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Pack AM, Oskoui M, Williams Roberson S, Donley DK, French J, Gerard EE, Gloss D, Miller WR, Munger Clary HM, Osmundson SS, McFadden B, Parratt K, Pennell PB, Saade G, Smith DB, Sullivan K, Thomas SV, Tomson T, Dolan O'Brien M, Botchway-Doe K, Silsbee HM, Keezer MR. Teratogenesis, Perinatal, and Neurodevelopmental Outcomes After In Utero Exposure to Antiseizure Medication: Practice Guideline From the AAN, AES, and SMFM. Neurology 2024; 102:e209279. [PMID: 38748979 PMCID: PMC11175651 DOI: 10.1212/wnl.0000000000209279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/21/2024] [Indexed: 06/15/2024] Open
Abstract
This practice guideline provides updated evidence-based conclusions and recommendations regarding the effects of antiseizure medications (ASMs) and folic acid supplementation on the prevalence of major congenital malformations (MCMs), adverse perinatal outcomes, and neurodevelopmental outcomes in children born to people with epilepsy of childbearing potential (PWECP). A multidisciplinary panel conducted a systematic review and developed practice recommendations following the process outlined in the 2017 edition of the American Academy of Neurology Clinical Practice Guideline Process Manual. The systematic review includes studies through August 2022. Recommendations are supported by structured rationales that integrate evidence from the systematic review, related evidence, principles of care, and inferences from evidence. The following are some of the major recommendations. When treating PWECP, clinicians should recommend ASMs and doses that optimize both seizure control and fetal outcomes should pregnancy occur, at the earliest possible opportunity preconceptionally. Clinicians must minimize the occurrence of convulsive seizures in PWECP during pregnancy to minimize potential risks to the birth parent and to the fetus. Once a PWECP is already pregnant, clinicians should exercise caution in attempting to remove or replace an ASM that is effective in controlling generalized tonic-clonic or focal-to-bilateral tonic-clonic seizures. Clinicians must consider using lamotrigine, levetiracetam, or oxcarbazepine in PWECP when appropriate based on the patient's epilepsy syndrome, likelihood of achieving seizure control, and comorbidities, to minimize the risk of MCMs. Clinicians must avoid the use of valproic acid in PWECP to minimize the risk of MCMs or neural tube defects (NTDs), if clinically feasible. Clinicians should avoid the use of valproic acid or topiramate in PWECP to minimize the risk of offspring being born small for gestational age, if clinically feasible. To reduce the risk of poor neurodevelopmental outcomes, including autism spectrum disorder and lower IQ, in children born to PWECP, clinicians must avoid the use of valproic acid in PWECP, if clinically feasible. Clinicians should prescribe at least 0.4 mg of folic acid supplementation daily preconceptionally and during pregnancy to any PWECP treated with an ASM to decrease the risk of NTDs and possibly improve neurodevelopmental outcomes in the offspring.
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Affiliation(s)
- Alison M Pack
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Maryam Oskoui
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Shawniqua Williams Roberson
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Diane K Donley
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Jacqueline French
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Elizabeth E Gerard
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - David Gloss
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Wendy R Miller
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Heidi M Munger Clary
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Sarah S Osmundson
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Brandy McFadden
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Kaitlyn Parratt
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Page B Pennell
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - George Saade
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Don B Smith
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Kelly Sullivan
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Sanjeev V Thomas
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Torbjörn Tomson
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Mary Dolan O'Brien
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Kylie Botchway-Doe
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Heather M Silsbee
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
| | - Mark R Keezer
- From the Department of Neurology (A.M.P.), Columbia University, New York City; Departments of Pediatrics and Neurology & Neurosurgery (M.O.), McGill University, Montreal, Quebec, Canada; Departments of Neurology (S.W.R.), Biomedical Engineering (S.W.R.), and Obstetrics and Gynecology (S.S.O.), Vanderbilt University Medical Center, Nashville, TN; Northern Michigan Neurology and Munson Medical Center (D.K.D.), Traverse City, MI; Department of Neurology (J.F.), NYU Grossman School of Medicine, New York City; Feinberg School of Medicine (E.E.G.), Northwestern University, Chicago, IL; The NeuroMedical Center (D.G.), Baton Rouge, LA; Epilepsy Foundation (W.R.M.), Bowie, MD; Department of Neurology (H.M.M.C.), Wake Forest University School of Medicine, Winston-Salem, NC; My Epilepsy Story (B.M.), Nashville, TN; Institute of Clinical Neurosciences (K.P.), Royal Prince Alfred Hospital, Sydney, Australia; Department of Neurology (P.B.P.), University of Pittsburgh School of Medicine, PA; Department of Ob-Gyn (G.S.), Eastern Virginia Medical School, Norfolk; Department of Neurology (D.B.S.), University of Colorado School of Medicine, Aurora; Department of Biostatistics, Epidemiology, and Environmental Health Sciences (K.S.), Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro; Department of Neurology (S.V.T.), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; Department of Clinical Neuroscience (T.T.), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; American Academy of Neurology (M.D.O.B., K.B.-D., H.M.S.), Minneapolis, MN; and Centre Hospitalier de l'Université de Montréal Research Centre (CRCHUM) (M.R.K.), Quebec, Canada
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2
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Bluett-Duncan M, Bullen P, Campbell E, Clayton-Smith J, Craig J, García-Fiñana M, Hughes DM, Ingham A, Irwin B, Jackson C, Kelly T, Morrow J, Rushton S, Winterbottom J, Wood AG, Yates LM, Bromley RL. The use of parent-completed questionnaires to investigate developmental outcomes in large populations of children exposed to antiseizure medications in pregnancy. Epilepsia 2024. [PMID: 38776170 DOI: 10.1111/epi.18001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/24/2024]
Abstract
OBJECTIVE This study was undertaken to assess the utility of the Ages and Stages Questionnaire-3rd Edition (ASQ-3) and the Vineland Adaptive Behavior Scales-2nd Edition (VABS-II) as neurodevelopmental screening tools for infants exposed to antiseizure medications in utero, and to examine their suitability for use in large-population signal generation initiatives. METHODS Participants were women with epilepsy who were recruited from 21 hospitals in England and Northern Ireland during pregnancy between 2014 and 2016. Offspring were assessed at 24 months old using the Bayley Scales of Infant Development-3rd Edition (BSID-III), the VABS-II, and the ASQ-3 (n = 223). The sensitivity and specificity of the ASQ-3 and VABS-II to identify developmental delay at 24 months were examined, using the BSID-III to define cases. RESULTS The ASQ-3 identified 65 children (29.1%) as at risk of developmental delay at 24 months using standard referral criteria. Using a categorical approach and standard referral criteria to identify delay in the ASQ-3 and BSID-III at 24 months, the ASQ-3 showed excellent sensitivity (90.9%) and moderate specificity (74.1%). Utilizing different cut-points resulted in improved properties and may be preferred in certain contexts. The VABS-II exhibited the strongest psychometric properties when borderline impairment (>1 SD below the mean) was compared to BSID-III referral data (sensitivity = 100.0%, specificity = 96.6%). SIGNIFICANCE Both the ASQ-3 and VABS-II have good psychometric properties in a sample of children exposed to antiseizure medications when the purpose is the identification of at-risk groups. These findings identify the ASQ-3 as a measure that could be used effectively as part of a tiered surveillance system for teratogenic exposure by identifying a subset of individuals for more detailed investigations. Although the VABS-II has excellent psychometric properties, it is more labor-intensive for both the research team and participants and is available in fewer languages than the ASQ-3.
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Affiliation(s)
| | - Philip Bullen
- Department of Obstetric and Fetal Medicine, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Ellen Campbell
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Jill Clayton-Smith
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
| | - John Craig
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Marta García-Fiñana
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - David M Hughes
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Amy Ingham
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
| | - Beth Irwin
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Cerian Jackson
- Department of Neuropsychology, Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Teresa Kelly
- Department of Obstetric and Fetal Medicine, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - James Morrow
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Sarah Rushton
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
| | - Janine Winterbottom
- Department of Neurology, Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Amanda G Wood
- School of Psychology, Deakin University, Burwood, Victoria, Australia
| | - Laura M Yates
- Department for Clinical Genetics, Northern Genetics Service, Newcastle, UK
| | - Rebecca L Bromley
- Division of Neuroscience, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust and Manchester Academic Health Sciences Centre, Manchester, UK
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3
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Desrochers B, Lavu A, Valencia E, Vaccaro C, Peymani P, Eltonsy S. Risks of congenital malformations and neonatal intensive care unit admissions with gabapentin use in pregnancy: A cohort study and scoping review with meta-analysis. Paediatr Perinat Epidemiol 2024. [PMID: 38773683 DOI: 10.1111/ppe.13086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND The increasing and prevalent use of gabapentin among pregnant people highlights the necessity to assess its neonatal safety. OBJECTIVES This study aimed to investigate the foetal safety of gabapentin during pregnancy using a cohort study and scoping review with a meta-analysis of published evidence. METHODS We conducted a population-based cohort study using the Manitoba health databases between 1995 and 2019. We examined the association between gabapentin use during pregnancy and the prevalence of major congenital malformations, cardiac and orofacial malformations, and neonatal intensive care unit (NICU) admissions using multivariate regression models. We searched the literature in MEDLINE and EMBASE databases from inception to October 2022 to identify relevant observational studies and conducted a meta-analysis using random-effects models, including our cohort study results. RESULTS Of the 289,227 included pregnancies, 870 pregnant people were exposed to gabapentin. Gabapentin exposure during the First trimester was not associated with an increased risk of any malformations (adjusted relative risk [aRR]) 1.16 (95% confidence interval [CI] 0.92, 1.46), cardiac malformations (aRR 1.29, 95% CI 0.72, 2.29), orofacial malformations (aRR 1.37, 95% CI 0.50, 3.75), and major congenital malformations (aRR 1.00, 95% CI 0.73, 1.36). whereas exposure during any trimester was associated with an increased NICU admission risk (aRR, 1.99 [95% CI 1.70, 2.32]). The meta-analysis of unadjusted results revealed an increased risk of major congenital malformations (RR 1.44, 95% CI 1.28, 1.61, I2 = 0%), cardiac malformations (RR 1.66, 95% CI 1.11, 2.47, I2 = 68%), and NICU admissions (RR 3.15, 95% CI 2.90, 3.41, I2 = 10%), and increased trend of orofacial malformations (RR 1.98, 95% CI 0.79, 5.00, I2 = 0%). CONCLUSIONS Gabapentin use was associated with an increased risk of NICU admissions in the cohort study and pooled meta-analysis. Clinicians should prescribe gabapentin with caution during pregnancy and further studies are warranted.
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Affiliation(s)
| | - Alekhya Lavu
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eunice Valencia
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christine Vaccaro
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Payam Peymani
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sherif Eltonsy
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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Ornoy A, Echefu B, Becker M. Valproic Acid in Pregnancy Revisited: Neurobehavioral, Biochemical and Molecular Changes Affecting the Embryo and Fetus in Humans and in Animals: A Narrative Review. Int J Mol Sci 2023; 25:390. [PMID: 38203562 PMCID: PMC10779436 DOI: 10.3390/ijms25010390] [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: 12/11/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
Valproic acid (VPA) is a very effective anticonvulsant and mood stabilizer with relatively few side effects. Being an epigenetic modulator, it undergoes clinical trials for the treatment of advanced prostatic and breast cancer. However, in pregnancy, it seems to be the most teratogenic antiepileptic drug. Among the proven effects are congenital malformations in about 10%. The more common congenital malformations are neural tube defects, cardiac anomalies, urogenital malformations including hypospadias, skeletal malformations and orofacial clefts. These effects are dose related; daily doses below 600 mg have a limited teratogenic potential. VPA, when added to other anti-seizure medications, increases the malformations rate. It induces malformations even when taken for indications other than epilepsy, adding to the data that epilepsy is not responsible for the teratogenic effects. VPA increases the rate of neurodevelopmental problems causing reduced cognitive abilities and language impairment. It also increases the prevalence of specific neurodevelopmental syndromes like autism (ASD) and Attention Deficit Hyperactivity Disorder (ADHD). High doses of folic acid administered prior to and during pregnancy might alleviate some of the teratogenic effect of VPA and other AEDs. Several teratogenic mechanisms are proposed for VPA, but the most important mechanisms seem to be its effects on the metabolism of folate, SAMe and histones, thus affecting DNA methylation. VPA crosses the human placenta and was found at higher concentrations in fetal blood. Its concentrations in milk are low, therefore nursing is permitted. Animal studies generally recapitulate human data.
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Affiliation(s)
- Asher Ornoy
- Department of Morphological Sciences and Teratology, Adelson School of Medicine, Ariel University, Ariel 40700, Israel; (B.E.); (M.B.)
- Department of Medical Neurobiology, Hebrew University Hadassah Medical School, Jerusalem 9112102, Israel
| | - Boniface Echefu
- Department of Morphological Sciences and Teratology, Adelson School of Medicine, Ariel University, Ariel 40700, Israel; (B.E.); (M.B.)
| | - Maria Becker
- Department of Morphological Sciences and Teratology, Adelson School of Medicine, Ariel University, Ariel 40700, Israel; (B.E.); (M.B.)
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Mehra S, Ahsan AU, Sharma M, Budhwar M, Chopra M. Gestational Fisetin Exerts Neuroprotection by Regulating Mitochondria-Directed Canonical Wnt Signaling, BBB Integrity, and Apoptosis in Prenatal VPA-Induced Rodent Model of Autism. Mol Neurobiol 2023:10.1007/s12035-023-03826-6. [PMID: 38048031 DOI: 10.1007/s12035-023-03826-6] [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: 08/28/2023] [Accepted: 11/21/2023] [Indexed: 12/05/2023]
Abstract
Embryonic valproic acid (VPA) has been considered a potential risk factor for autism. Majority of studies indicated that targeting autism-associated alterations in VPA-induced autistic model could be promising in defining and designing therapeutics for autism. Numerous investigations in this field investigated the role of canonical Wnt signaling cascade in regulating the pathophysiology of autism. The impaired blood-brain barrier (BBB) permeability and mitochondrial dysfunction are some key implied features of the autistic brain. So, the current study was conducted to target canonical Wnt signaling pathway with a natural polyphenolic modulator cum antioxidant namely fisetin. A single dose of intraperitoneal VPA sodium salt (400 mg/kg) at gestational day 12.5 induced developmental delays, social behaviour impairments (tube dominance test), and anxiety-like behaviour (sucrose preference test) similar to autism. VPA induced mitochondrial damage and over-activated the canonical Wnt signaling which further increased the blood-brain barrier (BBB) disruption, apoptosis, and neuronal damage. Our findings revealed that oral administration of 10 mg/kg gestational fisetin (GD 13-till parturition) improved social and anxiety-like behaviour by modulating the ROS-regulated mitochondrial-canonical Wnt signaling. Moreover, fisetin controls BBB permeability, apoptosis, and neuronal damage in autism model proving its neuroprotective efficacy. Collectively, our findings revealed that fisetin-evoked modulation of the Wnt signaling cascade successfully relieved the associated symptoms of autism along with developmental delays in the model and indicates its potential as a bioceutical against autism.
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Affiliation(s)
- Sweety Mehra
- Cell and Molecular Biology Lab, Department of Zoology, Panjab University, Chandigarh, 160014, India
| | - Aitizaz Ul Ahsan
- Cell and Molecular Biology Lab, Department of Zoology, Panjab University, Chandigarh, 160014, India
| | - Madhu Sharma
- Cell and Molecular Biology Lab, Department of Zoology, Panjab University, Chandigarh, 160014, India
| | - Muskan Budhwar
- Cell and Molecular Biology Lab, Department of Zoology, Panjab University, Chandigarh, 160014, India
| | - Mani Chopra
- Cell and Molecular Biology Lab, Department of Zoology, Panjab University, Chandigarh, 160014, India.
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Lee SK. Issues of Women with Epilepsy and Suitable Antiseizure Drugs. J Epilepsy Res 2023; 13:23-35. [PMID: 38223363 PMCID: PMC10783964 DOI: 10.14581/jer.23005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/12/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Seizure aggravation in women with epilepsy (WWE) tends to occur at two specific times during the menstrual cycle: the perimenstrual phase and the ovulation period. Antiseizure drugs (ASDs), especially those that induce enzymes, can accelerate the metabolism of hormones in oral contraceptives, rendering them less effective. Estrogen in contraceptive pills increases the metabolism of lamotrigine. Physiological changes during pregnancy can significantly impact the pharmacokinetics of ASDs, potentially necessitating adjustments in dosage for women with epilepsy to maintain seizure control. The use of valproate in pregnant women is associated with the highest risk of major congenital malformations among ASDs. Risks of major congenital malformations associated with lamotrigine, levetiracetam, and oxcarbazepine were within the range reported in the general population. Exposure to valproate can lead to lower IQ in offspring. Reduced folic acid levels are linked to orofacial clefts, cardiovascular malformations, and urogenital and limb anomalies in WWE. Decreased folate levels are expected with the use of enzyme-inducing ASDs. However, a high dose of folate was associated with an increased risk of cancer in children of mothers with epilepsy. Most ASDs are generally considered safe for breastfeeding and should be encouraged. However, no single ASD is considered ideal for childbearing WWE. Lamotrigine and levetiracetam are relatively more suitable options for this situation.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Aggarwal S, Barman M, Poudel B, Joshi K, Devi R, Singh P, Priyadarshi M, Chaurasia S, Basu S. Fetal Hydantoin Syndrome: A Case Report. Cureus 2023; 15:e49663. [PMID: 38161950 PMCID: PMC10756398 DOI: 10.7759/cureus.49663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Epilepsy is not a common cause of morbidity in pregnancy. It has widespread effects on maternal and fetal health necessitating adequate control of seizures. Many anti-seizure medications (ASM) have teratogenic effects on the fetus. We report a case of severe fetal hydantoin syndrome resulting in life-threatening major congenital anomalies. The mother was on phenytoin for the last three years and the pregnancy was not registered. We discuss various features of fetal hydantoin syndrome and the ideal management of epilepsy in pregnancy in brief.
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Affiliation(s)
- Sanchit Aggarwal
- Paediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Manidipa Barman
- Paediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Binita Poudel
- Paediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Kamal Joshi
- Paediatrics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Risha Devi
- Neonatology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Poonam Singh
- Neonatology, All India Institute of Medical Sciences, Rishikesh, IND
| | | | - Suman Chaurasia
- Neonatology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Sriparna Basu
- Neonatology, All India Institute of Medical Sciences, Rishikesh, IND
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Válóczy R, Fekete I, Horváth L, Mészáros Z, Fekete K. Comparative analysis of three decades' experience in the management of pregnant women with epilepsy: a real-life scenario. Front Neurol 2023; 14:1254214. [PMID: 37771456 PMCID: PMC10525340 DOI: 10.3389/fneur.2023.1254214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/21/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction People with epilepsy have to face many challenges, including regular follow-ups, the need to take antiseizure medications (ASMs), and the fear of seizures. Pregnant women with epilepsy (PWWE) are a special group with even more challenges because they are responsible for the fetus. We aimed to evaluate the change in the frequency of pregnancies over the years and the possible role of newer types of ASMs concerning this change, the shift in medication use over three decades, and their possible impact on the outcome of the observed pregnancies. Methods Data were retrieved from the prospective Epilepsy Database of the Outpatient Clinic at our tertiary center between 1 January 1992 and 31 December 2020. Groups were formed for comparison in time and depending on whether regular care consultation was our task. Statistical analysis was carried out using Microsoft Office Excel 2021. Basic statistics and categorical variables were assessed using Pearson's χ2 test with Yates' correction. Differences were considered significant if the p-value was <0.05. The odds ratio and 95% confidence intervals were calculated wherever needed. Results Altogether, 181 pregnancies were studied, mostly after 2002. The regular follow-up group consisted of 101 patients, with 44.5% presenting in the first trimester. The majority of seizures were either generalized or focal to bilateral tonic-clonic seizure types (85.6%). Pregnancies ended in live births in 91.7%, which gradually improved over time, while spontaneous abortion did not differ significantly in the time interval groups. Mostly, monotherapy was provided. PWWEs had higher chances for seizure freedom in the regular-care group I: OR = 2.9 (2.15-3.65) p < 0.0001. A shift toward newer-type ASMs was found as time passed. Levetiracetam and lamotrigine were more commonly used in the regular care group I than by those patients who were sent to consultation only and not treated at our center [OR = 3.18 (2.49-3.87)] p < 0.0001. Conclusion This is the first study in our region to evaluate experience in the treatment and outcome of PWWE. Having received reliable care and safer ASMs, the number of pregnancies among PWWEs grew. Data suggested that specialized centers' care offered cooperation with obstetricians is important. Moreover, professional care can also enable PWWEs to have uneventful pregnancies.
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Affiliation(s)
- Réka Válóczy
- Faculty of Medicine, Doctoral School of Neuroscience, University of Debrecen, Debrecen, Hungary
| | - István Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Horváth
- Department of Pharmaceutical Surveillance and Economy, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Zsófia Mészáros
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Klára Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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9
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Hope OA, Harris KM. Management of epilepsy during pregnancy and lactation. BMJ 2023; 382:e074630. [PMID: 37684052 DOI: 10.1136/bmj-2022-074630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Epilepsy is a group of neurological diseases characterized by susceptibility to recurrent seizures. Antiseizure medications (ASMs) are the mainstay of treatment, but many antiseizure medications with variable safety profiles have been approved for use. For women with epilepsy in their childbearing years, the safety profile is important for them and their unborn children, because treatment is often required to protect them from seizures during pregnancy and lactation. Since no large randomized controlled trials have investigated safety in this subgroup of people with epilepsy, pregnancy registries, cohort and case-control studies from population registries, and a few large prospective cohort studies have played an important role. Valproate, in monotherapy and polytherapy, has been associated with elevated risk of major congenital malformations and neurodevelopmental disorders in children born to mothers who took it. Topiramate and phenobarbital are also associated with elevated risks of congenital malformations and neurodevelopmental disorders, though the risks are lower than those of valproate. Lamotrigine and levetiracetam are relatively safe. Insufficient data exist to reach strong conclusions about the newest antiseizure medications such as eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Besides antiseizure medications, other treatments such as vagal nerve stimulation, responsive neurostimulation, and deep brain stimulation are likely safe. In general, breastfeeding does not appear to add any additional long term risks to the child. Creative ways of optimizing registry enrollment and data collection are needed to enhance patient safety.
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Affiliation(s)
- Omotola A Hope
- Houston Methodist Sugarland Neurology Associates, Houston, TX, USA
| | - Katherine Mj Harris
- Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, USA
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Bromley R, Adab N, Bluett-Duncan M, Clayton-Smith J, Christensen J, Edwards K, Greenhalgh J, Hill RA, Jackson CF, Khanom S, McGinty RN, Tudur Smith C, Pulman J, Marson AG. Monotherapy treatment of epilepsy in pregnancy: congenital malformation outcomes in the child. Cochrane Database Syst Rev 2023; 8:CD010224. [PMID: 37647086 PMCID: PMC10463554 DOI: 10.1002/14651858.cd010224.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Prenatal exposure to certain anti-seizure medications (ASMs) is associated with an increased risk of major congenital malformations (MCM). The majority of women with epilepsy continue taking ASMs throughout pregnancy and, therefore, information on the potential risks associated with ASM treatment is required. OBJECTIVES To assess the effects of prenatal exposure to ASMs on the prevalence of MCM in the child. SEARCH METHODS For the latest update of this review, we searched the following databases on 17 February 2022: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to February 16, 2022), SCOPUS (1823 onwards), and ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP). No language restrictions were imposed. SELECTION CRITERIA We included prospective cohort controlled studies, cohort studies set within pregnancy registries, randomised controlled trials and epidemiological studies using routine health record data. Participants were women with epilepsy taking ASMs; the two control groups were women without epilepsy and untreated women with epilepsy. DATA COLLECTION AND ANALYSIS Five authors independently selected studies for inclusion. Eight authors completed data extraction and/or risk of bias assessments. The primary outcome was the presence of an MCM. Secondary outcomes included specific types of MCM. Where meta-analysis was not possible, we reviewed included studies narratively. MAIN RESULTS From 12,296 abstracts, we reviewed 283 full-text publications which identified 49 studies with 128 publications between them. Data from ASM-exposed pregnancies were more numerous for prospective cohort studies (n = 17,963), than data currently available for epidemiological health record studies (n = 7913). The MCM risk for children of women without epilepsy was 2.1% (95% CI 1.5 to 3.0) in cohort studies and 3.3% (95% CI 1.5 to 7.1) in health record studies. The known risk associated with sodium valproate exposure was clear across comparisons with a pooled prevalence of 9.8% (95% CI 8.1 to 11.9) from cohort data and 9.7% (95% CI 7.1 to 13.4) from routine health record studies. This was elevated across almost all comparisons to other monotherapy ASMs, with the absolute risk differences ranging from 5% to 9%. Multiple studies found that the MCM risk is dose-dependent. Children exposed to carbamazepine had an increased MCM prevalence in both cohort studies (4.7%, 95% CI 3.7 to 5.9) and routine health record studies (4.0%, 95% CI 2.9 to 5.4) which was significantly higher than that for the children born to women without epilepsy for both cohort (RR 2.30, 95% CI 1.47 to 3.59) and routine health record studies (RR 1.14, 95% CI 0.80 to 1.64); with similar significant results in comparison to the children of women with untreated epilepsy for both cohort studies (RR 1.44, 95% CI 1.05 to 1.96) and routine health record studies (RR 1.42, 95% CI 1.10 to 1.83). For phenobarbital exposure, the prevalence was 6.3% (95% CI 4.8 to 8.3) and 8.8% (95% CI 0.0 to 9277.0) from cohort and routine health record data, respectively. This increased risk was significant in comparison to the children of women without epilepsy (RR 3.22, 95% CI 1.84 to 5.65) and those born to women with untreated epilepsy (RR 1.64, 95% CI 0.94 to 2.83) in cohort studies; data from routine health record studies was limited. For phenytoin exposure, the prevalence of MCM was elevated for cohort study data (5.4%, 95% CI 3.6 to 8.1) and routine health record data (6.8%, 95% CI 0.1 to 701.2). The prevalence of MCM was higher for phenytoin-exposed children in comparison to children of women without epilepsy (RR 3.81, 95% CI 1.91 to 7.57) and the children of women with untreated epilepsy (RR 2.01. 95% CI 1.29 to 3.12); there were no data from routine health record studies. Pooled data from cohort studies indicated a significantly increased MCM risk for children exposed to lamotrigine in comparison to children born to women without epilepsy (RR 1.99, 95% CI 1.16 to 3.39); with a risk difference (RD) indicating a 1% increased risk of MCM (RD 0.01. 95% CI 0.00 to 0.03). This was not replicated in the comparison to the children of women with untreated epilepsy (RR 1.04, 95% CI 0.66 to 1.63), which contained the largest group of lamotrigine-exposed children (> 2700). Further, a non-significant difference was also found both in comparison to the children of women without epilepsy (RR 1.19, 95% CI 0.86 to 1.64) and children born to women with untreated epilepsy (RR 1.00, 95% CI 0.79 to 1.28) from routine data studies. For levetiracetam exposure, pooled data provided similar risk ratios to women without epilepsy in cohort (RR 2.20, 95% CI 0.98 to 4.93) and routine health record studies (RR 0.67, 95% CI 0.17 to 2.66). This was supported by the pooled results from both cohort (RR 0.71, 95% CI 0.39 to 1.28) and routine health record studies (RR 0.82, 95% CI 0.39 to 1.71) when comparisons were made to the offspring of women with untreated epilepsy. For topiramate, the prevalence of MCM was 3.9% (95% CI 2.3 to 6.5) from cohort study data and 4.1% (0.0 to 27,050.1) from routine health record studies. Risk ratios were significantly higher for children exposed to topiramate in comparison to the children of women without epilepsy in cohort studies (RR 4.07, 95% CI 1.64 to 10.14) but not in a smaller comparison to the children of women with untreated epilepsy (RR 1.37, 95% CI 0.57 to 3.27); few data are currently available from routine health record studies. Exposure in utero to topiramate was also associated with significantly higher RRs in comparison to other ASMs for oro-facial clefts. Data for all other ASMs were extremely limited. Given the observational designs, all studies were at high risk of certain biases, but the biases observed across primary data collection studies and secondary use of routine health records were different and were, in part, complementary. Biases were balanced across the ASMs investigated, and it is unlikely that the differential results observed across the ASMs are solely explained by these biases. AUTHORS' CONCLUSIONS Exposure in the womb to certain ASMs was associated with an increased risk of certain MCMs which, for many, is dose-dependent.
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Affiliation(s)
- Rebecca Bromley
- Division of Neuroscience, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Manchester, UK
| | - Naghme Adab
- Department of Neurology, A5 Corridor, Walsgrave Hospital, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Matt Bluett-Duncan
- Institute of Human Development, University of Manchester, Manchester, UK
| | - Jill Clayton-Smith
- Institute of Human Development, University of Manchester, Manchester, UK
| | - Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Katherine Edwards
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Janette Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Ruaraidh A Hill
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Cerian F Jackson
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sonia Khanom
- Institute of Human Development, University of Manchester, Manchester, UK
| | - Ronan N McGinty
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Jennifer Pulman
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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11
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Besag FMC, Vasey MJ, Chin RFM. Current and emerging pharmacotherapy for the treatment of Lennox-Gastaut syndrome. Expert Opin Pharmacother 2023; 24:1249-1268. [PMID: 37212330 DOI: 10.1080/14656566.2023.2215924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Lennox-Gastaut syndrome (LGS) is a severe childhood-onset epileptic encephalopathy, characterized by multiple seizure types, generalized slow spike-and-wave complexes in the EEG, and cognitive impairment. Seizures in LGS are typically resistant to treatment with antiseizure medications (ASMs). Tonic/atonic ('drop') seizures are of particular concern, due to their liability to cause physical injury. AREAS COVERED We summarize evidence for current and emerging ASMs for the treatment of seizures in LGS. The review focuses on findings from randomized, double-blind, placebo-controlled trials (RDBCTs). For ASMs for which no double-blind trials were identified, lower quality evidence was considered. Novel pharmacological agents currently undergoing investigation for the treatment of LGS are also briefly discussed. EXPERT OPINION Evidence from RDBCTs supports the use of cannabidiol, clobazam, felbamate, fenfluramine, lamotrigine, rufinamide, and topiramate as adjunct treatments for drop seizures. Percentage decreases in drop seizure frequency ranged from 68.3% with high-dose clobazam to 14.8% with topiramate. Valproate continues to be considered the first-line treatment, despite the absence of RDBCTs specifically in LGS. Most individuals with LGS will require treatment with multiple ASMs. Treatment decisions should be individualized and take into account adverse effects, comorbidities, general quality of life, and drug interactions, as well as individual efficacy.
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Affiliation(s)
- Frank M C Besag
- East London NHS Foundation Trust, Bedford, UK
- School of Pharmacy, University College London, London, UK
- Department of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, The University of Edinburgh, Edinburgh, UK
- Department of Paediatric Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
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12
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Bottemanne H, Joly L, Javelot H, Ferreri F, Fossati P. Guide de prescription psychiatrique pendant la grossesse, le postpartum et l’allaitement. L'ENCEPHALE 2023:S0013-7006(22)00228-7. [PMID: 37031069 DOI: 10.1016/j.encep.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/16/2022] [Indexed: 04/09/2023]
Abstract
Perinatal psychopharmacology is an emerging specialty that is gradually developing alongside perinatal psychiatry. The management of psychiatric disorders during the perinatal period is a challenge for perinatal practitioners due to the multiple changes occurring during this crucial period. This little-known specialty still suffers from inappropriate considerations on the impact of psychotropic treatments on the mother and the infant during pregnancy and postpartum, which can promote a deficiency in perinatal psychic care. However, the risks associated with insufficient management of mental health are major, impacting both the mental and physical health of the mother and the infant. In this paper, we propose a perinatal psychopharmacology prescription guide based on available scientific evidence and international and national recommendations. We thus propose a decision-making process formalized on simple heuristics in order to help the clinician to prescribe psychotropic drugs during the perinatal period.
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13
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Ademi Z, Marquina C, Perucca P, Hitchcock A, Graham J, Eadie MJ, Liew D, O'Brien TJ, Vajda FJ. Economic Evaluation of the Community Benefit of the Australian Pregnancy Register of Antiseizure Medications. Neurology 2023; 100:e1028-e1037. [PMID: 36460471 PMCID: PMC9990855 DOI: 10.1212/wnl.0000000000201655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/19/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The Raoul Wallenberg Australian Pregnancy Register (APR) was established to collect, analyze, and publish data on the risks to babies exposed to antiseizure medications (ASMs) and to facilitate quality improvements in management care over time. It is one of the seveal prospective observational pregnancy registers of ASMs that has been established around the world. Although the APR and other registries have contributed to knowledge gain that has been applied to decrease adverse pregnancy outcomes, their cost-effectiveness remains unknown. Here, we aimed to evaluate the economic impacts of the APR from both societal and health care system perspectives. METHODS Using decision analytic modeling, we estimated the effectiveness (prevention of adverse pregnancy outcomes) and costs (costs of adverse pregnancy outcomes and the register itself) of the APR over a 20-year time horizon (2000-2019). The comparator was set as the adverse pregnancy outcomes collected by the APR between 1998 and 2002 (i.e., no APR derived improvements in care). In the scenario analysis, we conservatively assumed a 2.5% and 5% contribution of the APR to the savings in health care and societal costs. Adverse pregnancy outcomes included stillbirth, birth defects, and induced abortion. All cost data were derived from published sources. Health and economic outcomes were extrapolated to the total target Australian epilepsy population. The primary outcomes of interest were the return of investment (ROI) for the APR and incremental cost-effectiveness ratio (ICER) for cost per adverse outcome avoided. RESULTS Over the 20-year time horizon, the ROI from the APR from a societal perspective was Australian dollars (AUD) 2,250 (i.e., every dollar spent on the program resulted in a return of AUD2,250). Over this time, it was estimated that 9,609 adverse pregnancy outcomes were avoided, and health care and societal costs were reduced by AUD 191 million and AUD 9.0 billion, respectively. Hence, from a health economic point of view, the APR was dominant, providing cost saving ICERs from both perspectives. DISCUSSION Following its inception 20+ years ago, the APR has represented excellent value for investment for Australia, being also health-saving and cost saving from a societal and a health care perspective. With the growing number of marketed ASMs, the APR is expected to continue to have a major impact in the foreseeable future.
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Affiliation(s)
- Zanfina Ademi
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia.
| | - Clara Marquina
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia
| | - Piero Perucca
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia
| | - Alison Hitchcock
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia
| | - Janet Graham
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia
| | - Mervyn J Eadie
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia
| | - Danny Liew
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia
| | - Terence J O'Brien
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia
| | - Frank J Vajda
- From the Centre for Medicine Use and Safety (Z.A., C.M.), Faculty of Pharmacy and Pharmaceutical Sciences, School of Public Health and Preventive Medicine (Z.A., D.L.), Department of Neuroscience (Z.A., P.P., T.J.O.B.), Central Clinical School, Monash University, Melbourne; Epilepsy Research Centre (P.P.), Department of Medicine (Austin Health), The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health, Melbourne; Department of Neurology (P.P., T.J.O.B.), Alfred Health, Melbourne; Department of Neurology (P.P., A.H., J.G., T.J.O.B., F.J.V.), The Royal Melbourne Hospital; Department of Medicine (M.J.E.), The University of Queensland, Brisbane; Adelaide Medical School (D.L.), University of Adelaide, South Australia; and Department of Medicine (The Royal Melbourne Hospital) (T.J.O.B., F.J.V.), The University of Melbourne, Australia
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14
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Knight R, Craig J, Irwin B, Wittkowski A, Bromley RL. Adaptive behaviour in children exposed to topiramate in the womb: An observational cohort study. Seizure 2023; 105:56-64. [PMID: 36731257 DOI: 10.1016/j.seizure.2023.01.008] [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] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Many women with epilepsy need to continue anti-seizure medications (ASMs) throughout pregnancy. The current study investigated adaptive behaviour outcomes in children exposed to topiramate in the womb. METHOD An observational, cross-sectional study was designed, recruiting mother-child-pairs from the UK Epilepsy and Pregnancy Register (UKEPR). Health, developmental histories and Vineland Adaptive Behaviour Scale-Third Edition (VABS-III) assessments were administered via telephone by a blinded researcher, supplemented with prospectively collected pregnancy and medication information. Topiramate monotherapy exposed children were compared to VABS-III normative data as recruitment was disrupted by the COVID-19 pandemic. RESULTS Thirty-four women with epilepsy from 135 (25%) initially agreed to participate in the study, of whom 26 women completed telephone interviews about their children (n = 28). Children ranged from 2.5 to 17 years of age at the time of assessment. Six topiramate-exposed children were born small for gestational age, and there were significant associations between birthweight, dose and VABS-III scores. Significantly lower scores were observed in topiramate-exposed children (n = 21) with a significant dose-response relationship established after adjustment for parental educational level. Daily mean dosage was 280.21 mg, with high dosages of topiramate associated with a 12-point reduction in VABS-III scores. Additionally, four topiramate-exposed children (19.05%) had diagnoses of Autism Spectrum Disorder, which was significantly higher than UK prevalence rates (1.1%). CONCLUSIONS The findings of poorer adaptive behaviour, higher incidence of ASD and associations with birth weight are of concern and require further validation and replication using larger prospectively-recruited samples and comparator cohorts. Implications for research and clinical practice are discussed.
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Affiliation(s)
- R Knight
- Division of Psychology and Mental Health, The University of Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, UK
| | - J Craig
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - B Irwin
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - A Wittkowski
- Division of Psychology and Mental Health, The University of Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, UK
| | - R L Bromley
- Division of Neuroscience and Experimental Psychology Science, The University of Manchester, UK; Royal Manchester Children's Hospital, Manchester Academic Health Sciences, Manchester, UK.
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Sha L, Yong X, Shao Z, Duan Y, Hong Q, Zhang J, Zhang Y, Chen L. Targeting adverse effects of antiseizure medication on offspring: current evidence and new strategies for safety. Expert Rev Neurother 2023; 23:141-156. [PMID: 36731825 DOI: 10.1080/14737175.2023.2176751] [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] [Indexed: 02/04/2023]
Abstract
INTRODUCTION For women with epilepsy of reproductive age, antiseizure medications (ASMs) are associated with an increased risk of offspring malformations. There are safety concerns for most anti-seizure medications in the perinatal period, and there is a clear need to identify safe medications. ASMs must transport through biological barriers to exert toxic effects on the fetus, and transporters play essential roles in trans-barrier drug transport. Therefore, it is vital to understand the distribution and properties of ASM-related transporters in biological barriers. AREAS COVERED This study reviews the structure, transporter distribution, and properties of the blood-brain, placental, and blood-milk barrier, and summarizes the existing evidence for the trans-barrier transport mechanism of ASMs and standard experimental models of biological barriers. EXPERT OPINION Ideal ASMs in the perinatal period should have the following characteristics: 1) Increased transport through the blood-brain barrier, and 2) Reduced transport of the placental and blood-milk barriers. Thus, only low-dose or almost no antiseizure medication could enter the fetus's body, which could decrease medication-induced fetal abnormalities. Based on the stimulated structure and molecular docking, we propose a development strategy for new ASMs targeting transporters of biological barriers to improve the perinatal treatment of female patients with epilepsy.
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Affiliation(s)
- Leihao Sha
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Xihao Yong
- Division of Nephrology and Kidney Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhenhua Shao
- Division of Nephrology and Kidney Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yifei Duan
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Qiulei Hong
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Jifa Zhang
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Yunwu Zhang
- The current form, Fujian Provincial Key Laboratory of Neurodegenerative Disease and Aging Research, Institute of Neuroscience, School of Medicine, Xiamen University, Xiamen, 361102, China
| | - Lei Chen
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
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Schelhaas M, Wegner I, Edens M, Wammes-Van Der Heijden E, Touw D, Ter Horst P. Association of Levetiracetam Concentration With Seizure Frequency in Pregnant Women With Epilepsy. Neurology 2023; 100:e172-e181. [PMID: 36257713 DOI: 10.1212/wnl.0000000000201348] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 08/19/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pharmacologic treatment of epilepsy in pregnant women is balancing between risks for the mother and fetus. Levetiracetam (LEV) is considered to be safe during pregnancy because of its low teratogenic potential and lack of drug-drug interaction with other antiseizure medications (ASMs). Recent studies have shown decline of ASM concentrations during pregnancy because of physiologically based pharmacokinetic changes. In this study, we established this decrease in LEV concentration during pregnancy. In addition, we aimed at investigating the effect of the low LEV levels during pregnancy and developing a target value for the level during pregnancy. METHODS Pregnant patients using levetiracetam were studied in this retrospective cohort study. Blood samples were monthly collected through venous puncture or the dried blood spot method. ASM serum concentrations were determined at least 6 months before conception and for each month of pregnancy. Seizure frequency and ASM dosages during pregnancy were obtained from patient records. Patients were divided into 2 groups: a seizure-free group and a non-seizure-free group, which contained pregnancies in which the mother had experienced an epileptic seizure more than 12 months and less than 12 months before pregnancy, respectively. RESULTS We found decreased concentration/dose ratios in 29 pregnancies throughout all months of pregnancy. In the non-seizure-free group, it was found that low LEV concentrations were associated with seizure increase frequency (p = 0.022). For this group, the cutoff value with the highest sum of sensitivity and specificity was 0.466. DISCUSSION All in all, we recommend therapeutic drug monitoring for all pregnant patients on LEV as the concentrations of LEV significantly decrease throughout most months of pregnancy. However, this decrease in LEV concentration was only significantly correlated with seizure deterioration in patients who had a seizure in the year preceding the pregnancy. Therefore, we suggest more careful monitoring of non-seizure-free patients as they are at higher risk for experiencing an increase of seizure frequency. For this group, we advise physicians to keep LEV concentration above 65% of the preconceptional concentration. For seizure-free patients, we recommend an LEV threshold value of approximately 46% of the preconceptional concentration.
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Affiliation(s)
- Meike Schelhaas
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Ilse Wegner
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Mireille Edens
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Elisabeth Wammes-Van Der Heijden
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Daniel Touw
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Peter Ter Horst
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
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Güler H, Esen EE, Balcıoğlu E, Göktepe Ö, Yılmaz H, Yay AH, Nisari M, Al Ö, Uçar S, Güçlü Ekinci HK, Tokpınar A, Yılmaz S. Bone development in offspring of pregnant rats treated with carbamazepine: Evaluation by three different methods. Epilepsia 2022; 63:3066-3077. [PMID: 36168801 DOI: 10.1111/epi.17422] [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: 06/23/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE This study was carried out to determine the effect of intrauterine carbamazepine (CBZ) exposure on fetal bone development during pregnancy. METHODS In the study, 24 female Wistar pregnant rats were used. Rats were 20 weeks old. They had an average body weight of 150-200 g. Pregnant rats were randomly selected and divided (n = 6) into a control group, low-dose CBZ (10 mg/kg/day) group, medium-dose CBZ (25 mg/kg/day) group, and high-dose CBZ (50 mg/kg/day) group. The ossification length (mm) and ossification area (mm2 ) of the long bones of the fetuses in the experimental and control groups were calculated. The densities of alkaline phosphatase (AP) and tartrate-resistant acid phosphatase (TRAP) were analyzed. The ossification regions of the femurs of the fetuses were examined under a light microscope. Microstructural images of the femurs were evaluated with scanning electron microscope photographs. The densities of minerals involved in the ossification process were analyzed. RESULTS According to the results of the study, all three doses of CBZ caused loss of ossification areas, and it was observed that this bone loss also increased statistically significantly depending on the dose increase (p < .05). Calcium concentration decreased in the CBZ groups. When the electron microscope images were examined, it was determined that the cartilage matrix of the CBZ groups was thinned. In the histological evaluation of the groups, narrowing of the primary bone collar and smaller bone spicules in the ossification region compared to the control group were noted due to the increase in dose in the CBZ groups. In immunohistochemical staining, it was observed that the TRAP and AP expression values of the femurs were the lowest in the CBZ groups. These decreases were also statistically significant when compared with the control group. SIGNIFICANCE It was revealed with both microscopic and macroscopic findings that exposure to intrauterine CBZ negatively affected ossification and bone growth.
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Affiliation(s)
- Hatice Güler
- Basic Medical Sciences, Department of Anatomy, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Eda Esra Esen
- Basic Medical Sciences, Department of Anatomy, Sütçü İmam University, Kahramanmaraş, Turkey
| | - Esra Balcıoğlu
- Basic Medical Sciences, Department of Histology-Embryology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Özge Göktepe
- Basic Medical Sciences, Department of Histology-Embryology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Halil Yılmaz
- Basic Medical Sciences, Department of Anatomy, Ordu University, Ordu, Turkey
| | - Arzu Hanım Yay
- Basic Medical Sciences, Department of Histology-Embryology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Mehtap Nisari
- Basic Medical Sciences, Department of Anatomy, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Özge Al
- Basic Medical Sciences, Department of Anatomy, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Sümeyye Uçar
- Basic Medical Sciences, Department of Anatomy, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Hilal Kübra Güçlü Ekinci
- Basic Medical Sciences, Department of Anatomy, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Adem Tokpınar
- Basic Medical Sciences, Department of Anatomy, Ordu University, Ordu, Turkey
| | - Seher Yılmaz
- Basic Medical Sciences, Department of Anatomy, Yozgat Bozok University, Yozgat, Turkey
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18
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Shi X, Wang Y, Zhang Y, Song C, Jiang Y, Zhao J, Xia L, Ma L, Jiang W. Effects of antiepileptic drugs polytherapy on pregnancy outcomes in women with epilepsy: An observation study in northwest China. Epilepsy Behav 2022; 135:108904. [PMID: 36095876 DOI: 10.1016/j.yebeh.2022.108904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/01/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The management of pregnant women with epilepsy (WWE) treated with antiepileptic drugs (AEDs) polytherapy poses a great challenge. The purpose of this study was to evaluate the major congenital malformations (MCMs) associated with AED polytherapy, to assess the impacts of polytherapy regimens on seizure control and breastfeeding, and to determine the potential predictors for pregnancy outcomes. METHODS This study was based on prospectively acquired data from a registry enrolling WWE in early pregnancy from Feb 2010 to July 2019, in which 123 pregnancies in 110 WWE were exposed to 27 different AED combinations. RESULTS There were 123 pregnancies in 110 WWE analyzed in our study. The live birth rate was 86.2 % and the risk of MCMs was 10.4 %. Multivariate analysis indicated that prenatal exposure to phenobarbital (odds ratio [OR], 17.424; 95 %CI, 1.510-201.067; P = 0.022) and topiramate (OR, 9.469; 95 %CI, 1.149-62.402; P = 0.036) was associated with increased risk of MCMs. Valproate (OR, 4.441; 95 %CI, 1.165-16.934; P = 0.029), phenobarbital (OR, 13.636; 95 %CI, 2.146-86.660; P = 0.006) and topiramate (OR, 7.527; 95 %CI, 1.764-32.118; P = 0.006) were significantly correlated with adverse pregnancy outcomes. Among 67 pregnancies in four combinations over 10 patients, 15 (22.4 %) remained seizure free through pregnancy, seizure frequency increased in 17 (25.4 %), decreased in 24 (35.8 %) women, in 26 (38.8 %) remained unchanged. Only 23.6 % of mothers undertook exclusive breastfeeding. Planned pregnancy was the only independent factor significantly associated with decreased risk of adverse pregnancy outcomes (OR, 0.139; 95 % CI, 0.051-0.382; P < 0.001). Notably, no adverse pregnancy outcome was recorded in pregnancies exposed to the combination of lamotrigine plus levetiracetam. CONCLUSION Prenatal exposure to the combinations containing valproate, phenobarbital, or topiramate was associated with increased risk of adverse pregnant outcomes. AED-related teratogenicity may be reduced by planned pregnancy in WWE exposed to polytherapy. Our findings also suggest the combination of lamotrigine and levetiracetam seems to be most desirable to balance seizure control and fetal safety.
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Affiliation(s)
- Xiaojing Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yaoyao Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yongli Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Liang Xia
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Lei Ma
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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19
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Jin XL, Song BH, Zhao XD, Huang GB. Neonatal outcomes after gamma-aminobutyric acid analog use during pregnancy: a meta-analysis of cohort studies. Eur J Clin Pharmacol 2022; 78:1739-1747. [DOI: 10.1007/s00228-022-03384-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 09/03/2022] [Indexed: 11/03/2022]
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20
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P A B, G SS, Thomas G, K P A. Dosage Optimization of Lamotrigine in Pregnancy: A Pharmacometric Approach using Modeling and Simulation. J Clin Pharmacol 2022; 62:1557-1565. [PMID: 35739074 DOI: 10.1002/jcph.2111] [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: 03/03/2022] [Accepted: 06/10/2022] [Indexed: 11/05/2022]
Abstract
Lamotrigine is the most widely used anti-epileptic drug in pregnancy due to its low teratogenicity. However, there is an increased metabolism & clearance of Lamotrigine in pregnancy contributing to suboptimal drug therapy and poor disease control, prompting the need for pro-active dosage adjustments. The present study aimed to develop a pharmacometric model-based framework for recommending optimal dosage regimen for Lamotrigine in pregnancy. A systematic review was performed to obtain the literature aggregate data on clearance of Lamotrigine in pregnancy. The data was incorporated into simulations using PUMAS software for estimating the plasma concentrations at preconception stage and three trimesters. Simulated drug-exposures for different doses were investigated to ascertain plasma concentrations similar to the pre-conception and above minimum effective concentration. The simulated mean steady state trough plasma concentrations (mg/L) of Lamotrigine in non-pregnant and pregnant women at 3 trimesters decreased significantly (p<0.001) viz. 4.31±1.14, 3.17± 0.93, 2.14±0.86, 1.51±0.65 respectively. The simulation studies revealed that 150mg, 175mg, 225mg and 250mg twice daily doses, in pre-conception stage and three trimesters respectively achieve the target concentrations. Thus, the model-informed dosage regimen of Lamotrigine proposed in this study shall be considered to initiate the dosing in pregnant women, however the safety and efficacy of the drug have to be assured through therapeutic drug monitoring, in order to avoid therapeutic failure of Lamotrigine in pregnancy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Bhavatharini P A
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, The Nilgiris, Tamil Nadu, 643001, India
| | - Shri Sanghavi G
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, The Nilgiris, Tamil Nadu, 643001, India
| | - Grace Thomas
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, The Nilgiris, Tamil Nadu, 643001, India
| | - Arun K P
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, The Nilgiris, Tamil Nadu, 643001, India
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Di Filippo S, Godoy DA, Manca M, Paolessi C, Bilotta F, Meseguer A, Severgnini P, Pelosi P, Badenes R, Robba C. Ten Rules for the Management of Moderate and Severe Traumatic Brain Injury During Pregnancy: An Expert Viewpoint. Front Neurol 2022; 13:911460. [PMID: 35756939 PMCID: PMC9218270 DOI: 10.3389/fneur.2022.911460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
Moderate and severe traumatic brain injury (TBI) are major causes of disability and death. In addition, when TBI occurs during pregnancy, it can lead to miscarriage, premature birth, and maternal/fetal death, engendering clinical and ethical issues. Several recommendations have been proposed for the management of TBI patients; however, none of these have been specifically applied to pregnant women, which often have been excluded from major trials. Therefore, at present, evidence on TBI management in pregnant women is limited and mostly based on clinical experience. The aim of this manuscript is to provide the clinicians with practical suggestions, based on 10 rules, for the management of moderate to severe TBI during pregnancy. In particular, we firstly describe the pathophysiological changes occurring during pregnancy; then we explore the main strategies for the diagnosis of TBI taking in consideration the risks related to mother and fetus, and finally we discuss the most appropriate approaches for the management in this particular condition. Based on the available evidence, we suggest a stepwise approach consisting of different tiers of treatment and we describe the specific risks according to the severity of the neurological and systemic conditions of both fetus and mother in relation to each trimester of pregnancy. The innovative feature of this approach is the fact that it focuses on the vulnerability and specificity of this population, without forgetting the current knowledge on adult non-pregnant patients, which has to be applied to improve the quality of the care process.
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Affiliation(s)
- Simone Di Filippo
- Department of Biotechnology and Sciences of Life, Anesthesia and Intensive Care, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina
- Intensive Care, Hospital Carlos Malbran, Catamarca, Argentina
| | - Marina Manca
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Camilla Paolessi
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Federico Bilotta
- Department of Anesthesiology, University of Rome “Sapienza”, Rome, Italy
| | - Ainhoa Meseguer
- Department of Obstetrics, Hospital Francesc de Borja, Gandia, Spain
| | - Paolo Severgnini
- Department of Biotechnology and Sciences of Life, Anesthesia and Intensive Care, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, Universitat de València, Valencia, Spain
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genova, Italy
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22
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Abstract
OBJECTIVE Valproate has undergone significant changes in labeling to the boxed warnings associated with it. This review will analyze evidence regarding the valproate-boxed warnings for teratogenicity, hepatotoxicity, and pancreatitis, with a particular emphasis on the fetal risk. DATA SOURCES A review of Pubmed, Cochrane Central Register, Google Scholar, manufacturer websites, and product labeling was performed from 1963 to February 2022, using the following search terms: valproate, valproic acid, depakote, teratogenicity, birth defects, fetal risk, hepatotoxicity, and pancreatitis. Relevant English-language studies and those conduced in humans were considered. Product labeling was also reviewed. DATA SYNTHESIS There is a significant fetal risk following in utero valproate exposure (risk of malformation development: 8.6% in 360 women in North America). Current labeling in the United States recommends co-prescribing effective contraception for women of childbearing age. The risk of hepatotoxicity and pancreatitis is much lower in the general population (1/20 000 and 1/40 000 patients, respectively) compared with those patients with certain risk factors who are taking valproate (1/500). CONCLUSIONS Overstated monitoring recommendations for the potential risk of hepatotoxicity and pancreatitis distracts from a much more common and severe risk of fetal harm. Clinicians must be diligent about discussing this risk with patients and documenting when this discussion occurs. Changes to the current recommendations for monitoring of the boxed warnings associated with valproate therapy should be considered, such as more stringent monitoring requirements for the inherent fetal risk. This could be accomplished through a Risk Evaluation and Mitigation Strategy program or through institution-based policies and procedures. In addition, monitoring recommendations for the risk of hepatotoxicity and pancreatitis should account for contributing risk factors.
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Affiliation(s)
| | - Amy VandenBerg
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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23
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Nevitt SJ, Sudell M, Cividini S, Marson AG, Tudur Smith C. Antiepileptic drug monotherapy for epilepsy: a network meta-analysis of individual participant data. Cochrane Database Syst Rev 2022; 4:CD011412. [PMID: 35363878 PMCID: PMC8974892 DOI: 10.1002/14651858.cd011412.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in 2017. Epilepsy is a common neurological condition with a worldwide prevalence of around 1%. Approximately 60% to 70% of people with epilepsy will achieve a longer-term remission from seizures, and most achieve that remission shortly after starting antiepileptic drug treatment. Most people with epilepsy are treated with a single antiepileptic drug (monotherapy) and current guidelines from the National Institute for Health and Care Excellence (NICE) in the United Kingdom for adults and children recommend carbamazepine or lamotrigine as first-line treatment for focal onset seizures and sodium valproate for generalised onset seizures; however, a range of other antiepileptic drug (AED) treatments are available, and evidence is needed regarding their comparative effectiveness in order to inform treatment choices. OBJECTIVES To compare the time to treatment failure, remission and first seizure of 12 AEDs (carbamazepine, phenytoin, sodium valproate, phenobarbitone, oxcarbazepine, lamotrigine, gabapentin, topiramate, eventrate, zonisamide, eslicarbazepine acetate, lacosamide) currently used as monotherapy in children and adults with focal onset seizures (simple focal, complex focal or secondary generalised) or generalised tonic-clonic seizures with or without other generalised seizure types (absence, myoclonus). SEARCH METHODS For the latest update, we searched the following databases on 12 April 2021: the Cochrane Register of Studies (CRS Web), which includes PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Epilepsy Group Specialised Register and MEDLINE (Ovid, 1946 to April 09, 2021). We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators and experts in the field. SELECTION CRITERIA We included randomised controlled trials of a monotherapy design in adults or children with focal onset seizures or generalised onset tonic-clonic seizures (with or without other generalised seizure types). DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD) and network meta-analysis (NMA) review. Our primary outcome was 'time to treatment failure', and our secondary outcomes were 'time to achieve 12-month remission', 'time to achieve six-month remission', and 'time to first seizure post-randomisation'. We performed frequentist NMA to combine direct evidence with indirect evidence across the treatment network of 12 drugs. We investigated inconsistency between direct 'pairwise' estimates and NMA results via node splitting. Results are presented as hazard ratios (HRs) with 95% confidence intervals (CIs) and we assessed the certainty of the evidence using the CiNeMA approach, based on the GRADE framework. We have also provided a narrative summary of the most commonly reported adverse events. MAIN RESULTS IPD were provided for at least one outcome of this review for 14,789 out of a total of 22,049 eligible participants (67% of total data) from 39 out of the 89 eligible trials (43% of total trials). We could not include IPD from the remaining 50 trials in analysis for a variety of reasons, such as being unable to contact an author or sponsor to request data, data being lost or no longer available, cost and resources required to prepare data being prohibitive, or local authority or country-specific restrictions. No IPD were available from a single trial of eslicarbazepine acetate, so this AED could not be included in the NMA. Network meta-analysis showed high-certainty evidence that for our primary outcome, 'time to treatment failure', for individuals with focal seizures; lamotrigine performs better than most other treatments in terms of treatment failure for any reason and due to adverse events, including the other first-line treatment carbamazepine; HRs (95% CIs) for treatment failure for any reason for lamotrigine versus: eventrate 1.01 (0.88 to 1.20), zonisamide 1.18 (0.96 to 1.44), lacosamide 1.19 (0.90 to 1.58), carbamazepine 1.26 (1.10 to 1.44), oxcarbazepine 1.30 (1.02 to 1.66), sodium valproate 1.35 (1.09 to 1.69), phenytoin 1.44 (1.11 to 1.85), topiramate 1.50 (1.23 to 1.81), gabapentin 1.53 (1.26 to 1.85), phenobarbitone 1.97 (1.45 to 2.67). No significant difference between lamotrigine and eventrate was shown for any treatment failure outcome, and both AEDs seemed to perform better than all other AEDs. For people with generalised onset seizures, evidence was more limited and of moderate certainty; no other treatment performed better than first-line treatment sodium valproate, but there were no differences between sodium valproate, lamotrigine or eventrate in terms of treatment failure; HRs (95% CIs) for treatment failure for any reason for sodium valproate versus: lamotrigine 1.06 (0.81 to 1.37), eventrate 1.13 (0.89 to 1.42), gabapentin 1.13 (0.61 to 2.11), phenytoin 1.17 (0.80 to 1.73), oxcarbazepine 1.24 (0.72 to 2.14), topiramate 1.37 (1.06 to 1.77), carbamazepine 1.52 (1.18 to 1.96), phenobarbitone 2.13 (1.20 to 3.79), lacosamide 2.64 (1.14 to 6.09). Network meta-analysis also showed high-certainty evidence that for secondary remission outcomes, few notable differences were shown for either seizure type; for individuals with focal seizures, carbamazepine performed better than gabapentin (12-month remission) and sodium valproate (six-month remission). No differences between lamotrigine and any AED were shown for individuals with focal seizures, or between sodium valproate and other AEDs for individuals with generalised onset seizures. Network meta-analysis also showed high- to moderate-certainty evidence that, for 'time to first seizure,' in general, the earliest licensed treatments (phenytoin and phenobarbitone) performed better than the other treatments for individuals with focal seizures; phenobarbitone performed better than both first-line treatments carbamazepine and lamotrigine. There were no notable differences between the newer drugs (oxcarbazepine, topiramate, gabapentin, eventrate, zonisamide and lacosamide) for either seizure type. Generally, direct evidence (where available) and network meta-analysis estimates were numerically similar and consistent with confidence intervals of effect sizes overlapping. There was no important indication of inconsistency between direct and network meta-analysis results. The most commonly reported adverse events across all drugs were drowsiness/fatigue, headache or migraine, gastrointestinal disturbances, dizziness/faintness and rash or skin disorders; however, reporting of adverse events was highly variable across AEDs and across studies. AUTHORS' CONCLUSIONS High-certainty evidence demonstrates that for people with focal onset seizures, current first-line treatment options carbamazepine and lamotrigine, as well as newer drug eventrate, show the best profile in terms of treatment failure and seizure control as first-line treatments. For people with generalised tonic-clonic seizures (with or without other seizure types), current first-line treatment sodium valproate has the best profile compared to all other treatments, but lamotrigine and eventrate would be the most suitable alternative first-line treatments, particularly for those for whom sodium valproate may not be an appropriate treatment option. Further evidence from randomised controlled trials recruiting individuals with generalised tonic-clonic seizures (with or without other seizure types) is needed.
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Affiliation(s)
- Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Maria Sudell
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Sofia Cividini
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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Abstract
PURPOSE OF REVIEW Seizure disorders are the most frequent major neurologic complication in pregnancy, affecting 0.3% to 0.8% of all gestations. Women of childbearing age with epilepsy require special care related to pregnancy. This article provides up-to-date information to guide practitioners in the management of epilepsy in pregnancy. RECENT FINDINGS Ongoing multicenter pregnancy registries and studies continue to provide important information on issues related to pregnancy in women with epilepsy. Valproate poses a special risk for malformations and cognitive/behavioral impairments. A few antiseizure medications pose low risks (eg, lamotrigine, levetiracetam), but the risks for many antiseizure medications remain uncertain. Although pregnancy rates differ, a prospective study found no difference in fertility rates between women with epilepsy who were attempting to get pregnant and healthy controls. During pregnancy, folic acid supplementation is important, and a dose greater than 400 mcg/d during early pregnancy (ie, first 12 weeks) is associated with better neurodevelopmental outcome in children of women with epilepsy. Breastfeeding is not harmful and should be encouraged in women with epilepsy even when they are on antiseizure medication treatment. SUMMARY Women with epilepsy should be counseled early and regularly about reproductive health. Practitioners should discuss the risks of various obstetric complications; potential anatomic teratogenicity and neurodevelopmental dysfunction related to fetal antiseizure medication exposure; and a plan of care during pregnancy, delivery, and postpartum. Women with epilepsy should also be reassured that the majority of pregnancies are uneventful.
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Affiliation(s)
- Yi Li
- Clinical Assistant Professor of Neurology and Neurological Sciences, Stanford University, Palo Alto, California
| | - Kimford J. Meador
- Stanford, University School of Medicine, Stanford Neuroscience Health, Center, 213 Quarry Rd, MC 5979, Palo Alto, CA 94304
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Bohîlțea RE, Margareta Mihai B, Munteanu O, Ducu I, Adrian Dumitru V, Gheorghe CM, Augustin Georgescu T, Varlas V, Vlădăreanu R. Early prenatal diagnosis of an atypical phenotype of sacral spina bifida. J Med Life 2022; 14:716-721. [PMID: 35027976 PMCID: PMC8742886 DOI: 10.25122/jml-2021-0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/06/2021] [Indexed: 11/27/2022] Open
Abstract
Neural tube defects (NTDs) occur during embryogenesis, specifically during the fifth or sixth week of gestation, and are described as aberrant neural tube closing. The defect may alter the normal development of the vertebrae, spinal cord, cranium, or brain. The present study describes the case of a 41-year-old pregnant woman with fetal sacral meningocele, no associated pathologies, no family history of neural tube defects, a pregnancy under folate supplementation with the aim of highlighting the importance of ultrasound in diagnosing neural tube defects. The ultrasonographic diagnosis was not clear from the beginning. In our case, the differential diagnosis of meningocele was made with the cystic compound of a sacrococcygeal teratoma, which represents one of the most common congenital tumors in newborns. The particularity of this case was that a neural tube defect occurred despite the prophylactic administration of folic acid during pregnancy, which represents a well-documented protection against neural tube defects in fetuses.
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Affiliation(s)
- Roxana Elena Bohîlțea
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, Bucharest, Romania
| | - Bianca Margareta Mihai
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, Bucharest, Romania
| | - Octavian Munteanu
- Department of Obstetrics and Gynecology, University Emergency Hospital, Bucharest, Bucharest, Romania
| | - Ioniță Ducu
- Department of Obstetrics and Gynecology, University Emergency Hospital, Bucharest, Bucharest, Romania
| | - Vasile Adrian Dumitru
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Consuela-Mădălina Gheorghe
- Department of Marketing and Medical Technology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Valentin Varlas
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, Bucharest, Romania
| | - Radu Vlădăreanu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Obstetrics and Gynecology, Elias University Emergency Hospital, Bucharest, Romania
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26
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Parekh K, Kravets HD, Spiegel R. Special Considerations in the Management of Women with Epilepsy in Reproductive Years. J Pers Med 2022; 12:jpm12010088. [PMID: 35055403 PMCID: PMC8781280 DOI: 10.3390/jpm12010088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/23/2021] [Accepted: 01/05/2022] [Indexed: 12/07/2022] Open
Abstract
Anti-seizure medications (ASMs) fail to prevent seizure recurrence in more than 30% of patients with epilepsy. The treatment is more difficult in premenopausal women with epilepsy (WWE) because changes in plasma estrogen and progesterone concentrations during the menstrual cycle often affect seizure frequency and intensity. Interactions between enzyme-inducin ASMs and hormonal contraceptives can lead to both a loss of seizure control and failure of contraception. Significant changes in the function of the liver and kidneys during pregnancy can accelerate metabolism and elimination of ASMs, causing breakthrough seizures. In addition, the teratogenic, cognitive, and psychological effects of ASMs on potential offspring have to be considered when choosing the best ASM regimen. Therefore, aspecialized approach is necessary for the treatment of premenopausal WWE.
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Alsfouk BA, Almarzouqi MR, Alageel S, Alsfouk AA, Alsemari A. Patterns of antiseizure medication prescription in pregnancy and maternal complications in women with epilepsy: A retrospective study in Saudi Arabia. Saudi Pharm J 2022; 30:205-211. [PMID: 35498221 PMCID: PMC9051954 DOI: 10.1016/j.jsps.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/27/2021] [Indexed: 11/29/2022] Open
Abstract
Aim To evaluate patterns of antiseizure medication (ASM) prescription in pregnancy and changes over a 16-year period: 2005–2020, and to investigate maternal complications in pregnant women with epilepsy (WWE). Method Data of pregnant WWE was retrospectively reviewed at the King Faisal Specialist Hospital and Research Centre, Riyadh and Jeddah, Saudi Arabia. Results Out of 162 pregnancies, 81.5% were prescribed ASMs. During the study period, the prescription rate increased from 68.8% to 93.5%. Between 2005 and 2020, the use of new ASMs increased from 15.4% to 75.5% (p < 0.0001). Furthermore, valproate use markedly decreased from 23.08% to 2.04%. The rate of maternal and delivery complications was 29.6%; the most frequent was gestational diabetes (5.6%), followed by bleeding during pregnancy (4.9%). Furthermore, preeclampsia and eclampsia were documented in 3.7% and 1.8%, respectively. ASMs use and other factors were not found to be associated with maternal complications (p > 0.05). However, first generation ASMs, i.e. carbamazepine (38.71%) and valproate (41.67%), were associated with higher maternal complication rates than new ASMs, i.e. levetiracetam (25%) and lamotrigine (20%), but the difference was not statistically significant (p = 0.4403). Conclusion ASM prescription in pregnancy is increasing as is the use of new ASMs. The rate of maternal and delivery complications was relatively low, particularly preeclampsia and eclampsia. ASMs use was not found to associated with these complications. However, exposure to first generation ASMs seemed to be a predictor of adverse pregnancy outcomes.
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Marson AG, Burnside G, Appleton R, Smith D, Leach JP, Sills G, Tudur-Smith C, Plumpton CO, Hughes DA, Williamson PR, Baker G, Balabanova S, Taylor C, Brown R, Hindley D, Howell S, Maguire M, Mohanraj R, Smith PE. Lamotrigine versus levetiracetam or zonisamide for focal epilepsy and valproate versus levetiracetam for generalised and unclassified epilepsy: two SANAD II non-inferiority RCTs. Health Technol Assess 2021; 25:1-134. [PMID: 34931602 DOI: 10.3310/hta25750] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Levetiracetam (Keppra®, UCB Pharma Ltd, Slough, UK) and zonisamide (Zonegran®, Eisai Co. Ltd, Tokyo, Japan) are licensed as monotherapy for focal epilepsy, and levetiracetam is increasingly used as a first-line treatment for generalised epilepsy, particularly for women of childbearing age. However, there is uncertainty as to whether or not they should be recommended as first-line treatments owing to a lack of evidence of clinical effectiveness and cost-effectiveness. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of lamotrigine (Lamictal®, GlaxoSmithKline plc, Brentford, UK) (standard treatment) with levetiracetam and zonisamide (new treatments) for focal epilepsy, and to compare valproate (Epilim®, Sanofi SA, Paris, France) (standard treatment) with levetiracetam (new treatment) for generalised and unclassified epilepsy. DESIGN Two pragmatic randomised unblinded non-inferiority trials run in parallel. SETTING Outpatient services in NHS hospitals throughout the UK. PARTICIPANTS Those aged ≥ 5 years with two or more spontaneous seizures that require anti-seizure medication. INTERVENTIONS Participants with focal epilepsy were randomised to receive lamotrigine, levetiracetam or zonisamide. Participants with generalised or unclassifiable epilepsy were randomised to receive valproate or levetiracetam. The randomisation method was minimisation using a web-based program. MAIN OUTCOME MEASURES The primary outcome was time to 12-month remission from seizures. For this outcome, and all other time-to-event outcomes, we report hazard ratios for the standard treatment compared with the new treatment. For the focal epilepsy trial, the non-inferiority limit (lamotrigine vs. new treatments) was 1.329. For the generalised and unclassified epilepsy trial, the non-inferiority limit (valproate vs. new treatments) was 1.314. Secondary outcomes included time to treatment failure, time to first seizure, time to 24-month remission, adverse reactions, quality of life and cost-effectiveness. RESULTS Focal epilepsy. A total of 990 participants were recruited, of whom 330 were randomised to receive lamotrigine, 332 were randomised to receive levetiracetam and 328 were randomised to receive zonisamide. Levetiracetam did not meet the criteria for non-inferiority (hazard ratio 1.329) in the primary intention-to-treat analysis of time to 12-month remission (hazard ratio vs. lamotrigine 1.18, 97.5% confidence interval 0.95 to 1.47), but zonisamide did meet the criteria (hazard ratio vs. lamotrigine 1.03, 97.5% confidence interval 0.83 to 1.28). In the per-protocol analysis, lamotrigine was superior to both levetiracetam (hazard ratio 1.32, 95% confidence interval 1.05 to 1.66) and zonisamide (hazard ratio 1.37, 95% confidence interval 1.08 to 1.73). For time to treatment failure, lamotrigine was superior to levetiracetam (hazard ratio 0.60, 95% confidence interval 0.46 to 0.77) and zonisamide (hazard ratio 0.46, 95% confidence interval 0.36 to 0.60). Adverse reactions were reported by 33% of participants starting lamotrigine, 44% starting levetiracetam and 45% starting zonisamide. In the economic analysis, both levetiracetam and zonisamide were more costly and less effective than lamotrigine and were therefore dominated. Generalised and unclassifiable epilepsy. Of 520 patients recruited, 260 were randomised to receive valproate and 260 were randomised to receive to levetiracetam. A total of 397 patients had generalised epilepsy and 123 had unclassified epilepsy. Levetiracetam did not meet the criteria for non-inferiority in the primary intention-to-treat analysis of time to 12-month remission (hazard ratio 1.19, 95% confidence interval 0.96 to 1.47; non-inferiority margin 1.314). In the per-protocol analysis of time to 12-month remission, valproate was superior to levetiracetam (hazard ratio 1.68, 95% confidence interval 1.30 to 2.15). Valproate was superior to levetiracetam for time to treatment failure (hazard ratio 0.65, 95% confidence interval 0.50 to 0.83). Adverse reactions were reported by 37.4% of participants receiving valproate and 41.5% of those receiving levetiracetam. Levetiracetam was both more costly (incremental cost of £104, 95% central range -£587 to £1234) and less effective (incremental quality-adjusted life-year of -0.035, 95% central range -0.137 to 0.032) than valproate, and was therefore dominated. At a cost-effectiveness threshold of £20,000 per quality-adjusted life-year, levetiracetam was associated with a probability of 0.17 of being cost-effective. LIMITATIONS The SANAD II trial was unblinded, which could have biased results by influencing decisions about dosing, treatment failure and the attribution of adverse reactions. FUTURE WORK SANAD II data could now be included in an individual participant meta-analysis of similar trials, and future similar trials are required to assess the clinical effectiveness and cost-effectiveness of other new treatments, including lacosamide and perampanel. CONCLUSIONS Focal epilepsy - The SANAD II findings do not support the use of levetiracetam or zonisamide as first-line treatments in focal epilepsy. Generalised and unclassifiable epilepsy - The SANAD II findings do not support the use of levetiracetam as a first-line treatment for newly diagnosed generalised epilepsy. For women of childbearing potential, these results inform discussions about the benefit (lower teratogenicity) and harm (worse seizure outcomes and higher treatment failure rate) of levetiracetam compared with valproate. TRIAL REGISTRATION Current Controlled Trials ISRCTN30294119 and EudraCT 2012-001884-64. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 75. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anthony G Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Richard Appleton
- The Roald Dahl EEG Unit, Alder Hey Children's Health Park, Liverpool, UK
| | - Dave Smith
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Graeme Sills
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Catrin Tudur-Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Catrin O Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Paula R Williamson
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Gus Baker
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Silviya Balabanova
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Claire Taylor
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Richard Brown
- Addenbrooke's Hospital NHS Foundation Trust, Cambridge, UK
| | - Dan Hindley
- Bolton NHS Foundation Trust, Royal Bolton Hospital, Bolton, UK
| | - Stephen Howell
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | - Philip Em Smith
- The Alan Richens Epilepsy Unit, University Hospital of Wales, Cardiff, UK
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Christensen J, Trabjerg BB, Sun Y, Gilhus NE, Bjørk MH, Tomson T, Dreier JW. Prenatal exposure to valproate and risk of congenital malformations-Could we have known earlier?-A population-based cohort study. Epilepsia 2021; 62:2981-2993. [PMID: 34585373 DOI: 10.1111/epi.17085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Prenatal exposure to the antiseizure medication (ASM) valproate is associated with an increased risk of congenital malformations, but warnings against the use of valproate in pregnancy were not issued until 2009. The objective was to study how early administrative health registers could have identified the teratogenic risk associated with valproate. METHODS This was a population-based cohort study of individual-linked data from Danish health care and socioeconomic registers including children born in Denmark between January 1, 1997 and December 31, 2014. Information on ASM use, including valproate, in pregnancy was obtained from the Danish National Prescription Registry. Children identified with major congenital malformations from the Danish National Patient Register and the Danish Register of Causes of Death were included. Using logistic regression models, we estimated odds ratios (ORs) and 95% confidence intervals (CIs) for major congenital malformations during the first year of life in children with and without prenatal exposure to ASMs adjusted for potential confounders. RESULTS Among the 895 507 children (males, 51.3%), 31 790 (3.6%) were diagnosed with a major congenital malformation in the first year of life. In the analyses including children born in 1997, the risk of major congenital malformations among children prenatally exposed to valproate compared with children not exposed to ASMs was increased by a fully adjusted OR (aOR) of 3.95 (95% CI = 1.65-9.47). With the addition of data from the following years, the teratogenic effect of valproate was further substantiated, as the precision of the estimate improved (1997-2014: aOR = 2.44, 95% CI = 1.80-3.30). SIGNIFICANCE Using Danish health care data, we were able to identify a teratogenic risk associated with prenatal valproate exposure in children born in 1997, which is much earlier than prospective clinical cohorts. Health registry data represent an important tool for early identification of risk associated with drugs in pregnancy.
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Affiliation(s)
- Jakob Christensen
- Department of Economics and Business Economics, National Center for Register-Based Research, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Betina B Trabjerg
- Department of Economics and Business Economics, National Center for Register-Based Research, Aarhus University, Aarhus, Denmark.,Center for Integrated Register-Based Research, Aarhus University, Aarhus, Denmark
| | - Yuelian Sun
- Department of Economics and Business Economics, National Center for Register-Based Research, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Marte-Helene Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Julie Werenberg Dreier
- Department of Economics and Business Economics, National Center for Register-Based Research, Aarhus University, Aarhus, Denmark.,Center for Integrated Register-Based Research, Aarhus University, Aarhus, Denmark
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30
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Alsfouk BA, Almarzouqi MR, Alsfouk AA, Alageel S, Alsemari A. Antiseizure medications use during pregnancy and congenital malformations: A retrospective study in Saudi Arabia. Saudi Pharm J 2021; 29:939-945. [PMID: 34588839 PMCID: PMC8463505 DOI: 10.1016/j.jsps.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022] Open
Abstract
AIM To evaluate the incidence of congenital malformations in children exposed prenatally to antiseizure medications (ASMs), to assess other perinatal and fetal complications, and to determine the potential predictors for these complications. METHOD A retrospective review of pregnancy outcomes of women with epilepsy. Patients were followed up at the King Faisal Specialist Hospital and Research Centre, Riyadh and Jeddah, Saudi Arabia, between Dec 1993 and Oct 2020. RESULTS Of 162 pregnancies included, 10 (6.17%) congenital malformations were observed, 6.82% in ASM-exposed babies versus 3.33% in babies of epilepsy-untreated mothers (P = 0.69). The overall incidence of perinatal and fetal complications was 53%; most frequent were low birth weight (24%), preterm birth (19%), transfer to neonatal intensive care unit (18%) and abortion (8%). These complications were higher in the untreated group (66.67%) than in the ASM group (50%). The use of other non-antiseizure medications during pregnancy was the only factor that significantly increased the risk of complications. CONCLUSION Prenatal exposure to ASMs was associated with increased risk of congenital malformations. However, overall perinatal and fetal complications were higher in the untreated group than in the ASM group, which could be explained by maternal seizures. Therefore, taking ASMs to control epilepsy and prevent perinatal complications may outweigh the risks of teratogenicity.
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Affiliation(s)
- Bshra A. Alsfouk
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Manal Rashed Almarzouqi
- Biostatistics, Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Aisha A. Alsfouk
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Saleh Alageel
- Biostatistics, Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulaziz Alsemari
- Department of Neuroscience, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Gao H, Hao N, Liu S, Zhou D. Seizure frequency and obstetric complications at advanced maternal age: a preliminary observational study in women with epilepsy. ACTA EPILEPTOLOGICA 2021. [DOI: 10.1186/s42494-021-00052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Seizure control during pregnancy and obstetric outcomes are of important concerns for women with epilepsy (WWE) and their families. Advanced maternal age (≥35 years) shows a growing trend in the society with changes of lifestyle, which also occurs in diseased populations. The advanced maternal age is an independent factor for some unsatisfying obstetric outcomes. In this study we explored the seizure control and obstetric complications associated with advanced maternal age in WWE.
Methods
This study was based on the epilepsy pregnancy registry at West China Hospital. Patients with epilepsy in this registry who were aged 35 or older when starting pregnancy were included in this study. Their basic demographics and detailed information on epilepsy management and obstetric issues in all trimesters and during 1-year follow-up after birth were documented and reviewed. Data were processed by IBM SPSS version 22.0. The demographic characteristics, seizure frequency, treatment change, obstetric complications, and outcomes were analyzed and compared.
Results
Fifteen patients were included in this study, with an average age of 36.32 ± 2.39 years at pregnancy, and 73.33% of them were primiparas. The change of seizure frequency during pregnancy was not in a clear pattern, but there was an increased incidence of tonic-clonic seizures during the mid- and last trimesters. More than 20% of the patients had obstetric complications throughout the trimesters, including vaginal bleeding, hypothyroidism, and pre-eclampsia. The pre-eclampsia seemed extraordinarily complicated with other conditions. However, none of the complications were related with malformations or poor outcome of babies after 1-year follow-up.
Conclusion
Advanced maternal age combined with WWE is associated with frequent common obstetric complications. Future controlled studies with large sample sizes are needed to explore the related risks in comparison with other WWE and non-epileptic populations.
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Finnell RH, Caiaffa CD, Kim SE, Lei Y, Steele J, Cao X, Tukeman G, Lin YL, Cabrera RM, Wlodarczyk BJ. Gene Environment Interactions in the Etiology of Neural Tube Defects. Front Genet 2021; 12:659612. [PMID: 34040637 PMCID: PMC8143787 DOI: 10.3389/fgene.2021.659612] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/31/2021] [Indexed: 12/24/2022] Open
Abstract
Human structural congenital malformations are the leading cause of infant mortality in the United States. Estimates from the United States Center for Disease Control and Prevention (CDC) determine that close to 3% of all United States newborns present with birth defects; the worldwide estimate approaches 6% of infants presenting with congenital anomalies. The scientific community has recognized for decades that the majority of birth defects have undetermined etiologies, although we propose that environmental agents interacting with inherited susceptibility genes are the major contributing factors. Neural tube defects (NTDs) are among the most prevalent human birth defects and as such, these malformations will be the primary focus of this review. NTDs result from failures in embryonic central nervous system development and are classified by their anatomical locations. Defects in the posterior portion of the neural tube are referred to as meningomyeloceles (spina bifida), while the more anterior defects are differentiated as anencephaly, encephalocele, or iniencephaly. Craniorachischisis involves a failure of the neural folds to elevate and thus disrupt the entire length of the neural tube. Worldwide NTDs have a prevalence of approximately 18.6 per 10,000 live births. It is widely believed that genetic factors are responsible for some 70% of NTDs, while the intrauterine environment tips the balance toward neurulation failure in at risk individuals. Despite aggressive educational campaigns to inform the public about folic acid supplementation and the benefits of providing mandatory folic acid food fortification in the United States, NTDs still affect up to 2,300 United States births annually and some 166,000 spina bifida patients currently live in the United States, more than half of whom are now adults. Within the context of this review, we will consider the role of maternal nutritional status (deficiency states involving B vitamins and one carbon analytes) and the potential modifiers of NTD risk beyond folic acid. There are several well-established human teratogens that contribute to the population burden of NTDs, including: industrial waste and pollutants [e.g., arsenic, pesticides, and polycyclic aromatic hydrocarbons (PAHs)], pharmaceuticals (e.g., anti-epileptic medications), and maternal hyperthermia during the first trimester. Animal models for these teratogens are described with attention focused on valproic acid (VPA; Depakote). Genetic interrogation of model systems involving VPA will be used as a model approach to discerning susceptibility factors that define the gene-environment interactions contributing to the etiology of NTDs.
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Affiliation(s)
- Richard H. Finnell
- Department of Molecular and Human Genetics and Medicine, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
| | - Carlo Donato Caiaffa
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
| | - Sung-Eun Kim
- Department of Pediatrics, The University of Texas at Austin Dell Medical School, Austin, TX, United States
| | - Yunping Lei
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
| | - John Steele
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
| | - Xuanye Cao
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
| | - Gabriel Tukeman
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
| | - Ying Linda Lin
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
| | - Robert M. Cabrera
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
| | - Bogdan J. Wlodarczyk
- Department of Molecular and Cellular Biology, Center for Precision Environmental Health, Baylor College of Medicine, Houston, TX, United States
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Tetro N, Moushaev S, Shmuel M, Eyal S. Antiseizure medications and fetal nutrients: Effects on choline transporters in a human placental cell line. Epilepsia 2021; 62:1451-1459. [PMID: 33890297 DOI: 10.1111/epi.16905] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Many nutrients essential to the fetus and for proper function of the placenta itself cannot freely diffuse across membrane barriers, and their transplacental transfer depends on transporters. Our previous studies provided evidence for altered expression of transporters for folic acid in trophoblasts exposed to antiseizure medications (ASMs). The goal of the current study was to explore the effects of older and newer ASMs on the expression and function of uptake transporters for choline, which interacts with folate at pathways for methyl group donation. METHODS BeWo cells were incubated for 2 or 5 days with valproate (42, 83, or 166 µg/ml), carbamazepine (6 or 12 µg/ml), levetiracetam (10 or 30 µg/ml), lamotrigine (3 or 12 µg/ml), lacosamide (5, 10, or 20 µg/ml), or their vehicles (n = 6/treatment group). Quantitative polymerase chain reaction (PCR) analysis was utilized to study the effects of ASMs on the transcript levels of the choline transporters SLC44A1 (CTL1) and SLC44A2 (CTL2). Transporter protein expression in valproate-treated cells was assessed by western blot analysis. Choline and acetylcholine were quantified in cell lysates by a choline/acetylcholine assay kit. RESULTS Compared with controls, valproate and levetiracetam at high therapeutic concentrations (83 and 30 µg/ml, respectively) lowered choline transporter transcript levels by up to 42% and 26%, and total choline levels by 20% and 21%, respectively (p < .05). At 83 μg/ml, valproate additionally reduced CTL1 and CTL2 protein expression, by 39 ± 21% and 61 ± 13% (mean ± SD), respectively (p < .01). Carbamazepine reduced SLC44A1 transcript levels, whereas lacosamide modestly decreased the expression of SLC44A2. Lamotrigine did not alter choline transporter expression. SIGNIFICANCE Antiseizure medications, particularly at high therapeutic concentrations, can interfere with the placental uptake of choline. In line with current knowledge from pregnancy registries and clinical studies, the present in vitro findings further support careful adjustment of maternal ASM doses during pregnancy.
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Affiliation(s)
- Nino Tetro
- School of Pharmacy, Institute for Drug Research, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sonia Moushaev
- School of Pharmacy, Institute for Drug Research, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Miri Shmuel
- School of Pharmacy, Institute for Drug Research, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sara Eyal
- School of Pharmacy, Institute for Drug Research, The Hebrew University of Jerusalem, Jerusalem, Israel
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Besag FMC, Vasey MJ, Sharma AN, Lam ICH. Efficacy and safety of lamotrigine in the treatment of bipolar disorder across the lifespan: a systematic review. Ther Adv Psychopharmacol 2021; 11:20451253211045870. [PMID: 34646439 PMCID: PMC8504232 DOI: 10.1177/20451253211045870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 08/25/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Bipolar disorder (BD) is a cyclic mood disorder characterised by alternating episodes of mania/hypomania and depression interspersed with euthymic periods. Lamotrigine (LTG) demonstrated some mood improvement in patients treated for epilepsy, leading to clinical studies in patients with BD and its eventual introduction as maintenance therapy for the prevention of depressive relapse in euthymic patients. Most current clinical guidelines include LTG as a recommended treatment option for the maintenance phase in adult BD, consistent with its global licencing status. AIMS To review the evidence for the efficacy and safety of LTG in the treatment of all phases of BD. METHODS PubMed was searched for double-blind, randomised, placebo-controlled trials using the keywords: LTG, Lamictal, 'bipolar disorder', 'bipolar affective disorder', 'bipolar I', 'bipolar II', cyclothymia, mania, manic, depression, depressive, 'randomised controlled trial', 'randomised trial', RCT and 'placebo-controlled' and corresponding MeSH terms. Eligible articles published in English were reviewed. RESULTS Thirteen studies were identified. The strongest evidence supports utility in the prevention of recurrence and relapse, particularly depressive relapse, in stabilised patients. Some evidence suggests efficacy in acute bipolar depression, but findings are inconsistent. There is little or no strong evidence in support of efficacy in acute mania, unipolar depression, or rapid-cycling BD. Few controlled trials have evaluated LTG in bipolar II or in paediatric patients. Indications for safety, tolerability and patient acceptability are relatively favourable, provided there is slow dose escalation to reduce the probability of skin rash. CONCLUSION On the balance of efficacy and tolerability, LTG might be considered a first-line drug for BD, except for acute manic episodes or where rapid symptom control is required. In terms of efficacy alone, however, the evidence favours other medications.
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Affiliation(s)
- Frank M C Besag
- East London NHS Foundation Trust, 9 Rush Court, Bedford MK40 3JT, UK
| | | | - Aditya N Sharma
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ivan C H Lam
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Mostacci B, Ranzato F, Giuliano L, La Neve A, Aguglia U, Bilo L, Durante V, Ermio C, Monti G, Zambrelli E, Lodi MAM, Galimberti CA. Alternatives to valproate in girls and women of childbearing potential with Idiopathic Generalized Epilepsies: state of the art and guidance for the clinician proposed by the Epilepsy and Gender Commission of the Italian League Against Epilepsy (LICE). Seizure 2020; 85:26-38. [PMID: 33418162 DOI: 10.1016/j.seizure.2020.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/12/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Following recent European Medication Agency restrictions on valproate (VPA) use in girls and women of childbearing potential (WOCP), the Commission on Epilepsy and Gender of the Italian League against Epilepsy integrated current literature and legislative data in order to provide clinicians with guidance on antiseizure medication (ASM) prescription for Idiopathic Generalized Epilepsies (IGEs) in this population, avoiding VPA. We reviewed the updated literature on ASMs and examined the teratogenicity of those showing efficacy in IGEs. For all relevant ASMs, we considered the indications for use and the pregnancy and contraception-related recommendations given in the Italian Summary of Product Characteristics (SmPC) and on the websites of the European Medicines Agency (EMA) and other European Union (EU) countries' regulatory agencies. With the exception of absence seizures, the literature lacks high quality studies on ASMs in IGEs. In girls and WOCP, levetiracetam and lamotrigine should be considered the first-choice drugs in Generalized Tonic-Clonic Seizures Alone and in Juvenile Myoclonic Epilepsy, lamotrigine in Juvenile Absence Epilepsy, and ethosuximide in Childhood Absence Epilepsy. Although supported by the literature, several ASMs are off label, contraindicated or burdened by special warnings in pregnancy. Some discrepancies emerged between the various SmPC warnings for different brands of the same active principle. We provided a therapeutic algorithm for each IGE syndrome and highlighted the need for revised prescription rules, consistent with the latest literature data, uniformity of SmPC warnings for the same active principle, and more data on the efficacy of new ASMs in IGEs and their safety in pregnancy.
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Affiliation(s)
- Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy(2)
| | | | - Loretta Giuliano
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy.
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Umberto Aguglia
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy
| | - Leonilda Bilo
- Epilepsy Center, University of Napoli "Federico II", Napoli, Italy
| | - Vania Durante
- Ospedale "A. Perrino" di Brindisi- UO Neurologia, Brindisi, Italy
| | - Caterina Ermio
- Department of Neuroscience, "S. Giovanni Paolo II" Hospital, Lamezia Terme, Catanzaro, Italy
| | - Giulia Monti
- Neurology Unit, Ospedale Ramazzini di Carpi, AUSL di Modena, Italy
| | - Elena Zambrelli
- Epilepsy Center, ASST SS. Paolo e Carlo, San Paolo Hospital, Milano, Italy
| | - Monica Anna Maria Lodi
- Pediatric Neurology Unit and Epilepsy Center, Department of Neuroscience, Fatebenefratelli e Oftalmico, Hospital, Milano, Italy
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Beydoun A, DuPont S, Zhou D, Matta M, Nagire V, Lagae L. Current role of carbamazepine and oxcarbazepine in the management of epilepsy. Seizure 2020; 83:251-263. [PMID: 33334546 DOI: 10.1016/j.seizure.2020.10.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/30/2020] [Accepted: 10/22/2020] [Indexed: 02/08/2023] Open
Abstract
Epilepsy is one of the most common neurological disorders, affecting approximately 50 million people worldwide. Despite a dramatic increase in treatment options over the past 30 years, it still ranks fourth in the world's disease burden. There are now close to 30 antiepileptic drugs (AEDs), with more than two thirds introduced to the market after carbamazepine (CBZ) and one third after its derivative, oxcarbazepine (OXC). Following the introduction of these newer AEDs, the role of CBZ and OXC in the therapeutic armamentarium for seizure control and effective epilepsy management needs to be reviewed. The main guidelines list both CBZ and OXC as first-line options or second-line alternatives for the treatment of focal-onset epilepsy and primary generalized tonic-clonic seizures. While evidence suggests that overall AEDs have similar efficacy, some newer AEDs may be better tolerated than CBZ. In line with this, there have been changes in treatment patterns, with many variations across different countries. However, CBZ remains among the two or three most prescribed drugs for focal epilepsy in many countries, and is widely used across Europe, Africa, South America, and Asia, where it represents a good compromise between cost, availability, and effectiveness. OXC is among the first-choice options for the initial treatment of focal-onset seizures in several countries, including the US and China, where the oral suspension is commonly prescribed. This review provides guidance on the optimal use of these two drugs in clinical practice, including in children, the elderly, and in pregnancy.
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Affiliation(s)
- Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sophie DuPont
- Epilepsy Unit and Rehabilitation Unit, Hôpital de la Pitié-Salpêtrière, AP-HP, Centre de recherche de l'Institut du cerveau et de la moelle épinière (ICM), UMPC-UMR 7225 CNRS-UMRS 975 Inserm, Paris, France; Université Paris Sorbonne, Paris, France
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Maha Matta
- Novartis Pharma Services, Dubaï, United Arab Emirates
| | | | - Lieven Lagae
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium.
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Davies G, Jordan S, Thayer D, Tucker D, Humphreys I. Medicines prescribed for asthma, discontinuation and perinatal outcomes, including breastfeeding: A population cohort analysis. PLoS One 2020; 15:e0242489. [PMID: 33296383 PMCID: PMC7725302 DOI: 10.1371/journal.pone.0242489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To explore associations between exposures to medicines prescribed for asthma and their discontinuation in pregnancy and preterm birth [<37 or <32 weeks], SGA [<10th and <3rd centiles], and breastfeeding at 6-8 weeks. METHODS Design. A population-based cohort study. Setting. The Secure Anonymised Information Linkage [SAIL] databank in Wales, linking maternal primary care data with infant outcomes. Population. 107,573, 105,331, and 38,725 infants born 2000-2010 with information on premature birth, SGA and breastfeeding respectively, after exclusions. Exposures. maternal prescriptions for asthma medicines or their discontinuation in pregnancy. Methods. Odds ratios for adverse pregnancy outcomes were calculated for the exposed versus the unexposed population, adjusted for smoking, parity, age and socio-economic status. RESULTS Prescriptions for asthma, whether continued or discontinued during pregnancy, were associated with birth at<32 weeks' gestation, SGA <10th centile, and no breastfeeding (aOR 1.33 [1.10-1.61], 1.10 [1.03-1.18], 0.93 [0.87-1.01]). Discontinuation of asthma medicines in pregnancy was associated with birth at<37 weeks' and <32 weeks' gestation (aOR 1.22 [1.06-1.41], 1.53 [1.11-2.10]). All medicines examined, except ICS and SABA prescribed alone, were associated with SGA <10th centile. CONCLUSIONS Prescription of asthma medicines before or during pregnancy was associated with higher prevalence of adverse perinatal outcomes, particularly if prescriptions were discontinued during pregnancy. Women discontinuing medicines during pregnancy could be identified from prescription records. The impact of targeting close monitoring and breastfeeding support warrants exploration.
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Affiliation(s)
- Gareth Davies
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | - Sue Jordan
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | - Daniel Thayer
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
| | | | - Ioan Humphreys
- Faculty of Health and Life Science, Swansea University, Swansea, United Kingdom
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Toussi M, Isabelle B, Tcherny-Lessenot S, de Voogd H, Dimos V, Kaplan S. Effectiveness of risk minimisation measures for valproate: A cross-sectional survey among physicians in Europe. Pharmacoepidemiol Drug Saf 2020; 30:283-291. [PMID: 33216434 PMCID: PMC7894483 DOI: 10.1002/pds.5119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 11/24/2022]
Abstract
Purpose This study evaluated the effectiveness of risk minimisation measures (RMMs) implemented following the 2014 referral for valproate in Europe. Methods Cross‐sectional survey was conducted over 2‐month period in 2016 among physicians who prescribed valproate in France, Germany, the United Kingdom, Spain and Sweden. The web‐based questionnaire included five endpoints to evaluate physicians' knowledge on (a) prescribing valproate only for epilepsy and bipolar disorder in women if other treatments were ineffective or not tolerated; (b) ensuring supervision by experienced physicians while treating these conditions; (c) considering alternative treatments for women planning pregnancy, regular review of treatment needs and re‐assessing the benefit–risk balance in women and girls reaching puberty; (d) informing patients about the risks of taking valproate during pregnancy and (e) advising women on effective contraception during their treatment. Results Among 1153 physicians, 95.5% responded prescribing valproate for epilepsy and bipolar disorder in women only if other treatments are ineffective/not tolerated; 66.5% supervised while treatment; 76.6% considered alternative treatments for women planning pregnancy; 92.1% informed patients about the risks of taking valproate during pregnancy and 94.4% advised patients on the use of effective contraception during its treatment. Overall, 25.8% physicians recalled receiving both educational material (EM) and Dear Healthcare Professional Communication (DHPC). All endpoint rates were higher for physicians who acknowledged receipt of both DHPC and EM compared to physicians who did not receive them. Conclusions Although results varied across geography and physician speciality, majority of physicians had good knowledge about the indication and safety aspects of prescribing and using valproate.
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Affiliation(s)
- Massoud Toussi
- Real World Evidence Solutions, IQVIA, La Défense Cedex, France
| | | | | | - Hanka de Voogd
- Global Clinical Research, Mylan, Amstelveen, The Netherlands
| | - Vasilis Dimos
- Department of Pharmacovigilance (medical section), Demo S.A., Athens, Greece
| | - Sigal Kaplan
- Global Patient Safety & Pharmacovigilance, Teva Pharmaceutical Industries Ltd, Netanya, Israel
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Menon S, Benova L, Mabeya H. Epilepsy management in pregnant HIV+ women in sub-Saharan Africa, clinical aspects to consider: a scoping review. BMC Med 2020; 18:341. [PMID: 33198766 PMCID: PMC7670685 DOI: 10.1186/s12916-020-01799-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Since the introduction of highly active antiretroviral therapy (HAART), acquired immune deficiency syndrome (AIDS) related mortality has markedly declined. As HAART is becoming increasingly available, the infection with human immunodeficiency virus (HIV+) in sub-Saharan Africa (SSA) is becoming a chronic condition. While pregnancy in HIV+ women in SSA has always been considered a challenging event for the mother and the fetus, for pregnant HIV+ women also diagnosed with epilepsy (WWE), there are additional risks as HIV increases the odds of developing seizures due to the vulnerability of the central nervous system to other infections, immune dysfunction, and overall metabolic disturbances. In light of a growing proportion of HIV+ WWE on HAART and an increasing number of pregnant women accessing mother-to-child transmission of HIV programs through provision of HAART in SSA, there is a need to develop contextualized and evidenced-based clinical strategies for the management of epilepsy in this population. In this study, we conduct a literature scoping review to identify issues that warrant consideration for clinical management. RESULT Twenty-three articles were retained after screening, which covered six overarching clinical aspects: status epilepticus (SE), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), dyslipidemia, congenital malformation (CM), chronic kidney disease (CKD), and neurological development. No studies for our population of interest were identified, highlighting the need for a cautionary approach to be employed when extrapolating findings. CONCLUSION High risks of CM and drug interactions with first-line antiepileptic drugs (AEDs) warrant measures to increase the accessibility and choices of safer second-line AEDs. To ensure evidence-based management of epilepsy within this population, the potential high prevalence of SE, CKD, dyslipidemia, and SJS/TEN and the cumulative effect of drug-drug interactions should be considered. Further understanding of the intersections between pregnancy and drug-drug interactions in SSA is needed to ensure evidenced-based management of epilepsy in pregnant HIV+ WWE. To prevent SE, the barriers for AED treatment adherence in pregnant HIV+ women should be explored. Our review underscores the need to conduct cohort studies of HIV+ WWE in reproductive age over time and across pregnancies to capture the cumulative effect of HAART and AED to inform clinical management.
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Affiliation(s)
- Sonia Menon
- Instiute of Tropical Medicine Antwerp, Antwerp, Belgium.
| | - Lenka Benova
- Instiute of Tropical Medicine Antwerp, Antwerp, Belgium
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Wong HT, Khalil M, Ahmed F. OnabotulinumtoxinA for chronic migraine during pregnancy: a real world experience on 45 patients. J Headache Pain 2020; 21:129. [PMID: 33121432 PMCID: PMC7599093 DOI: 10.1186/s10194-020-01196-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/22/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To report the pregnancy outcomes on patients with chronic migraine exposed to onabotulinumtoxinA from Hull Headache Clinic. BACKGROUND Migraines are common in women of reproductive age and those with chronic migraine have a major impact on their activities of daily living and health-related quality of life. Apart from low dose amitriptyline and beta-blockers all other prophylactic agents have proven teratogenic effects. OnabotulinumtoxinA is approved as preventive treatment for adult patients with chronic migraine, although its impact on pregnancy is unknown. METHODS We prospectively collected data for efficacy and safety on all patients treated with onabotulinumtoxinA at the Hull Headache Clinic. The toxin is administered as per PREEMPT paradigm. Female patients of reproductive age group receiving onabotulinumtoxinA are given advice on contraception and the unknown impact of the toxin on pregnancy. They are asked to report pregnancy when they are appraised on the risk/benefit of treatment continuation. All patients are consented for access to their medical records and pregnancy outcome and those who wished to continue are asked to sign a disclaimer. Pregnancy outcome data was collected on all patients for the mode of delivery, birth weight and congenital malformation and any other unexpected outcomes. RESULTS Over 9 years period 45 patients reported pregnancy while receiving onabotulinumtoxinA. All patients had received onabotulinumtoxinA within 3 months prior to the date of conception. 32 patients wished to continue treatment during pregnancy while the remaining 13 stopped treatment. Apart from 1 miscarriage in the treatment group, all patients had full term healthy babies of normal birth weight and no congenital malformations. CONCLUSION We report our experience of 45 patients exposed to onabotulinumtoxinA during pregnancy. Although the numbers are small, there was no impact of the toxin found on the pregnancy outcomes.
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Affiliation(s)
- Ho-Tin Wong
- Department of Neurosciences, Hull University Teaching Hospitals, Hull, UK
| | - Modar Khalil
- Department of Neurosciences, Hull University Teaching Hospitals, Hull, UK
| | - Fayyaz Ahmed
- Department of Neurosciences, Hull University Teaching Hospitals, Hull, UK. .,Hull York Medical School, Hull, UK. .,Spire Hospitals Hull and East Riding, Hull, UK.
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Patorno E, Hernandez-Diaz S, Huybrechts KF, Desai RJ, Cohen JM, Mogun H, Bateman BT. Gabapentin in pregnancy and the risk of adverse neonatal and maternal outcomes: A population-based cohort study nested in the US Medicaid Analytic eXtract dataset. PLoS Med 2020; 17:e1003322. [PMID: 32870921 PMCID: PMC7462308 DOI: 10.1371/journal.pmed.1003322] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 07/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite the widespread use, only sparse information is available on the safety of gabapentin during pregnancy. We sought to evaluate the association between gabapentin exposure during pregnancy and risk of adverse neonatal and maternal outcomes. METHODS AND FINDINGS Using the United States Medicaid Analytic eXtract (MAX) dataset, we conducted a population-based study of 1,753,865 Medicaid-eligible pregnancies between January 2000 and December 2013. We examined the risk of major congenital malformations and cardiac defects associated with gabapentin exposure during the first trimester (T1), and the risk of preeclampsia (PE), preterm birth (PTB), small for gestational age (SGA), and neonatal intensive care unit admission (NICUa) associated with gabapentin exposure early, late, or both early and late in pregnancy. Gabapentin-unexposed pregnancies served as the reference. We estimated relative risks (RRs) and 95% confidence intervals (CIs) using fine stratification on the propensity score (PS) to control for over 70 confounders (e.g., maternal age, race/ethnicity, indications for gabapentin, other pain conditions, hypertension, diabetes, use of opioids, and specific morphine equivalents). We identified 4,642 pregnancies exposed in T1 (mean age = 28 years; 69% white), 3,745 exposed in early pregnancy only (28 years; 67% white), 556 exposed in late pregnancy only (27 years; 60% white), and 1,275 exposed in both early and late pregnancy (29 years; 75% white). The reference group consisted of 1,744,447 unexposed pregnancies (24 years; 40% white). The adjusted RR for major malformations was 1.07 (95% CI 0.94-1.21, p = 0.33) and for cardiac defects 1.12 (0.89-1.40, p = 0.35). Requiring ≥2 gabapentin dispensings moved the RR to 1.40 (1.03-1.90, p = 0.03) for cardiac defects. There was a higher risk of preterm birth among women exposed to gabapentin either late (RR, 1.28 [1.08-1.52], p < 0.01) or both early and late in pregnancy (RR, 1.22 [1.09-1.36], p < 0.001), SGA among women exposed to gabapentin early (1.17 [1.02-1.33], p = 0.02), late (1.39 [1.01-1.91], p = 0.05), or both early and late in pregnancy (RR, 1.32 [1.08-1.60], p < 0.01), and NICU admission among women exposed to gabapentin both early and late in pregnancy (RR, 1.35 [1.20-1.52], p < 0.001). There was no higher risk of preeclampsia among women exposed to gabapentin after adjustment. Study limitations include the potential for residual confounding and exposure misclassification. CONCLUSIONS In this large population-based study, we did not find evidence for an association between gabapentin exposure during early pregnancy and major malformations overall, although there was some evidence of a higher risk of cardiac malformations. Maternal use of gabapentin, particularly late in pregnancy, was associated with a higher risk of PTB, SGA, and NICUa.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rishi J. Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jacqueline M. Cohen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
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Balabanova S, Taylor C, Sills G, Burnside G, Plumpton C, Smith PEM, Appleton R, Leach JP, Johnson M, Baker G, Pirmohamed M, Hughes DA, Williamson PR, Tudur-Smith C, Marson AG. Study protocol for a pragmatic randomised controlled trial comparing the effectiveness and cost-effectiveness of levetiracetam and zonisamide versus standard treatments for epilepsy: a comparison of standard and new antiepileptic drugs (SANAD-II). BMJ Open 2020; 10:e040635. [PMID: 32847927 PMCID: PMC7451282 DOI: 10.1136/bmjopen-2020-040635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Antiepileptic drugs (AEDs) are the mainstay of epilepsy treatment. Over the past 20 years, a number of new drugs have been approved for National Health Service (NHS) use on the basis of information from short-term trials that demonstrate efficacy. These trials do not provide information about the longer term outcomes, which inform treatment policy. This trial will assess the long-term clinical and cost-effectiveness of the newer treatment levetiracetam and zonisamide. METHODS AND ANALYSIS This is a phase IV, multicentre, open-label, randomised, controlled clinical trial comparing new and standard treatments for patients with newly diagnosed epilepsy. Arm A of the trial randomised 990 patients with focal epilepsy to standard AED lamotrigine or new AED levetiracetam or zonisamide. Arm B randomised 520 patients with generalised epilepsy to standard AED sodium valproate or new AED levetiracetam. Patients are recruited from UK NHS outpatient epilepsy, general neurology and paediatric clinics. Included patients are aged 5 years or older with two or more spontaneous seizures requiring AED monotherapy, who are not previously treated with AEDs. Patients are followed up for a minimum of 2 years. The primary outcome is time to 12-month remission from seizures. Secondary outcomes include time to treatment failure (including due to inadequate seizure control or unacceptable adverse reactions); time to first seizure; time to 24-month remission; adverse reactions and quality of life. All primary analyses will be on an intention to treat basis. Separate analyses will be undertaken for each arm. Health economic analysis will be conducted from the perspective of the NHS to assess the cost-effectiveness of each AED. ETHICS AND DISSEMINATION This trial has been approved by the North West-Liverpool East REC (Ref. 12/NW/0361). The trial team will disseminate the results through scientific meetings, peer-reviewed publications and patient and public involvement. TRIAL REGISTRATION NUMBERS EudraCT 2012-001884-64; ISRCTN30294119.
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Affiliation(s)
- Silviya Balabanova
- Liverpool Clinical Trials Centre, University of Liverpool, Faculty of Health and Life Sciences, Liverpool, UK
| | - Claire Taylor
- Liverpool Clinical Trials Centre, University of Liverpool, Faculty of Health and Life Sciences, Liverpool, UK
| | - Graeme Sills
- School of Life Sciences, University of Glasgow, Glasgow, UK
| | - Girvan Burnside
- Biostatistics, University of Liverpool, Faculty of Health and Life Sciences, Liverpool, UK
| | - Catrin Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Phil E M Smith
- Department of Neurology, University Hospital of Wales, Cardiff, UK
| | - Richard Appleton
- Paediatric Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Michael Johnson
- Department of Brain Sciences, Imperial College London Faculty of Medicine-South Kensington Campus, London, UK
| | - Gus Baker
- Molecular and Clinical Pharmacology, University of Liverpool, Faculty of Health and Life Sciences, Liverpool, UK
| | - Munir Pirmohamed
- Department of Pharmacology, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | | | - Catrin Tudur-Smith
- Biostatistics, University of Liverpool, Faculty of Health and Life Sciences, Liverpool, UK
| | - Anthony Guy Marson
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Abstract
BACKGROUND Pregabalin is a gamma-aminobutyric acid analog that binds to the α2-δ subunits of the pre-synaptic voltage-dependent calcium channels of nerves with a high affinity and selectivity. In this study, the retinal teratogenic potential of pregabalin was investigated in a chick embryo model. MATERIALS AND METHODS Fertilised chicken eggs were divided into groups for administration with different doses of pregabalin. All eggs were opened on the 10th day of incubation. The embryos were dissected and the effects of pregabalin on the retina were investigated histopathologically, morphometrically, and immunohistochemically (Caspase-3). RESULTS There was no statistically significant difference between the low dose pregabalin, control, or vehicle control groups in terms of the number of retina layers and retinal thickness. Medium and high dose pregabalin caused a statistically significant decrease in the number of retina layers, as well as sensory retinal and pigment epithelium layer thicknesses. The outer nuclear and outer plexiform layer did not form in the group administered a medium dose. Similarly, the outer nuclear, outer plexiform, inner nuclear, and inner plexiform layer did not form in the high-dose group. No statistically significant difference was observed between the groups in terms of cellular damage and Caspase-3 expression. CONCLUSION The use of pregabalin during pregnancy compromises retinal development in a dose-dependent manner. The use of pregabalin in pregnancy causes the aforementioned defects in this system and it may have developmental effects that needs to be further evaluated.
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Affiliation(s)
- Ilke Evrim Secinti
- Department of Pathology, School of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
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Gheysen W, Kennedy D. An update on maternal medication-related embryopathies. Prenat Diagn 2020; 40:1168-1177. [PMID: 32524623 DOI: 10.1002/pd.5764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022]
Abstract
There is a general perception that any exposure to medication during pregnancy poses a potential risk to the fetus. Most available data about teratogenic drugs is derived from animal studies, case reports, or cohort studies. As a result, counseling women and their partners about the safety of drugs during pregnancy can be difficult due to limited information about efficacy, pharmacokinetics, and teratogenicity of some drugs. However, this should always be done in the context of weighing up potential teratogenic risks with the perinatal risks of an untreated medical or psychiatric condition. Ideally, this counseling should occur prior to a planned pregnancy so that medications and treatment of chronic medical conditions can be optimized. It is important that clinicians providing antenatal care are able to confidently manage women including utilizing appropriate resources. This paper aims at reviewing a selected (non-exhaustive) list of the most commonly prescribed medications considered significant human teratogens and provides recommendations for pre-conception and antenatal counseling.
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Affiliation(s)
- Willem Gheysen
- Department of Maternal-Fetal-Medicine, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Debra Kennedy
- MotherSafe, Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of NSW, Sydney, New South Wales, Australia
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Liu Z, Li J, Yang F, Hu Y, Liu J, Hu H, Su W. Sodium valproate combined with levetiracetam in pediatric epilepsy and its influence on NSE, IL-6, hs-CRP and electroencephalogram improvement. Exp Ther Med 2020; 20:2043-2048. [PMID: 32782515 PMCID: PMC7401305 DOI: 10.3892/etm.2020.8916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/10/2019] [Indexed: 01/25/2023] Open
Abstract
Efficacy of sodium valproate combined with levetiracetam (LEV) in pediatric epilepsy and its influence on neuron-specific enolase (NSE), interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) as well as electroencephalogram (EEG) improvement were studied. Patients (n=100) with pediatric epilepsy admitted to and treated in Xiantao First People's Hospital Affiliated to Yangtze University from December 2015 to 2018 were enrolled in this study and randomly divided into observation group (n=50) and control group (n=50). Sodium valproate was administered in the control group, and the treatment with LEV was combined with sodium valproate in the observation group. After 12 weeks the cognitive function of patients was assessed using the Mini-Mental State Examination (MMSE) scale, Montreal cognitive assessment (MoCA) scale and Wechsler Memory Scale-Revised in China (WMS-RC). The quality of life (QOL) of patients was evaluated with the QOL in epilepsy-31 inventory (QOLIE-31) scale and Barthel Index, and blood was drawn from the patients to detect the neurological function indicators [NSE and glial fibrillary acidic protein (GFAP)] and inflammatory indicators (IL-6, IL-2 and hs-CRP). After treatment, the incidence rates of adverse reactions notably declined in the observation group (P<0.05), and the improvement in the cognitive function in the observation group were both superior to those in the control group (P<0.05). Observation group had lowered content of NSE, GFAP, IL-6, hs-CRP and IL-2 (P<0.05), and α wave was markedly decreased, but θ and δ waves were notably increased in the observation group (P<0.05). In the treatment of pediatric epilepsy, sodium valproate combined with LEV produces better efficacy, fewer adverse reactions, significantly improves patients' QOL and notably lowers the content of NSE, IL-6 and hs-CRP with notable EEG improvement, so it is a safe and reliable treatment that is worth popularization.
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Affiliation(s)
- Zhaoyang Liu
- Department of Pediatrics, Xiantao First People's Hospital Affiliated to Yangtze University, Xiantao, Hubei 433000, P.R. China
| | - Jianmu Li
- Department of Pediatrics, Xiantao First People's Hospital Affiliated to Yangtze University, Xiantao, Hubei 433000, P.R. China
| | - Fan Yang
- Department of Pediatrics, Xiantao First People's Hospital Affiliated to Yangtze University, Xiantao, Hubei 433000, P.R. China
| | - Yongbo Hu
- Department of Gastrointestinal Surgery, Xiantao First People's Hospital Affiliated to Yangtze University, Xiantao, Hubei 433000, P.R. China
| | - Jun Liu
- Department of Oncology, Xiantao First People's Hospital Affiliated to Yangtze University, Xiantao, Hubei 433000, P.R. China
| | - Hongmei Hu
- Department of Ophthalmology, Xiantao First People's Hospital Affiliated to Yangtze University, Xiantao, Hubei 433000, P.R. China
| | - Wenbing Su
- Department of Gastrointestinal Medicine, Xiantao First People's Hospital Affiliated to Yangtze University, Xiantao, Hubei 433000, P.R. China
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Kim H, Faught E, Thurman DJ, Fishman J, Kalilani L. Antiepileptic Drug Treatment Patterns in Women of Childbearing Age With Epilepsy. JAMA Neurol 2020; 76:783-790. [PMID: 30933252 DOI: 10.1001/jamaneurol.2019.0447] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Limited population-based data are available on antiepileptic drug (AED) treatment patterns in women of childbearing age with epilepsy; the current population risk is not clear. Objectives To examine the AED treatment patterns and identify differences in use of valproate sodium and topiramate by comorbidities among women of childbearing age with epilepsy. Design, Setting, and Participants A retrospective cohort study used a nationwide commercial database and supplemental Medicare as well as Medicaid insurance claims data to identify 46 767 women with epilepsy aged 15 to 44 years. The eligible study cohort was enrolled between January 1, 2009, and December 31, 2013. Data analysis was conducted from January 1, 2017, to February 22, 2018. Exposures Cases required an International Classification of Diseases, Ninth Revision, Clinical Modification-coded epilepsy diagnosis with continuous medical and pharmacy enrollment. Incident cases required a baseline of 2 or more years without an epilepsy diagnosis or AED prescription before the index date. For both incident and prevalent cases, focal and generalized epilepsy cohorts were matched by age, payer type, and enrollment period and then compared. Main Outcomes and Measures Antiepileptic drug treatment pattern according to seizure type and comorbidities. Results Of the 46 767 patients identified, there were 8003 incident cases (mean [SD] age, 27.3 [9.4] years) and 38 764 prevalent cases (mean [SD] age, 29.7 [9.0] years). Among 3219 women in the incident epilepsy group who received AEDs for 90 days or more, 3173 (98.6%) received monotherapy as first-line treatment; among 28 239 treated prevalent cases, 18 987 (67.2%) received monotherapy. In 3544 (44.3%) incident cases and 9480 (24.5%) prevalent cases, AED treatment was not documented during 180 days or more of follow-up after diagnosis. Valproate (incident: 35 [5.81%]; prevalent: 514 [13.1%]) and phenytoin (incident: 33 [5.48%]; prevalent: 178 [4.53%]) were more commonly used for generalized epilepsy and oxcarbazepine (incident: 53 [8.03%]; prevalent: 386 [9.89%]) was more often used for focal epilepsy. Levetiracetam (incident: focal, 267 [40.5%]; generalized, 271 [45.0%]; prevalent: focal, 794 [20.3%]; generalized, 871 [22.2%]), lamotrigine (incident: focal, 123 [18.6%]; generalized, 106 [17.6%]; prevalent: focal, 968 [24.8%]; generalized, 871 [22.2%]), and topiramate (incident: focal, 102 [15.5%]; generalized, 64 [10.6%]; prevalent: focal, 499 [12.8%]; generalized, 470 [12.0%]) were leading AEDs prescribed for both focal and generalized epilepsy. Valproate was more commonly prescribed for women with comorbid headache or migraine (incident: 53 of 1251 [4.2%]; prevalent: 839 of 8046 [10.4%]), mood disorder (incident: 63 of 860 [7.3%]; prevalent: 1110 of 6995 [15.9%]), and anxiety and dissociative disorders (incident: 57 of 881 [6.5%]; prevalent: 798 of 5912 [13.5%]). Topiramate was more likely prescribed for those with comorbid headache or migraine (incident: 335 of 1251 [26.8%]; prevalent: 2322 of 8046 [28.9%]). Conclusions and Relevance Many women appear to be treated with valproate and topiramate despite known teratogenicity risks. Comorbidities may affect selecting certain AEDs despite their teratogenicity risks.
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Affiliation(s)
- Hyunmi Kim
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California
| | - Edward Faught
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - David J Thurman
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
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Kuo CY, Liu YH, Chou IJ, Wang HS, Hung PC, Chou ML, Lin JJ, Lan SY, Hsieh MY, Wang YS, Lin KL. Shifting Valproic Acid to Levetiracetam in Women of Childbearing Age With Epilepsy: A Retrospective Investigation and Review of the Literature. Front Neurol 2020; 11:330. [PMID: 32390936 PMCID: PMC7193743 DOI: 10.3389/fneur.2020.00330] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/06/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: Valproic acid is the most high-risk teratogenic antiepileptic drug, and it may lead to fetal major congenital malformations. However, it is still used in women of childbearing age with epilepsy. The aim of this study was to report our experience of discontinuing or lowering valproic acid by adding levetiracetam, a low-risk teratogenic antiepileptic drug. Methods: We reviewed the medical records of childbearing age female patients with epilepsy who were treated with valproic acid initially and then switched to levetiracetam. The clinical profiles were recorded. The primary outcome was successful switching, which was defined as a decrease in the daily valproic acid dosage, after levetiracetam had been added. Results: Twenty-four female patients were enrolled (median age 22 years). The successful switching rate was 83.3% (20/24), and 55% (11/20) discontinued valproic acid after levetiracetam had been added. There were no significant differences between the successful and unsuccessful groups in etiology, electroencephalogram, and magnetic resonance imaging findings. Pharmacoresistant to levetiracetam was much higher in the unsuccessful group (45 vs. 100%). The median switching duration was 19.5 months in the successful group. There were improvements in metrorrhagia and alopecia in all of the patients in the successful group after valproic acid had been tapered. Conclusions: Our experience supports switching valproic acid to levetiracetam in childbearing age women with epilepsy as an effective strategy to lower the teratogenic rate and adverse effects. A long switching period was noted in this study. We suggest starting early in childbearing age women with epilepsy.
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Affiliation(s)
- Cheng-Yen Kuo
- Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Hsuan Liu
- Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - I-Jun Chou
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Cheng Hung
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Min-Liang Chou
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Yun Lan
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Pediatric Neurology, Saint Paul's Hospital, Taoyuan, Taiwan
| | - Meng-Ying Hsieh
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Shan Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Romoli M, Mazzocchetti P, D'Alonzo R, Siliquini S, Rinaldi VE, Verrotti A, Calabresi P, Costa C. Valproic Acid and Epilepsy: From Molecular Mechanisms to Clinical Evidences. Curr Neuropharmacol 2020; 17:926-946. [PMID: 30592252 PMCID: PMC7052829 DOI: 10.2174/1570159x17666181227165722] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/03/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022] Open
Abstract
After more than a century from its discovery, valproic acid (VPA) still represents one of the most efficient antiepi-leptic drugs (AEDs). Pre and post-synaptic effects of VPA depend on a very broad spectrum of actions, including the regu-lation of ionic currents and the facilitation of GABAergic over glutamatergic transmission. As a result, VPA indirectly mod-ulates neurotransmitter release and strengthens the threshold for seizure activity. However, even though participating to the anticonvulsant action, such mechanisms seem to have minor impact on epileptogenesis. Nonetheless, VPA has been reported to exert anti-epileptogenic effects. Epigenetic mechanisms, including histone deacetylases (HDACs), BDNF and GDNF modulation are pivotal to orientate neurons toward a neuroprotective status and promote dendritic spines organization. From such broad spectrum of actions comes constantly enlarging indications for VPA. It represents a drug of choice in child and adult with epilepsy, with either general or focal seizures, and is a consistent and safe IV option in generalized convulsive sta-tus epilepticus. Moreover, since VPA modulates DNA transcription through HDACs, recent evidences point to its use as an anti-nociceptive in migraine prophylaxis, and, even more interestingly, as a positive modulator of chemotherapy in cancer treatment. Furthermore, VPA-induced neuroprotection is under investigation for benefit in stroke and traumatic brain injury. Hence, VPA has still got its place in epilepsy, and yet deserves attention for its use far beyond neurological diseases. In this review, we aim to highlight, with a translational intent, the molecular basis and the clinical indications of VPA.
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Affiliation(s)
- Michele Romoli
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia, Italy
| | - Petra Mazzocchetti
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia, Italy
| | - Renato D'Alonzo
- Pediatric Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia, Italy
| | | | - Victoria Elisa Rinaldi
- Pediatric Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila - San Salvatore Hospital, L'Aquila, Italy
| | - Paolo Calabresi
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia, Italy.,IRCCS "Santa Lucia", Rome, Italy
| | - Cinzia Costa
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia, Italy
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Antiseizure drugs use during pregnancy and congenital malformations: A retrospective review from the United Arab Emirates. Epilepsy Res 2020; 159:106259. [PMID: 31901526 DOI: 10.1016/j.eplepsyres.2019.106259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/21/2019] [Accepted: 12/20/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To observe the incidence of congenital malformations occurring in foetuses exposed to antiseizure drugs (ASDs) during the first trimester and to identify individual drug associations in a population cohort from the United Arab Emirates (UAE). METHODS Pregnancy outcomes were observed and reported from women with epilepsy (WWE), attending the Obstetric Medicine Neurology Clinic at Corniche Hospital in Abu Dhabi, United Arab Emirates (UAE) from February 2008 to December 2015. RESULTS Outcome data were available for 179 pregnancies in 112 WWE. There were 139 pregnancies who received ASD treatment during the first trimester, of these 124 were on monotherapy. Thirteen (7.26 %) congenital malformations (CMs) were observed in this cohort, seven were major ones and six were minor. Thirteen of the CMs were from the group with ASDs while one had no ASD-exposure. From the ASD-group, we identified 32 (23.0 %) with poor pregnancy outcomes, including 13 (9.3 %) with CMs and 19 (13.7 %) miscarriages. These figures were significantly higher than that of the no ASD-exposure group (7.9 %) (p = 0.04, Fisher test). The most commonly used ASDs in monotherapy were levetiracetam (25.6 %), carbamazepine (16.2 %), valproate (13.4 %), and lamotrigine (7.3 %). There were 57 (31.8 %) consanguineous marriages in this cohort; there was no statistically significant difference in the CM rate within the consanguineous group between those with and without exposure to ASD. CONCLUSION This study was the first to report pregnancy outcomes in a WWE cohort from the Middle East and North Africa (MENA) region. It is the first step towards establishing a national / regional pregnancy registry to create a database on ASD use and pregnancy outcomes among the WWE.
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Wang Z, Ho PWH, Choy MTH, Wong ICK, Brauer R, Man KKC. Advances in Epidemiological Methods and Utilisation of Large Databases: A Methodological Review of Observational Studies on Central Nervous System Drug Use in Pregnancy and Central Nervous System Outcomes in Children. Drug Saf 2020; 42:499-513. [PMID: 30421346 DOI: 10.1007/s40264-018-0755-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Studies have used various epidemiological approaches to study associations between central nervous system (CNS) drug use in pregnancy and CNS outcomes in children. Studies have generally focused on clinical adverse effects, whereas variations in methodologies have not received sufficient attention. OBJECTIVE Our objective was to review the methodological characteristics of existing studies to identify any limitations and recommend further research. METHODS A systematic literature search was conducted on observational studies listed in PubMed from 1 January 1946 to 21 September 2017. Following independent screening and data extraction, we conducted a review addressing the trends of relevant studies, differences between various data sources, and methods used to address bias and confounders; we also conducted statistical analyses. RESULTS In total, 111 observational studies, 25 case-control studies, and 86 cohort studies were included in the review. Publications dating from 1978 to 2006 mainly focused on antiepileptic drugs, but research on antidepressants increased from 2007 onwards. Only one study focused on antipsychotic use during pregnancy. A total of 46 studies obtained data from an administrative database/registry, 20 from ad hoc disease registries, and 41 from ad hoc clinical samples. Most studies (58%) adjusted the confounding factors using general adjustment, whereas only a few studies used advanced methods such as sibling-matched models and propensity score methods; 42 articles used univariate analyses and 69 conducted multivariable regression analyses. CONCLUSION Multiple factors, including different study designs and data sources, have led to inconsistent findings in associations between CNS drug use in pregnancy and CNS outcomes in children. Researchers should allow for study designs with clearly defined exposure periods, at the very least in trimesters, and use advanced confounding adjustment methodology to increase the accuracy of the findings.
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Affiliation(s)
- Zixuan Wang
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Entrance A, Tavistock Square, London, WC1H 9JP, UK
| | - Phoebe W H Ho
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Michael T H Choy
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Ian C K Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Entrance A, Tavistock Square, London, WC1H 9JP, UK.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Ruth Brauer
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Entrance A, Tavistock Square, London, WC1H 9JP, UK
| | - Kenneth K C Man
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Entrance A, Tavistock Square, London, WC1H 9JP, UK. .,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong. .,Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands.
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