Antiepileptic drugs and bone metabolism

Lithium and the risk of fractures in patients with bipolar disorder: A population-based cohort study

Lithium is considered to be the most effective mood stabilizer for bipolar disorder. Evolving evidence suggested lithium can also regulate bone metabolism which may reduce the risk of fractures. While there are concerns about fractures for antipsychotics and mood stabilizing antiepileptics, very little is known about the overall risk of fractures associated with specific treatments. This study aimed to compare the risk of fractures in patients with bipolar disorder prescribed lithium, antipsychotics or mood stabilizing antiepileptics (valproate, lamotrigine, carbamazepine). Among 40,697 patients with bipolar disorder from 1993 to 2019 identified from a primary care electronic health record database in the UK, 13,385 were new users of mood stabilizing agents (lithium:2339; non-lithium: 11,046). Lithium was associated with a lower risk of fractures compared with non-lithium treatments (HR 0.66, 95 % CI 0.44-0.98). The results were similar when comparing lithium with prolactin raising and sparing antipsychotics, and individual antiepileptics. Lithium use may lower fracture risk, a benefit that is particularly relevant for patients with serious mental illness who are more prone to falls due to their behaviors. Our findings could help inform better treatment decisions for bipolar disorder, and lithium's potential to prevent fractures should be considered for patients at high risk of fractures.

Sedative-hypnotics and osteoporotic fractures: A systematic review of observational studies with over six million individuals

We reviewed and meta-analyzed 20 observational studies to examine the relationship between sedative-hypnotic use and osteoporotic fractures. We searched PubMed, Embase, APA PsycINFO, and Web of Science™ for studies that used cohort, case-control, case-crossover, and self-controlled case series designs. We further assessed the quality of each study and performed meta-analyses of association estimates, e.g., odds ratios (ORs). The analysis included 6,084,083 participants and found a slight association between the use of sedative-hypnotics and osteoporotic fractures, with differing strength of associations between different classes of drugs and greater sedative-hypnotics exposure. The pooled estimates ORs for case-control studies were 1.33 (95% CI 0.98-1.80) with benzodiazepines (BZD) and any fractures, 1.32 (95% CI 1.05-1.66) with BZDs and hip fractures, and case-crossover studies were 1.15 (95% CI 0.95-1.41) with BZDs and any fractures, 1.41 (95% CI 1.08-1.85) with Z-drugs and any fractures. The study suggests that more research is needed to aid medical professionals in balancing this potential risk of osteoporotic fractures associated with sedative-hypnotic use against other reported adverse events and anticipated therapy outcomes.

Ketogenic Diet in Children and Adolescents: the Effects on Growth and Nutritional Status

The ketogenic diet is known to be a possible adjuvant treatment in several medical conditions, such as in patients with severe or drug-resistant forms of epilepsy. Its use has recently been increasing among adolescents and young adults due to its supposed weight-loss effect, mediated by lipolysis and lowered insulin levels. However, there are still no precise indications on the possible use of ketogenic diets in pediatric age for weight loss. This approach has also recently been proposed for other types of disorder such as inherited metabolic disorders, Prader-Willi syndrome, and some specific types of cancers. Due to its unbalanced ratio of lipids, carbohydrates and proteins, a clinical evaluation of possible side effects with a strict evaluation of growth and nutritional status is essential in all patients following a long-term restrictive diet such as the ketogenic one. The prophylactic use of micronutrients supplementation should be considered before starting any ketogenic diet. Lastly, while there is sufficient literature on possible short-term side effects of ketogenic diets, their possible long-term impact on growth and nutritional status is not yet fully understood, especially when started in pediatric age.

A Systematic Review of the Management of Upper Extremity Orthopaedic Injuries in Epileptic Patients

BACKGROUND

During seizures, injury of the upper extremities may occur. Standardized guidelines are deficient for diagnosis and perioperative care.

METHODS

PubMed, Embase, Cochrane, Scopus, and Web of Science databases were systematically screened using predefined search terms.

RESULTS

Of the 59 patients included, 36 (61.0%) involved a posterior shoulder dislocation. Associated fractures were observed in 34 (57.6%) cases with surgical procedures performed in 30 (50.8%) patients. Functional outcomes were reported in 44 patients, with over half (23 of 44, [52.2%]) endorsing range of motion deficits.

CONCLUSION

Standardized guidelines, to guarantee timely management of injury in post-seizure patients, are needed with a customized treatment approach that accommodates the various aspects of their condition.

Antiepileptic Stiripentol May Influence Bones

Bone structure abnormalities are increasingly observed in patients chronically treated with antiepileptic drugs (AEDs). The majority of the available data concern older conventional AEDs, while the amount of information regarding newer AEDs, including stiripentol, is limited. The aim of the study was to assess the effect of stiripentol on bones. For 24 weeks, male Wistar rats, received 0.9% sodium chloride (control group) or stiripentol (200 mg/kg/day) (STP group). In the 16th week of the study, we detected lower serum PINP levels in the STP group compared to the control group. In the 24th week, a statistically significant lower 1,25-dihydroxyvitamin D3 level, higher inorganic phosphate level and higher neutrophil gelatinase-associated lipocalin (NGAL) levels in serum were found in the STP group compared to the control. Micro X-ray computed tomography of the tibias demonstrated lower bone volume fraction, lower trabecular thickness, higher trabecular pattern factor and a higher structure model index in the stiripentol group. Considering the results of this experiment on rats which suggests that long-term administration of stiripentol may impair the cancellous bone microarchitecture, further prospective human studies seem to be justified. However, monitoring plasma vitamin D, calcium, inorganic phosphate and kidney function in patients on long-term stiripentol therapy may be suggested.

Association of Vitamin D Receptor Gene Polymorphisms with Serum Vitamin D Levels in a Greek Rural Population (Velestino Study)

BACKGROUND/AIM

An alarming increase in vitamin D deficiency even in sunny regions highlights the need for a better understanding of the genetic background of the vitamin D endocrine system and the molecular mechanisms of gene polymorphisms of the vitamin D receptor (VDR). In this study, the serum levels of 25(OH)D3 were correlated with common VDR polymorphisms (ApaI, BsmI, FokI, and TaqI) in 98 subjects of a Greek homogeneous rural population.

METHODS

25(OH)D3 concentration was measured by ultra-HPLC, and the VDR gene polymorphisms were identified by quantitative real-time PCR followed by amplicon high-resolution melting analysis.

RESULTS

Subjects carrying either the B BsmI (OR: 0.52, 95% CI: 0.27-0.99) or t TaqI (OR: 2.06, 95%: 1.06-3.99) allele presented twice the risk for developing vitamin D deficiency compared to the reference allele. Moreover, subjects carrying 1, 2, or all 3 of these genotypes (BB/Bb, Tt/tt, and FF) demonstrated 2-fold (OR: 2.04, 95% CI: 0.42-9.92), 3.6-fold (OR: 3.62, 95% CI: 1.07-12.2), and 7-fold (OR: 6.92, 95% CI: 1.68-28.5) increased risk for low 25(OH)D3 levels, respectively.

CONCLUSIONS

Our findings reveal a cumulative effect of specific VDR gene polymorphisms that may regulate vitamin D concentrations explaining, in part, the paradox of vitamin D deficiency in sunny regions, with important implications for precision medicine.

Management of lower extremity orthopaedic injuries in epileptic patients: A systematic review

Lower-extremity injuries may occur during seizures. There is a lack of standardized guidelines when diagnosing and planning perioperative care. Databases were systematically screened using predefined search terms. Of the 13 patients included, seven (53.8%) involved bilateral femoral neck fractures. Associated fractures were observed in all cases with surgical intervention performed in eight (61.5%) patients. Eleven patients reported functional outcomes, with over a quarter (three of 11, [27.3%]) endorsing mild range of motion deficits or issues with ambulation. Post-seizure patients may require standardized diagnostic protocols to ensure prompt management with a specialized treatment approach that accommodates the nuances of their condition.

Rehabilitation pharmacotherapy: A scoping review

Many patients in rehabilitation facilities are affected by polypharmacy. Polypharmacy is associated with rehabilitation outcomes and functional recovery. Consequently, a combination of rehabilitation and pharmacotherapy may improve the outcomes of older people undergoing rehabilitation. A recent report described the concept of rehabilitation pharmacotherapy. The concept envisages helping frail older people and people with disabilities to achieve the highest possible body function, activity level and quality of life. There are two key tenets of rehabilitation pharmacotherapy: "pharmacotherapy in consideration of rehabilitation" and "rehabilitation in consideration of pharmacotherapy." "Pharmacotherapy in consideration of rehabilitation" includes use of drugs to treat impairment, activity limitation and participation restriction based on the International Classification of Functioning, Disability, and Health. "Rehabilitation in consideration of pharmacotherapy" refers to tailoring of rehabilitation considering the content of pharmacotherapy. With respect to drugs and motor dysfunction, anticholinergic drugs are associated with dysphagia and fractures. Increased use of potentially inappropriate medications may adversely affect the nutritional status. With respect to activities of daily living, polypharmacy and use of potentially inappropriate medications negatively affect the improvement in motor function during rehabilitation. Potent anticholinergic drugs are more likely to impede the improvement in cognitive function. In this review, we address the concept of rehabilitation pharmacotherapy and discuss its importance from the perspective of polypharmacy, the effect of drugs on disability and disease, nutritional status and activities of daily living. Geriatr Gerontol Int 2020; 20: -.

Management of antiepileptic drug-induced nutrition-related adverse effects

Although antiepileptic drugs (AEDs) are mainstay of the treatment of epilepsy, they are associated with significant adverse effects. The present study reviews the adverse effects of AEDs on some of the nutrition-related issues, including bone health, body weight, glucose and lipid metabolism, vitamin homeostasis, antioxidant defense system, and pregnancy. This paper also provides some nutritional recommendations for people with epilepsy. Patients with epilepsy should be regularly evaluated with regard to their nutrition status and any possible nutritional problems. Daily intake of adequate amounts of all nutrients from various sources should be encouraged, especially for vulnerable groups such as children, adolescents, elderly, and pregnant women. When necessary, preventative or therapeutic supplementation with appropriate micronutrients could be helpful. Graphical abstract.

Vitamin D Status in Epileptic Children on Valproic Acid; a Case-Control Study

INTRODUCTION

Much attention has been paid to the association between valproic acid treatment and bone health. The objective of this study is to compare the serum vitamin D3 level in the epileptic children under valproic acid treatment with the healthy control group.

METHODS

A case-control study has been carried out to compare vitamin D3 levels in 50 epileptic children who were treated with valproic acid with 50 healthy children selected from children visiting the hospital for routine checkup as control group.

RESULTS

100 cases with the mean age of 7.57± 3.62 years (range: 2 - 15 years) were studied (44% boys). Among the 50 epileptic cases; 41 (82%) had generalized and 9 (18%) had partial seizure (56% well controlled and 44% poorly controlled). 15 (30%) of epileptic cases were using anti-epileptic drugs for 6-12 months, 36% for 12-24 months, and 34% for more than 24 months. The case and control groups were similar regarding gender (p =0.99), age (p = 0.24), and BMI (p = 0.64). 49 (49%) patients had some grade of vitamin D3 deficiency. There was a significant difference between case and control groups regarding vitamin D3 levels (p = 0.001). None of the controls had severe vitamin D3 deficiency, while 14% of cases did. 36 (72%) individuals in control group had sufficient or optimal vitamin D3 levels; while only 15 (30%) case patients had such levels. Generally, the control group had higher vitamin D3 levels in comparison to case group (p = 0.001).

CONCLUSIONS

The study revealed that there was a higher prevalence of vitamin D3 insufficiency in epileptic children receiving valproate monotherapy compared with healthy children. Vitamin D3 supplementation should be given to all epileptic children even before initiation of anti-epileptic drugs.

Vitamin D Status of Epileptic Children in India: A Prospective Cross-Sectional Study from a Tertiary Care Centre

Vitamin D deficiency is prevalent all over the world, especially in tropical countries. In epileptics, antiepileptic drugs (AED) and associated comorbidities further impact vitamin D status. The aim of this study is to estimate the prevalence of 25(OH) vitamin D deficiency in epileptic children and evaluate probable risk factors. A cross-sectional study of 200 children between 1 and 18 years of age on AED was undertaken in the pediatric neurology clinic of a tertiary care center of Northern India. In all children, serum 25(OH) vitamin D levels, calcium, phosphorus, and alkaline phosphatase were estimated. The deficiency levels of vitamin D were categorized as: deficiency <20 ng/mL, insufficiency 20 to 30 ng/mL, and sufficiency >30 ng/mL. The potential risk factors for hypovitaminosis D, including type of epilepsy, AED regimen (specific medications, polytherapy vs. monotherapy), cerebral palsy, ambulatory status, intellectual disability, body mass index, gender, and vegetarianism were examined. Among the 200 enrolled children (60% boys), 106/200 (53%) were vitamin D deficient. There was no significant relation of vitamin D levels with gender, type of epilepsy, neurological deficit, and type of AED. An inverse relationship of higher phenytoin doses during monotherapy associated with lower vitamin D levels in monotherapy was found, thereby suggesting adverse effect of high doses of phenytoin on vitamin D levels. VDD is common among epileptic children on AED therapy. Vitamin D deficiency is common prevalent among epileptic children on AED therapy, and its detection and treatment correction should be an integral part of epilepsy management.

Bone Health Screening Practices Among Neurologists in Patients on Antiepileptic Drugs: A Quality Improvement Project

BACKGROUND

Pediatric patients with epilepsy are at risk for low vitamin D levels, increasing the risk for bone fractures, yet standardized bone health screening is not part of routine care.

METHODS

We surveyed pediatric neurologists (n = 68) at our center regarding screening practices, using an 11-item survey; constructed a bone health treatment algorithm; and developed a training intervention to improve screening rates.

RESULTS

The overall survey response rate was 47%. Among respondents, 64% estimated that they screened for bone health less than 25% of the time. Chart review before the intervention demonstrated an overall screening rate of 25.1% (n = 50/199). One year after implementation of a standardized algorithm, the overall screening rates increased to 53.8% (n = 100/186). The frequency of prescribing vitamin D for patients treated with antiepileptic medications increased among general neurologists (preintervention rate 16%, postintervention rate 51%, P < 0.01) as well as among epileptologists (preintervention rate 45%, postintervention rate 57%, P = 0.04).

CONCLUSION

In a relatively short follow-up period, there were significant changes in care patterns regarding screening for bone health in pediatric patients with epilepsy. Further implementation measures are underway to increase bone health screening and care in this population.

The effect of gabapentin and pregabalin on bone turnover and bone strength: A prospective study in Wistar rats

BACKGROUND

There are limited data on the effects of GBP on bone and no data for PGB. Some data suggest that there is a significant influence of sex hormone balance on the susceptibility of bone to antiepileptic drug-induced bone loss.

METHODS

Forty-eight male Wistar rats were divided into six groups that were subjected to two surgeries, sham (noORX) or real orchidectomy (ORX), and were fed three diets, a SLD, a SLD enriched with GBP or a SLD enriched with PGB. Dual energy X-ray absorptiometry was used to measure the bone mineral density. The concentrations of bone turnover markers were assayed. The femurs were biomechanically tested.

RESULTS

Significant reductions in bone mineral density, weight and biomechanical strength were observed in ORX animals. GBP or PGB exposure did not cause significant alterations in bone mineral density or biomechanical strength. No changes in bone turnover markers were observed, except for RANKL. A significant increase was found in the ORX GBP and ORX PGB groups. Within the orchidectomized animal group, RANKL levels were significantly higher in the ORX PGB group than in the ORX GBP group.

CONCLUSIONS

Because neither GBP nor PGB affected bone mineral density or mechanical bone strength, both of these antiepileptic drugs could be considered drugs with lower risks to bone health. A shift in RANKL levels indicates that the effects of GBP and PGB on osteoclast activity may be dependent on the hormonal status of animals.

Vitamin D supplementation and bone markers in ambulatory children on long-term valproic acid therapy. A prospective interventional study

PURPOSE

Our aim was to investigate any adverse effects of long-term valproic acid (VPA) therapy on bone biochemical markers in ambulatory children and adolescents with epilepsy, and the possible benefits of vitamin D supplementation on the same markers.

METHODS

In this single center, the prospective interventional study levels of 25-hydroxyvitamin D (25OHD) and the bone turnover indices of Crosslaps (CTX), total alkaline phosphatase (tALP), osteoprotegerin (OPG), and the receptor activator for nuclear factor kB (RANK) ligand (sRANKL) were assessed before and after one year of vitamin D intake (400 IU/d) and were compared with those of clinically healthy controls. Fifty-four ambulatory children with mean (±standard deviation [SD]) age 9.0 ± 4.5 yrs on VPA (200-1200 mg/d) long-term monotherapy (mean: 3.2 ± 2.6 yrs) were studied, before and after a year's vitamin D intake (400 IU/d).

RESULTS

Nearly half of the cases were vitamin D insufficient/deficient with mean levels 23.1 ± 12.8 vs 31.8 ± 16.2 ng/mL of controls (p = 0.004) and after the year of vitamin D intake increased to 43.2 ± 21.7 ng/mL (p < 0.0001). In parallel, serum CTX and tALP had a decreasing trend approaching control levels but OPG and sRANKL did not change and were not different from controls. However, after vitamin D intake, a positive correlation was seen between 25OHD and OPG but not before.

CONCLUSIONS

The findings imply a higher bone turnover in the young patients on long-term VPA therapy that decreased after vitamin D intake.

Fragility fractures and reversible osteopaenia due to chronic hyponatraemia in an adolescent male

Fragility fractures are common in older adults and rare in children. Recent studies have demonstrated that hyponatraemia is a novel risk factor for the development of osteoporosis and hip fractures in older people. Animal studies suggest that hyponatraemia can lead to decreased bone mineral density by stimulating osteoclastic activity in order to mobilise sodium from the bone. Reported is a 16-year-old man with intractable epilepsy and an 11-year history of chronic hyponatraemia (126-135 mEq/L) due to valproic acid induced syndrome of inappropriate antidiuresis who sustained low-impact fragility fractures and had evidence of osteopaenia on both X-ray and dual energy X-ray absorptiometry (DEXA). Hyponatraemia resolved following the discontinuation of valproic acid and bone mineral density normalised on a repeat DEXA 19 months later. This case provides evidence supporting the contention that chronic hyponatraemia contributes to osteopaenia and fragility fractures and that the bone abnormalities are potentially reversible following the correction of hyponatraemia.

Collaboration of Care for Women with Epilepsy in their Reproductive Years

Over half a million women of childbearing age have epilepsy, many of which will require family planning care at some point in their reproductive years. Matters relating to contraception, pregnancy, fertility, and sexual functioning are all impacted to varying degrees by the use of antiepileptic drugs (AEDs) to treat epilepsy and require active management by a woman's neurologist. It is important that a woman's obstetrician/gynecologist (OBGYN) and internist are aware of the way in which their care may be related to her epilepsy care and how this can be successfully comanaged with her neurologist. This includes the impact AED therapies have on pregnancy, such as risk of teratogenicity, changes to AED clearance rates during pregnancy and postpartum, and risk of seizure worsening while pregnant; interactions of hormonal contraceptives and AEDs; side effects of AED treatment on hormonal systems and sexual functioning; and matters of fertility and infertility treatments. The current editorial discusses these relationships between AED choice, dose, and family planning matters for women with epilepsy in their childbearing years to support the collaboration of care between her neurologist, OBGYN, and internist.

Evaluation of bone health among epileptic patients using biochemical markers and DEXA scan: an Egyptian study

BACKGROUND

An association between antiepileptic drugs, low bone mineral density (BMD), fractures, and abnormalities in bone metabolism has been suggested for a longer period, although conclusive evidence has not been reported.

METHODS

Thirty epileptic patients and 30 matched healthy subjects participated in the study. Measurements of serum levels of calcium, phosphorus, vitamin D, parathormone, and alkaline phosphatase were done for included subjects. Dual-energy X-ray absorptiometry (DEXA) scan was also performed.

RESULTS

Serum calcium, phosphorus, and vitamin D were significantly lower, whereas serum parathormone and alkaline phosphatase were significantly higher in epileptic patients compared to control subjects. Bone mineral density (BMD) abnormalities were detected in 22 patients (73.4%). A statistically significant difference in DEXA scan measurements at different regions was detected between epileptic patients and control subjects. Epileptic patients receiving enzyme inducer antiepileptic drugs (AEDs) had significantly lower serum (calcium, phosphorous, and vitamin D) and lower BMD values compared to those receiving enzyme inhibitors. Results of BMD were positively correlated with serum calcium, phosphorous, and vitamin D, while negatively correlated with serum alkaline phosphatase and duration of therapy.

CONCLUSIONS

Abnormal bone health is common in epileptic patients. These abnormalities may be attributed to prolonged intake of AEDs especially enzyme inducers.

Which information on women's issues in epilepsy does a community pharmacist need to know? A Delphi consensus study

OBJECTIVE

The aim of this study was to develop and achieve consensus on a core list of important knowledge items that community pharmacists should know on women's issues in epilepsy.

METHODS

This was a consensual study using a modified Delphi technique. Knowledge items were collected from the literature and from nine key contacts who were interviewed on their views on what information community pharmacists should have on women's issues in epilepsy. More knowledge items were suggested by five researchers with interest in women's issues who were contacted to rate and comment on the knowledge items collected. Two iterative Delphi rounds were conducted among a panel of pharmacists (n=30) to achieve consensus on the knowledge items to be included in the core list. Ten panelists ranked the knowledge items by their importance using the Analytical Hierarchy Process (AHP).

RESULTS

Consensus was achieved to include 68 knowledge under 13 categories in the final core list. Items ranked by their importance were related to the following: teratogenicity (10.3%), effect of pregnancy on epilepsy (7.4%), preconception counseling (10.3%), bone health (5.9%), catamenial epilepsy (7.4%), menopause and hormonal replacement therapy (2.9%), contraception (14.7%), menstrual disorders and infertility (8.8%), eclampsia (2.9%), breastfeeding (4.4%), folic acid and vitamin K (5.9%), counseling on general issues (14.7%), and sexuality (4.4%).

CONCLUSION

Using consensual knowledge lists might promote congruence in educating and/or training community pharmacists on women's issues in epilepsy. Future studies are needed to investigate if such lists can improve health services provided to women with epilepsy (WWE).

Bone Health in Patients with Epilepsy: A Community-based Pilot Nested Case-control Study

Background:

Antiepileptic drugs (AEDs) adversely affect bone health and there are reports describing association of alternations of bone and mineral metabolism in epileptic patients.

Objectives:

This study was undertaken to evaluate the bone profile (bone mineral parameters and bone mineral density [BMD]) of patients with epilepsy and compare them to their age-, gender-, and socioeconomic status-matched healthy controls in a community.

Materials and Methods:

This was a nested case–control study conducted in fifty individuals, which included 25 cases (age above 18 years and on AEDs for at least 3 years) for which 25 controls were selected from the same community. Bone mineral parameters (serum calcium, proteins, phosphorous, alkaline phosphate, parathyroid hormone, and Vitamin D) and BMD were measured.

Results:

There was significant hypocalcemia (P = 0.003), hypoproteinemia (P = 0.014), hyperparathyroidism (P = 0.048), and increased levels of serum alkaline phosphatase (P = 0.019) in cases as compared to controls. The difference was insignificant in the serum levels of Vitamin D and phosphorous among both the groups. Vitamin D was significantly low in female patients as compared to males (P = 0.043). There was no significant difference in BMD at the lumbar spine and femur neck among both the groups. Mean duration of epilepsy was longest in patients with osteoporosis (23.6 years), and increasing duration of epilepsy was associated with reduction in age- and sex-corrected total BMD mean Z-score anteroposterior spine. There was negative correlation between cumulative drug load and T-score of patients with epilepsy.

Conclusion:

Patients on long-term AED treatment have altered bone profile as evident from biochemical parameters and reduced BMD. There is a need for more extensive research and that too on a larger sample size.

Association of 25-Hydroxyvitamin D Deficiency in Pediatric Epileptic Patients

OBJECTIVE

Epilepsy is a chronic neurological disorder requiring long-term therapy using antiepileptic medications. Reports have incriminated long-term antiepileptic drugs use in deficiency of vitamin D and bone diseases in all age groups. We aimed to investigate the association between serum 25-hydroxyvitamin D levels and pediatric epilepsy in Indian patients.

MATERIALS & METHODS

We prospectively recruited 100 pediatric epilepsy patients, on monotherapy for minimum one-year duration, and 50 age and sex matched controls. This study was carried out at Yashoda Hospital, India from 2011-2014. All cases and controls underwent tests for serum 25-hydroxyvitamin D, alkaline phosphatase, serum calcium and phosphorus levels.

RESULTS

Patients with 25-hydroxyvitamin D deficiency were significantly higher among cases (45%) than controls (24%). Mean alkaline phosphatase was significantly higher in cases and mean serum calcium was significantly lower (8.3±1.5) in cases. Amongst antiepileptic drugs, carbamazepine and sodium valproate were significantly associated with 25-hydroxyvitamin D deficiency. Risk of vitamin D deficiency was highest with sodium valproate usage (odds:4.0;95%CI 1.4-11.6) followed by carbamazepine use (odds: 2.7; 95%CI 1.0-6.8). After adjustment using multiple logistic regression, antiepileptic drugs showed independent association with 25-hydroxyvitamin D deficiency (odds:2.2;95%CI 0.9-4.5).

CONCLUSION

25-hydroxyvitamin D deficiency was significantly associated with use of carbamazepine and sodium valproate in pediatric epilepsy.

Bone Mineral Status in Children with Epilepsy: Biochemical and Radiologic Markers

Objective:

The aim of this study is to assess bone mineral status in children with epilepsy, on different antiepileptic drugs (AEDs) regimen, using dual-energy X-ray absorptiometry (DXA) and routine biochemical bone markers.

Patients and Methods:

This is observational prospective controlled cohort study, conducted at Mansoura University Children Hospital, from January 2014 to June 2015. In this study, we had 152 participants with ages 3–13 years, 70 children diagnosed with epilepsy and 82 were controls. Children classified into two groups according to the duration of treatment, Group 1 children maintained on AEDs for 6–24 months, Group 2 children ≥24 months. Bone mineral density (BMD) measured by DXA and biochemical markers includes serum calcium, phosphorus, alkaline phosphatase (ALP), and parathyroid hormone (PTH).

Results:

In this study, we found that the serum level of calcium and phosphate were significantly low (P > 0.05) in total cases versus control. We found that the serum level of and ALP and PTH were significantly high (P > 0.05) in total cases versus control. Regarding the DXA markers, there was a significant decrease of BMD and Z-score for the total body and lumbar area in the total cases versus control (P > 0.05).

Conclusion:

The present study showed that all AEDs (new and old) affect bone mineral status in children receiving therapy for more than 6 months, altering both biochemical markers (serum calcium, phosphorus, ALP, and PTH) and radiologic markers (BMD assessed using DXA). Children on AEDs for a longer duration (≥2 years) showed more severe side effects on BMD. Children receiving multiple AEDs are more prone to altered bone mineral status, especially with long duration of therapy. The study also highlights the role of DXA as a safe noninvasive method to assess BMD in children on long-term AEDs.

Epileptic seizure, as the first symptom of hypoparathyroidism in children, does not require antiepileptic drugs

OBJECTIVE

Patients with hypoparathyroidism exhibit metabolic disorders (hypocalcemia) and brain structural abnormalities (brain calcifications). Currently, studies have determined whether antiepileptic drug (AED) treatment is required for epileptic seizures in children with hypoparathyroidism.

METHOD

This study aims to evaluate the data of two medical centers in Beijing based on the diagnosis of epileptic seizures as the first symptom of hypoparathyroidism in children.

RESULT

A total of 42 patients were included and assigned into AED and non-AED treatment groups in a 1:2 matched case-control study. Results show that the seizure outcome after 1 year of AED treatment is not significantly different from that of the control. In the subgroup analysis of patients with subcortical calcifications, the seizure outcome is still not significantly different from that of the control.

CONCLUSION

Thus, AED treatment cannot improve the seizure outcomes in children with parathyroid disorder, even in such cases as suspected structural seizure caused by subcortical calcifications. Clinicians must take adequate considerations on the use of AEDs in these patients. Epileptic seizures, as the first symptom of hypoparathyroidism in children, do not require epilepsy drugs.

Relationship between Bone Density and Biochemical Markers of Bone among Two Groups Taking Carbamazepine and Sodium Valproate for Epilepsy in Comparison with Healthy Individuals in Yazd

Introduction

Chronic antiepileptic therapy has been associated with metabolic bone diseases including osteomalacia and osteoporosis. The aim of this study was to determine frequency of changes in biochemical and bone mineral density (BMD) in adults receiving valproaic acid (VPA) & carbamazepine (CBZ).

Methods

In a cross sectional study evaluating adults (age 20–50 y) epileptic patients receiving valproic acid or carbamazepine for at least 2 years. This study was conducted from May 2014 to May 2015 in Shahid Sadoughi Hospital of Yazd University of Medical Science, Yazd, Iran. Bone metabolism was evaluated by measurement of serum calcium (Ca), phosphorus (P), alkaline phosphatase (ALP) and parathormone hormone (PTH), BMD at lumbar and femoral measured by dual energy X ray absorptiometry (DXA). SPSS software (version 18) was used for data analysis. The t-test was used for quantitative data, and the chi-squared test was used for the qualitative variables.

Results

Eighty two epileptic patients (mean age: 31.67±10.69 year) treated with either carbamazepine (n=41) or valproate sodium (n=41) were studied. Normal serum Ca and P levels were observed in 98.8% and 97.6% of patients respectively. Serum ALP and PTH were normal in 97.6% and 97.6% of patients. Means of Ca and P in CBZ group were significantly lower than VPA group (Ca: 9.02 vs. 9.1, p-value: 0.03 and P: 3.54 vs. 3.76 p-value: 0.004). BMD values at lumbar spine were not significant in either group (T. score CBZ: −0.43± 0.744 vs. T. score VPA: −0.615± 0.904 and p-value: 0.333) and were significantly higher than Iranian normal population BMD value at femoral neck in CBZ group was lower than VPA group (T. score CBZ: −0.707± 0.896 vs. T. score VPA: − 0.297± 0.850 p-value: 0.04). Dosage of CBZ and VPA did not correlate with BMD and biochemical parameters. Duration of CBZ use had correlation with increased ALP and duration of VPA use had correlation with decreased BMD in adult patients.

Conclusion

long term anti-epileptic drug treatment either with CBZ and VPA which has unknown effects on skeletal mineralization and induces a state of decreased bone mineral density BMD values at femoral neck were significant in CBZ group Therefore regular screening for monitoring of biochemical markers of bone turnover and BMD with DXA during the treat period is recommended. In addition, Ca supplement could be considered for all patients with epilepsy upon initiation of CBZ and VPA therapy.

Bone Mineral Changes in Epilepsy Patients During Initial Years of Antiepileptic Drug Therapy

Antiepileptic drug (AED) therapy is associated with decreased bone mineral density; however, the time course for this development is unclear. The aim of this study was to evaluate bone mineral changes during the initial years of AED therapy in AED-naive, newly diagnosed epilepsy patients compared with non-AED users. In 49 epilepsy patients newly started on AEDs and in 53 non-AED users of both genders, bone mineral density (BMD) and bone mineral content were measured using dual-energy X-ray absorptiometry at baseline (within the first year of therapy) and at least 1 yr later. Bone changes between the 2 assessments, adjusted for age, height, and weight, were calculated as the annual rate of change. The median duration of AED therapy was 3.5 mo at baseline and 27.6 mo at follow-up. No overall difference was found in mean BMD and bone mineral content measures between user and nonuser cohorts in both cross-sectional baseline and the annual rate of change (p > 0.05). However, users on carbamazepine monotherapy (n = 11) had an increased annual rate of total hip (-2.1% vs -0.8%, p = 0.020) and femoral neck BMD loss (-2.1% vs -0.6%, p = 0.032) compared to nonusers. They also had a marginally higher rate of femoral neck BMD loss (-2.1%, p = 0.049) compared with valproate (-0.1%, n = 13) and levetiracetam users (+0.6%, n = 13). During the initial years of AED treatment for epilepsy, no difference was found in bone measures between AED users as a group and nonuser cohorts. However, the data suggested that carbamazepine monotherapy was associated with increased bone loss at the hip regions, compared to users of levetiracetam or valproate and nonusers. Larger studies of longer duration are warranted to better delineate the bone effects of specific AEDs, with further consideration of the role of early dual-energy X-ray absorptiometry scanning and careful AED selection in potentially minimizing the impact on bone health in these patients.

Impact of antiepileptic drugs on bone health: Need for monitoring, treatment, and prevention strategies

Epilepsy is the most common neurological disorder affecting approximately 50 million people worldwide. In India, overall prevalence of epilepsy is reported to be 5.59/1000 population. Antiepileptic drugs (AEDs) constitute the main-stay of treatment with a large number of AEDs available in the market. High incidence of adverse effects is a major limitation with AEDs. One of the major concerns is significant metabolic effects on the bone. However, little attention has been paid to this issue because most of the bone effects remain subclinical for a long time and may take years to manifest clinically. The main effects include hypocalcemia, hypophosphatemia, reduced serum levels of Vitamin D, increase in parathormone (PTH) levels, and alterations in bone turnover markers. The CYP450 enzyme-inducing AEDs such as phenytoin, phenobarbital, carbamazepine, and primidone are the most common AEDs associated with bone disorders while the data regarding the effect of valproate and newer AEDs such as lamotrigine, gabapentin, vigabatrin, levetiracetam, and topiramate on bone metabolism and bone density are scanty and controversial. Deficiency of Vitamin D is commonly described as a cause for the bone loss in epileptic patients while others being decreased absorption of calcium, increased PTH levels, and inhibition of calcitonin secretion, etc. However, there are no formal practical guidelines for the management of bone disease among those taking AEDs. Evidence-based strategies regarding monitoring, prevention, and treatment of bone diseases in patients on AED therapy are needed.

Phenytoin Induced Osteopathy -Too Common to be Neglected

Anticonvulsants have the broad spectrum of side effects on the bone that are collectively known as osteopathy. Anticonvulsant induced osteopathy can have detrimental consequences. We present an unusual case that uniquely highlights both adverse effects of phenytoin on bone metabolism and side effects of its overtreatment. A 29-year-old lady came for evaluation of metabolic bone disease. Since last one year, she had severe bilateral hip pain resulting in restriction of movements. She was taking phenytoin 300 mg daily for last ten years for a seizure disorder. During evaluation at another center, she was diagnosed to have vitamin D deficiency, osteomalacia and secondary hyperparathyroidism. She received recombinant parathormone, high doses of vitamin D along with phenytoin. She presented at our centre with persistent pain and hypervitaminosis D. We stopped recombinant PTH, vitamin D and changed phenytoin to levetiracetam. Her condition improved over next six months with normalization of vitamin D. Thus, patients on phenytoin should be actively screened for side effects and the appropriate preventive and correctional measures should be undertaken. While managing these side effects overtreatment should be avoided.

Increase of 25-hydroxyvitamin D levels after initiation of combination antiretroviral therapy

Although vitamin D deficiency in HIV patients reported worldwide, the mechanisms and the effect of combination antiretroviral therapy (cART) on vitamin D levels are unclear. Patients were 50 male Japanese with HIV who visited Teikyo University Hospital, Tokyo, Japan. Patients were divided into those receiving cART (cART-experienced group, n = 30) and those who had not received cART (cART-naïve group, n = 20). Patients in the cART-experienced group had received treatment with cART for more than one year and those in the cART-naïve group were just about to start cART at study entry. Patients underwent measurement of serum 25-hydroxyvitamin D (25(OH)D) levels and assessment of clinical factors twice at one year intervals. At study entry, 23 (76.7%) in the cART-experienced group and 19 (95.0%) in the cART-naïve group had vitamin D insufficiency or deficiency. Mean 25(OH)D values were significantly higher in the cART-experienced group (25.2 ng/ml vs. 19.3 ng/ml, p = 0.01). However, levels of 25(OH)D at one year increased more in the cART-naïve group (-1.1 ng/ml vs. 5.0 ng/ml, p = 0.01), with mean 25(OH)D values in the cART-naïve group increasing to match those in the cART-experienced group. HIV infected patients who initiated cART showed increases in vitamin D levels in one year.

Characteristics of 22q 11.2 deletion syndrome undiagnosed until adulthood: an example suggesting the importance of psychiatric manifestations

Patients with chromosome 22q11.2 deletion syndrome (22q11.2DS) exhibit various combinations of signs and symptoms including facial dysmorphism, thymus absence, hypoparathyroidism, cellular immunodeficiency and cardiac abnormalities caused by microdeletion of chromosome 22q11.2. Most cases are diagnosed during post-natal cardiac evaluation, though some are diagnosed at later stages. We report the case of a 39-year-old man with 22q11.2DS presenting with seizure due to tardily manifested hypocalcaemia and anxiety disorder. Our experience suggests that 22q11.2DS patients lacking fatal or well-recognised manifestations such as cardiac defects, immunodeficiency and facial dysmorphism tend to survive without medical attention, and are therefore overlooked. Recognition of the age-related variance of the manifestations, and specifically of tardily manifested hypocalcaemia and psychiatric or developmental disorders as manifestations of 22q11.2DS in adulthood, is important for diagnosis and can also help us provide appropriate medical and psychosocial support for newly diagnosed 22q11.2DS patients in adolescence or adulthood and their families.

Medication-induced osteoporosis: screening and treatment strategies

Drug-induced osteoporosis is a significant health problem and many physicians are unaware that many commonly prescribed medications contribute to significant bone loss and fractures. In addition to glucocorticoids, proton pump inhibitors, selective serotonin receptor inhibitors, thiazolidinediones, anticonvulsants, medroxyprogesterone acetate, aromatase inhibitors, androgen deprivation therapy, heparin, calcineurin inhibitors, and some chemotherapies have deleterious effects on bone health. Furthermore, many patients are treated with combinations of these medications, possibly compounding the harmful effects of these drugs. Increasing physician awareness of these side effects will allow for monitoring of bone health and therapeutic interventions to prevent or treat drug-induced osteoporosis.

Phenytoin and sodium valproate but not levetiracetam induce bone alterations in female mice

Adverse effects on the bone are amongst the potentially adverse clinical consequences with antiepileptic drugs (AEDs). This study compared the effects of 3 AEDs (phenytoin (PHT), sodium valproate (SVP), and levetiracetam (LTM)) on the bones of a Swiss strain of albino female mice. Drugs were administered daily for 4 months at doses that produced plasma concentrations corresponding to the clinically relevant therapeutic ranges. PHT and SVP (but not LTM) significantly lowered the bone mineral density (BMD) of lumbar vertebrae (L2–L4) as evaluated by dual-energy X-ray absorptiometry (DEXA) scan. The findings were supported by histopathology of vertebral (lumbar) bone and analysis of bone turnover markers. While both PHT and SVP reduced alkaline phosphatase (ALP) and hydroxyproline (HxP) in lumbar vertebrae, and elevated tartarate-resistant acid phosphatase (TRAP) and urinary excretion of calcium, LTM did not affect any of these markers of bone turnover, indicating that the drug might be a safer option in female epileptic patients prone to bone changes.

Prenatal exposure to lamotrigine: effects on postnatal development and behaviour in rat offspring

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.

Epilepsy and vitamin D

Several disorders, both systemic and those of the nervous system, have been linked with vitamin D deficiency. Neurological disorders with a vitamin D link include but are not limited to multiple sclerosis, Alzheimer and Parkinson disease, as well as cerebrovascular disorders. Epilepsy which is the second leading neurological disorder received much less attention. We review evidence supporting a link between vitamin D and epilepsy including those coming from ecological as well as interventional and animal studies. We also assess the literature on the interaction between antiepileptic drugs and vitamin D. Converging evidence indicates a role for vitamin D deficiency in the pathophysiology of epilepsy.

Recurrent fractures as a new skeletal problem in the course of Angelman syndrome

Angelman syndrome is a genetically inherited syndrome with severe retardation of psychomotor development and speech disturbances, usually accompanied by epilepsy, typical dysmorphic features, and some skeletal symptoms. The aim of the current report is to present new skeletal symptoms which may occur in the course of AS, based on a case report of an 8-year-old girl with confirmed 15q11;12 microdeletion and recurrent low-trauma bone fractures. According to our knowledge it is the first report of such skeletal symptoms in patient with a diagnosis of AS.

Primidone--an antiepileptic drug--characterisation by quantum chemical and spectroscopic (FTIR, FT-Raman, 1H, 13C NMR and UV-Visible) investigations

The solid phase FTIR and FT-Raman spectra of primidone were recorded in the regions 4000-400 cm(-1) and 4000-100 cm(-1), respectively. The vibrational spectra were analysed and the observed fundamentals were assigned and analysed. The experimental wavenumbers were compared with the theoretical scaled vibrational wavenumbers determined by DFT methods. The Raman intensities were also determined with B3LYP/6-31G(d,p) method. The total electron density and molecular electrostatic potential surface of the molecule were constructed by using B3LYP/6-311++G(d,p) method to display electrostatic potential (electron+nuclei) distribution. The HOMO and LUMO energies were measured. Natural bond orbital analysis of primidone has been performed to indicate the presence of intramolecular charge transfer. The (1)H and (13)C NMR spectra were recorded and the chemical shifts of the molecule were calculated.

Factors contributing to chronic fatigue after traumatic brain injury

BACKGROUND

The annual incidence of traumatic brain injury in Europe amounts to 235 per 100 000 persons. About two-thirds will develop posttraumatic brain injury chronic fatigue (pTBI-CF).

AIM

To identify the reversible hormonal and nonhormonal causes of pTBI-CF.

PATIENTS AND METHODS

Ninety patients with varying degrees of pTBI-CF underwent endocrine testing and an evaluation of sleep, attention, coping style, daily activity and dependency, physical performance, emotional well-being, and quality of life.

RESULTS

Vitamin D deficiency was found in 65%, poor sleep quality in 54%, anxiety disorders in 36%, growth hormone deficiency in 16%, and gonadal hormone deficiencies in 9%. Fatigue severity was correlated with poor sleep (R = +0.65, P < .0001), serum 25-hydroxy vitamin D levels (R = -0.50, P < .0001), and anxiety (R = +0.50, P < .0001) but not with growth hormone deficiency or gonadal hormone deficiencies. The first 3 factors together explained 59% of the fatigue score variance.

CONCLUSIONS

Poor sleep, vitamin D deficiency, and anxiety were the most important factors associated with pTBI-CF. Appropriate treatment of these disorders may help to reduce fatigue in these patients.

Prevalence of low bone mineral density in inpatients with traumatic brain injury receiving neurobehavioural rehabilitation: a postoperative, observational study

BACKGROUND

Osteoporosis is characterised by low bone mineral density (BMD) leading to an increased risk of fracture. Patients who have sustained a significant traumatic brain injury may have an increased risk of secondary reduced BMD as a result of immobility and other factors.

OBJECTIVES

To describe BMD in a cohort of patients recovering from traumatic brain injury, and to discuss the implications of the findings for physiotherapy practice.

DESIGN

Prospective, observational.

SETTING

Specialist, residential unit providing care for individuals with brain injury, many with a history of severe challenging behaviour.

PARTICIPANTS

Current inpatients (n=51, 80% male) with the capacity to provide consent, as judged by their responsible clinician. The median age was 41 years (range 20 to 60 years), and the median time since the brain injury was sustained was 22 years (range 4 to 54 years).

METHODS

Participants' BMD was measured at the radius and tibia using quantitative ultrasound. Various clinical and demographic details were collected.

RESULTS

Participants had suboptimal BMD measurements that were generally low for their age and gender. Nine (18%) participants met the criteria for osteopenia measured at the radius, and 26 (51%) participants met criteria for osteoporosis or osteopenia measured at the tibia.

CONCLUSIONS

Some participants had reduced BMD, putting them at risk of fracture or of developing such risk in the future. This group is at particular risk because they frequently display challenging aggressive behaviours that may be met with responses including proportionate use of manual restraint. Physiotherapists should bear this increased risk in mind when devising exercise programmes assessing risk in neurobehavioural rehabilitation settings.

Influence of drugs on vitamin D and calcium metabolism

In the past, interactions between drugs and vitamin D have received only little or no attention in the health care practices. However, since more and more drugs are used for the treatment of patients, this topic is increasingly relevant. Several drugs can interfere with the vitamin D and bone metabolism. Drugs that activate the pregnane X receptor can disrupt vitamin D metabolism and vitamin D function. Beside this, the medication oriented supplementation of vitamin D can ameliorate the pharmacologic action of some drugs, such as bisphosphonates, cytostatics and statins.

Epilepsy: fractures and the role of cumulative antiepileptic drug load

BACKGROUND

An association between antiepileptic drugs (AEDs), low bone mineral density (BMD), fractures, and abnormalities in bone metabolism has been suggested for a longer period, although conclusive evidence has not been reported. We aimed at studying patient characteristics in a high-risk population.

METHODS

All adult patients from a residential unit of a tertiary epilepsy center who were diagnosed with osteoporosis and consequently treated with a bisphosphonate at that moment were included. Correlations between reported fractures and patient characteristics were explored.

RESULTS

Of the total population of 261 adult patients, 54 patients were included resulting in a high prevalence rate of 21% osteoporosis in this population. The number of fractures correlated significantly with ambulatory status (r = -0.269, P = 0.05), drug load (r = 0.286, P = 0.04), and current number of AEDs (r = 0.283, P = 0.04). Correlations could not be provided for individual drugs in our population as only a minority was on monotherapy and even less patients had always been on monotherapy of the same antiepileptic drug. Linear regression analysis showed that cumulative drug load (defined by a surrogate parameter: the total duration of epilepsy multiplied by the number of AEDs) was the dominant factor explaining the occurrence of fractures.

CONCLUSION

In this high-risk population, we obtained a positive and strong correlation between the occurrence of fractures in a diagnosed population with osteoporosis and the cumulative drug load of AEDs. This effect seems general, independent of the type of AEDs that were used.

The Rapidly Evolving Research on Vitamin D Among HIV-Infected Populations

With ongoing improvement in antiretroviral therapy, mortality among HIV-infected persons has dramatically decreased. For HIV-infected persons who remain engaged in care on suppressive therapy, life expectancy approaches that of the general population. Additionally, we have seen increases in comorbidities traditionally associated with aging: diabetes, hypertension, dyslipidemia, ischemic heart disease, and osteoporosis. Vitamin D deficiency has also been identified as a highly prevalent entity among HIV-infected populations. The association of vitamin D deficiency with several of these comorbidities and its impact on immune function provide the impetus for well-designed studies to evaluate the impact of vitamin D supplementation on HIV disease and antiretroviral therapy. This review summarizes the role of vitamin D in several disease states that are prevalent among HIV populations, with a specific focus on bone health and the interactions with antiretroviral medications.