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Tamaoki Y, Pasapula V, Chandler C, Borland MS, Olajubutu OI, Tharakan LS, Engineer CT. Degraded inferior colliculus responses to complex sounds in prenatally exposed VPA rats. J Neurodev Disord 2024; 16:2. [PMID: 38166599 PMCID: PMC10759431 DOI: 10.1186/s11689-023-09514-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Individuals with autism spectrum disorders (ASD) often exhibit altered sensory processing and deficits in language development. Prenatal exposure to valproic acid (VPA) increases the risk for ASD and impairs both receptive and expressive language. Like individuals with ASD, rodents prenatally exposed to VPA exhibit degraded auditory cortical processing and abnormal neural activity to sounds. Disrupted neuronal morphology has been documented in earlier processing areas of the auditory pathway in VPA-exposed rodents, but there are no studies documenting early auditory pathway physiology. Therefore, the objective of this study is to characterize inferior colliculus (IC) responses to different sounds in rats prenatally exposed to VPA compared to saline-exposed rats. METHODS In vivo extracellular multiunit recordings from the inferior colliculus were collected in response to tones, speech sounds, and noise burst trains. RESULTS Our results indicate that the overall response to speech sounds was degraded in VPA-exposed rats compared to saline-exposed controls, but responses to tones and noise burst trains were unaltered. CONCLUSIONS These results are consistent with observations in individuals with autism that neural responses to complex sounds, like speech, are often altered, and lays the foundation for future studies of potential therapeutics to improve auditory processing in the VPA rat model of ASD.
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Affiliation(s)
- Yuko Tamaoki
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA.
- The University of Texas at Dallas, Texas Biomedical Device Center, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA.
| | - Varun Pasapula
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
- The University of Texas at Dallas, Texas Biomedical Device Center, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
| | - Collin Chandler
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
- The University of Texas at Dallas, Texas Biomedical Device Center, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
| | - Michael S Borland
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
- The University of Texas at Dallas, Texas Biomedical Device Center, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
| | - Olayinka I Olajubutu
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
- The University of Texas at Dallas, Texas Biomedical Device Center, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
| | - Liza S Tharakan
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
- The University of Texas at Dallas, Texas Biomedical Device Center, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
| | - Crystal T Engineer
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
- The University of Texas at Dallas, Texas Biomedical Device Center, 800 West Campbell Road BSB11, Richardson, TX, 75080, USA
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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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Bluett-Duncan M, Astill D, Charbak R, Clayton-Smith J, Cole S, Cook PA, Cozens J, Keely K, Morris J, Mukherjee R, Murphy E, Turnpenny P, Williams J, Wood AG, Yates LM, Bromley RL. Neurodevelopmental outcomes in children and adults with Fetal Valproate Spectrum Disorder: A contribution from the ConcePTION project. Neurotoxicol Teratol 2023; 100:107292. [PMID: 37666366 DOI: 10.1016/j.ntt.2023.107292] [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: 04/12/2023] [Revised: 07/17/2023] [Accepted: 09/01/2023] [Indexed: 09/06/2023]
Abstract
AIM To describe the neurodevelopmental phenotype of older children and adults with a diagnosis of Fetal Valproate Spectrum Disorder (FVSD). METHODS In this cross-sectional study, 90 caregivers were recruited and completed a series of questionnaires regarding the neurodevelopmental outcomes of 146 individuals aged 7-37 years (M = 18.1), including individuals with a formal diagnosis of FVSD (n = 99), individuals exposed to Valproate but without an FVSD diagnosis (n = 24), and individuals not exposed to Valproate (N = 23). The mean dose of valproate exposure for individuals with an FVSD diagnosis was 1470 mg/day. RESULTS Individuals with a diagnosis of FVSD showed significantly higher levels of moderate (43.4%) and severe (14.4%) cognitive impairment than other groups (p = 0.003), high levels of required formal educational support (77.6%), and poorer academic competence than individuals not exposed to Valproate (p = 0.001). Overall psychosocial problems (p = 0.02), internalising problems (p = 0.05) and attention problems (p = 0.001), but not externalising problems, were elevated in individuals with a diagnosis of FVSD. Rates of neurodevelopmental disorders, particularly autistic spectrum disorders (62.9%) and sensory problems (80.6%) are particularly central to the FVSD phenotype. There was no evidence of a statistical dose-dependent effect, possibly due to the high mean dose of exposure having a uniformly negative impact across the sample. Individuals with FVSD had required a significant number of health and child development services. INTERPRETATION Children and young adults with a diagnosis of FVSD are at an increased risk of a range of altered neurodevelopmental outcomes, highlighting the need for a multidisciplinary approach to clinical management across the lifespan.
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Affiliation(s)
- M Bluett-Duncan
- Division of Neuroscience, School of Biological Sciences, The University of Manchester, UK.
| | - D Astill
- Foetal Anti-Convulsant Syndrome New Zealand, Aukland, New Zealand
| | - R Charbak
- Division of Neuroscience, School of Biological Sciences, The University of Manchester, UK
| | - J Clayton-Smith
- Division of Evolution, Systems and Genomics, University of Manchester, UK
| | - S Cole
- Pharma Consent, London, UK
| | - P A Cook
- School of Health and Society, University of Salford, UK
| | - J Cozens
- Organisation for Anti-Convulsant Syndrome, UK
| | - K Keely
- Organisation for Anti-Convulsant Syndrome, Ireland
| | - J Morris
- Foetal Anti-Convulsant Syndrome New Zealand, Aukland, New Zealand
| | - R Mukherjee
- Department of Health and Social Science, University of Salford, Allerton Building, Salford, England, UK
| | - E Murphy
- Independent Fetal Anti-Convulsant Trust, Preston, UK
| | - P Turnpenny
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - J Williams
- Independent Fetal Anti-Convulsant Trust, Preston, UK
| | - A G Wood
- Clinical Sciences, Murdoch Children's Research Institute, & School of Psychology, Deakin University, Melbourne, Australia; Institute of Health and Neurodevelopment, Aston University, UK
| | - L M Yates
- Northern Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK; KRISP, University of KwaZulu-Natal, South Africa
| | - R L Bromley
- Division of Neuroscience, School of Biological Sciences, The University of Manchester, UK; Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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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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Liu C, Pace S, Bromley R, Dobson R. Exposure to medication for neurological disease in pregnancy - time to consider the long-term implications? EClinicalMedicine 2023; 63:102157. [PMID: 37662523 PMCID: PMC10474373 DOI: 10.1016/j.eclinm.2023.102157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023] Open
Abstract
A range of long-term neurological conditions may be diagnosed in young adulthood. These conditions are generally not curable, and most people need to take ongoing treatment for symptom control and/or disease modification. When chronic diseases are diagnosed before people have completed their families, there is a need to balance the potential benefits of treatment for the mother against potential risk(s) to the fetus from exposure to medications during pregnancy. Whilst available data regarding short-term fetal outcomes following treatment exposures during pregnancy is rapidly increasing, information regarding longer-term outcomes is more limited. The association of fetal exposure to valproate with serious long-term neurodevelopmental outcomes has highlighted the importance of capturing and evaluating long-term data. In this review we examine available evidence around the long-term effects of treatments used for the most common long-term neurological conditions diagnosed in early adulthood, namely epilepsy, migraine and neuroinflammatory disorders. We draw from existing literature across a range of diseases and discuss strategies to improve future knowledge.
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Affiliation(s)
- Chen Liu
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
| | - Samuel Pace
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Rebecca Bromley
- Division of Neuroscience, School of Biological Sciences, Faculty of Medicine, Biology and Health, University of Manchester, UK
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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Tamaoki Y, Pasapula V, Chandler C, Borland MS, Olajubutu OI, Tharakan LS, Engineer CT. Degraded inferior colliculus responses to complex sounds in prenatally exposed VPA rats. RESEARCH SQUARE 2023:rs.3.rs-3168097. [PMID: 37577524 PMCID: PMC10418539 DOI: 10.21203/rs.3.rs-3168097/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Background Individuals with autism spectrum disorders (ASD) often exhibit altered sensory processing and deficits in language development. Prenatal exposure to valproic acid (VPA) increases the risk for ASD and impairs both receptive and expressive language. Like individuals with ASD, rodents prenatally exposed to VPA exhibit degraded auditory cortical processing and abnormal neural activity to sounds. Disrupted neuronal morphology has been documented in earlier processing areas of the auditory pathway in VPA-exposed rodents, but there are no studies documenting early auditory pathway physiology. Therefore, the objective of this study is to characterize inferior colliculus (IC) responses to different sounds in rats prenatally exposed to VPA compared to saline-exposed rats. Methods Neural recordings from the inferior colliculus were collected in response to tones, speech sounds, and noise burst trains. Results Our results indicate that the overall response to speech sounds was degraded in VPA-exposed rats compared saline-exposed controls, but responses to tones and noise burst trains were unaltered. Conclusions These results are consistent with observations in individuals with autism that neural responses to complex sounds, like speech, are often altered, and lays the foundation for future studies of potential therapeutics to improve auditory processing in the VPA rat model of ASD.
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Affiliation(s)
- Yuko Tamaoki
- The University of Texas at Dallas School of Behavioral and Brain Sciences
| | - Varun Pasapula
- The University of Texas at Dallas School of Behavioral and Brain Sciences
| | - Collin Chandler
- The University of Texas at Dallas School of Behavioral and Brain Sciences
| | - Michael S Borland
- The University of Texas at Dallas School of Behavioral and Brain Sciences
| | | | - Liza S Tharakan
- The University of Texas at Dallas School of Behavioral and Brain Sciences
| | - Crystal T Engineer
- The University of Texas at Dallas School of Behavioral and Brain Sciences
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Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5. Obstet Gynecol 2023; 141:1262-1288. [PMID: 37486661 DOI: 10.1097/aog.0000000000005202] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
PURPOSE To assess the evidence regarding safety and efficacy of psychiatric medications to treat mental health conditions during pregnancy and lactation. The conditions reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, and acute psychosis. For information on screening and diagnosis, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 4, "Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum" (1). TARGET POPULATION Pregnant or postpartum individuals with mental health conditions with onset that may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time. METHODS This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements. RECOMMENDATIONS This Clinical Practice Guideline includes recommendations on treatment and management of perinatal mental health conditions including depression, anxiety, bipolar disorders, and acute postpartum psychosis, with a focus on psychopharmacotherapy. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
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Egenasi CK, Moodley AA, Steinberg WJ, Adefuye AO. Current norms and practices in using a seizure diary for managing epilepsy: A scoping review. S Afr Fam Pract (2004) 2022; 64:e1-e9. [PMID: 36226950 PMCID: PMC9575367 DOI: 10.4102/safp.v64i1.5540] [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: 03/28/2022] [Revised: 07/22/2022] [Accepted: 07/24/2022] [Indexed: 11/07/2022] Open
Abstract
Background Epilepsy is a chronic and debilitating condition affecting people of all ages in many nations. Healthcare practitioners look for effective ways to track patients’ seizures, and a seizure diary is one of the methods used. This scoping review sought to identify current norms and practices for using seizure diaries to manage epilepsy. Method A scoping review was performed by screening relevant studies and identifying themes, categories and subcategories. Results A total of 1125 articles were identified from the database; 46 full-text articles were assessed for eligibility, of which 23 articles were selected. The majority (48%) of the studies were prospective studies. The majority (65%) of the articles were studies conducted in the United States. The themes identified were types of seizure diaries used in clinical practice, contents and structure of a standardised seizure diary, the use and efficacy of seizure diaries in medicine and challenges relating to using a seizure diary for patient management. Conclusion The study revealed that a seizure diary remains a relevant tool in managing epilepsy. The two forms of diaries in use are electronic and paper-based diaries. The high cost of data and the expensive devices required to access electronic diaries make it unsuitable in a resource-limited setting. Despite its disadvantages, imperfections and inadequacies, the paper-based diary is still relevant for managing patients with epilepsy in resource-limited settings. Contribution This study reviewed the literature to find the current norms and practices in using seizure diaries. The benefits of the different formats were emphasised.
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Affiliation(s)
- Chika K. Egenasi
- Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Anandan A. Moodley
- Department of Neurology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Wilhelm J. Steinberg
- Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Anthonio O. Adefuye
- Division of Health Sciences Education, Faculty of Health Science, University of the Free State, Bloemfontein, South Africa
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Degremont A, Polard E, Kerbrat S, Grimaud O, Jonville-Béra AP, Ringa V, Travers D, Oger E, Biraben A, Nowak E. Impact of recommendations on sodium valproate prescription among women with epilepsy: An interrupted time-series study. Epilepsy Behav 2021; 125:108449. [PMID: 34839242 DOI: 10.1016/j.yebeh.2021.108449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The European Medicines Agency (EMA) has developed risk minimization measures (RMMs) to reduce the use of the teratogenic drug, sodium valproate (VPA). The objective was to assess the impact of these RMMs among females with epilepsy in France. METHODS We used data from the French National Health Insurance Database (SNDS), including 114,936 females aged under 50, with a reimbursement claim for an antiepileptic drug from January 2011 to December 2017, and identified as people with epilepsy. We used a controlled interrupted time series stratifying on age: girls (0-14 years old) and women of childbearing age (15-49 years), and with 129,917 males as controls. RESULTS VPA prevalent use among girls and women of childbearing age with epilepsy decreased significantly after the issue of the RMMs (trend changes of, respectively, -5 and -4 users per 1000 females at-risk per quarter in comparison to the control group). We did not detect any significant change in VPA incident use. CONCLUSIONS VPA use decreased over the study period among females with epilepsy but there were still 317 women and 206 girls started on VPA therapy VPA in 2017 (8 per 1000 at-risk and 18 per 1000, respectively). This suggests that either the measures should be strengthened or that the lowest level of VPA use has been reached. In this context, the introduction of a new RMM (in 2018) needs to be evaluated.
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Affiliation(s)
- Adeline Degremont
- Pharmacovigilance, Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, CHU de Rennes, 35033 Rennes, France; Univ Rennes, EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', 35000 Rennes, France.
| | - Elisabeth Polard
- Pharmacovigilance, Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, CHU de Rennes, 35033 Rennes, France; Univ Rennes, EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', 35000 Rennes, France
| | - Sandrine Kerbrat
- Univ Rennes, EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', 35000 Rennes, France
| | - Olivier Grimaud
- Ecole des Hautes Etudes en Sante Publique, 35000 Rennes, France
| | - Annie-Pierre Jonville-Béra
- Pharmacovigilance and Drug Information Centre, Department of Pharmacosurveillance, CHU de Tours, 37044 Tours, France
| | - Virginie Ringa
- INSERM, Univ Paris-Saclay, Univ Paris-Sud, UVSQ, CESP, Villejuif, France
| | - David Travers
- Psychiatry Department, Department of Psychiatry, CHU Rennes, Rennes, France
| | - Emmanuel Oger
- Pharmacovigilance, Pharmacoepidemiology and Drug Information Centre, Department of Clinical Pharmacology, CHU de Rennes, 35033 Rennes, France; Univ Rennes, EA 7449 REPERES 'Pharmacoepidemiology and Health Services Research', 35000 Rennes, France
| | - Arnaud Biraben
- Epilepsy Unit, Neurology Department, Rennes University Hospital and INSERM 1099, Signal and Image Processing Laboratory, University of Rennes 1, France
| | - Emmanuel Nowak
- CHU de Brest et Université Européenne de Bretagne, Université de Brest, INSERM CIC 1412, IFR 148, France
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Marxer CA, Rüegg S, Rauch MS, Panchaud A, Meier CR, Spoendlin J. A review of the evidence on the risk of congenital malformations and neurodevelopmental disorders in association with antiseizure medications during pregnancy. Expert Opin Drug Saf 2021; 20:1487-1499. [PMID: 34128743 DOI: 10.1080/14740338.2021.1943355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The majority of women with epilepsy require treatment with antiseizure medications (ASM) throughout pregnancy. However, in utero exposure to several ASM has been associated with an increased risk of congenital malformations and/or neurodevelopmental disorders (CM/NDD) in the child, but observational evidence is methodologically heterogeneous.Areas covered: We critically evaluate current evidence on the risk of CM/NDD in children of women with epilepsy after in utero exposure to different ASM. We highlight characteristics of different data sources and discuss their benefits and drawbacks. This review includes evidence published before December 2020.Expert opinion: Given the lack of randomized controlled trials, evidence on in utero safety of ASM originates from methodologically heterogeneous post-marketing observational studies based on registries, prospective cohorts, and large electronic health databases. It has been clearly demonstrated that valproate is associated with a high risk of CM/NDD, whereas lamotrigine and levetiracetam are relatively safe. However, evidence is less explicit for other ASM. Reported risks vary depending on the size and origin of the underlying study population, the definition of exposure and outcomes, and other aspects of the study design. Increased collaboration between data sources to increase sample size is desirable.
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Affiliation(s)
- Carole A Marxer
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marlene S Rauch
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute for Pharmaceutical Sciences of Western Switzerland, Switzerland
| | - Christoph R Meier
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.,Boston Collaborative Drug Surveillance Program, Lexington, MA, United States
| | - Julia Spoendlin
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
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Sharma SR, Sharma N, Hussain M, Mobing H, Hynniewta Y. Levetiracetam Use During Pregnancy in Women With Active Epilepsy: A Hospital-Based, Retrospective Study from a Tertiary Care Hospital in North Eastern INDIA. Neurol India 2021; 69:692-697. [PMID: 34169870 DOI: 10.4103/0028-3886.319234] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background and Purpose Epilepsy during pregnancy is a therapeutic challenge. Since the 1990s, the number of licensed antiepileptic drugs has substantially increased, but safety data on managing epilepsy during conception, pregnancy, and postpartum period use of newer generation antiepileptic drugs and birth defects are limited. We analyzed efficacy and safety of levetiracetam during pregnancy in northeast Indian women with active epilepsy (WWAE) which is being presented here. Design Hospital based retrospective study. Patients and Methods A retrospective analysis was conducted based on clinical records at a tertiary care teaching hospital and referral center in Northeast India between June 2008 through June 2018 without any personal identifying information. The Obstetric data from pregnancy register was supplemented with detailed neurologic data retrieved from medical records. Results Of 103 women with active epilepsy, 47 (45.6%) received levetiracetam as monotherapy and 56 (54.4%) as polytherapy. During pregnancy, the seizure frequency was unchanged, or the change was better in the majority (61.1%) of the patients. With one twin pregnancy, there were 96 live births, 5 spontaneous abortions, 2 induced abortions, 1 stillbirth. However, the rate of small for gestational age was higher in WWAE, Apgar score at 5 min was lower in infants of WWAE, and the need for care in the neonatal ward and neonatal intensive care was higher. Seven of 103 exposed pregnancies had a major congenital malformation (6.79%), all 7 were exposed to other antiepileptic drugs. Generalized epilepsy accounted for 57.2%. Conclusion Pregnancy course is uncomplicated and neonatal outcome is good in the majority of women with active epilepsy with proper antenatal and neurologic care. Levetiracetam taken in monotherapy can be considered as safer alternative for women with epilepsy of childbearing age. Long-term follow-up of neuropsychological and cognitive development of the children of WWAE is still needed.
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Affiliation(s)
- Shri Ram Sharma
- Department of Neurology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Nalini Sharma
- Department of Obstetrics and Gynecology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Masaraf Hussain
- Department of Neurology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Hibung Mobing
- Department of Neurology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Yasmeen Hynniewta
- Department of Pediatric Medicine, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
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12
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Risk of early neurodevelopmental disorders associated with in utero exposure to valproate and other antiepileptic drugs: a nationwide cohort study in France. Sci Rep 2020; 10:17362. [PMID: 33093466 PMCID: PMC7581762 DOI: 10.1038/s41598-020-74409-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 08/25/2020] [Indexed: 12/21/2022] Open
Abstract
Information available on the risks of neurodevelopmental disorders (NDs) associated with in utero exposure to valproate (VPA) and to other antiepileptic drugs (AEDs) is limited. A nationwide population-based cohort study was conducted based on comprehensive data of the French National Health Data System (SNDS). Liveborn infants without brain malformation, born between January 2011 and December 2014, were followed from birth up to December 2016. NDs were identified based on diagnoses of mental or behavioural disorders and utilization of speech therapy, orthoptic or psychiatric services. The risk of NDs was compared between children exposed in utero to AED monotherapy and unexposed children, using Cox proportional hazard models adjusted for maternal and neonatal characteristics. The cohort included 1,721,990 children, 8848 of whom were exposed in utero to AED monotherapy. During a mean follow-up of 3.6 years, 15,458 children had a diagnosis of mental or behavioural disorder. In utero exposure to VPA was associated with an increased risk of NDs overall (aHR: 3.7; 95% CI 2.8–4.9) and among children born to a mother without mental illness (aHR 5.1; 95% CI 3.6–7.3). A dose–response relationship was demonstrated and the risk of NDs was more particularly increased for an exposure to VPA during the second or third trimesters of pregnancy. Among the other AEDs, only pregabalin was consistently associated with an increased risk of NDs (aHR: 1.5; 95% CI 1.0–2.1). This study confirms a four to fivefold increased risk of early NDs associated with exposure to VPA during pregnancy. The risk associated with other AEDs appears much lower.
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Unnikrishnan G, Jacob NS, Salim S, Jose M, Salini RA, Pavithran V, Jeemon P, Thomas SV. Enduring language deficits in children of women with epilepsy and the potential role of intrauterine exposure to antiepileptic drugs. Epilepsia 2020; 61:2442-2451. [PMID: 33345345 DOI: 10.1111/epi.16685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/14/2020] [Accepted: 08/14/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Exposure to certain intrauterine antiepileptic drugs (AEDs) can negatively influence the language skills and intelligence of young children. It remains unanswered whether these deficits are transient or persist as children grow up. This study aims to evaluate the language function of children of women with epilepsy (CWE) aged 9-13 years in comparison with their peers, and its relationship with intrauterine AED exposure. METHODS We included 191 CWE in our study from the Kerala Registry of Epilepsy and Pregnancy. Children in the same age group (n = 144) and without maternal epilepsy or antenatal AED exposure served as controls. We used Clinical Examination for Language Function version IV to assess language in both groups. Relevant data related to maternal epilepsy and AED use were obtained from the registry records. RESULTS The average Core Language Scaled Score (CLSS) was significantly lower in CWE as compared to controls (83.19 vs 90.18, P = .001). Similarly, the mean scaled scores in other language parameters were also significantly lower in CWE. In the multivariate analysis, compared to control children, the average CLSS in CWE was 4.5 units lower (95% confidence interval [CI] = -8.8 to -0.2, P = .04) with AED monotherapy exposure and 7.3 units lower with exposure to AED polytherapy (95% CI = -13.8 to -0.8, P = .03). Intrauterine exposure to phenobarbitone (n = 61) and valproate (n = 55) as either monotherapy or polytherapy showed a negative effect on CLSS in CWE as compared to control children. However, carbamazepine (n = 75) and phenytoin (n = 37) use was not associated with significant variation of CLSS. In head-to-head comparisons between AED monotherapies in CWE, phenobarbitone showed a negative effect on CLSS (-14.7, 95% CI = -23.1 to -6.4, P = .001) as compared to carbamazepine. SIGNIFICANCE Intrauterine exposure to phenobarbitone and valproate impairs language development in CWE, with effects persisting into the second decade.
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Affiliation(s)
| | - Nikita Susan Jacob
- Department of Neurology, Kerala Registry of Epilepsy and Pregnancy, Trivandrum, India
| | - Salma Salim
- Department of Neurology, Kerala Registry of Epilepsy and Pregnancy, Trivandrum, India
| | - Manna Jose
- Department of Neurology, Kerala Registry of Epilepsy and Pregnancy, Trivandrum, India
| | - Reshma A Salini
- Department of Neurology, Kerala Registry of Epilepsy and Pregnancy, Trivandrum, India
| | - Veena Pavithran
- Department of Neurology, Kerala Registry of Epilepsy and Pregnancy, Trivandrum, India
| | - Panniyammakal Jeemon
- Achutha Menon Center for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Sanjeev V Thomas
- Department of Neurology, Kerala Registry of Epilepsy and Pregnancy, Trivandrum, India
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14
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Clayton-Smith J, Bromley R, Dean J, Journel H, Odent S, Wood A, Williams J, Cuthbert V, Hackett L, Aslam N, Malm H, James G, Westbom L, Day R, Ladusans E, Jackson A, Bruce I, Walker R, Sidhu S, Dyer C, Ashworth J, Hindley D, Diaz GA, Rawson M, Turnpenny P. Diagnosis and management of individuals with Fetal Valproate Spectrum Disorder; a consensus statement from the European Reference Network for Congenital Malformations and Intellectual Disability. Orphanet J Rare Dis 2019; 14:180. [PMID: 31324220 PMCID: PMC6642533 DOI: 10.1186/s13023-019-1064-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/12/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A pattern of major and minor congenital anomalies, facial dysmorphic features, and neurodevelopmental difficulties, including cognitive and social impairments has been reported in some children exposed to sodium valproate (VPA) during pregnancy. Recognition of the increased risks of in utero exposure to VPA for congenital malformations, and for the neurodevelopmental effects in particular, has taken many years but these are now acknowledged following the publication of the outcomes of several prospective studies and registries. As with other teratogens, exposure to VPA can have variable effects, ranging from a characteristic pattern of major malformations and significant intellectual disability to the other end of the continuum, characterised by facial dysmorphism which is often difficult to discern and a more moderate effect on neurodevelopment and general health. It has become clear that some individuals with FVSD have complex needs requiring multidisciplinary care but information regarding management is currently lacking in the medical literature. METHODS An expert group was convened by ERN-ITHACA, the European Reference Network for Congenital Malformations and Intellectual Disability comprised of professionals involved in the care of individuals with FVSD and with patient representation. Review of published and unpublished literature concerning management of FVSD was undertaken and the level of evidence from these sources graded. Management recommendations were made based on strength of evidence and consensus expert opinion, in the setting of an expert consensus meeting. These were then refined using an iterative process and wider consultation. RESULTS Whilst there was strong evidence regarding the increase in risk for major congenital malformations and neurodevelopmental difficulties there was a lack of high level evidence in other areas and in particular in terms of optimal clinical management.. The expert consensus approach facilitated the formulation of management recommendations, based on literature evidence and best practice. The outcome of the review and group discussions leads us to propose the term Fetal Valproate Spectrum Disorder (FVSD) as we feel this better encompasses the broad range of effects seen following VPA exposure in utero. CONCLUSION The expert consensus approach can be used to define the best available clinical guidance for the diagnosis and management of rare disorders such as FVSD. FVSD can have medical, developmental and neuropsychological impacts with life-long consequences and affected individuals benefit from the input of a number of different health professionals.
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Affiliation(s)
- Jill Clayton-Smith
- Division of Evolution and Genomic Sciences School of Biological Sciences, University of Manchester, Manchester, UK
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Rebecca Bromley
- Division of Evolution and Genomic Sciences School of Biological Sciences, University of Manchester, Manchester, UK
- Paediatric Psychosocial Department, Royal Manchester Children’s Hospital, Manchester Academic Health Sciences Centre, Manchester, UK
| | - John Dean
- Clinical Genetics, Clinical Genetics Service, Ashgrove House, Foresterhill, Aberdeen, UK
| | - Hubert Journel
- Génétique Médicale – Consultation, CHBA Centre Hospitalier Bretagne Atlantique - CH Chubert, 20 boulevard du Général Maurice Guillaudot, BP 70555, 56017 Vannes Cedex, France
| | - Sylvie Odent
- Service de Génétique Clinique, CNRS UMR 6290, Université de Rennes, CHU de Rennes - Hôpital Sud, 16 Boulevard de Bulgarie, 35203 Rennes Cedex 2, France
| | - Amanda Wood
- Aston Brain Centre, School of Life and Health Sciences, Aston Triangle, Birmingham, UK
- Brain and Mind, Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Melbourne, Australia
| | - Janet Williams
- INFACT/FACSA, Independent Fetal Anti-Convulsant Trust & FACS Syndrome Association, Preston, UK
| | - Verna Cuthbert
- Department of Paediatric Rheumatology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Latha Hackett
- Child and Adolescent Mental Health Services (CAMHS), Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Neelo Aslam
- Child and Adolescent Mental Health Services (CAMHS), Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Heli Malm
- Teratology Information Service, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Tukholmankatu 17, 00029 HUS, Helsinki, Finland
| | - Gregory James
- Department of Neurosurgery, Great Ormond Street Hospital, Great Ormond Street, London, UK
- Craniofacial Unit, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH UK
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH UK
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG UK
| | - Lena Westbom
- Lund University, Barnmed klin, SUS, Lund, Sweden
| | - Ruth Day
- Guardian Medical Centre, Guardian Street, Warrington, UK
| | - Edmund Ladusans
- Department of Paediatric Cardiology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK
| | - Adam Jackson
- Department of Neurology, Salford Royal Hospital NHS Trust, Stott Lane, Salford, UK
| | - Iain Bruce
- Paediatric ENT Department, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Robert Walker
- Department of Paediatric Anaesthesia, Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
| | - Sangeet Sidhu
- Department of Paediatric Nephrology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK
| | - Catrina Dyer
- Cleft Lip and Palate Team, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK
| | - Jane Ashworth
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Daniel Hindley
- Community Paediatrics, Bolton NHS Foundation Trust, Breightmet Health Centre, Bolton, UK
| | - Gemma Arca Diaz
- Department of Neonatology, Hospital Clinic (Maternitat), Sabino Arana 1, 08028 Barcelona, Spain
| | - Myfanwy Rawson
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Peter Turnpenny
- Clinical Genetics, Royal Devon and Exeter NHS Foundation Trust, Gladstone Rd, Exeter, UK
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15
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Richards N, Reith D, Stitely M, Smith A. Developmental outcomes at age four following maternal antiepileptic drug use. Epilepsy Behav 2019; 93:73-79. [PMID: 30836322 DOI: 10.1016/j.yebeh.2019.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/14/2018] [Accepted: 01/11/2019] [Indexed: 01/18/2023]
Abstract
We investigated whether prenatal antiepileptic drug (AED) exposure was associated with adverse outcomes in the Before School Check (B4SC) assessments, particularly the assessments measuring neurodevelopment. Children exposed to AEDs were identified by linking women dispensed AEDs in the Pharmaceutical Collection to births recorded on the National Minimum Dataset (NMDS). Multinomial logistic regression was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) for outcomes of the parent-completed Parental Evaluation of Developmental Status (PEDS) questionnaire and Strengths and Difficulties Questionnaire (SDQ), after adjusting for gender, ethnicity, and socioeconomic deprivation. Between 2012 and 2016, 606 children with a mother who had been dispensed one or more AEDs during pregnancy had taken part in the B4SC. Prenatal exposure to sodium valproate (n = 161) or lamotrigine (n = 149) monotherapy was associated with an increased risk of having an abnormal SDQ - parent-completed (SDQP) score, ≥17 - indicating emotional or behavioral concerns (9.32% of children exposed to sodium valproate monotherapy had an abnormal score; aRR: 2.11; 1.23-3.63; lamotrigine 8.05%; aRR: 2.21; 1.21-4.02). Prenatal exposure to carbamazepine monotherapy (n = 201) was not associated with an increased risk of having an abnormal total SDQP score but was associated with increased risks in the individual domains of the SDQP. Prenatal exposure to AED polytherapy (n = 57) was associated with the highest risk of abnormal SDQP scores (17.54% of children exposed to polytherapy had abnormal scores; aRR: 2.75; 1.25-6.02). Prenatal exposure to sodium valproate and lamotrigine is associated with an increased risk of concerns about emotional and behavioral development being reported by parents in a neurodevelopmental screening program. Additional investigation is required into why significant differences between AEDs were not seen in this study.
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Affiliation(s)
- Noni Richards
- School of Pharmacy, University of Otago, Dunedin, New Zealand.
| | - David Reith
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Michael Stitely
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Alesha Smith
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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16
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Cohen MJ, Meador KJ, May R, Loblein H, Conrad T, Baker GA, Bromley RL, Clayton-Smith J, Kalayjian LA, Kanner A, Liporace JD, Pennell PB, Privitera M, Loring DW. Fetal antiepileptic drug exposure and learning and memory functioning at 6 years of age: The NEAD prospective observational study. Epilepsy Behav 2019; 92:154-164. [PMID: 30660966 DOI: 10.1016/j.yebeh.2018.12.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/29/2018] [Accepted: 12/30/2018] [Indexed: 10/27/2022]
Abstract
The Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) Study was a prospective observational multicenter study in the USA and UK, which enrolled pregnant women with epilepsy on antiepileptic drug (AED) monotherapy from 1999 to 2004. The study aimed to determine if differential long-term neurodevelopmental effects exist across four commonly used AEDs (carbamazepine, lamotrigine, phenytoin, and valproate). In this report, we examine fetal AED exposure effects on learning and memory functions in 221 six-year-old children (including four sets of twins) whose mothers took one of these AEDs during pregnancy. Their performance was compared with that of a national sample of normally developing six year olds from the standardization sample of the Children's Memory Scale (CMS). The major results of this study indicate that the mean performance levels of children exposed to valproate were significantly below that of the children in the normal comparison group across all seven of the CMS Indexes. With one exception, this finding held up at the subtest level as well. These findings taken together with nonsignificant verbal and nonverbal forgetting scores appear to indicate that, as a group, children exposed to valproate experienced significant difficulty in their ability to process, encode, and learn both auditory/verbal as well as visual/nonverbal material. In addition, they exhibited significant difficulty holding and manipulating information in immediate auditory working memory. However, once the information was learned and stored, the valproate-exposed children appeared to be able to retrieve the information they did learn at normal levels. Finally, the processing, working memory, and learning deficits demonstrated by the valproate-exposed children are dose-related. In contrast to valproate, the findings pertaining to the children exposed to carbamazepine, lamotrigine, and phenytoin in monotherapy are less clear. Therefore, further research will be required to delineate the potential risks to learning and memory functions in children exposed to carbamazepine, lamotrigine, and phenytoin in monotherapy during pregnancy. Additional research employing larger prospective studies will be required to confirm the long-term cognitive and behavioral risks to children of mothers who are prescribed these four AEDs during pregnancy as well as to delineate any potential risks of newer AEDs and to understand the underlying mechanisms of adverse AED effects on the immature brain.
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Affiliation(s)
- Morris J Cohen
- Pediatric Neuropsychology International, Augusta, GA, United States of America.
| | - Kimford J Meador
- Neurology & Neurological Sciences, Stanford University, Stanford, CA, United States of America
| | - Ryan May
- EMMES Corp., Rockville, MD, United States of America
| | | | - Thomas Conrad
- EMMES Corp., Rockville, MD, United States of America
| | - Gus A Baker
- Neurological Science, University of Liverpool, Merseyside, UK
| | - Rebecca L Bromley
- Manchester University Hospitals NHS Trust, Manchester, UK; Division of Evolution and Genomic Science, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jill Clayton-Smith
- Manchester University Hospitals NHS Trust, Manchester, UK; Division of Evolution and Genomic Science, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Laura A Kalayjian
- University of Southern California, Los Angeles, CA, United States of America
| | - Andres Kanner
- Neurology, University of Miami, Miami, FL, United States of America
| | - Joyce D Liporace
- Great Valley Neurological Associates, Paoli, PA, United States of America
| | - Page B Pennell
- Neurology, Harvard University, Boston, MA, United States of America
| | - Michael Privitera
- Neurology, University of Cincinnati, Cincinnati, OH, United States of America
| | - David W Loring
- Neurology, Emory University, Atlanta, GA, United States of America
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17
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Bech LF, Polcwiartek C, Kragholm K, Andersen MP, Rohde C, Torp-Pedersen C, Nielsen J, Hagstrøm S. In utero exposure to antiepileptic drugs is associated with learning disabilities among offspring. J Neurol Neurosurg Psychiatry 2018; 89:1324-1331. [PMID: 30076271 DOI: 10.1136/jnnp-2018-318386] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/21/2018] [Accepted: 07/12/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES In utero exposure to antiepileptic drugs has previously been associated with adverse outcome among offspring, but evidence on longer term milestone development remains limited. We investigated the association between in utero exposure to antiepileptic drugs and learning disabilities in the first year of compulsory education among offspring and assessed which antiepileptic drugs carried the highest risk. METHODS This population-based case-cohort study used Danish nationwide register data from 2005 to 2008. Cases were offspring exposed to antiepileptic drugs in utero, and controls were unexposed offspring of mothers previously redeeming antiepileptic drug prescriptions. Offspring were followed from birth until the first year of compulsory education from 2011 to 2015. Learning disabilities were defined as mental retardation, specific developmental disorders, autism spectrum disorders, emotional/behavioural disorders or having special educational needs. Logistic regression was used to compute ORs with 95% CIs adjusted for potential confounding. RESULTS Of 117 475 incident singleton births, 636 cases and 434 controls were included (median age: 6.1 years, males: 55.7%). Learning disabilities were identified among 7.1% cases compared with 3.7% for controls. During any trimester, the adjusted OR of the association between in utero exposure to antiepileptic drugs and learning disabilities was 2.20 (95% CI 1.16 to 4.17). Among cases not exposed to polytherapy (n=556), in utero exposure to lamotrigine compared with another antiepileptic drug was associated with the lowest adjusted risk (OR 0.42, 95% CI 0.19 to 0.92), and valproate carried a higher risk (OR 4.67, 95% CI 1.73 to 12.59). CONCLUSION In utero exposure to antiepileptic drugs was significantly associated with learning disabilities among offspring. Lamotrigine should preferentially be considered over, for example, valproate if clinically feasible.
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Affiliation(s)
| | - Christoffer Polcwiartek
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kristian Kragholm
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Christopher Rohde
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jimmi Nielsen
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Hagstrøm
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Bromley RL, Baker GA, Clayton-Smith J, Wood AG. Intellectual functioning in clinically confirmed fetal valproate syndrome. Neurotoxicol Teratol 2018; 71:16-21. [PMID: 30453023 DOI: 10.1016/j.ntt.2018.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 10/17/2018] [Accepted: 11/15/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND An increased risk of impaired intelligence (IQ) has been documented in valproate-exposed children, but investigations have not previously focused on those with a clinical diagnosis of Fetal Valproate Syndrome (FVS). METHODS This cross sectional observational study recruited individuals with a diagnosis of FVS and completed standardized assessments of intellectual abilities making comparisons to a normative comparison group. Both mean difference (MD) and prevalence of scores below the lower average range were analyzed. RESULTS The mean full-scale IQ in 31 individuals with FVS (mean age 14.97; range 6-27 years) was 19 points lower (19.55, 95% CI -24.94 to 14.15), and IQ scores <70 were present in 26%. The mean differences for verbal comprehension (21.07, 95% CI -25.84 to -16.29), working memory (19.77, 95% CI -25.00 to -14.55) and processing speed (16.87, 95% CI -22.24 to -11.50) performances were poorer than expected with the mean differences over one standard deviation from the comparison group. Sixty one percent of cases demonstrated disproportionately lower verbal comprehension ability. There were no significant group differences for IQ in high vs. moderate dose valproate or mono vs. polytherapy. There were no differences in IQ between those with and those without a major congenital malformation. The requirement for educational intervention was high at 74%. CONCLUSION Intellectual difficulties are a central feature of FVS and are more severe in their presentation in individuals with a diagnosis of valproate embryopathy. Individuals with FVS who present with the characteristic facial presentation should be considered at high risk of cognitive difficulties regardless of the dose of valproate exposure or the presence of a major congenital malformation.
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Affiliation(s)
- Rebecca L Bromley
- Division of Evolution and Genomic Science, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Gus A Baker
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Jill Clayton-Smith
- Division of Evolution and Genomic Science, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Amanda G Wood
- School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham B4 7ET, UK; Clinical Sciences, Murdoch Children's Research Institute, Flemington Road, Parkville, Victoria 3052, Australia
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19
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Reduced brain volumes in children of women with epilepsy: A neuropsychological and voxel based morphometric analysis in pre-adolescent children. J Neuroradiol 2018; 45:380-385. [DOI: 10.1016/j.neurad.2018.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 12/20/2017] [Accepted: 02/03/2018] [Indexed: 01/18/2023]
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20
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Bansal R, Jain G, Kharbanda P, Goyal M, Suri V. Maternal and neonatal complications during pregnancy in women with epilepsy. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.ijep.2016.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractEpilepsy is the commonest serious neurological problem faced by obstetricians and gynaecologists. Epidemiological studies estimate epilepsy to complicate 0.3–0.7% of all pregnancies.1 2 The importance of epilepsy in pregnancy lies in the fact that many women with epilepsy (WWE) have to go through their pregnancy while taking antiepileptic (AED) drugs. Both the seizures and AEDs can have harmful effects on the mother as well the foetus. Thus, during pregnancy, the clinician faces dual challenge of controlling seizures as well as preventing teratogenicity of AEDs.1 In this review we discuss the possible impact of seizures as well as AEDs on mother as well as the child. We try to answer some of the commonest questions which are relevant to successful management of pregnancy and ensuring birth of a healthy baby.
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Affiliation(s)
- R. Bansal
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - G. Jain
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - P. Kharbanda
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - M. Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - V. Suri
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
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Bolin K, Berggren F, Berling P, Morberg S, Gauffin H, Landtblom AM. Patterns of antiepileptic drug prescription in Sweden: A register-based approach. Acta Neurol Scand 2017; 136:521-527. [PMID: 28585316 DOI: 10.1111/ane.12776] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine drug utilization pathways from the incident healthcare visit due to epilepsy and three years onward. MATERIAL AND METHODS Anti-epileptic drug utilization was calculated using individual information on inpatient- and outpatient care utilization and drug sales. Throughout, we used national register information pertaining to pharmaceutical sales linked to diagnosis-related healthcare utilization. Information on pharmaceutical sales was collected for the 2007-2013 period. RESULTS For the entire studied period, a majority of new patients with epilepsy were initiated on anti-epileptic drug treatment with a monotherapy (98%); most of these patients remained on that first treatment (64%). The three most frequently prescribed drugs accounted for 72% of the initiated AED treatments. Patients with epilepsy (ICD-10: G40/41) were most commonly prescribed carbamazepine, lamotrigine and valproate. The most common second-line monotherapy was levetiracetam. About 12% of new patients with epilepsy who were initiated on AED treatment during the period eventually switched to an add-on therapy. The proportion of patients who were initiated on treatment with carbamazepine or valproate decreased, and the proportion of patients who remained on their initial monotherapy increased between 2007 and 2013. CONCLUSIONS A limited number of anti-epileptic drugs accounted for the treatment of a majority of new patients with epilepsy (carbamazepine, lamotrigine and valproate accounted for more than 70%). Add-on therapies showed the same pattern, as the most frequently prescribed add-on regimens were the same ones that accounted for most of the monotherapies. There was a tendency towards fewer patients being initiated on AED treatment with either carbamazepine or valproate.
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Affiliation(s)
- K. Bolin
- Department of Economics; University of Gothenburg; Gothenburg Sweden
- Centre for Health Economics; University of Gothenburg; Gothenburg Sweden
| | | | | | | | - H. Gauffin
- Department of Neurology; Department of Clinical and Experimental Medicine; Linköping University; Linköping Sweden
| | - A.-M. Landtblom
- Department of Neurology; Department of Clinical and Experimental Medicine; Linköping University; Linköping Sweden
- Department of Neuroscience/Neurology; University of Uppsala; Uppsala Sweden
- Department of Medical Specialist; Department of Clinical and Experimental Medicine; Linköping University; Motala Sweden
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Additional considerations are required when preparing a protocol for a systematic review with multiple interventions. J Clin Epidemiol 2017; 83:65-74. [PMID: 28088593 DOI: 10.1016/j.jclinepi.2016.11.015] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 11/21/2016] [Accepted: 11/30/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The number of systematic reviews that aim to compare multiple interventions using network meta-analysis is increasing. In this study, we highlight aspects of a standard systematic review protocol that may need modification when multiple interventions are to be compared. STUDY DESIGN AND SETTING We take the protocol format suggested by Cochrane for a standard systematic review as our reference and compare the considerations for a pairwise review with those required for a valid comparison of multiple interventions. We suggest new sections for protocols of systematic reviews including network meta-analyses with a focus on how to evaluate their assumptions. We provide example text from published protocols to exemplify the considerations. CONCLUSION Standard systematic review protocols for pairwise meta-analyses need extensions to accommodate the increased complexity of network meta-analysis. Our suggested modifications are widely applicable to both Cochrane and non-Cochrane systematic reviews involving network meta-analyses.
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Bromley RL, Baker GA. Fetal antiepileptic drug exposure and cognitive outcomes. Seizure 2017; 44:225-231. [DOI: 10.1016/j.seizure.2016.10.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022] Open
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Gerard EE, Meador KJ. An Update on Maternal Use of Antiepileptic Medications in Pregnancy and Neurodevelopment Outcomes. J Pediatr Genet 2016; 4:94-110. [PMID: 27617120 DOI: 10.1055/s-0035-1556741] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Antiepileptic drugs (AEDs) are prescribed commonly to women of childbearing age. In utero exposure to some AEDs can have significant cognitive and behavioral consequences for the unborn child. Recently, prospective studies of women taking AEDs during pregnancy have added significantly to our understanding of cognitive and behavioral teratogenic risks posed by fetal AED exposure. Valproate is clearly associated with impaired cognitive development as well as an increased risk of disorders such as autism and autism spectrum disorder. Exposure to carbamazepine, lamotrigine, levetiracetam, or phenytoin monotherapy is associated with more favorable cognitive and behavioral outcomes than valproate, but more data are required to clarify if these AEDs have more subtle effects on cognition and behavior. There are insufficient data on the developmental effects of other AEDs in humans. Further, the underlying mechanisms of cognitive teratogenesis are poorly understood, including the genetic factors that affect susceptibility to AEDs.
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Affiliation(s)
- Elizabeth E Gerard
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, United States
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Bromley R. The treatment of epilepsy in pregnancy: The neurodevelopmental risks associated with exposure to antiepileptic drugs. Reprod Toxicol 2016; 64:203-10. [PMID: 27312074 DOI: 10.1016/j.reprotox.2016.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/12/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022]
Abstract
A number of antiepileptic drugs (AEDs) have been confirmed as teratogens due to their association with an increased malformation rate. The majority of research to date does not find an association between prenatal exposure to monotherapy carbamazepine, lamotrigine or phenytoin and neurodevelopmental outcome in comparison to control children and noted higher abilities in comparison to children exposed to valproate; but further work is needed before conclusions can be drawn. Data for levetiracetam was limited to one study, as was the evidence for topiramate. Sodium valproate exposure appeared to carry a dose dependent risk to the developing brain, with evidence of reduced levels of IQ, poorer verbal abilities and increased rate of autistic spectrum disorder both in comparison to control children and children exposed to other AEDs. The severity of the neurodevelopmental deficits associated with prenatal exposure to valproate highlight the critical need to consider neurodevelopmental outcomes as a central aspect of teratological research.
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Affiliation(s)
- R Bromley
- Institute of Human Development, Faculty of Medical & Human Sciences, University of Manchester, United Kingdom; Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, United Kingdom.
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Soysal H, Doğan Z, Kamışlı Ö. Effects of phenytoin and lamotrigine treatment on serum BDNF levels in offsprings of epileptic rats. Neuropeptides 2016; 56:1-8. [PMID: 26706181 DOI: 10.1016/j.npep.2015.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 12/01/2015] [Accepted: 12/06/2015] [Indexed: 12/01/2022]
Abstract
The role of brain-derived neurotrophic factor (BDNF) is to promote and modulate neuronal responses across neurotransmitter systems in the brain. Therefore, abnormal BDNF signaling may be associated with the pathophysiology of schizophrenia. Low BDNF levels have been reported in brains and serums of patients with psychotic disorders. In the present study, we investigated the effects of antiepileptic drugs on BDNF in developing rats. Pregnant rats were treated with phenytoin (PHT), lamotrigine (LTG) and folic acid for long-term, all through their gestational periods. Experimental epilepsy (EE) model was applied in pregnant rats. Epileptic seizures were determined with electroencephalography. After birth, serum BDNF levels were measured in 136 newborn rats on postnatal day (PND) 21 and postnatal day 38. In postnatal day 21, serum BDNF levels of experimental epilepsy group were significantly lower compared with PHT group. This decrease is statistically significant. Serum BDNF levels increased in the group LTG. This increase compared with LTG+EE group was statistically significant. In the folic acid (FA) group, levels of serum BDNF decreased statistically significantly compared to the PHT group. On postnatal day 38, no significant differences were found among the groups for serum BDNF levels. We concluded that, the passed seizures during pregnancy adversely affect fetal brain development, lowering of serum BDNF levels. PHT use during pregnancy prevents seizure-induced injury by increasing the levels of BDNF. About the increase level of BDNF, LTG is much less effective than PHT, the positive effect of folic acid on serum BDNF levels was not observed. LTG increase in BDNF is much less effective than PHT, folic acid did not show a positive effect on serum BDNF levels. Epilepsy affects fetal brain development during gestation in pregnant rats, therefore anti-epileptic therapy should be continued during pregnancy.
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Affiliation(s)
- Handan Soysal
- Faculty of Medicine, Department of Anatomy, Başkent University, Ankara, Turkey.
| | - Zümrüt Doğan
- Faculty of Medicine, Department of Anatomy, Adıyaman University, Adıyaman, Turkey
| | - Özden Kamışlı
- Faculty of Medicine, Department of Nörology, Inönü University, Malatya, Turkey
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Deshmukh U, Adams J, Macklin EA, Dhillon R, McCarthy KD, Dworetzky B, Klein A, Holmes LB. Behavioral outcomes in children exposed prenatally to lamotrigine, valproate, or carbamazepine. Neurotoxicol Teratol 2016; 54:5-14. [PMID: 26791321 DOI: 10.1016/j.ntt.2016.01.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 01/02/2016] [Accepted: 01/04/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate adaptive behavior outcomes of children prenatally exposed to lamotrigine, valproate, or carbamazepine, and to determine if these outcomes were dose-dependent. METHODS Data were collected from women enrolled in the North American Anti epileptic Drug (AED) Pregnancy Registry who had taken lamotrigine, valproate, or carbamazepine monotherapies throughout pregnancy to suppress seizures. The adaptive behavior of 252 exposed children (including 104 lamotrigine-exposed, 97 carbamazepine-exposed, and 51 valproate-exposed), ages 3- to 6-years-old, was measured using the Vineland-II Adaptive Behavior Scales, administered to each mother by telephone. Mean Adaptive Behavior Composite (ABC), domain standard scores for communication, daily living, socialization and motor skills, and adaptive levels were analyzed and correlated with first trimester drug dose. RESULTS After adjusting for maternal age, education, folate use, cigarette and alcohol exposure, gestational age, and birth weight by propensity score analysis, the mean ABC score for valproate-exposed children was 95.6 (95% CI [91, 101]), versus 100.8 (95% CI [98, 103]) and 103.5 (95% CI [101, 106]) for carbamazepine- and lamotrigine-exposed children, respectively (ANOVA; p=0.017). Significant differences were observed among the three drug groups in the ABC (p=0.017), socialization (p=0.026), and motor (p=0.018) domains, with a trend toward significance in the communication domain (p=0.053). Valproate-exposed children scored lowest and lamotrigine-exposed children scored highest in every category. Valproate-exposed children were most likely to perform at a low or moderately low adaptive level in each category. Higher valproate dose was associated with significantly lower ABC (p=0.020), socialization (p=0.009), and motor (p=0.041) scores before adjusting for confounders. After adjusting for the above variables, increasing VPA dose was associated with decreasing Vineland scores in all domains, but the relationships were not statistically significant. No dose effect was observed for carbamazepine or lamotrigine. CONCLUSIONS Unlike carbamazepine and lamotrigine, prenatal valproate exposure was associated with adaptive behavior impairments with specific deficits in socialization and motor function, along with a relative weakness in communication. Increasing valproate dose was associated with a decline in adaptive functioning. This finding of a linear dose-dependent teratogenic effect suggests that valproate should be avoided at any dose during pregnancy. However, some women with epilepsy controlled only by valproate will decide, in consultation with their provider, that the benefits of continuing valproate during pregnancy outweigh the fetal risks. Faced with difficult choices, clinicians should be supportive as these patients consider their options.
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Affiliation(s)
- Uma Deshmukh
- MassGeneral Hospital for Children, United States; Yale University School of Medicine, United States.
| | - Jane Adams
- University of Massachusetts, Boston, United States
| | - Eric A Macklin
- Harvard Medical School, United States; Massachusetts General Hospital Biostatistics Center, United States
| | - Ruby Dhillon
- MassGeneral Hospital for Children, United States
| | | | - Barbara Dworetzky
- Harvard Medical School, United States; Brigham and Women's Hospital, United States
| | - Autumn Klein
- Harvard Medical School, United States; Brigham and Women's Hospital, United States
| | - Lewis B Holmes
- MassGeneral Hospital for Children, United States; University of Massachusetts, Boston, United States; Brigham and Women's Hospital, United States
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Abstract
Many studies investigating cognitive outcomes in children of women with epilepsy report an increased risk of mental impairment. Verbal scores on neuropsychometric measures may be selectively more involved. While a variety of factors contribute to the cognitive problems of children of women with epilepsy, antiepileptic drugs (AEDs) appear to play a major role. The mechanisms by which AEDs affect neurodevelopmental outcomes remain poorly defined. Animal models suggest that AED-induced apoptosis, altered neurotransmitter environment, and impaired synaptogenesis are some of the mechanisms responsible for cognitive and behavioral teratogenesis. AEDs that are known to induce apoptosis, such as valproate, appear to affect children's neurodevelopment in a more severe fashion. Fetal valproate exposure has dose-dependent associations with reduced cognitive abilities across a range of domains, and these appear to persist at least until the age of 6. Some studies have shown neurodevelopmental deficiencies associated with the use of phenobarbital and possibly phenytoin. So far, most of the investigations available suggest that fetal exposures to lamotrigine or levetiracetam are safer with regard to cognition when compared with other AEDs. Studies on carbamazepine show contradictory results, but most information available suggests that major poor cognitive outcomes should not be attributed to this medication. Overall, children exposed to polytherapy prenatally appear to have worse cognitive and behavioral outcomes compared with children exposed to monotherapy, and with the unexposed. There is an increase risk of neurodevelopmental deficits when polytherapy involves the use of valproate versus other agents.
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Affiliation(s)
- Naymee J Velez-Ruiz
- Department of Neurology, Emory University, 1365 Clifton Rd., Clinic A, 2nd Fl., Atlanta, GA, 30322, USA,
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Bhakta J, Bainbridge J, Borgelt L. Teratogenic medications and concurrent contraceptive use in women of childbearing ability with epilepsy. Epilepsy Behav 2015; 52:212-7. [PMID: 26460786 DOI: 10.1016/j.yebeh.2015.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 07/07/2015] [Accepted: 08/04/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many antiepileptic drugs (AEDs) have the potential to cause teratogenicity. We evaluated eight antiepileptic drugs (AEDs) classified as Federal Drug Administration (FDA) pregnancy category D, X, or N designations and having documented teratogenic effects. These include carbamazepine, ethosuximide, fosphenytoin, phenobarbital, phenytoin, primidone, topiramate, and valproate. Women with epilepsy (WWE) may need one or more of these AEDs for seizure control but may be unaware of the potential teratogenicity associated with their use. In utero exposure to AEDs increases the risks for both congenital malformations and other teratogenic defects. Given that approximately 50% of pregnancies are unintended, it is likely that women with epilepsy taking these medications could unknowingly put a growing fetus at risk. For women using contraception while taking these medications, many choose combined hormonal contraceptives (CHCs). Drug-drug interactions exist between AEDs and CHCs that may decrease contraceptive efficacy. The aim of this study was to evaluate prescribing patterns for potentially teratogenic AEDs and contraceptive use in WWE of childbearing ability, including those with potential drug-drug interactions. This study also determined the number of WWE of childbearing ability prescribed potentially teratogenic AEDs and documentation of a pregnancy or contraception plan. METHODS This was a retrospective, observational study of WWE age 15-44 years, of childbearing ability, prescribed an AED from July 1, 2011 to June 30, 2012, and who had an appointment at the University of Colorado Hospital Outpatient Neurology Clinic (Anschutz Medical Campus). RESULTS One hundred fifteen women with an average age of 30.7 years and various types of seizures were evaluated. The majority of patients were prescribed topiramate (34/115, 30%) or carbamazepine (27/115, 23%). Of the women, 30/115 (26%) had a documented contraception method when taking a potentially teratogenic AED. Of these women prescribed contraception, most (18/30, 60%) used an oral combined hormonal contraceptive or progestin-only pill, a majority of which had a potential for a drug-drug interaction with their AEDs (16/18, 89%). Less than 7% of women received counseling on a contraception plan, and 18% of subjects received counseling on a pregnancy plan. CONCLUSIONS Most WWE of childbearing ability taking potentially teratogenic AEDs were not using contraception. Those using contraception frequently had a method that has a significant drug-drug interaction which reduces the effectiveness of contraception. Women with epilepsy of childbearing ability prescribed an AED should be using effective contraception or participating in active discussions about pregnancy planning to avoid unplanned pregnancies and possible teratogenic effects of these AEDs. Documentation about pregnancy planning or contraceptive use in WWE of childbearing ability is minimal and should be discussed at least annually. It is critical for providers to discuss with WWE of childbearing ability the benefits and risks of various AED treatments; the need to select appropriate, effective contraception when pregnancy is not desired; and the importance of counseling regarding contraceptive or pregnancy planning.
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Affiliation(s)
- Janki Bhakta
- University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora, CO, USA
| | - Jacquelyn Bainbridge
- University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora, CO, USA
| | - Laura Borgelt
- University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora, CO, USA.
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Gopinath N, Muneer AK, Unnikrishnan S, Varma RP, Thomas SV. Children (10-12 years age) of women with epilepsy have lower intelligence, attention and memory: Observations from a prospective cohort case control study. Epilepsy Res 2015; 117:58-62. [PMID: 26418668 DOI: 10.1016/j.eplepsyres.2015.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 06/30/2015] [Accepted: 09/07/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the cognitive outcome of children of women with epilepsy (CWE) with matched controls (CWO). METHODS CWE (10-12 years) under follow up in Kerala Registry of Epilepsy and Pregnancy (n=190) were evaluated with WISC-IV, Trail Making Test (TMT), Rey Auditory Verbal Learning Test (RAVLT) and compared with age and sex matched children of women without epilepsy - CWO (n=149) drawn from schools in the same region. The dosage was expressed as prescribed daily dose/daily-defined dose (PDD/DDD) ratio in order to make comparisons. RESULTS The Full Scale IQ of CWE (77.9 ± 14.6) was 8.5 points lower than that of CWO (86.4 ± 13.4), which was statistically significant (p=0.001). They performed lower on TMT Part A & B and RAVLT. The FSIQ mean ± SD; PDD/DDD ratio and number of monotherapy exposure for different anti-epileptic drugs were phenobarbital: (74.5 ± 14; 1.1 ± 0.8; 22), valproate: (82.8 ± 12.4; 0.3 ± 0.1; 36), carbamazepine: (82.2 ± 13.9; 0.6 ± 0.3; 41), phenytoin: (82.6 ± 13.5; 0.8±0.3; 11). The FSIQ for those exposed to phenobarbital was significantly (p=0.01) lower than others. The significant predictors of FSIQ differed at lower and higher ends of its spectrum. These predictors were low body mass index and low maternal education for FSIQ<80 and low maternal education, low maternal IQ and high anti-epileptic drug dosage for FSIQ<86. High anti-epileptic drug dosage, low maternal IQ, and low paternal education were the predictors for FSIQ<92. SIGNIFICANCE The IQ, attention and memory were significantly lower for 10-12 year old CWE when compared to CWO. The important predictors of low FSIQ were antiepileptic drug dosage, maternal IQ, and parental education.
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Affiliation(s)
- Neelima Gopinath
- Kerala Registry of Epilepsy and Pregnancy, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India.
| | - Anila K Muneer
- Kerala Registry of Epilepsy and Pregnancy, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India.
| | - Syam Unnikrishnan
- Kerala Registry of Epilepsy and Pregnancy, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India.
| | - Ravi Prasad Varma
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India.
| | - Sanjeev V Thomas
- Kerala Registry of Epilepsy and Pregnancy, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India.
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Does in utero exposure of antiepileptic drugs lead to failure to reach full cognitive potential? Seizure 2015; 28:51-6. [DOI: 10.1016/j.seizure.2015.01.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 01/22/2015] [Indexed: 02/07/2023] Open
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Cross JH. Epilepsy (generalised seizures). BMJ CLINICAL EVIDENCE 2015; 2015:1201. [PMID: 25882687 PMCID: PMC4400652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION About 3% of people will be diagnosed with epilepsy during their lifetime, but about 70% of people with epilepsy eventually go into remission. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What are the effects of additional treatments in people with drug-resistant epilepsy characterised by generalised seizures? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found four studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety on the addition of the following interventions: lacosamide, lamotrigine, levetiracetam, perampanel, and zonisamide versus the addition of placebo.
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Affiliation(s)
- J Helen Cross
- UCL-Institute of Child Health, Great Ormond Street Hospital for Children & National Centre for Young People with Epilepsy, London, UK
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Putta S, Pennell PB. Management of epilepsy during pregnancy: evidence-based strategies. FUTURE NEUROLOGY 2015; 10:161-176. [PMID: 30774557 DOI: 10.2217/fnl.15.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Child-bearing years are often the most precarious management period in the life of a woman with epilepsy. This article reviews the results of many different studies with findings that enable the healthcare team to make confident decisions and recommendations during these critical periods. Preconceptional planning, effective contraception and folic acid supplementation are important fundamentals in preparation for pregnancy. There is growing evidence to avoid valproic acid use during the child-bearing years. Emerging data on congenital malformations and neurocognitive outcomes are available for some of the second-generation antiepileptic drugs and appear reassuring for lamotrigine and levetiracetam. Also reviewed are the benefits of postpartum drug tapers and favorable breastfeeding facts. Counseling the mother and her family on medication choices enables the healthcare team to implement informed decisions that are beneficial for the mother and child.
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Affiliation(s)
- Swapna Putta
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Page B Pennell
- Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Division of Women's Health, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Baker GA, Bromley RL, Briggs M, Cheyne CP, Cohen MJ, García-Fiñana M, Gummery A, Kneen R, Loring DW, Mawer G, Meador KJ, Shallcross R, Clayton-Smith J. IQ at 6 years after in utero exposure to antiepileptic drugs: a controlled cohort study. Neurology 2014; 84:382-90. [PMID: 25540307 DOI: 10.1212/wnl.0000000000001182] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To delineate the risk to child IQ associated with frequently prescribed antiepileptic drugs. METHODS Children born to women with epilepsy (n = 243) and women without epilepsy (n = 287) were recruited during pregnancy and followed prospectively. Of these, 408 were blindly assessed at 6 years of age. Maternal and child demographics were collected and entered into statistical models. RESULTS The adjusted mean IQ was 9.7 points lower (95% confidence interval [CI] -4.9 to -14.6; p < 0.001) for children exposed to high-dose (>800 mg daily) valproate, with a similar significant effect observed for the verbal, nonverbal, and spatial subscales. Children exposed to high-dose valproate had an 8-fold increased need of educational intervention relative to control children (adjusted relative risk, 95% CI 8.0, 2.5-19.7; p < 0.001). Valproate at doses <800 mg daily was not associated with reduced IQ, but was associated with impaired verbal abilities (-5.6, 95% CI -11.1 to -0.1; p = 0.04) and a 6-fold increase in educational intervention (95% CI 1.4-18.0; p = 0.01). In utero exposure to carbamazepine or lamotrigine did not have a significant effect on IQ, but carbamazepine was associated with reduced verbal abilities (-4.2, 95% CI -0.6 to -7.8; p = 0.02) and increased frequency of IQ <85. CONCLUSIONS Consistent with data from younger cohorts, school-aged children exposed to valproate at maternal doses more than 800 mg daily continue to experience significantly poorer cognitive development than control children or children exposed to lamotrigine and carbamazepine.
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Affiliation(s)
- Gus A Baker
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Rebecca L Bromley
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA.
| | - Maria Briggs
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Christopher P Cheyne
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Morris J Cohen
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Marta García-Fiñana
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Alison Gummery
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Rachel Kneen
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - David W Loring
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - George Mawer
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Kimford J Meador
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Rebekah Shallcross
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
| | - Jill Clayton-Smith
- From the Departments of Molecular and Clinical Pharmacology (G.A.B.), Biostatistics (C.P.C., M.G.-F.), and Clinical Psychology (R.S.), Institute of Infection and Global Health (M.J.C., A.G.), and Alder Hey Children's Hospital & Institute of Infection & Global Health (R.K.), University of Liverpool; Institute of Human Development (R.L.B., J.C.-S.), University of Manchester; Manchester Academic Health Sciences Centre (R.L.B., M.B., G.M., J.C.-S.), Central Manchester University Hospitals Foundation Trust, UK; Department of Neurology (M.J.C.), Georgia Regents University, Augusta; Department of Neurology & Pediatrics (D.W.L.), Emory University, Atlanta, GA; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University, CA
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Epstein RA, Moore KM, Bobo WV. Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 7:7-29. [PMID: 25565896 PMCID: PMC4284049 DOI: 10.2147/dhps.s50556] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Treating pregnant women with bipolar disorder is among the most challenging clinical endeavors. Patients and clinicians are faced with difficult choices at every turn, and no approach is without risk. Stopping effective pharmacotherapy during pregnancy exposes the patient and her baby to potential harms related to bipolar relapses and residual mood symptom-related dysfunction. Continuing effective pharmacotherapy during pregnancy may prevent these occurrences for many; however, some of the most effective pharmacotherapies (such as valproate) have been associated with the occurrence of congenital malformations or other adverse neonatal effects in offspring. Very little is known about the reproductive safety profile and clinical effectiveness of atypical antipsychotic drugs when used to treat bipolar disorder during pregnancy. In this paper, we provide a clinically focused review of the available information on potential maternal and fetal risks of untreated or undertreated maternal bipolar disorder during pregnancy, the effectiveness of interventions for bipolar disorder management during pregnancy, and potential obstetric, fetal, and neonatal risks associated with core foundational pharmacotherapies for bipolar disorder.
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Affiliation(s)
- Richard A Epstein
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Katherine M Moore
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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Bromley R, Weston J, Adab N, Greenhalgh J, Sanniti A, McKay AJ, Tudur Smith C, Marson AG. Treatment for epilepsy in pregnancy: neurodevelopmental outcomes in the child. Cochrane Database Syst Rev 2014; 2014:CD010236. [PMID: 25354543 PMCID: PMC7390020 DOI: 10.1002/14651858.cd010236.pub2] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Accumulating evidence suggests an association between prenatal exposure to antiepileptic drugs (AEDs) and increased risk of both physical anomalies and neurodevelopmental impairment. Neurodevelopmental impairment is characterised by either a specific deficit or a constellation of deficits across cognitive, motor and social skills and can be transient or continuous into adulthood. It is of paramount importance that these potential risks are identified, minimised and communicated clearly to women with epilepsy. OBJECTIVES To assess the effects of prenatal exposure to commonly prescribed AEDs on neurodevelopmental outcomes in the child and to assess the methodological quality of the evidence. SEARCH METHODS We searched the Cochrane Epilepsy Group Specialized Register (May 2014), Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2014, Issue 4), MEDLINE (via Ovid) (1946 to May 2014), EMBASE (May 2014), Pharmline (May 2014) and Reprotox (May 2014). No language restrictions were imposed. Conference abstracts from the last five years were reviewed along with reference lists from the included studies. SELECTION CRITERIA Prospective cohort controlled studies, cohort studies set within pregnancy registers and randomised controlled trials were selected for inclusion. Participants were women with epilepsy taking AED treatment; the two control groups were women without epilepsy and women with epilepsy who were not taking AEDs during pregnancy. DATA COLLECTION AND ANALYSIS Three authors (RB, JW and JG) independently selected studies for inclusion. Data extraction and risk of bias assessments were completed by five authors (RB, JW, AS, NA, AJM). The primary outcome was global cognitive functioning. Secondary outcomes included deficits in specific cognitive domains or prevalence of neurodevelopmental disorders. Due to substantial variation in study design and outcome reporting only limited data synthesis was possible. MAIN RESULTS Twenty-two prospective cohort studies were included and six registry based studies. Study quality varied. More recent studies tended to be larger and to report individual AED outcomes from blinded assessments, which indicate improved methodological quality.The developmental quotient (DQ) was lower in children exposed to carbamazepine (CBZ) (n = 50) than in children born to women without epilepsy (n = 79); mean difference (MD) of -5.58 (95% confidence interval (CI) -10.83 to -0.34, P = 0.04). The DQ of children exposed to CBZ (n = 163) was also lower compared to children of women with untreated epilepsy (n = 58) (MD -7.22, 95% CI -12.76 to - 1.67, P = 0.01). Further analysis using a random-effects model indicated that these results were due to variability within the studies and that there was no significant association with CBZ. The intelligence quotient (IQ) of older children exposed to CBZ (n = 150) was not lower than that of children born to women without epilepsy (n = 552) (MD -0.03, 95% CI -3.08 to 3.01, P = 0.98). Similarly, children exposed to CBZ (n = 163) were not poorer in terms of IQ in comparison to the children of women with untreated epilepsy (n = 87) (MD 1.84, 95% CI -2.13 to 5.80, P = 0.36). The DQ in children exposed to sodium valproate (VPA) (n = 123) was lower than the DQ in children of women with untreated epilepsy (n = 58) (MD -8.72, 95% -14.31 to -3.14, P = 0.002). The IQ of children exposed to VPA (n = 76) was lower than for children born to women without epilepsy (n = 552) (MD -8.94, 95% CI -11.96 to -5.92, P < 0.00001). Children exposed to VPA (n = 89) also had lower IQ than children born to women with untreated epilepsy (n = 87) (MD -8.17, 95% CI -12.80 to -3.55, P = 0.0005).In terms of drug comparisons, in younger children there was no significant difference in the DQ of children exposed to CBZ (n = 210) versus VPA (n=160) (MD 4.16, 95% CI -0.21 to 8.54, P = 0.06). However, the IQ of children exposed to VPA (n = 112) was significantly lower than for those exposed to CBZ (n = 191) (MD 8.69, 95% CI 5.51 to 11.87, P < 0.00001). The IQ of children exposed to CBZ (n = 78) versus lamotrigine (LTG) (n = 84) was not significantly different (MD -1.62, 95% CI -5.44 to 2.21, P = 0.41). There was no significant difference in the DQ of children exposed to CBZ (n = 172) versus phenytoin (PHT) (n = 87) (MD 3.02, 95% CI -2.41 to 8.46, P = 0.28). The IQ abilities of children exposed to CBZ (n = 75) were not different from the abilities of children exposed to PHT (n = 45) (MD -3.30, 95% CI -7.91 to 1.30, P = 0.16). IQ was significantly lower for children exposed to VPA (n = 74) versus LTG (n = 84) (MD -10.80, 95% CI -14.42 to -7.17, P < 0.00001). DQ was higher in children exposed to PHT (n = 80) versus VPA (n = 108) (MD 7.04, 95% CI 0.44 to 13.65, P = 0.04). Similarly IQ was higher in children exposed to PHT (n = 45) versus VPA (n = 61) (MD 9.25, 95% CI 4.78 to 13.72, P < 0.0001). A dose effect for VPA was reported in six studies, with higher doses (800 to 1000 mg daily or above) associated with a poorer cognitive outcome in the child. We identified no convincing evidence of a dose effect for CBZ, PHT or LTG. Studies not included in the meta-analysis were reported narratively, the majority of which supported the findings of the meta-analyses. AUTHORS' CONCLUSIONS The most important finding is the reduction in IQ in the VPA exposed group, which are sufficient to affect education and occupational outcomes in later life. However, for some women VPA is the most effective drug at controlling seizures. Informed treatment decisions require detailed counselling about these risks at treatment initiation and at pre-conceptual counselling. We have insufficient data about newer AEDs, some of which are commonly prescribed, and further research is required. Most women with epilepsy should continue their medication during pregnancy as uncontrolled seizures also carries a maternal risk.
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Affiliation(s)
- Rebecca Bromley
- Institute of Human Development, University of Manchester, 6th Floor, Genetic Medicine, St Mary's Hospital, Oxford Road, Manchester, UK, M13 9WL
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Engineer CT, Centanni TM, Im KW, Kilgard MP. Speech sound discrimination training improves auditory cortex responses in a rat model of autism. Front Syst Neurosci 2014; 8:137. [PMID: 25140133 PMCID: PMC4122159 DOI: 10.3389/fnsys.2014.00137] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 07/14/2014] [Indexed: 11/28/2022] Open
Abstract
Children with autism often have language impairments and degraded cortical responses to speech. Extensive behavioral interventions can improve language outcomes and cortical responses. Prenatal exposure to the antiepileptic drug valproic acid (VPA) increases the risk for autism and language impairment. Prenatal exposure to VPA also causes weaker and delayed auditory cortex responses in rats. In this study, we document speech sound discrimination ability in VPA exposed rats and document the effect of extensive speech training on auditory cortex responses. VPA exposed rats were significantly impaired at consonant, but not vowel, discrimination. Extensive speech training resulted in both stronger and faster anterior auditory field (AAF) responses compared to untrained VPA exposed rats, and restored responses to control levels. This neural response improvement generalized to non-trained sounds. The rodent VPA model of autism may be used to improve the understanding of speech processing in autism and contribute to improving language outcomes.
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Affiliation(s)
- Crystal T Engineer
- Cortical Plasticity Laboratory, School of Behavioral and Brain Sciences, The University of Texas at Dallas Richardson, TX, USA
| | - Tracy M Centanni
- Cortical Plasticity Laboratory, School of Behavioral and Brain Sciences, The University of Texas at Dallas Richardson, TX, USA
| | - Kwok W Im
- Cortical Plasticity Laboratory, School of Behavioral and Brain Sciences, The University of Texas at Dallas Richardson, TX, USA
| | - Michael P Kilgard
- Cortical Plasticity Laboratory, School of Behavioral and Brain Sciences, The University of Texas at Dallas Richardson, TX, USA
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Forsberg L, Wide K. Long-term consequences after exposure to antiepileptic drugs in utero. Ther Adv Drug Saf 2014; 2:227-34. [PMID: 25083215 DOI: 10.1177/2042098611419003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Most pregnant women with epilepsy need pharmacological treatment during pregnancy. Children exposed to antiepileptic drugs have an increased risk of being born with major malformations. Some antiepileptic drugs seem to have negative effects on psychomotor or cognitive development in children exposed during foetal life. Neither carbamazepine nor lamotrigine in monotherapy seem to affect the cognition of exposed children. Several studies have shown negative effects on the long-term neurodevelopment of children prenatally exposed to valproic acid or polytherapy (two or more antiepileptic drugs during pregnancy). For most of the newer antiepileptic drugs there are insufficient data regarding long-term outcome.
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Affiliation(s)
- Lisa Forsberg
- Astrid Lindgren Children's Hospital at Karolinska University Hospital Huddinge and Department of Clinical Science, Intervention and Technique (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Katarina Wide
- Astrid Lindgren Children's Hospital at Karolinska University Hospital Huddinge and Department of Clinical Science, Intervention and Technique (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Risks of neurobehavioral teratogenicity associated with prenatal exposure to valproate monotherapy: a systematic review with regulatory repercussions. CNS Spectr 2014; 19:305-15. [PMID: 24571806 DOI: 10.1017/s1092852913000990] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Beyond its formal indications (epilepsy, bipolar disorder, and migraine), valproate sodium (VPA) is widely used in a number of other clinical conditions. Recently, however, the U.S. Food and Drug Administration (FDA) issued a warning regarding a decrease in IQ scores in children prenatally exposed to the drug. For patients with migraine, the pregnancy labeling of VPA will be changed from Category "D" to "X." VPA products will remain in pregnancy category "D" for treating epilepsy and manic episodes associated with bipolar disorder. Thus, this article aims to assess (through a computerized Medline/PubMed search) the neurobehavioral teratogenicity of valproate monotherapy, in order to evaluate alternative regulatory decisions. Reviewed information suggests a detrimental impact of antenatal valproate exposure on the global child neurodevelopment. Affected areas include not just reduced IQ scores, but also behavioral problems and a potential increase in the risk for a future diagnosis of attention-deficit/hyperactivity disorder. An increased risk of developing autism-spectrum disorders has also been reported. Thus, in my opinion, VPA should be assigned definitively to the Category "X," independent of any considerations about its clinical indications, and should be strictly avoided during pregnancy, due to the demonstrated risk of both neurobehavioral and neurocognitive teratogenicity.
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Tricco AC, Cogo E, Angeliki VA, Soobiah C, Hutton B, Hemmelgarn BR, Moher D, Finkelstein Y, Straus SE. Comparative safety of anti-epileptic drugs among infants and children exposed in utero or during breastfeeding: protocol for a systematic review and network meta-analysis. Syst Rev 2014; 3:68. [PMID: 24964932 PMCID: PMC4086277 DOI: 10.1186/2046-4053-3-68] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 06/17/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Epilepsy affects about 1% of the general population. Anti-epileptic drugs (AEDs) prevent or terminate seizures in individuals with epilepsy. Pregnant women with epilepsy may continue taking AEDs. Many of these agents cross the placenta and increase the risk of major congenital malformations, early cognitive and developmental delays, and infant mortality. We aim to evaluate the comparative safety of AEDs approved for chronic use in Canada when administered to pregnant and breastfeeding women and the effects on their infants and children through a systematic review and network meta-analysis. METHODS Studies examining the effects of AEDs administered to pregnant and breastfeeding women regardless of indication (e.g., epilepsy, migraine, pain, psychiatric disorders) on their infants and children will be included. We will include randomized clinical trials (RCTs), quasi-RCTs, non-RCTs, controlled before-after, interrupted time series, cohort, registry, and case-control studies. The main literature search will be executed in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. We will seek unpublished literature through searches of trial protocol registries and conference abstracts. The literature search results screening, data abstraction, and risk of bias appraisal will be performed by two individuals, independently. Conflicts will be resolved through discussion. The risk of bias of experimental and quasi-experimental studies will be appraised using the Cochrane Effective Practice and Organization of Care Risk-of-Bias tool, methodological quality of observational studies will be appraised using the Newcastle-Ottawa Scale, and quality of reporting of safety outcomes will be conducted using the McMaster Quality Assessment Scale of Harms (McHarm) tool. If feasible and appropriate, we will conduct random effects meta-analysis. Network meta-analysis will be considered for outcomes that fulfill network meta-analysis assumptions.The primary outcome is major congenital malformations (overall and by specific types), while secondary outcomes include fetal loss/miscarriage, minor congenital malformations (overall and by specific types), cognitive development, psychomotor development, small for gestational age, preterm delivery, and neonatal seizures. DISCUSSION Our systematic review will address safety concerns regarding the use of AEDs during pregnancy and breastfeeding. Our results will be useful to healthcare providers, policy-makers, and women of childbearing age who are taking anti-epileptic medications. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014008925.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St, Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario M5B 1 T8, Canada.
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Verrotti A, Scaparrotta A, Cofini M, Chiarelli F, Tiboni GM. Developmental neurotoxicity and anticonvulsant drugs: a possible link. Reprod Toxicol 2014; 48:72-80. [PMID: 24803404 DOI: 10.1016/j.reprotox.2014.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 04/05/2014] [Accepted: 04/18/2014] [Indexed: 01/16/2023]
Abstract
In utero exposure to antiepileptic drugs (AEDs) may affect neurodevelopment causing postnatal cognitive and behavioral alterations. Phenytoin and phenobarbital may lead to motor and learning dysfunctions in the pre-exposed children. These disorders may reflect the interference of these AEDs with the development of hippocampal and cerebellar neurons, as suggested by animal studies. Exposure to valproic acid may result in inhibition of neural stem cell proliferation and/or immature neuron migration in the cerebral cortex with consequent increased risk of neurodevelopmental impairment, such as autistic spectrum disorders. A central issue in the prevention of AED-mediated developmental effects is the identification of drugs that should be avoided in women of child-bearing potential and during pregnancy. The aim of this review is to explore the possible link between AEDs and neurodevelopmental dysfunctions both in human and in animal studies. The possible mechanisms underlying this association are also discussed.
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Affiliation(s)
- A Verrotti
- Department of Pediatrics, University of Perugia, Italy
| | - A Scaparrotta
- Department of Medicine and Aging Sciences, University "G. d'Annunzio" of Chieti-Pescara, Italy
| | - M Cofini
- Department of Pediatrics, University of Perugia, Italy
| | - F Chiarelli
- Department of Medicine and Aging Sciences, University "G. d'Annunzio" of Chieti-Pescara, Italy
| | - G M Tiboni
- Department of Medicine and Aging Sciences, University "G. d'Annunzio" of Chieti-Pescara, Italy.
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Sathiya S, Ganesh M, Kalaivani P, Ranju V, Janani S, Pramila B, Saravana Babu C. Prenatal exposure to lamotrigine: effects on postnatal development and behaviour in rat offspring. ISRN NEUROSCIENCE 2014; 2014:163459. [PMID: 24967313 PMCID: PMC4045557 DOI: 10.1155/2014/163459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 02/19/2014] [Indexed: 11/17/2022]
Abstract
Use of antiepileptic drugs (AEDs) in pregnancy warrants various side effects and also deleterious effects on fetal development. The present study was carried out to assess the effects of prenatal exposure to lamotrigine (LTG) on postnatal development and behavioural alterations of offspring. Adult male and female Sprague Dawley rats weighing 150-180 g b. wt. were allowed to copulate and pregnancy was confirmed by vaginal cytology. Pregnant rats were treated with LTG (11.5, 23, and 46 mg/kg, p.o) from gestational day 3 (GND 3) and this treatment continued till postnatal day 11 (PND 11). Offspring were separated from their dam on day 21 following parturition. LTG, at 46 mg/kg, p.o, produced severe clinical signs of toxicity leading to death of dam between GND 15 and 17. LTG, at 11.5 and 23 mg/kg, p.o, showed significant alterations in offspring's incisors eruption and vaginal opening when compared to age matched controls. LTG (23 mg/kg, p.o) exposed female offspring expressed hyperactive behaviour and decreased GABA-A receptor expression when compared to control rats. These results reveal that prenatal exposure to LTG may impart differential postnatal behavioural alterations between male and female rats which paves way for further investigations.
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Affiliation(s)
- Sekar Sathiya
- Centre for Toxicology and Developmental Research (CEFT), Sri Ramachandra University, Chennai, Tamil Nadu 600116, India
| | - Murugan Ganesh
- Department of Biochemistry, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India
| | - Periyathambi Kalaivani
- Centre for Toxicology and Developmental Research (CEFT), Sri Ramachandra University, Chennai, Tamil Nadu 600116, India
| | - Vijayan Ranju
- Centre for Toxicology and Developmental Research (CEFT), Sri Ramachandra University, Chennai, Tamil Nadu 600116, India
| | - Srinivasan Janani
- School of Chemical and Biotechnology, Shanmugha Arts, Science, Technology and Research Academy (SASTRA University), Thanjavur, Tamil Nadu 613402, India
| | - Bakthavachalam Pramila
- Centre for Toxicology and Developmental Research (CEFT), Sri Ramachandra University, Chennai, Tamil Nadu 600116, India
| | - Chidambaram Saravana Babu
- Centre for Toxicology and Developmental Research (CEFT), Sri Ramachandra University, Chennai, Tamil Nadu 600116, India
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Engineer CT, Centanni TM, Im KW, Borland MS, Moreno NA, Carraway RS, Wilson LG, Kilgard MP. Degraded auditory processing in a rat model of autism limits the speech representation in non-primary auditory cortex. Dev Neurobiol 2014; 74:972-86. [PMID: 24639033 DOI: 10.1002/dneu.22175] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/17/2014] [Accepted: 03/07/2014] [Indexed: 01/22/2023]
Abstract
Although individuals with autism are known to have significant communication problems, the cellular mechanisms responsible for impaired communication are poorly understood. Valproic acid (VPA) is an anticonvulsant that is a known risk factor for autism in prenatally exposed children. Prenatal VPA exposure in rats causes numerous neural and behavioral abnormalities that mimic autism. We predicted that VPA exposure may lead to auditory processing impairments which may contribute to the deficits in communication observed in individuals with autism. In this study, we document auditory cortex responses in rats prenatally exposed to VPA. We recorded local field potentials and multiunit responses to speech sounds in primary auditory cortex, anterior auditory field, ventral auditory field. and posterior auditory field in VPA exposed and control rats. Prenatal VPA exposure severely degrades the precise spatiotemporal patterns evoked by speech sounds in secondary, but not primary auditory cortex. This result parallels findings in humans and suggests that secondary auditory fields may be more sensitive to environmental disturbances and may provide insight into possible mechanisms related to auditory deficits in individuals with autism.
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Affiliation(s)
- C T Engineer
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, Texas, 75080
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Winterbottom JB, Smyth RMD, Jacoby A, Baker GA. WITHDRAWN: Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome. Cochrane Database Syst Rev 2014; 2014:CD006645. [PMID: 24647831 PMCID: PMC10641638 DOI: 10.1002/14651858.cd006645.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This review has been replaced by the protocol 'Preconception counselling for women with epilepsy' (Winterbottom 2014). The full review is expected to be published by 1st July 2014. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
| | - Rebecca MD Smyth
- The University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Ann Jacoby
- The University of LiverpoolDivision of Public HealthWhelan BuildingThe Quadrangle, Brownlow HillLiverpoolUKL69 3GB
| | - Gus A Baker
- Clinical Sciences Centre for Research & EducationUniversity Department of Neurological ScienceLower LaneLiverpoolMerseysideUKL9 7LJ
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Kanner AM, Balabanov A. Valproate: a practical review of its uses in neurological and psychiatric disorders. Expert Rev Neurother 2014; 2:151-65. [DOI: 10.1586/14737175.2.2.151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Babies born to mothers exposed to antiepileptic drugs (AEDs) are at increased risk for major congenital malformations, cognitive impairment and fetal death. For the millions of women with epilepsy, maintaining the safest drug that will successfully prevent seizures during pregnancy remains a primary consideration. The recent development of collaborative international registries to examine the differential and dose-dependent effects of the expanding number of old and new AEDs, have shed light upon potential differences during pregnancy. Valproic acid appears to be associated with the highest risk of overall, as well as AED-specific, birth defects, becoming more evident as doses exceed 1000 mg/day. Lamotrigine may be less teratogenic to humans than other AEDs, although orofacial clefts have recently been reported. The effects of polytherapy appear to carry greater risks compared with monotherapy. Limited data exist for many of the newer AEDs. Furthermore, AED effects may persist during postnatal development. Although no class 1 outcome data are available, prepregnancy counseling to optimize patient-specific treatment is recommended for women of childbearing potential with epilepsy.
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Affiliation(s)
- William O Tatum
- Tampa General Hospital and the University of South Florida, Department of Neurology, Tampa, c/o 13801 Bruce B. Downs Blvd, #401Tampa, FL, 33613 USA. www.wtatum.com
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Åberg E, Holst S, Neagu A, Ögren SO, Lavebratt C. Prenatal exposure to carbamazepine reduces hippocampal and cortical neuronal cell population in new-born and young mice without detectable effects on learning and memory. PLoS One 2013; 8:e80497. [PMID: 24244693 PMCID: PMC3828387 DOI: 10.1371/journal.pone.0080497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 10/14/2013] [Indexed: 12/21/2022] Open
Abstract
Pregnant women with epilepsy have to balance maternal and fetal risks associated with uncontrolled seizures against the potential teratogenic effects from antiepileptic drugs (AEDs). Carbamazepine (CBZ) is among the four most commonly used AEDs for treatment of pregnant epileptic women. We previously reported that new-born children had a decreased head circumference after in utero CBZ exposure. This study investigates how prenatal exposure of CBZ influences the number of neurons in new-born and young mouse hippocampus, amygdala and cortex cerebri. Clinical studies describe inconclusive results on if prenatal CBZ treatment influences cognition. Here we investigate this issue in mice using two well characterized cognitive tasks, the passive avoidance test and the Morris water maze test. Prenatal exposure of CBZ reduced the number of neurons (NeuN-immunoreactive cells) in the new-born mouse hippocampus with 50% compared to non-exposed mice. A reduction of neurons (20%) in hippocampus was still observed when the animals were 5 weeks old. These mice also displayed a 25% reduction of neurons in cortex cerebri. Prenatal CBZ treatment did not significantly impair learning and memory measured in the passive avoidance test and in the Morris water maze. However, these mice displayed a higher degree of thigmotaxic behaviour than the control mice. The body weight of prenatally CBZ exposed five-week old mice were lower compared to control mice not exposed to CBZ (p = 0.001). In conclusion, prenatal exposure to CBZ reduces the number of neurons dramatically in areas important for cognition such as hippocampus and cortex, without severe impairments on learning and memory. These results are in line with some clinical studies, reporting that CBZ has minor negative effects on cognition. The challenge for future studies are to segment out what possible effects a reduction of neurons could have on different types of cognition, like intellectual ability and social interaction.
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Affiliation(s)
- Elin Åberg
- Neurogenetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden and Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
- * E-mail:
| | - Sarah Holst
- Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Alexandru Neagu
- Neurogenetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden and Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Ove Ögren
- Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Catharina Lavebratt
- Neurogenetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden and Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
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Kjaer D, Christensen J, Bech BH, Pedersen LH, Vestergaard M, Olsen J. Preschool behavioral problems in children prenatally exposed to antiepileptic drugs - a follow-up study. Epilepsy Behav 2013; 29:407-11. [PMID: 24090777 DOI: 10.1016/j.yebeh.2013.08.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 10/26/2022]
Abstract
We studied the association between maternal epilepsy, antiepileptic drug (AED) treatment, and behavioral problems in preschool children. In the Danish National Birth Cohort, we identified 4- to 5-year-old children whose mothers had epilepsy and received AED treatment (n=133) or not (n=304) during pregnancy and compared them with randomly selected children whose mothers did not have epilepsy (n=1193). The children's behavioral problems were assessed by the use of the Strengths and Difficulties Questionnaire (SDQ). Children prenatally exposed to AEDs more often had an abnormal total SDQ score as compared with children of women without epilepsy (odds ratio (OR)=4.8 (95% CI: 1.9-12.1)) and as compared with children of women with epilepsy who were not treated with AEDs during their pregnancy (OR=4.0 (95% CI: 1.3-12.8)). In conclusion, prenatal AED exposure may increase the risk of behavioral problems in preschool children even after adjustments for potential confounders and maternal epilepsy.
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Affiliation(s)
- D Kjaer
- Section for Epidemiology, Department of Public Health, Aarhus University, Denmark; Department of Pathology, Aarhus University Hospital, Denmark; Department of Clinical Pharmacology, Aarhus University Hospital, Denmark.
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