonvulsants and the risk of perinatal bleeding complications: A pregnancy cohort study. Neurology 2018; 91:e533-e542. [PMID: 29980637 DOI: 10.1212/wnl.0000000000005944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/08/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the risk of postpartum hemorrhage (PPH) and neonatal bleeding complications associated with late-pregnancy exposure to anticonvulsant drugs (ACDs) that induce cytochrome P450 enzymes (ACDi) and alter the metabolism of vitamin K compared to other ACDs. METHODS We used a population-based cohort study stemming from a nationwide sample of publicly insured pregnant women with a liveborn infant from the 2000 to 2010 Medicaid Analytic eXtract. ACDi (carbamazepine, phenobarbital, phenytoin, oxcarbazepine, topiramate) were compared to other ACDs dispensed during the last month of pregnancy. Relative risks (RRs) and 95% confidence intervals (CIs) of PPH and neonatal bleeding complications were estimated using generalized linear models with fine stratification on the propensity score to control for indication and other potential confounders. RESULTS Among 11,572 women with an ACD prescription overlapping delivery, 2.6% (135/5,109) in the ACDi group and 3.6% (231/6,463) in the other ACDs group had a diagnosis of PPH: unadjusted RR 0.74 (95% CI 0.60-0.91), adjusted RR 0.77 (95% CI 0.58-1.00). The prevalence of neonatal bleeding complications was 3.1% (157/5,109) in the ACDi group and 3.5% (229/6,463) in the other ACDs group: unadjusted RR 0.87 (95% CI 0.71-1.06), adjusted RR 0.83 (95% CI 0.64-1.08). CONCLUSIONS Evidence from this large observational study suggests that use of ACDi near delivery does not increase the risk of bleeding complications compared to other ACDs in clinical settings where neonatal intramuscular or oral vitamin K administration is considered standard of care. These findings provide reassurance for clinicians and pregnant women successfully treated with ACDi.
Collapse
Affiliation(s)
- Alice Panchaud
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA.
| | - Jacqueline M Cohen
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Elisabetta Patorno
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Krista F Huybrechts
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Rishi J Desai
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Kathryn J Gray
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Helen Mogun
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Sonia Hernandez-Diaz
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Brian T Bateman
- From the Department of Epidemiology (A.P., J.M.C., S.H.-D.), Harvard T.H. Chan School of Public Health, Boston; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.P., K.F.H., R.J.D., H.M., B.T.B.), and Department of Anesthesiology, Perioperative and Pain Medicine (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston; and Division of Maternal-Fetal Medicine (K.J.G.), Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
27
|
Abstract
BACKGROUND This study aims to improve the rate of folic acid supplementation to adolescent women with epilepsy on an antiepileptic drug (AED) regimen seen by the pediatric neurology providers at the Children's Hospital at Montefiore, in compliance with the 2009 American Academy of Neurology and American Epilepsy Society practice parameter. METHODS We designed a quality improvement study with implementation of a series of interventions and compared folic acid supplementation rates before and after intervention. We made additional comparisons based on specific age groups (12 to 15 years and 16 to 21 years) and a diagnosis with or without developmental impairment. RESULTS A review of 1850 charts from 2004 to 2015 showed an average folic acid prescription rate of 41%. Supplementation rates gradually increased to 52.2%, 58.5%, 60.3%, and finally up to 81.6% after this respective intervention: initial email reminder, provider education, posting signs in examination rooms, and implementation of an electronic medical record best practice advisory. There was improvement across all categories, in both age groups (12 to 15 years and 16 to 21 years) and in those with or without developmental impairment. There was a trend for higher compliance rates in adolescents without developmental impairment. CONCLUSIONS Our interventions resulted in an increase in folic acid supplementation rates of adolescent women with epilepsy. These results are encouraging. We plan to extend education about the recommendations for folic acid supplementation to non-neurology providers, as well as expand to apply our interventions and assess adherence to other defined epilepsy quality measures.
Collapse
Affiliation(s)
- Puja Patel
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
| | - Jules C Beal
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Shlomo Shinnar
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW The purpose of this review was to discuss the prevalence, impact, pathophysiology, and treatment of headaches (H/As) in patients with multiple sclerosis (MS). RECENT FINDINGS Headaches and multiple sclerosis are more common in women than in men with the ratio of female to male being 3:1. It is not entirely clear if there is a correlation or an incidental comorbidity of two neurological conditions. A review of the literature shows a variable prevalence of H/As in MS patients. Using the International Classification of Headache Disorders (ICHD) criteria, the primary type of H/As, especially migraine, is the most common type seen in patients with MS. One of the theories of the pathophysiologic mechanisms of migraine in MS patients is inflammation leading to demyelinating lesions in the pain-producing centers in the midbrain. Secondary H/As due to MS medications such as interferons are also frequently present. H/As can be a cause for significant comorbidity in patients with MS. The treatment of H/As in patients with MS should be addressed in the same fashion as in the non-MS population, which is a combination of pharmacological and non-pharmacological methods. Preventive medicines for the H/As should be carefully selected because of their side effect profiles. Acute attacks of migraines can be treated with medications such as triptans. Patients with MS who have migraine H/As should be educated about the phenomenon of overuse H/As, keeping headache journals, avoiding stress, and monitoring sleeping habits. The presence of depression in patients with MS and migraine affects quality of life (QOL) and should also be addressed for better outcomes.
Collapse
|
29
|
Samba Reddy D. Sex differences in the anticonvulsant activity of neurosteroids. J Neurosci Res 2017; 95:661-670. [PMID: 27870400 DOI: 10.1002/jnr.23853] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/21/2016] [Accepted: 07/06/2016] [Indexed: 12/11/2022]
Abstract
Epilepsy is one of the leading causes of chronic neurological morbidity worldwide. Acquired epilepsy may result from a number of conditions, such as brain injury, anoxia, tumors, stroke, neurotoxicity, and prolonged seizures. Sex differences have been observed in many seizure types; however, some sex-specific seizure disorders are much more prevalent in women. Despite some inconsistencies, substantial data indicates that sensitivity to seizure stimuli differs between the sexes. Men generally exhibit greater seizure susceptibility than women, whereas many women with epilepsy experience a cyclical occurrence of seizures that tends to center around the menstrual period, which has been termed catamenial epilepsy. Some epilepsy syndromes show gender differences with female predominance or male predominance. Steroid hormones, endogenous neurosteroids, and sexually dimorphic neural networks appear to play a key role in sex differences in seizure susceptibility. Neurosteroids, such as allopregnanolone, reflect sex differences in their anticonvulsant activity. This Review provides a brief overview of the evidence for sex differences in epilepsy and how sex differences influence the use of neurosteroids in epilepsy and epileptogenesis. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Sciences Center, College of Medicine, Bryan, Texas
| |
Collapse
|
30
|
Hernández-Díaz S, McElrath TF, Pennell PB, Hauser WA, Yerby M, Holmes LB. Fetal growth and premature delivery in pregnant women on antiepileptic drugs. Ann Neurol 2017; 82:457-465. [DOI: 10.1002/ana.25031] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Sonia Hernández-Díaz
- Department of Epidemiology; Harvard T. H. Chan School of Public Health; Boston MA
| | - Thomas F. McElrath
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital; Boston MA
| | - Page B. Pennell
- Divisions of Epilepsy and Women's Health, Department of Neurology, Brigham and Women's Hospital; Boston MA
| | - W. Allen Hauser
- College of Physicians and Surgeons and Mailman School of Public Health; Columbia University; New York NY
| | - Mark Yerby
- Oregon Health and Science University; Portland OR
| | - Lewis B. Holmes
- North American Antiepileptic Drug Pregnancy Registry, MassGeneral Hospital for Children; Boston MA
| | | |
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW The aim of this paper is to evaluate recent literature on valproic acid (VPA) in women and girls of childbearing age and to emphasize new findings. RECENT FINDINGS Recent research confirms VPAs teratogenicity and risk of hormone disruption. VPA exposure in utero increases the risk for a variety of major congenital malformations (MCMs), reduced IQ and behavioral problems. In girls and women, VPA increases the risk of hormone abnormalities, obesity, and polycystic ovarian syndrome (PCOS). Despite guidelines recommending caution, VPA use continues to be prescribed to reproductive-aged women and girls. Despite significant and well-documented risk, adherence to guidelines in VPA use in reproductive-aged girls and women remains low.
Collapse
Affiliation(s)
- Dorothy Gotlib
- Michigan Medicine, Department of Psychiatry, Ann Arbor, MI, USA.
| | - Rachel Ramaswamy
- Department of Psychiatry and Behavioral Neurosciences, Loyola University, Tampa, FL, USA
| | | | - Alana DeRiggi
- Michigan Medicine, Department of Psychiatry, Ann Arbor, MI, USA
| | - Michelle Riba
- Michigan Medicine, Department of Psychiatry, Ann Arbor, MI, USA
| |
Collapse
|
32
|
Veroniki AA, Rios P, Cogo E, Straus SE, Finkelstein Y, Kealey R, Reynen E, Soobiah C, Thavorn K, Hutton B, Hemmelgarn BR, Yazdi F, D'Souza J, MacDonald H, Tricco AC. Comparative safety of antiepileptic drugs for neurological development in children exposed during pregnancy and breast feeding: a systematic review and network meta-analysis. BMJ Open 2017; 7:e017248. [PMID: 28729328 PMCID: PMC5642793 DOI: 10.1136/bmjopen-2017-017248] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Compare the safety of antiepileptic drugs (AEDs) on neurodevelopment of infants/children exposed in utero or during breast feeding. DESIGN AND SETTING Systematic review and Bayesian random-effects network meta-analysis (NMA). MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched until 27 April 2017. Screening, data abstraction and quality appraisal were completed in duplicate by independent reviewers. PARTICIPANTS 29 cohort studies including 5100 infants/children. INTERVENTIONS Monotherapy and polytherapy AEDs including first-generation (carbamazepine, clobazam, clonazepam, ethosuximide, phenobarbital, phenytoin, primidone, valproate) and newer-generation (gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate, vigabatrin) AEDs. Epileptic women who did not receive AEDs during pregnancy or breast feeding served as the control group. PRIMARY AND SECONDARY OUTCOME MEASURES Cognitive developmental delay and autism/dyspraxia were primary outcomes. Attention-deficit hyperactivity disorder, language delay, neonatal seizures, psychomotor developmental delay and social impairment were secondary outcomes. RESULTS The NMA on cognitive developmental delay (11 cohort studies, 933 children, 18 treatments) suggested that among all AEDs only valproate was statistically significantly associated with more children experiencing cognitive developmental delay compared with control (OR=7.40, 95% credible interval (CrI) 3.00 to 18.46). The NMA on autism (5 cohort studies, 2551 children, 12 treatments) suggested that oxcarbazepine (OR 13.51, CrI 1.28 to 221.40), valproate (OR 17.29, 95% CrI 2.40 to 217.60), lamotrigine (OR 8.88, CrI 1.28 to 112.00) and lamotrigine+valproate (OR 132.70, CrI 7.41 to 3851.00) were associated with significantly greater odds of developing autism compared with control. The NMA on psychomotor developmental delay (11 cohort studies, 1145 children, 18 treatments) found that valproate (OR 4.16, CrI 2.04 to 8.75) and carbamazepine+phenobarbital+valproate (OR 19.12, CrI 1.49 to 337.50) were associated with significantly greater odds of psychomotor delay compared with control. CONCLUSIONS Valproate alone or combined with another AED is associated with the greatest odds of adverse neurodevelopmental outcomes compared with control. Oxcarbazepine and lamotrigine were associated with increased occurrence of autism. Counselling is advised for women considering pregnancy to tailor the safest regimen. TRIAL REGISTRATION NUMBER PROSPERO database (CRD42014008925).
Collapse
Affiliation(s)
| | - Patricia Rios
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
| | - Elise Cogo
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, 27 King’s College Circle, Toronto, Canada
| | - Yaron Finkelstein
- The Hospital for Sick Children,555 University Avenue, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Medical Sciences Building, Toronto, Canada
| | - Ryan Kealey
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
| | - Emily Reynen
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
| | - Charlene Soobiah
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
- Institute for Health Policy Management & Evaluation,University of Toronto, Toronto, Canada
| | - Kednapa Thavorn
- School of Epidemiology,Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program,Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
- Institute of Clinical and Evaluative Sciences (ICES uOttawa), Ottawa, Canada
| | - Brian Hutton
- School of Epidemiology,Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute,Center for Practice Changing Research, Ottawa, Canada
| | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Fatemeh Yazdi
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
| | - Jennifer D'Souza
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
| | - Heather MacDonald
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
| | - Andrea C Tricco
- Li Ka Shing Knowledge Institute,St. Michael’s Hospital, Toronto, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| |
Collapse
|
33
|
Veroniki AA, Cogo E, Rios P, Straus SE, Finkelstein Y, Kealey R, Reynen E, Soobiah C, Thavorn K, Hutton B, Hemmelgarn BR, Yazdi F, D'Souza J, MacDonald H, Tricco AC. Comparative safety of anti-epileptic drugs during pregnancy: a systematic review and network meta-analysis of congenital malformations and prenatal outcomes. BMC Med 2017; 15:95. [PMID: 28472982 PMCID: PMC5418725 DOI: 10.1186/s12916-017-0845-1] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 03/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pregnant women with epilepsy frequently experience seizures related to pregnancy complications and are often prescribed anti-epileptic drugs (AEDs) to manage their symptoms. However, less is known about the comparative safety of AED exposure in utero. We aimed to compare the risk of congenital malformations (CMs) and prenatal outcomes of AEDs in infants/children who were exposed to AEDs in utero through a systematic review and Bayesian random-effects network meta-analysis. METHODS MEDLINE, EMBASE, and Cochrane CENTRAL were searched from inception to December 15, 2015. Two reviewers independently screened titles/abstracts and full-text papers for experimental and observational studies comparing mono- or poly-therapy AEDs versus control (no AED exposure) or other AEDs, then abstracted data and appraised the risk of bias. The primary outcome was incidence of major CMs, overall and by specific type (cardiac malformations, hypospadias, cleft lip and/or palate, club foot, inguinal hernia, and undescended testes). RESULTS After screening 5305 titles and abstracts, 642 potentially relevant full-text articles, and 17 studies from scanning reference lists, 96 studies were eligible (n = 58,461 patients). Across all major CMs, many AEDs were associated with higher risk compared to control. For major CMs, ethosuximide (OR, 3.04; 95% CrI, 1.23-7.07), valproate (OR, 2.93; 95% CrI, 2.36-3.69), topiramate (OR, 1.90; 95% CrI, 1.17-2.97), phenobarbital (OR, 1.83; 95% CrI, 1.35-2.47), phenytoin (OR, 1.67; 95% CrI, 1.30-2.17), carbamazepine (OR, 1.37; 95% CrI, 1.10-1.71), and 11 polytherapies were significantly more harmful than control, but lamotrigine (OR, 0.96; 95% CrI, 0.72-1.25) and levetiracetam (OR, 0.72; 95% CrI, 0.43-1.16) were not. CONCLUSION The newer generation AEDs, lamotrigine and levetiracetam, were not associated with significant increased risks of CMs compared to control, and were significantly less likely to be associated with children experiencing cardiac malformations than control. However, this does not mean that these agents are not harmful to infants/children exposed in utero. Counselling is advised concerning teratogenic risks when the prescription is written for a woman of childbearing age and before women continue with these agents when considering pregnancy, such as switching from polytherapy to monotherapy with evidence of lower risk and avoiding AEDs, such as valproate, that are consistently associated with CMs. These decisions must be balanced against the need for seizure control. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014008925.
Collapse
Affiliation(s)
- Areti Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada
| | - Elise Cogo
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada
| | - Patricia Rios
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.,Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada
| | - Yaron Finkelstein
- The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.,Department of Paediatrics, University of Toronto, 172 St. George Street, Toronto, Ontario, M5R 0A3, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Medical Sciences Building, Room 4207, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Ryan Kealey
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada
| | - Emily Reynen
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada
| | - Charlene Soobiah
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.,Institute for Health Policy Management & Evaluation, University of Toronto, 4th Floor, 155 College Street, Toronto, Ontario, M5T 3M6, Canada
| | - Kednapa Thavorn
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Roger-Guindon Building, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.,Institute of Clinical and Evaluative Sciences (ICES uOttawa), 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada
| | - Brian Hutton
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Roger-Guindon Building, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Center for Practice Changing Research, The Ottawa Hospital - General Campus, 501 Smyth Road, PO Box 201B, Ottawa, Ontario, K1H 8L6, Canada
| | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, TRW Building, 3rd Floor, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Fatemeh Yazdi
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada
| | - Jennifer D'Souza
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada
| | - Heather MacDonald
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada. .,Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 6th Floor, 155 College Street, Toronto, Ontario, M5T 3M7, Canada.
| |
Collapse
|
34
|
Bangar S, Shastri A, El-Sayeh H, Cavanna AE. Women with epilepsy: clinically relevant issues. FUNCTIONAL NEUROLOGY 2017; 31:127-34. [PMID: 27678205 DOI: 10.11138/fneur/2016.31.3.127] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Women with epilepsy (WWE) face specific challenges throughout their lifespan due to the effects of seizures and antiepileptic drugs on hormonal function, potentially affecting both sexual and reproductive health. This review article addresses the most common issues of practical relevance to clinicians treating WWE: epidemiology and clinical presentations (including catamenial epilepsy), contraception, reproductive and sexual dysfunction, pregnancy, lactation, menopause-related issues (including bone health), and mental health aspects. Awareness of these gender-specific issues and implementation/adaptation of effective interventions for WWE results in significantly improved health-related quality of life in this patient population.
Collapse
|
35
|
Wilson RD. Supplémentation préconceptionnelle en acide folique / multivitamines pour la prévention primaire et secondaire des anomalies du tube neural et d'autres anomalies congénitales sensibles à l'acide folique. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S646-S664. [PMID: 28063572 DOI: 10.1016/j.jogc.2016.09.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIF Offrir des renseignements à jour sur l'utilisation pré et postconceptionnelle d'acide folique par voie orale, avec ou sans supplément de multivitamines / micronutriments, aux fins de la prévention des anomalies du tube neural et d'autres anomalies congénitales. Ces renseignements aideront les médecins, les sages-femmes, les infirmières et les autres professionnels de la santé à contribuer aux efforts de sensibilisation des femmes quant à l'utilisation et aux posologies adéquates de la supplémentation en acide folique / multivitamines, avant et pendant la grossesse. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed, Medline, CINAHL et la Cochrane Library en janvier 2011 au moyen d'un vocabulaire contrôlé et de mots clés appropriés (p. ex. « folic acid », « prenatal multivitamins », « folate sensitive birth defects », « congenital anomaly risk reduction », « pre-conception counselling »). Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre 1985 et juin 2014. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en juin 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, et auprès de sociétés de spécialité médicale nationales et internationales. COûTS, RISQUES ET AVANTAGES: Les coûts financiers sont ceux de la supplémentation quotidienne en vitamines et de la consommation d'un régime alimentaire santé enrichi en folate. Les risques sont ceux qui sont liés à une association signalée entre la supplémentation alimentaire en acide folique et des modifications épigénétiques fœtales / la probabilité accrue d'obtenir une grossesse gémellaire. Ces associations pourraient devoir être prises en considération avant la mise en œuvre d'une supplémentation en acide folique. La supplémentation en acide folique par voie orale (ou l'apport alimentaire en folate combiné à un supplément de multivitamines / micronutriments) a pour avantage de mener à une baisse connexe du taux d'anomalies du tube neural et peut-être même des taux d'autres complications obstétricales et anomalies congénitales particulières. VALEURS La qualité des résultats est évaluée au moyen des critères décrits par le Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). DéCLARATION SOMMAIRE: RECOMMANDATIONS.
Collapse
|
36
|
Successful health communication in epileptology. Seizure 2017; 44:7-10. [DOI: 10.1016/j.seizure.2016.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 10/03/2016] [Indexed: 11/23/2022] Open
|
37
|
Pregnancy and epilepsy; meeting the challenges over the last 25 years: The rise of the pregnancy registries. Seizure 2016; 44:162-168. [PMID: 27839978 DOI: 10.1016/j.seizure.2016.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/03/2016] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Women with epilepsy (WWE), of all ages, have much to consider if their care is to be optimised and they are not to be denied the choices open to those without epilepsy. At no time is this more critical than during their child-bearing years when treatment decisions are complex. METHODS In this article we will provide a personal commentary and review of the pertinent literature on how the management of WWE of childbearing years has changed over the last 25 years. As well as reflecting on the state of knowledge at the start of the 1990s and the approach to managing WWE at this time, we will demonstrate that in addition to much more information now being available that there has also been an attempt to standardise how WWE should be managed. RESULTS As a means of achieving this increase in knowledge and standardisation of care, we argue that the various pregnancy registries have played a significant part in these positive developments. As vehicles for collecting clinically relevant data, they have provided information that has helped empower women and their health care providers to make sound clinical decisions, as well as highlighting the difficulties and unknowns. CONCLUSIONS Still being active the pregnancy registries maintain a continued focus on the relevant issues relating to WWE.
Collapse
|
38
|
Abstract
INTRODUCTION Hormonal contraceptives are used by over 100 million people worldwide. Recently, there has been an emerging interest in studying the potential impact of oral contraceptives (OCs) on certain neurological conditions. It has been suspected for some time that hormonal birth control increases seizure activity in women with epilepsy, but there is little supportive data. Areas covered: Literature from PubMed and online sources was analyzed with respect to hormonal contraception and epilepsy or seizures. New evidence indicates that OCs can cause an increase in seizures in women with epilepsy. The epilepsy birth control registry, which surveyed women with epilepsy, found that those using hormonal contraceptives self-reported 4.5 times more seizures than those that did not use such contraceptives. A preclinical study confirmed these outcomes wherein epileptic animals given ethinyl estradiol, the primary component of OCs, had more frequent seizures that are more likely to be resistant. Expert commentary: OC pills may increase seizures in women with epilepsy and such refractory seizures are more likely to cause neuronal damage in the brain. Thus, women of child bearing age with epilepsy should consider using non-hormonal forms of birth control to avoid risks from OC pills. Additional research into the mechanisms and prospective clinical investigation are needed.
Collapse
Affiliation(s)
- Doodipala Samba Reddy
- a Department of Neuroscience and Experimental Therapeutics, College of Medicine , Texas A&M University Health Science Center , Bryan , TX , USA
| |
Collapse
|
39
|
Abstract
Although prenatal exposure to antiepileptic drugs (AEDs) is known to impart relatively higher risks of major congenital malformations, prospective studies have provided refined data that allow us to differentiate the risks of different types and doses of AEDs. As the number of AED prescriptions has dramatically increased in reproductive-aged women with a variety of neuropsychiatric indications, the evolving concepts learned from studies in women with epilepsy can be applied to a much larger group of pregnant women to improve child outcomes while maintaining maternal disease control. In addition to careful selection of the type of medication, the amount of fetal exposure at conception and in the first trimester probably matters across all AEDs. Some AED polytherapy regimens are not associated with a higher risk of malformations, although other outcomes have not yet been formally studied. The individual woman's drug target concentration should be established preconception and maintained during pregnancy, to prevent seizure worsening. Substantial pharmacokinetic changes occur with many of the medications during pregnancy and postpartum, and interindividual variability supports the use of therapeutic drug monitoring for most AEDs. During pregnancy, vigilance and close monitoring should also include intrauterine fetal growth, obstetric complications, and neonatal complications. Breastfeeding can provide additional neurodevelopmental benefit and should be an option for women on AEDs. Knowledge of these key principles enhances our ability to make treatment recommendations with resultant improved maternal and child outcomes. Additional prospective studies are needed to further define the risk-benefit ratio across a variety of medications, dosing strategies, and neuropsychiatric disorders.
Collapse
Affiliation(s)
- Page B Pennell
- Department of Neurology, Division of Epilepsy, Division of Women's Health, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, 02115, USA.
| |
Collapse
|
40
|
Müffelmann B, Bien CG. [Pharmacological treatment of women with epilepsy before and during pregnancy]. DER NERVENARZT 2016; 87:1115-1126. [PMID: 27631817 DOI: 10.1007/s00115-016-0210-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In the vast majority of women with epilepsy, no complications occur during pregnancy. Important for that is early, preconceptional counseling and close surveillance during pregnancy. The aim should be to maintain the best possible seizure control without occurrence of generalized tonic-clonic seizures while using antiepileptic drugs and with the lowest possible risk of malformations. The warnings for the prescription of valproic acid in women of reproductive age were tightened because of the dose-dependent increase in the malformation rate and other risks, especially regarding adverse effects on childhood cognitive development. The pharmacokinetics of antiepileptic drugs in pregnancy require monitoring of serum drug levels and an early dose adjustment. Breastfeeding should be encouraged in women with epilepsy taking antiepileptic drugs as long as infants are closely monitored with respect to possible sedation and poor drinking.
Collapse
Affiliation(s)
- B Müffelmann
- Epilepsie-Zentrum Bethel, Krankenhaus Mara I, Maraweg 17-21, 33617, Bielefeld, Deutschland.
| | - C G Bien
- Epilepsie-Zentrum Bethel, Krankenhaus Mara I, Maraweg 17-21, 33617, Bielefeld, Deutschland
| |
Collapse
|
41
|
|
42
|
Geddes JR, Gardiner A, Rendell J, Voysey M, Tunbridge E, Hinds C, Yu LM, Hainsworth J, Attenburrow MJ, Simon J, Goodwin GM, Harrison PJ. Comparative evaluation of quetiapine plus lamotrigine combination versus quetiapine monotherapy (and folic acid versus placebo) in bipolar depression (CEQUEL): a 2 × 2 factorial randomised trial. Lancet Psychiatry 2016; 3:31-39. [PMID: 26687300 DOI: 10.1016/s2215-0366(15)00450-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/11/2015] [Accepted: 09/17/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Depressive symptoms are a major cause of disability in bipolar disorder and there are few safe and effective treatments. The combination of lamotrigine plus quetiapine potentially offers improved outcomes for people with bipolar depression. We aimed to determine if combination therapy with quetiapine plus lamotrigine leads to greater improvement in depressive symptoms over 12 weeks than quetiapine monotherapy plus lamotrigine placebo. METHODS In this double-blind, randomised, placebo-controlled, parallel group, 2 × 2 factorial trial (CEQUEL), patients with DSM-IV bipolar disorder I or II, who were aged 16 years or older, and required new treatment for a depressive episode, were enrolled from 27 sites in the UK. Patients were randomly assigned (1:1) by an adaptive minimisation algorithm to lamotrigine or placebo and to folic acid or placebo. Participants and investigators were masked to the treatment groups. The primary outcome was improvement in depressive symptoms at 12 weeks with the Quick Inventory of Depressive Symptomatology-self report version 16 (QIDS-SR16). Analysis was by modified intention-to-treat. This trial is registered with EUdraCT, number 2007-004513-33. FINDINGS Between Oct 21, 2008, and April 27, 2012, 202 participants were randomly assigned; 101 to lamotrigine and 101 to placebo. The mean difference in QIDS-SR16 total score between the group receiving lamotrigine versus the placebo group at 12 weeks was -1·73 ([95% CI -3·57 to 0·11]; p=0·066) and at 52 weeks was -2·69 ([-4·89 to -0·49]; p=0·017). Folic acid was not superior to placebo. There was a significant interaction (p=0·028), with folic acid reducing the effectiveness of lamotrigine at 12 weeks. The mean difference on QIDS-SR16 was -4·14 ([95% CI -6·90 to -1·37]; p=0·004) for patients receiving lamotrigine without folic acid compared with 0·12 ([-2·58 to 2·82]; p=0·931) for those receiving lamotrigine and folic acid. INTERPRETATION Addition of lamotrigine to quetiapine treatment improved outcomes. Folic acid seems to nullify the effect of lamotrigine. CEQUEL should encourage clinicians and patients to consider lamotrigine for bipolar depression, but also to be aware that concurrent folic acid might reduce its effectiveness. FUNDING Medical Research Council.
Collapse
Affiliation(s)
- John R Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Alexandra Gardiner
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jennifer Rendell
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Merryn Voysey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Tunbridge
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Christopher Hinds
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jane Hainsworth
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | | | - Judit Simon
- Centre for Public Health, Medical University of Vienna, Vienna, Austria
| | - Guy M Goodwin
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | | |
Collapse
|
43
|
Abstract
The clinical management of women with epilepsy on antiepileptic drugs (AEDs) during pregnancy presents unique challenges. The goal of treatment is optimal seizure control with minimal in utero fetal exposure to AEDs in an effort to reduce the risk of structural and neurodevelopmental teratogenic effects. This paper reviews the following key issues pertaining to women with epilepsy during pregnancy: AED pharmacokinetics; clinical management of AEDs; seizure frequency; major congenital malformation; neurodevelopmental outcomes; perinatal complications; and breast feeding.
Collapse
Affiliation(s)
- Sima I Patel
- Department of Neurology, University of Minnesota Health/MINCEP Epilepsy Care, 5775 Wayzata Blvd, Minneapolis, MN 55416, USA
| | - Page B Pennell
- Department of Neurology, Divisions of Epilepsy and Women's Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
44
|
Wilson RD, Wilson RD, Audibert F, Brock JA, Carroll J, Cartier L, Gagnon A, Johnson JA, Langlois S, Murphy-Kaulbeck L, Okun N, Pastuck M, Deb-Rinker P, Dodds L, Leon JA, Lowel HL, Luo W, MacFarlane A, McMillan R, Moore A, Mundle W, O'Connor D, Ray J, Van den Hof M. Pre-conception Folic Acid and Multivitamin Supplementation for the Primary and Secondary Prevention of Neural Tube Defects and Other Folic Acid-Sensitive Congenital Anomalies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:534-52. [PMID: 26334606 DOI: 10.1016/s1701-2163(15)30230-9] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To provide updated information on the pre- and post-conception use of oral folic acid with or without a multivitamin/micronutrient supplement for the prevention of neural tube defects and other congenital anomalies. This will help physicians, midwives, nurses, and other health care workers to assist in the education of women about the proper use and dosage of folic acid/multivitamin supplementation before and during pregnancy. EVIDENCE Published literature was retrieved through searches of PubMed, Medline, CINAHL, and the Cochrane Library in January 2011 using appropriate controlled vocabulary and key words (e.g., folic acid, prenatal multivitamins, folate sensitive birth defects, congenital anomaly risk reduction, pre-conception counselling). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from 1985 and June 2014. Searches were updated on a regular basis and incorporated in the guideline to June 2014 Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Costs, risks, and benefits: The financial costs are those of daily vitamin supplementation and eating a healthy folate-enriched diet. The risks are of a reported association of dietary folic acid supplementation with fetal epigenetic modifications and with an increased likelihood of a twin pregnancy. These associations may require consideration before initiating folic acid supplementation. The benefit of folic acid oral supplementation or dietary folate intake combined with a multivitamin/micronutrient supplement is an associated decrease in neural tube defects and perhaps in other specific birth defects and obstetrical complications. VALUES The quality of evidence in the document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). Summary Statement In Canada multivitamin tablets with folic acid are usually available in 3 formats: regular over-the-counter multivitamins with 0.4 to 0.6 mg folic acid, prenatal over-the-counter multivitamins with 1.0 mg folic acid, and prescription multivitamins with 5.0 mg folic acid. (III) Recommendations 1. Women should be advised to maintain a healthy folate-rich diet; however, folic acid/multivitamin supplementation is needed to achieve the red blood cell folate levels associated with maximal protection against neural tube defect. (III-A) 2. All women in the reproductive age group (12-45 years of age) who have preserved fertility (a pregnancy is possible) should be advised about the benefits of folic acid in a multivitamin supplementation during medical wellness visits (birth control renewal, Pap testing, yearly gynaecological examination) whether or not a pregnancy is contemplated. Because so many pregnancies are unplanned, this applies to all women who may become pregnant. (III-A) 3. Folic acid supplementation is unlikely to mask vitamin B12 deficiency (pernicious anemia). Investigations (examination or laboratory) are not required prior to initiating folic acid supplementation for women with a risk for primary or recurrent neural tube or other folic acid-sensitive congenital anomalies who are considering a pregnancy. It is recommended that folic acid be taken in a multivitamin including 2.6 ug/day of vitamin B12 to mitigate even theoretical concerns. (II-2A) 4. Women at HIGH RISK, for whom a folic acid dose greater than 1 mg is indicated, taking a multivitamin tablet containing folic acid, should be advised to follow the product label and not to take more than 1 daily dose of the multivitamin supplement. Additional tablets containing only folic acid should be taken to achieve the desired dose. (II-2A) 5. Women with a LOW RISK for a neural tube defect or other folic acid-sensitive congenital anomaly and a male partner with low risk require a diet of folate-rich foods and a daily oral multivitamin supplement containing 0.4 mg folic acid for at least 2 to 3 months before conception, throughout the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues. (II-2A) 6. Women with a MODERATE RISK for a neural tube defect or other folic acid-sensitive congenital anomaly or a male partner with moderate risk require a diet of folate-rich foods and daily oral supplementation with a multivitamin containing 1.0 mg folic acid, beginning at least 3 months before conception. Women should continue this regime until 12 weeks' gestational age. (1-A) From 12 weeks' gestational age, continuing through the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues, continued daily supplementation should consist of a multivitamin with 0.4 to 1.0 mg folic acid. (II-2A) 7. Women with an increased or HIGH RISK for a neural tube defect, a male partner with a personal history of neural tube defect, or history of a previous neural tube defect pregnancy in either partner require a diet of folate-rich foods and a daily oral supplement with 4.0 mg folic acid for at least 3 months before conception and until 12 weeks' gestational age. From 12 weeks' gestational age, continuing throughout the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues, continued daily supplementation should consist of a multivitamin with 0.4 to 1.0 mg folic acid. (I-A). The same dietary and supplementation regime should be followed if either partner has had a previous pregnancy with a neural tube defect. (II-2A).
Collapse
|
45
|
Abstract
Pregnancy is a complex state where changes in maternal physiology have evolved to favor the development and growth of the placenta and the fetus. These adaptations may affect preexisting disease or result in pregnancy-specific disorders. Similarly, variations in physiology may alter the pharmacokinetics or pharmacodynamics that determines drug dosing and effect. It follows that detailed pharmacologic information is required to adjust therapeutic treatment strategies during pregnancy. Understanding both pregnancy physiology and the gestation-specific pharmacology of different agents is necessary to achieve effective treatment and limit maternal and fetal risk. Unfortunately, most drug studies have excluded pregnant women based on often-mistaken concerns regarding fetal risk. Furthermore, over two-thirds of women receive prescription drugs while pregnant, with treatment and dosing strategies based on data from healthy male volunteers and non-pregnant women, and with little adjustment for the complex physiology of pregnancy and its unique disease states. This review will describe basic concepts in pharmacokinetics and their clinical relevance and highlight the variations in pregnancy that may impact the pharmacokinetic properties of medications.
Collapse
Affiliation(s)
- Maisa Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, Magee Womens Hospital of UPMC, University of Pittsburgh, 300 Halket St, Pittsburgh, PA 15213.
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA,Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, Magee Womens Hospital of UPMC, University of Pittsburgh, 300 Halket St, Pittsburgh, PA 15213
| |
Collapse
|
46
|
Abstract
Characteristics of using valproic acid drugs in women, from puberty to menopause period, are reviewed. Based on initial treatment efficacy, type of epileptic seizures and a form of epilepsy, the author emphasizes the practical use of valproates during pregnancy in dependence on the situation. Several scenarios of pregnancy course and possible treatment tactics are presented.
Collapse
Affiliation(s)
- P N Vlasov
- Evdokimov Moscow State University of Medical Dentistry, Moscow
| |
Collapse
|
47
|
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]
|
48
|
Improving the prescription of folate to women receiving antiepileptic drugs. Epilepsy Res 2015; 112:27-30. [DOI: 10.1016/j.eplepsyres.2015.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/20/2015] [Accepted: 02/06/2015] [Indexed: 11/20/2022]
|
49
|
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
|
50
|
Asadi-Pooya AA. High dose folic acid supplementation in women with epilepsy: Are we sure it is safe? Seizure 2015; 27:51-3. [DOI: 10.1016/j.seizure.2015.02.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/16/2015] [Accepted: 02/27/2015] [Indexed: 11/28/2022] Open
|