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Sibanyoni AU, Joubert M, Naidu K. Are female bipolar patients of reproductive age aware of the teratogenic risk of sodium valproate? A qualitative study. S Afr J Psychiatr 2022; 28:1719. [PMID: 35169512 PMCID: PMC8831931 DOI: 10.4102/sajpsychiatry.v28i0.1719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/06/2021] [Indexed: 11/03/2022] Open
Abstract
Background Sodium valproate is considered the most teratogenic of all anticonvulsant drugs. Internationally, new regulations require women to sign risk assessment forms if initiated on it. Aim This study aimed to explore patients’ awareness of the teratogenic risk of sodium valproate. Setting Weskoppies Psychiatric Hospital, Tshwane, Gauteng. Methods We conducted a qualitative study comprising 23 semi-structured interviews with female bipolar patients of reproductive age at a tertiary psychiatric hospital in South Africa. Results Patient psychoeducation and self-education is improving as many patients were aware of the risk of teratogenicity of sodium valproate either by being educated or by searching online after developing an interest. Our study identified the need for female patients to be educated about contraceptive use when starting on sodium valproate to avoid pregnancy. Conclusion Our study shows that patients are becoming more aware of the teratogenic risk of sodium valproate. This suggests that consultations focusing on the issues of conception and the use of sodium valproate in women of childbearing potential has improved.
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Affiliation(s)
- Amanda U. Sibanyoni
- Department of Psychiatry, Faculty of Medicine, University of Pretoria, Pretoria, South Africa
| | - Marinda Joubert
- Department of Psychiatry, Faculty of Medicine, University of Pretoria, Pretoria, South Africa
| | - Kalaivani Naidu
- Department of Psychiatry, Faculty of Medicine, University of Pretoria, Pretoria, South Africa
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Murphy OC, Wrigley S, Walsh RA, Freir DB, McCarthy AJ, O'Dowd S, McCabe DJH. Assessment of the adequacy of counselling regarding reproductive-related issues in women of childbearing age on anti-epileptic drugs. QJM 2021; 114:233-237. [PMID: 32298454 DOI: 10.1093/qjmed/hcaa131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/10/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The use of anti-epileptic drugs (AEDs) in women of childbearing age (WCBA) necessitates careful counselling regarding reproductive-related issues. AIM (i) To compare documentation of appropriate counselling regarding reproductive-related issues in WCBA prescribed AEDs for non-epilepsy vs. epilepsy indications, and (ii) to examine whether the frequency of counselling improved after introduction of 'standardized typed advice'. DESIGN Retrospective audit and quality assessment and improvement programme. METHODS We analysed medical records of all WCBA prescribed gabapentin, pregabalin, topiramate, valproate or carbamazepine by a general neurology clinical service before (Study period A) and after (Study period B) introduction of standardized typed passages regarding potential teratogenicity ± interactions with hormonal contraception at a university teaching hospital. The χ2 test or the Fisher's exact test was employed, as appropriate. RESULTS In WCBA prescribed AEDs for non-epilepsy indications, documentation of appropriate counselling regarding potential teratogenicity improved from 49% (17/35 patients) in Period A to 79% (27/34 patients) in Period B (P = 0.008). The frequency of counselling regarding teratogenicity was higher in patients prescribed AEDs for epilepsy compared with non-epilepsy indications in Study period A (100% vs. 49%, P = 0.002), but was no longer significantly different in Study period B (86% vs. 79%, P = 0.64). Documentation of counselling regarding potential interaction of enzyme-inducing AEDs with hormonal contraception did not significantly change between study periods. CONCLUSION Significant improvements in documentation regarding potential teratogenicity of AEDs prescribed for non-epilepsy indications can be achieved by introducing standardized, typed passages copied to patients. Such a practice change is practical and widely applicable to neurological and non-neurological practice worldwide.
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Affiliation(s)
- O C Murphy
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin D24 NR0A, Ireland
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - S Wrigley
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin D24 NR0A, Ireland
| | - R A Walsh
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin D24 NR0A, Ireland
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - D B Freir
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin D24 NR0A, Ireland
| | - A J McCarthy
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin D24 NR0A, Ireland
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
- Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin, D24 NR0A, Ireland
| | - S O'Dowd
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin D24 NR0A, Ireland
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
- Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin, D24 NR0A, Ireland
| | - D J H McCabe
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin D24 NR0A, Ireland
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
- Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin, D24 NR0A, Ireland
- Department of Clinical Neurosciences, Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK
- Vascular Neurology Research Foundation, C/O Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital (AMNCH) / Tallaght University Hospital, Dublin D24 NR0A, Ireland
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Shroukh WA, Steinke DT, Willis SC. Risk management of teratogenic medicines: A systematic review. Birth Defects Res 2020; 112:1755-1786. [DOI: 10.1002/bdr2.1799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Wejdan A. Shroukh
- Division of Pharmacy and Optometry, School of Health Sciences The University of Manchester Manchester UK
| | - Douglas T. Steinke
- Division of Pharmacy and Optometry, School of Health Sciences The University of Manchester Manchester UK
| | - Sarah C. Willis
- Division of Pharmacy and Optometry, School of Health Sciences The University of Manchester Manchester UK
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Puig-Molto M, Pol-Yanguas E, Segarra L, Lumbreras B. Impact of the EMA/FDA alerts on the use of effective contraceptive method in women of childbearing age undergoing valproic acid treatment in a long-stay psychiatric center. Epilepsy Behav 2020; 107:107072. [PMID: 32278266 DOI: 10.1016/j.yebeh.2020.107072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We aimed to evaluate the impact of the European Medicines Agency (EMA) and Food Drug and Administration (FDA) alerts on the use of effective contraceptive method in women of childbearing age undergoing valproic acid treatment in a long-stay psychiatric center. MATERIAL AND METHODS An interrupted time-series analysis of women of childbearing age admitted in a long-stay psychiatric center (2013-2019), according to the EMA/FDA restrictions dates (October 2014 and February 2018). RESULTS Of the 82 cases included, 50 (61.0%) had an 'off-label' prescription. The percentage of cases with a contraceptive method before October 2014 (31.6%) increased to 61.5% after October 2014, p = 0.004. Women with an 'off-label' prescription after 2018 were more likely to use a contraceptive method than those before 2014, and there were not statistically significant differences in women with an 'under indication' prescription. CONCLUSIONS The recent regulatory restrictions on the use of a contraceptive method had a positive effect, mainly in women with an 'off-label' prescription. No effect was seen in women with epilepsy, probably because the intervention had started long before.
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Affiliation(s)
- María Puig-Molto
- Pharmacy Faculty, Miguel Hernandez University, Crtra Alicante-Valencia km 81. Sant Joan d'Alacant, 03550 Alicante, Spain
| | | | - Lidia Segarra
- Pharmacy Faculty, Miguel Hernandez University, Crtra Alicante-Valencia km 81. Sant Joan d'Alacant, 03550 Alicante, Spain
| | - Blanca Lumbreras
- Department of Public Health, History of Science and Gynecology, Miguel Hernández University, Crtra Alicante-Valencia km 81. Sant Joan d'Alacant, 03550 Alicante, Spain; CIBER en Epidemiología y Salud Pública, Crtra Alicante-Valencia km 81. Sant Joan d'Alacant, 03550 Alicante, Spain.
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Prenatal valproate in rodents as a tool to understand the neural underpinnings of social dysfunctions in autism spectrum disorder. Neuropharmacology 2019; 159:107477. [DOI: 10.1016/j.neuropharm.2018.12.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/11/2018] [Accepted: 12/20/2018] [Indexed: 12/22/2022]
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Mulryan D, McIntyre A, McDonald C, Feeney S, Hallahan B. Awareness and documentation of the teratogenic effects of valproate among women of child-bearing potential. BJPsych Bull 2018; 42:233-237. [PMID: 30109830 PMCID: PMC6465217 DOI: 10.1192/bjb.2018.48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims and methodWe aimed to evaluate clinical note documentation of valproate prescribing and establish the level of knowledge among women of child-bearing potential regarding valproate-associated adverse effects, including teratogenesis, in a regional Irish mental health service. RESULTS: Of the 42 women prescribed sodium valproate, 21.4% (n = 9) had some documentation in relation to associated risks and 33.3% (n = 14) described an awareness of these risks from consultation with their treating mental health team. On clinical interview, 9.5% (n = 4) of individuals with clear documentation of the risks of teratogenesis described no such awareness. Augmentation with lithium was associated with greater awareness of the teratogenic risks of valproate (P = 0.011).Clinical implicationsA clear description of the teratogenic risks of valproate and potential management strategies, including advice regarding contraception and supplementation with folic acid, should be clearly documented and provided repeatedly and in context to all women of child-bearing age who are prescribed valproate.Declaration of interestNone.
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Affiliation(s)
| | - Anna McIntyre
- Department of Psychiatry,Roscommon County Hospital,Ireland
| | - Colm McDonald
- Department of Psychiatry,University Hospital Galway,Ireland
| | - Sabina Feeney
- Department of Psychiatry,Roscommon County Hospital,Ireland
| | - Brian Hallahan
- Department of Psychiatry,University Hospital Galway,Ireland
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Zhang Z, Xu L, Zhang Z, Ding H, Rayburn ER, Li H. The need for contraception in patients taking prescription drugs: a review of FDA warning labels, duration of effects, and mechanisms of action. Expert Opin Drug Saf 2018; 17:1171-1183. [PMID: 30394114 DOI: 10.1080/14740338.2018.1544617] [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: 10/27/2022]
Abstract
Introduction: This review provides a guide for the rational use of prescription drugs in patients of reproductive age. Areas covered: A comprehensive retrieval of the labels of FDA-approved drugs was performed to identify drugs where the label recommends contraceptive use during and/or after treatment. The acquired data were analyzed and organized into a table. Contraception was recommended or mandated for 268 single-ingredient drugs. These could be divided into four main categories, with many having effects across several categories: 177 drugs required contraception because they were associated with pregnancy loss or stillbirth, 177 drugs were associated with teratogenesis, 136 were associated with non-teratogenic adverse peri- or postnatal effects on the fetus (e.g. low birth weight), and 44 were associated with decreased efficacy of contraception or a change in ovulatory cycle. We also discuss the period of time contraception is required, as well as the known or hypothesized reasons for the reproductive toxicity of these agents. Expert opinion: We have provided a comprehensive overview of the FDA-approved drugs where the warning labels currently stipulate that contraception should be used. Although other references are available for clinicians, this review provides a useful source of information regarding the single-ingredient prescription drugs that may affect the outcome of pregnancy. This information is particularly relevant for researchers, as it provides an overview of the different drugs with reproductive toxicity, and because it highlights the specific needs for future research. In particular, more work (especially epidemiological studies) is needed to clarify the clinical relevance of these findings, most of which were obtained through animal studies.
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Affiliation(s)
- Zhanhu Zhang
- a Department of Clinical Laboratory Medicine , Nantong Maternal and Child Health Hospital , Jiangsu , China
| | - Lili Xu
- a Department of Clinical Laboratory Medicine , Nantong Maternal and Child Health Hospital , Jiangsu , China
| | - Zhenyu Zhang
- a Department of Clinical Laboratory Medicine , Nantong Maternal and Child Health Hospital , Jiangsu , China
| | - Hongxia Ding
- b Pharmacodia (Beijing) Co., LTD , Beijing , China
| | | | - Haibo Li
- a Department of Clinical Laboratory Medicine , Nantong Maternal and Child Health Hospital , Jiangsu , China
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Abstract
PURPOSE OF REVIEW The aim of this paper is to evaluate recent literature on valproic acid (VPA) in women and girls of childbearing age and to emphasize new findings. RECENT FINDINGS Recent research confirms VPAs teratogenicity and risk of hormone disruption. VPA exposure in utero increases the risk for a variety of major congenital malformations (MCMs), reduced IQ and behavioral problems. In girls and women, VPA increases the risk of hormone abnormalities, obesity, and polycystic ovarian syndrome (PCOS). Despite guidelines recommending caution, VPA use continues to be prescribed to reproductive-aged women and girls. Despite significant and well-documented risk, adherence to guidelines in VPA use in reproductive-aged girls and women remains low.
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Affiliation(s)
- Dorothy Gotlib
- Michigan Medicine, Department of Psychiatry, Ann Arbor, MI, USA.
| | - Rachel Ramaswamy
- Department of Psychiatry and Behavioral Neurosciences, Loyola University, Tampa, FL, USA
| | | | - Alana DeRiggi
- Michigan Medicine, Department of Psychiatry, Ann Arbor, MI, USA
| | - Michelle Riba
- Michigan Medicine, Department of Psychiatry, Ann Arbor, MI, USA
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9
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Abstract
This chapter includes the aspects of carbamazepine. The drug is synthesized by the use of 5H-dibenz[b,f]azepine and phosgene followed by subsequent reaction with ammonia. Carbamazepine is generally used for the treatment of seizure disorders and neuropathic pain, it is also important as off-label for a second-line treatment for bipolar disorder and in combination with an antipsychotic in some cases of schizophrenia when treatment with a conventional antipsychotic alone has failed. Other uses may include attention deficit hyperactivity disorder, schizophrenia, phantom limb syndrome, complex regional pain syndrome, borderline personality disorder, and posttraumatic stress disorder. The chapter discusses the drug metabolism and pharmacokinetics and presents various methods of analysis of this drug such electrochemical analysis, spectroscopic analysis, and chromatographic techniques of separation. It also discusses its physical properties such as solubility characteristics, X-ray powder diffraction pattern, and thermal methods of analysis. The chapter is concluded with a discussion on its biological properties such as activity, toxicity, and safety.
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Morriss R. Mandatory implementation of NICE Guidelines for the care of bipolar disorder and other conditions in England and Wales. BMC Med 2015; 13:246. [PMID: 26420497 PMCID: PMC4588679 DOI: 10.1186/s12916-015-0464-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/27/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Bipolar disorder is a common long-term mental health condition characterised by episodes of mania or hypomania and depression resulting in disability, early death, and high health and society costs. Public money funds the National Institute of Healthcare and Clinical Excellence (NICE) to produce clinical guidelines by systematically identifying the most up to date research evidence and costing its main recommendations for healthcare organisations and professionals to follow in England and Wales. Most governments, including those of England and Wales, need to improve healthcare but at reduced cost. There is evidence, particularly in bipolar disorder, that systematically following clinical guidelines achieves these outcomes. DISCUSSION NICE clinical guidelines, including those regarding bipolar disorder, remain variably implemented. They give clinicians and patients a non-prescriptive basis for deciding their care. Despite the passing of the Health and Social Care Act in 2012 in England requiring all healthcare organisations to consider NICE clinical guidelines in commissioning, delivering, and inspecting healthcare services, healthcare organisations in the National Health Service may ignore them with little accountability and few consequences. There is no mechanism to ensure that healthcare professionals know or consider them. Barriers to their implementation include the lack of political and professional leadership, the complexity of the organisation of care and policy, mistrust of some processes and recommendations of clinical guidelines, and a lack of a clear implementation model, strategy, responsibility, or accountability. Mitigation to these barriers is presented herein. SUMMARY The variability, safety, and quality of healthcare might be improved and its cost reduced if the implementation of NICE clinical guidelines, such as those for bipolar disorder, were made the minimum starting point for clinical decision-making and mandatory responsibilities of all healthcare organisations and professionals.
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Affiliation(s)
- Richard Morriss
- Psychiatry and Community Mental Health, University of Nottingham, Nottingham, UK.
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Murru A, Popovic D, Pacchiarotti I, Hidalgo D, León-Caballero J, Vieta E. Management of adverse effects of mood stabilizers. Curr Psychiatry Rep 2015; 17:603. [PMID: 26084665 DOI: 10.1007/s11920-015-0603-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mood stabilizers such as lithium and anticonvulsants are still standard-of-care for the acute and long-term treatment of bipolar disorder (BD). This systematic review aimed to assess the prevalence of their adverse effects (AEs) and to provide recommendations on their clinical management. We performed a systematic research for studies reporting the prevalence of AEs with lithium, valproate, lamotrigine, and carbamazepine/oxcarbazepine. Management recommendations were then developed. Mood stabilizers have different tolerability profiles and are eventually associated to cognitive, dermatological, endocrine, gastrointestinal, immunological, metabolic, nephrogenic, neurologic, sexual, and teratogenic AEs. Most of those can be transient or dose-related and can be managed by optimizing drug doses to the lowest effective dose. Some rare AEs can be serious and potentially lethal, and require abrupt discontinuation of medication. Integrated medical attention is warranted for complex somatic AEs. Functional remediation and psychoeducation may help to promote awareness on BD and better medication management.
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Affiliation(s)
- Andrea Murru
- Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain,
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Valproate Prescribing in Women of Childbearing Age: An Audit of Clinical Practice. ACTA ACUST UNITED AC 2015. [DOI: 10.1155/2015/520784] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background. Evidence is accruing regarding the risks of valproate exposure in women of childbearing age. Recommendations have recently been made for a higher standard of prenatal counselling and prescribing practice in respect of valproate use in this patient group. Aim and Method. A reaudit was carried out to review the standard of clinical discussion around teratogenic
risk and pregnancy planning offered to women of child-bearing age prescribed valproate.
Case notes and prescription charts of women 45 years old or less were examined and compared with the results of a previous audit in 2005. Results. The use of valproate was increased overall by 64% and there was an 18% increase in off-label
valproate use. The rate of clinical discussion carried out during commencement
declined from 70% to 35% and at annual review from 50% to 22%. There was less clinical discussion in outpatients and in older patients. More than 40% of doctors surveyed were not confident about giving information to women. Clinical Implication. There is a need for a multidisciplinary approach and action at Healthcare Trust level, to
increase awareness and reduce risks associated with valproate prescribing in childbearing
women.
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Viana M, Terreno E, Goadsby PJ, Nappi RE. Topiramate for migraine prevention in fertile women: reproductive counseling is warranted. Cephalalgia 2014; 34:1097-9. [PMID: 24723674 DOI: 10.1177/0333102414529669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- M Viana
- Headache Science Center - C. Mondino National Neurological Institute, Italy
| | - E Terreno
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Italy
| | - P J Goadsby
- Headache Group - NIHR-Wellcome Trust Clinical Research Facility, King's College London, UK
| | - R E Nappi
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Italy Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Italy
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