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Behn M, Kielhofner J, Panicker JN, Kaplan TB. Sexual dysfunction and commonly used drugs in neurology. Pract Neurol 2024; 24:207-214. [PMID: 38212111 DOI: 10.1136/pn-2023-003760] [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] [Accepted: 12/17/2023] [Indexed: 01/13/2024]
Abstract
Sexual dysfunction is common in men and women with neurological diseases. Medications used in neurology can cause sexual dysfunction independently of the disease process and this may adversely affect patients' quality of life. This review focuses on medications commonly prescribed to neurological patients that may contribute to altered sexual function, and discusses how they may differ in men and women.
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Affiliation(s)
- Maya Behn
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Tamara B Kaplan
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Hope OA, Harris KM. Management of epilepsy during pregnancy and lactation. BMJ 2023; 382:e074630. [PMID: 37684052 DOI: 10.1136/bmj-2022-074630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Epilepsy is a group of neurological diseases characterized by susceptibility to recurrent seizures. Antiseizure medications (ASMs) are the mainstay of treatment, but many antiseizure medications with variable safety profiles have been approved for use. For women with epilepsy in their childbearing years, the safety profile is important for them and their unborn children, because treatment is often required to protect them from seizures during pregnancy and lactation. Since no large randomized controlled trials have investigated safety in this subgroup of people with epilepsy, pregnancy registries, cohort and case-control studies from population registries, and a few large prospective cohort studies have played an important role. Valproate, in monotherapy and polytherapy, has been associated with elevated risk of major congenital malformations and neurodevelopmental disorders in children born to mothers who took it. Topiramate and phenobarbital are also associated with elevated risks of congenital malformations and neurodevelopmental disorders, though the risks are lower than those of valproate. Lamotrigine and levetiracetam are relatively safe. Insufficient data exist to reach strong conclusions about the newest antiseizure medications such as eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Besides antiseizure medications, other treatments such as vagal nerve stimulation, responsive neurostimulation, and deep brain stimulation are likely safe. In general, breastfeeding does not appear to add any additional long term risks to the child. Creative ways of optimizing registry enrollment and data collection are needed to enhance patient safety.
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Affiliation(s)
- Omotola A Hope
- Houston Methodist Sugarland Neurology Associates, Houston, TX, USA
| | - Katherine Mj Harris
- Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, USA
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Management of Anti-Seizure Medications during Pregnancy: Advancements in The Past Decade. Pharmaceutics 2022; 14:pharmaceutics14122733. [PMID: 36559227 PMCID: PMC9788450 DOI: 10.3390/pharmaceutics14122733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/24/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Management of seizures often involves continuous medication use throughout a patient's life, including when a patient is pregnant. The physiological changes during pregnancy can lead to altered drug exposure to anti-seizure medications, increasing patient response variability. In addition, subtherapeutic anti-seizure medication concentrations in the mother may increase seizure frequency, raising the risk of miscarriage and preterm labor. On the other hand, drug exposure increases can lead to differences in neurodevelopmental outcomes in the developing fetus. Established pregnancy registries provide insight into the teratogenicity potential of anti-seizure medication use. In addition, some anti-seizure medications are associated with an increased risk of major congenital malformations, and their use has declined over the last decade. Although newer anti-seizure medications are thought to have more favorable pharmacokinetics in general, they are not without risk, as they may undergo significant pharmacokinetic changes when an individual becomes pregnant. With known changes in metabolism and kidney function during pregnancy, therapeutic monitoring of drug concentrations helps to determine if and when doses should be changed to maintain similar seizure control as observed pre-pregnancy. This review concentrates on the results from research in the past decade (2010-2022) regarding risks of major congenital malformations, changes in prescribing patterns, and pharmacokinetics of the anti-seizure medications that are prescribed to pregnant patients with epilepsy.
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King C, Parker TM, Roussos-Ross K, Ramirez-Zamora A, Smulian JC, Okun MS, Wong JK. Safety of deep brain stimulation in pregnancy: A comprehensive review. Front Hum Neurosci 2022; 16:997552. [PMID: 36248692 PMCID: PMC9557283 DOI: 10.3389/fnhum.2022.997552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionDeep brain stimulation (DBS) is increasingly used to treat the symptoms of various neurologic and psychiatric conditions. People can undergo the procedure during reproductive years but the safety of DBS in pregnancy remains relatively unknown given the paucity of published cases. We thus conducted a review of the literature to determine the state of current knowledge about DBS in pregnancy and to determine how eligibility criteria are approached in clinical trials with respect to pregnancy and the potential for pregnancy.MethodsA literature review was conducted in EMBASE to identify articles involving DBS and pregnancy. Two reviewers independently analyzed the articles to confirm inclusion. Data extracted for analysis included conditions treated, complications at all stages of pregnancy, neonatal/pediatric outcomes, and DBS target. A second search was then conducted using www.clinicaltrials.gov. The same two reviewers then assessed whether each trial excluded pregnant individuals, lactating individuals, or persons of childbearing age planning to conceive. Also assessed was whether contraception had to be deemed adequate prior to enrollment.ResultsThe literature search returned 681 articles. Following independent analysis and agreement of two reviewers, 8 pregnancy related DBS articles were included for analysis. These articles described 27 subjects, 29 pregnancies (2 with subsequent pregnancies), and 31 infants (2 twin pregnancies). There was 1 preterm birth at 35 weeks, and 3 patients who experienced discomfort from the DBS battery (i.e., impulse generator) placement site. All 27 patients had a DBS device implanted before they became pregnant, which remained in use throughout their pregnancy. There was exclusion of pregnant individuals from 68% of 135 interventional trials involving DBS. Approximately 44% of these trials excluded persons of childbearing age not on “adequate contraception” or wishing to conceive in the coming years. Finally, 22% excluded breastfeeding persons.ConclusionThe data from 29 pregnancies receiving DBS treatment during pregnancy was not associated with unexpected pregnancy or post-partum complication patterns. Many clinical trials have excluded pregnant individuals. Documentation of outcomes in larger numbers of pregnancies will help clarify the safety profile and will help guide study designs that will safely include pregnant patients.
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Affiliation(s)
- Caroline King
- Department of Obstetrics & Gynecology, University of Florida College of Medicine, Gainesville, FL, United States
| | - T. Maxwell Parker
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL, United States
| | - Kay Roussos-Ross
- Department of Obstetrics & Gynecology, University of Florida College of Medicine, Gainesville, FL, United States
- Center for Research in Perinatal Outcomes, University of Florida College of Medicine, Gainesville, FL, United States
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL, United States
| | - John C. Smulian
- Department of Obstetrics & Gynecology, University of Florida College of Medicine, Gainesville, FL, United States
- Center for Research in Perinatal Outcomes, University of Florida College of Medicine, Gainesville, FL, United States
| | - Michael S. Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL, United States
| | - Joshua K. Wong
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL, United States
- *Correspondence: Joshua K. Wong,
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Octaviana F, Sumapraja K, Wiratman W, Indrawati LA, Budikayanti A. Characteristics of menstrual disorders and reproductive hormones in women with epilepsy at an Indonesian national referral hospital. Front Neurol 2022; 13:964761. [PMID: 36204000 PMCID: PMC9531022 DOI: 10.3389/fneur.2022.964761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveMenstrual disorders are more common in women with epilepsy than in those without epilepsy. This study aimed to examine the characteristics of reproductive function in women with epilepsy at an Indonesian national referral hospital.MethodsA case-control study was conducted from March 2020 to March 2021. Women with and without epilepsy aged ≥18 years were enrolled. All women were premenopausal before epilepsy diagnosis. Data on demographic characteristics, menstrual profiles, epileptic syndrome, seizure type, seizure frequency, etiology, localization, and anticonvulsant medication were collected. Hormone levels (follicle stimulating hormone, luteinizing hormone, prolactin, and estradiol) were measured.ResultsA total of 72 women with and 50 without epilepsy (controls) were included. Dysmenorrhea was more common in women with epilepsy than in those without (59.7 vs. 20%, p < 0.001; odds ratio: 5.931 [95% confidence interval: 2.566–13.709]). Marriage rates were higher in women without epilepsy (82 vs. 45.8%, p < 0.001). No difference was found in hormone levels between the groups. The frequency of seizures was associated with prolactin and estradiol levels (p < 0.001). Polytherapy with clobazam was associated with menstrual cycle regularity. In women with epilepsy with menstrual disorders, valproic acid was associated with higher estradiol levels (p = 0.001) and lamotrigine with lower follicle stimulating hormone levels (p = 0.008).SignificanceWomen with epilepsy experienced more dysmenorrhea. A higher frequency of seizures associated with lower prolactin and estradiol levels. Polytherapy with clobazam was associated with irregular menstrual cycles, while valproic acid and lamotrigine was associated with estradiol and follicle stimulating hormone levels.
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Affiliation(s)
- Fitri Octaviana
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Neurology, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia
- *Correspondence: Fitri Octaviana
| | - Kanadi Sumapraja
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Obstetrics and Gynecology, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia
| | - Winnugroho Wiratman
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Neurology, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia
| | - Luh Ari Indrawati
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Neurology, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia
| | - Astri Budikayanti
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Neurology, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia
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Waldman G, Benson R. Epilepsy Care in Transgender Patients. Curr Neurol Neurosci Rep 2022; 22:451-458. [PMID: 35666366 DOI: 10.1007/s11910-022-01208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to outline the main considerations when treating transgender patients with epilepsy. Points to be addressed include the gender affirming hormone therapy regimens and how they interact with anti-seizure medications and seizure control, as well as common co-morbidities in the transgender epilepsy population. RECENT FINDINGS Gender affirming hormone therapy (GAHT) may affect seizure control directly, due to proconvulsant or anticonvulsant properties. GAHT may interact with anti-seizure medications; most notably, estrogen will decrease serum concentration of lamotrigine. Enzyme-inducing anti-seizure medications may decrease hormone levels, potentially interfering with goals of GAHT. Transgender epilepsy patients are at risk for co-morbidities such as decreased bone mineral density and depression. There are minimal direct studies on treatment or outcomes in the transgender epilepsy population. Providers must be knowledgeable about the bi-directional interactions between gender affirming hormone therapy and anti-seizure medications, as well as direct hormonal influences on seizure control. Future research should directly evaluate outcomes in transgender epilepsy patients with regard to seizure control, success of hormone therapy, and management of co-morbidities, to further educate providers and patients how to best manage their healthcare.
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Affiliation(s)
- Genna Waldman
- Department of Neurology, Columbia University, 710 W. 168th Street, 7th floor, New York, NY, 10032, USA.,New York Presbyterian Hospital, 630 West 168th Street , New York, NY, 10032, USA
| | - Rachael Benson
- Department of Neurology, Columbia University, 710 W. 168th Street, 7th floor, New York, NY, 10032, USA.
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Adoukonou T, Agbétou M, Sidi RI, Gnansounou C, Accrombessi D, Hounzangbe-Adoukonou Y, Gnonlonfoun D, Kabibou S, Tonato-Bagnan JA, Houinato D. Prognosis of Pregnancy in Epileptics in Benin: A Case-Control Study. J Neurosci Rural Pract 2020; 11:395-402. [PMID: 32753803 PMCID: PMC7394660 DOI: 10.1055/s-0040-1709366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective The main purpose of this article is to define prognosis of pregnancies in epileptic women in Benin. Methods This was a case-control study that included 54 epileptic women who had at least one pregnancy matched to 162 controls on age, pregnancy term, and monitoring center. Information about epilepsy, treatment, pregnancy, and childbirth were collected. A logistic regression with odds ratio (OR) calculation was used to study the association. Results During pregnancy 22.22% of epileptic women experienced an increase in seizure frequency. Epileptics had more frequent miscarriages (OR: 1.84 [1.01-3.51]), more incidents during pregnancy (OR: 4.03 [1.04-15.60]), and were more often hospitalized (OR: 3.35 [1.46-7.69]) than women without epilepsy. They, more often, had premature children before 37 weeks of amenorrhea (OR: 2.10 [1.12-3.91]) and gave birth to low-birth-weight children (OR = 2.17 [1.00-4.76]). Conclusion Occurrence of a pregnancy in an epileptic woman in Benin is at risk and requires multidisciplinary monitoring by both neurologist and obstetrician to reduce complications.
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Affiliation(s)
- Thierry Adoukonou
- Department of Neurology, University of Parakou, Parakou, Benin
- Clinic of Neurology, University Teaching Hospital of Parakou, Parakou, Benin
| | - Mendinatou Agbétou
- Department of Neurology, University of Parakou, Parakou, Benin
- Clinic of Neurology, University Teaching Hospital of Parakou, Parakou, Benin
| | - Rachidi Imorou Sidi
- Department of Gynecology and Obstetrics, University of Parakou, Parakou, Benin
| | - Colombe Gnansounou
- Clinic of Neurology, University Teaching Hospital of Parakou, Parakou, Benin
| | - Donald Accrombessi
- Clinic of Neurology, University Teaching Hospital of Parakou, Parakou, Benin
| | | | | | - Salifou Kabibou
- Department of Gynecology and Obstetrics, University of Parakou, Parakou, Benin
| | | | - Dismand Houinato
- Department of Neurology, University of Abomey-Calavi, Cotonou, Benin
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Spiegel R, Merius H. Principles of Epilepsy Management for Women in Their Reproductive Years. Front Neurol 2020; 11:322. [PMID: 32411084 PMCID: PMC7198776 DOI: 10.3389/fneur.2020.00322] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/03/2020] [Indexed: 02/02/2023] Open
Abstract
In the United States, there are over one million women with epilepsy (WWE) in their childbearing years. Pregnancy can be challenging for this population. A number of international registries have documented that children born to these women are at increased risk for major congenital malformations (MCM), lower intelligence quotient scores and neurodevelopmental disorders, when the mother is managed on antiseizure medications (ASMs). To prevent poor neonatal outcomes for this population, safe and thoughtful management strategies are necessary. We propose to divide these management strategies into five principles. These include (I) choosing suitable ASMs for the patient's seizure type, (II) choosing an ASM with the least teratogenic and cognitive side effects, (III) dosing at the lowest possible effective dosage, (IV) selecting the best ASM regimen as promptly as possible, even before a woman has her first menses, and (V) supplementing these patients with folic acid in order to try to enhance cognition and reduce neural tube defects.
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Affiliation(s)
- Rebecca Spiegel
- Department of Neurology, Stony Brook Medicine, Stony Brook, NY, United States
| | - Heidy Merius
- Department of Neurology, Stony Brook Medicine, Stony Brook, NY, United States
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Abstract
The management of epilepsy during pregnancy involves optimizing seizure control for the mother, while ensuring the best outcome for the developing fetus. Preconception counseling regarding contraception, folic acid, and antiseizure medications (ASMs) will maximize positive outcomes. Folic acid supplementation is recommended to decrease risk of neural tube defects, similar to the general population, and has been associated with improved cognitive outcomes and decreased risk of autistic traits in offspring. Efforts should be made to optimize the ASM regimen before pregnancy to the fewest number of ASMs, lowest effective doses, with avoidance of more teratogenic agents such as valproic acid. Valproic acid is associated with the highest increased risk of major congenital malformations, as well as reduced cognitive outcomes and neurodevelopmental disorders. Decreasing or changing ASMs during pregnancy should be done with caution, as convulsive seizures have been associated with adverse fetal outcomes including cognitive impairment. Physiologic changes during pregnancy affect ASM levels and in turn, risk for seizures, necessitating frequent monitoring of ASM serum concentrations. Mothers should also be counseled postpartum about how the benefits of breastfeeding outweigh the transmission of medication into breast milk. Communication between providers (obstetrics and neurology) and pregnant women with epilepsy is essential.
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Affiliation(s)
- Rachael Benson
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States
| | - Alison Pack
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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