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Leinonen MK, Igland J, Dreier JW, Alvestad S, Cohen JM, Gilhus NE, Gissler M, Sun Y, Tomson T, Zoega H, Vegrim HM, Christensen J, Bjørk MH. Socioeconomic differences in use of antiseizure medication in pregnancies with maternal epilepsy: A population-based study from Nordic universal health care systems. Epilepsia 2024; 65:2397-2411. [PMID: 38804650 DOI: 10.1111/epi.18022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Research points to disparities in disease burden and access to medical care in epilepsy. We studied the association between socioeconomic status (SES) and antiseizure medication (ASM) use in pregnancies with maternal epilepsy. METHODS We conducted a cross-sectional study consisting of 21 130 pregnancies with maternal epilepsy identified from Nordic registers during 2006-2017. SES indicators included cohabitation status, migrant background, educational attainment, and household income. Main outcomes were the proportion and patterns of ASM use from 90 days before pregnancy to birth. We applied multiple imputation to handle SES variables with 2%-4% missingness. We estimated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) using modified Poisson regression with the highest SES category as reference. RESULTS Mothers with the highest education and the highest income quintile used ASMs least frequently (56% and 53%, respectively). We observed increased risks of ASM discontinuation prior to or during the first trimester for low SES. The risk estimates varied depending on the SES indicator from aRR = 1.27 for low income (95% CI: 1.03-1.57) to aRR = 1.66 for low education (95% CI: 1.30-2.13). Migrant background was associated with ASM initiation after the first trimester (aRR 2.17; 95% CI 1.88-2.52). Low education was associated with the use of valproate during pregnancy in monotherapy (aRR 1.70; 95% CI 1.29-2.24) and in polytherapy (aRR 2.65; 95% CI 1.66-4.21). Low education was also associated with a 37% to 39% increased risk of switching from one ASM to another depending on the ASM used. For the other SES indicators, aRRs of switching varied from 1.16 (foreign origin; 95% CI 1.08-1.26) to 1.26 (not married or cohabiting; 95% CI 1.17-1.36). SIGNIFICANCE Low SES was associated with riskier patterns of ASM use: discontinuation, late initiation, and switching during pregnancy. These findings may reflect unplanned pregnancies, disparities in access to preconception counseling, and suboptimal care.
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Affiliation(s)
- Maarit K Leinonen
- Finnish Institute for Health and Welfare, Knowledge Brokers, Helsinki, Finland
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
| | - Jannicke Igland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Julie Werenberg Dreier
- National Centre for Register-Based Research, Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Silje Alvestad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- National Centre for Epilepsy, Member of the ERN EpiCARE, Oslo University Hospital, Oslo, Norway
| | - Jacqueline M Cohen
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Mika Gissler
- Finnish Institute for Health and Welfare, Knowledge Brokers, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Yuelian Sun
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, and Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Helga Zoega
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Håkon M Vegrim
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
- National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marte-Helene Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Forbes H, Madley-Dowd P, Ahlqvist V, Campbell J, Davies NM, Liebling R, Lyall K, Newschaffer C, Rast J, Tomson T, Zhong C, Magnusson C, Rai D, Lee BK. First-trimester use of antiseizure medications and the risk of miscarriage: a population-based cohort study. J Neurol Neurosurg Psychiatry 2024; 95:693-703. [PMID: 38777577 PMCID: PMC11287565 DOI: 10.1136/jnnp-2023-333149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/27/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Antiseizure medications (ASMs) during the first trimester of pregnancy have been associated with an increased risk of miscarriage. METHODS We carried out a population-based cohort study using routinely collected healthcare data from the UK, 1995-2018. Pregnancies were identified in the Clinical Practice Research Datalink and we estimated the HR of miscarriage associated with prescriptions of ASMs during the first trimester of pregnancy, using Cox regression, adjusting for potential confounders, including ASM indications. RESULTS ASMs were prescribed during the first trimester in 7832 (0.8%) of 1 023 787 included pregnancies. 14.5% of pregnancies with first-trimester exposure to ASMs ended in miscarriage, while 12.2% without ASM exposure in the first trimester ended in miscarriage; after adjustment, there was a 1.06-fold relative hazard of miscarriage (95% CI 1.00 to 1.13) in women with first-trimester ASM use. After restricting to women with specific ASM indications, this association was not evident in women with epilepsy (adjusted HR 0.98, 95% CI 0.89 to 1.08), but was observed in women with bipolar or other psychiatric conditions (1.08, 95% CI 1.00 to 1.16) although CIs overlapped. Compared with discontinuation of ASMs prior to pregnancy, there was no evidence of increased risk of miscarriage for first-trimester ASM use in women with bipolar or other psychiatric conditions (1.02, 95% CI 0.87 to 1.20). CONCLUSION We found no clear evidence to suggest that first-trimester ASM use increased the risk of miscarriage. Taken together, our analyses suggest that apparent associations between first-trimester ASM use and miscarriage may be the result of confounding by the presence of a bipolar disorder or associated unmeasured variables.
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Affiliation(s)
- Harriet Forbes
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Madley-Dowd
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Viktor Ahlqvist
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Jennifer Campbell
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Neil M Davies
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Division of Psychiatry, University College London, London, UK
- K.G. Jebsen Center for Genetic Epidemiology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rachel Liebling
- Department of Obstetrics, University Hospitals Bristol and Weston, National Health Service England, Redditch, UK
| | - Kristen Lyall
- Department of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
| | - Craig Newschaffer
- College of Health and Human Development, The Pennsylvania State University, Pennsylvania, Texas, USA
| | - Jessica Rast
- Department of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
- A.J. Drexel Autism Institute, Philadelphia, Pennsylvania, USA
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Caichen Zhong
- Department of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
| | - Cecilia Magnusson
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Centre for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Dheeraj Rai
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Avon and Wiltshire Partnership NHS Mental Health Trust, Bristol, UK
| | - Brian K Lee
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Department of Epidemiology and Biostatistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
- A.J. Drexel Autism Institute, Philadelphia, Pennsylvania, USA
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Madley-Dowd P, Rast J, Ahlqvist VH, Zhong C, Martin FZ, Davies NM, Lyall K, Newschaffer C, Tomson T, Magnusson C, Rai D, Lee BK, Forbes H. Trends and patterns of antiseizure medication prescribing during pregnancy between 1995 and 2018 in the United Kingdom: A cohort study. BJOG 2024; 131:15-25. [PMID: 37340193 PMCID: PMC10730765 DOI: 10.1111/1471-0528.17573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/19/2023] [Accepted: 06/04/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE To examine antiseizure medication (ASM) prescription during pregnancy. DESIGN Population-based drug utilisation study. SETTING UK primary and secondary care data, 1995-2018, from the Clinical Practice Research Datalink GOLD version. POPULATION OR SAMPLE 752 112 completed pregnancies among women registered for a minimum of 12 months with an 'up to standard' general practice prior to the estimated start of pregnancy and for the duration of their pregnancy. METHODS We described ASM prescription across the study period, overall and by ASM indication, examined patterns of prescription during pregnancy including continuous prescription and discontinuation, and used logistic regression to investigate factors associated with those ASM prescription patterns. MAIN OUTCOME MEASURES Prescription of ASMs during pregnancy and discontinuation of ASMs before and during pregnancy. RESULTS ASM prescription during pregnancy increased from 0.6% of pregnancies in 1995 to 1.6% in 2018, driven largely by an increase in women with indications other than epilepsy. Epilepsy was an indication for 62.5% of pregnancies with an ASM prescription and non-epilepsy indications were present for 66.6%. Continuous prescription of ASMs during pregnancy was more common in women with epilepsy (64.3%) than in women with other indications (25.3%). Switching ASMs was infrequent (0.8% of ASM users). Factors associated with discontinuation included age ≥35, higher social deprivation, more frequent contact with the GP and being prescribed antidepressants or antipsychotics. CONCLUSIONS ASM prescription during pregnancy increased between 1995 and 2018 in the UK. Patterns of prescription around the pregnancy period vary by indication and are associated with several maternal characteristics.
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Affiliation(s)
- Paul Madley-Dowd
- - Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- - Medical Research Council Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, BS8 2BN, United Kingdom
| | - Jessica Rast
- - A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
- - Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Viktor H. Ahlqvist
- - Medical Research Council Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, BS8 2BN, United Kingdom
- - Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Caichen Zhong
- - A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
| | - Florence Z. Martin
- - Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- - Medical Research Council Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, BS8 2BN, United Kingdom
| | - Neil M. Davies
- - Medical Research Council Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, BS8 2BN, United Kingdom
- - K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Norway
- - Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Rd, London W1T 7NF
- - Department of Statistical Sciences, University College London, London WC1E 6BT, UK
| | - Kristen Lyall
- - Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Craig Newschaffer
- - College of Health and Human Development, The Pennsylvania State University, USA
| | - Torbjörn Tomson
- - Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Cecilia Magnusson
- - Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- - Centre for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Dheeraj Rai
- - Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- - Medical Research Council Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, BS8 2BN, United Kingdom
- - NIHR Biomedical Research Centre, University of Bristol, Bristol, United Kingdom
- - Avon and Wiltshire Partnership NHS Mental Health Trust, Bristol, United Kingdom
| | - Brian K. Lee
- - A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
- - Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
- - Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Harriet Forbes
- - Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- - Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Bromley R, Adab N, Bluett-Duncan M, Clayton-Smith J, Christensen J, Edwards K, Greenhalgh J, Hill RA, Jackson CF, Khanom S, McGinty RN, Tudur Smith C, Pulman J, Marson AG. Monotherapy treatment of epilepsy in pregnancy: congenital malformation outcomes in the child. Cochrane Database Syst Rev 2023; 8:CD010224. [PMID: 37647086 PMCID: PMC10463554 DOI: 10.1002/14651858.cd010224.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Prenatal exposure to certain anti-seizure medications (ASMs) is associated with an increased risk of major congenital malformations (MCM). The majority of women with epilepsy continue taking ASMs throughout pregnancy and, therefore, information on the potential risks associated with ASM treatment is required. OBJECTIVES To assess the effects of prenatal exposure to ASMs on the prevalence of MCM in the child. SEARCH METHODS For the latest update of this review, we searched the following databases on 17 February 2022: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to February 16, 2022), SCOPUS (1823 onwards), and ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP). No language restrictions were imposed. SELECTION CRITERIA We included prospective cohort controlled studies, cohort studies set within pregnancy registries, randomised controlled trials and epidemiological studies using routine health record data. Participants were women with epilepsy taking ASMs; the two control groups were women without epilepsy and untreated women with epilepsy. DATA COLLECTION AND ANALYSIS Five authors independently selected studies for inclusion. Eight authors completed data extraction and/or risk of bias assessments. The primary outcome was the presence of an MCM. Secondary outcomes included specific types of MCM. Where meta-analysis was not possible, we reviewed included studies narratively. MAIN RESULTS From 12,296 abstracts, we reviewed 283 full-text publications which identified 49 studies with 128 publications between them. Data from ASM-exposed pregnancies were more numerous for prospective cohort studies (n = 17,963), than data currently available for epidemiological health record studies (n = 7913). The MCM risk for children of women without epilepsy was 2.1% (95% CI 1.5 to 3.0) in cohort studies and 3.3% (95% CI 1.5 to 7.1) in health record studies. The known risk associated with sodium valproate exposure was clear across comparisons with a pooled prevalence of 9.8% (95% CI 8.1 to 11.9) from cohort data and 9.7% (95% CI 7.1 to 13.4) from routine health record studies. This was elevated across almost all comparisons to other monotherapy ASMs, with the absolute risk differences ranging from 5% to 9%. Multiple studies found that the MCM risk is dose-dependent. Children exposed to carbamazepine had an increased MCM prevalence in both cohort studies (4.7%, 95% CI 3.7 to 5.9) and routine health record studies (4.0%, 95% CI 2.9 to 5.4) which was significantly higher than that for the children born to women without epilepsy for both cohort (RR 2.30, 95% CI 1.47 to 3.59) and routine health record studies (RR 1.14, 95% CI 0.80 to 1.64); with similar significant results in comparison to the children of women with untreated epilepsy for both cohort studies (RR 1.44, 95% CI 1.05 to 1.96) and routine health record studies (RR 1.42, 95% CI 1.10 to 1.83). For phenobarbital exposure, the prevalence was 6.3% (95% CI 4.8 to 8.3) and 8.8% (95% CI 0.0 to 9277.0) from cohort and routine health record data, respectively. This increased risk was significant in comparison to the children of women without epilepsy (RR 3.22, 95% CI 1.84 to 5.65) and those born to women with untreated epilepsy (RR 1.64, 95% CI 0.94 to 2.83) in cohort studies; data from routine health record studies was limited. For phenytoin exposure, the prevalence of MCM was elevated for cohort study data (5.4%, 95% CI 3.6 to 8.1) and routine health record data (6.8%, 95% CI 0.1 to 701.2). The prevalence of MCM was higher for phenytoin-exposed children in comparison to children of women without epilepsy (RR 3.81, 95% CI 1.91 to 7.57) and the children of women with untreated epilepsy (RR 2.01. 95% CI 1.29 to 3.12); there were no data from routine health record studies. Pooled data from cohort studies indicated a significantly increased MCM risk for children exposed to lamotrigine in comparison to children born to women without epilepsy (RR 1.99, 95% CI 1.16 to 3.39); with a risk difference (RD) indicating a 1% increased risk of MCM (RD 0.01. 95% CI 0.00 to 0.03). This was not replicated in the comparison to the children of women with untreated epilepsy (RR 1.04, 95% CI 0.66 to 1.63), which contained the largest group of lamotrigine-exposed children (> 2700). Further, a non-significant difference was also found both in comparison to the children of women without epilepsy (RR 1.19, 95% CI 0.86 to 1.64) and children born to women with untreated epilepsy (RR 1.00, 95% CI 0.79 to 1.28) from routine data studies. For levetiracetam exposure, pooled data provided similar risk ratios to women without epilepsy in cohort (RR 2.20, 95% CI 0.98 to 4.93) and routine health record studies (RR 0.67, 95% CI 0.17 to 2.66). This was supported by the pooled results from both cohort (RR 0.71, 95% CI 0.39 to 1.28) and routine health record studies (RR 0.82, 95% CI 0.39 to 1.71) when comparisons were made to the offspring of women with untreated epilepsy. For topiramate, the prevalence of MCM was 3.9% (95% CI 2.3 to 6.5) from cohort study data and 4.1% (0.0 to 27,050.1) from routine health record studies. Risk ratios were significantly higher for children exposed to topiramate in comparison to the children of women without epilepsy in cohort studies (RR 4.07, 95% CI 1.64 to 10.14) but not in a smaller comparison to the children of women with untreated epilepsy (RR 1.37, 95% CI 0.57 to 3.27); few data are currently available from routine health record studies. Exposure in utero to topiramate was also associated with significantly higher RRs in comparison to other ASMs for oro-facial clefts. Data for all other ASMs were extremely limited. Given the observational designs, all studies were at high risk of certain biases, but the biases observed across primary data collection studies and secondary use of routine health records were different and were, in part, complementary. Biases were balanced across the ASMs investigated, and it is unlikely that the differential results observed across the ASMs are solely explained by these biases. AUTHORS' CONCLUSIONS Exposure in the womb to certain ASMs was associated with an increased risk of certain MCMs which, for many, is dose-dependent.
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Affiliation(s)
- Rebecca Bromley
- Division of Neuroscience, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Manchester, UK
| | - Naghme Adab
- Department of Neurology, A5 Corridor, Walsgrave Hospital, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Matt Bluett-Duncan
- Institute of Human Development, University of Manchester, Manchester, UK
| | - Jill Clayton-Smith
- Institute of Human Development, University of Manchester, Manchester, UK
| | - Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Katherine Edwards
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Janette Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Ruaraidh A Hill
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Cerian F Jackson
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sonia Khanom
- Institute of Human Development, University of Manchester, Manchester, UK
| | - Ronan N McGinty
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Jennifer Pulman
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Antiseizure medications (antiepileptic drugs) in adults: starting, monitoring and stopping. J Neurol 2023; 270:573-581. [PMID: 36153467 DOI: 10.1007/s00415-022-11378-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/06/2022] [Indexed: 01/07/2023]
Abstract
Up to 10% of people living to 80 years of age have one or more seizures; and many will not require anti-seizure medication (ASMs). In 85% of patients, the diagnosis comes from the history of the index event. One-third of patients with an apparent "first seizure" have previous events, changing their diagnosis to epilepsy. Targeted investigations are important for classification and risk prediction. Patients with a low risk of seizure recurrence are not usually offered ASM treatment. High-risk patients have multiple seizures, neurological deficits, intellectual disability and/or relevant abnormal investigations; and are offered ASMs. Individual factors modulate this decision-making. Future integrated technologies offer the game-changing potential for seizure monitoring and prediction, but are not yet robust, convenient or affordable. Therapeutic drug monitoring in patients taking ASMs may confirm ASM toxicity, or when non-adherence, malabsorption, or rapid metabolism are suspected causes of breakthrough seizures. They are less useful when these factors are intermittent or irregular. Current evidence does not favour routine monitoring of serum levels, as it neither reliably predicts control, relapse, or adverse effects. The decision to discontinue ASM should follow a full discussion with the patient of risks and benefits. Along with population risk factors for seizure recurrence, the patient's lifestyle and preferences must be considered. ASM are usually discontinued in a slow step-wise fashion, one at a time, after at least two years of remission. Seizure recurrence risk plateaus only after 2 years following ASM discontinuation, and patients need access to specialist follow-up over that period.
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Ershadi F, Mousavi Mirzaei SM, Tabrizi N, Roshanravan B, Sahebnasagh A, Avan R. Evaluation of family planning methods in married women with epilepsy. Epilepsy Behav 2022; 129:108618. [PMID: 35257991 DOI: 10.1016/j.yebeh.2022.108618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/13/2022] [Accepted: 02/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epilepsy is one of the most common neurologic unit diseases that have different prevalence in different parts of the world. Antiepileptic drugs (AEDs) are associated with major fertility risks for women of childbearing age. Due to the fact that studies on family planning methods in married women with epilepsy (WWE) have not been conducted in Iran, the aim of this study was to evaluate the family planning methods in married WWE in Birjand, Iran. METHODS An analytical-descriptive study was performed on 126 married WWE hospitalized in the neurology ward or referred to Vali-e-Asr specialized and sub-specialized clinic in Birjand. Demographic information of patients as well as data on the type of used AED, and various methods of family planning were collected in a questionnaire. Data analysis was performed using Chi-square and Fisher tests. All of the above analyses were considered at a significance level of less than 5% by SPSS v.19 software. RESULTS The mean age of the patients was 33.41 ± 9.15 years. The mean age of experiencing the first seizure and the onset of menstruation were 24.82 and 13.79 years, respectively. Fifty (35.5%), 38 (27%), 15 (10.6%), 14 (9.9%), and 14 (9.9%) patients used sodium valproate, carbamazepine, phenytoin, levetiracetam, and lamotrigine, respectively. The results showed that 72 sexually active patients (70.6%) used family planning methods, of which 43 patients (59.7%) used withdrawal method, 20 patients (27.8%) used condoms, and 6 patients (8.3%) used oral contraceptive pills (OCP). Eight patients (9.6%) had a history of unintended pregnancy and 3 patients (3.6%) had a history of abortion. CONCLUSION It is recommended to apply effective family planning methods in married WWE to prevent unintended pregnancies and the subsequent adverse effects in the fetus, considering the fact that a significant percentage of WWE did not use effective family planning methods and 8 cases of unintended pregnancies were reported. Because of high consumption of valproate in women of childbearing age in our study and concerning issue about its fetal malformation, it is recommended to reduce the administration of valproate in this population. Moreover, regarding the low consumption of folic acid, especially for women of childbearing age and pregnant WWE who are taking AED, the necessary recommendations should be made by our physicians.
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Affiliation(s)
- Faranak Ershadi
- Medical Student, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Nasim Tabrizi
- Department of Neurology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Babak Roshanravan
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Razieh Avan
- Department of Clinical Pharmacy, School of Pharmacy, Medical Toxicology and Drug Abuse Research Center, Birjand University of Medical Sciences, Birjand, Iran.
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Christensen J, Antonsen S, Sun Y, Dreier JW. Maternal Epilepsy and Long-term Offspring Mortality - a Nationwide Cohort Study. Ann Neurol 2022; 91:455-465. [PMID: 35148430 PMCID: PMC9315000 DOI: 10.1002/ana.26315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 11/13/2022]
Abstract
Objective We examined how maternal epilepsy and use of antiseizure medications in pregnancy was associated with offspring mortality. Methods This population‐based cohort study included all live‐ and stillborn singletons in Denmark between 1981 and 2016. We used nation‐wide registers to retrieve information on pregnancy characteristics, epilepsy diagnoses, use of antiseizure medications, and mortality. Adjusted mortality rate ratios (MRR) were estimated using log‐linear Poisson regression. Results The cohort consisted of 1,862,474 children. In total, 12,026 live‐born children died during follow‐up, of whom 170 (1.4%) were offspring of mothers with epilepsy. Overall mortality was increased in offspring of mothers with epilepsy compared to offspring of mothers without epilepsy (MRR = 1.46, 95% CI: 1.23–1.71), driven by an excess mortality only in the first year of life. Mortality was increased for natural deaths (MRR = 1.50, 95% CI: 1.25–1.78) but not from unnatural deaths (MRR = 1.38, 95% CI: 0.84–2.14), and only in offspring of women with epilepsy who used antiseizure medications during pregnancy (MRR = 1.51, 95% CI: 1.00–2.17), but not in offspring of women with epilepsy who did not use antiseizure medications while pregnant (MRR = 0.97, 95% CI: 0.69–1.31). When analyses were restricted to children born from 2000 and onwards, the excess mortality that was observed in the first year of life among children of mothers with epilepsy, was no longer evident. Interpretation During the 1981 to 1999 epoch, offspring of women with epilepsy were at increased risk of dying in the first year of life. However, this risk did not extend to children born after 2000. Future retrospective studies of the effects of maternal epilepsy on the health of the offspring should take this difference into account. ANN NEUROL 2022;91:455–465
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Affiliation(s)
- Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,National Center for Register-Based Research, Aarhus University, Denmark
| | - Sussie Antonsen
- National Center for Register-Based Research, Aarhus University, Denmark
| | - Yuelian Sun
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,National Center for Register-Based Research, Aarhus University, Denmark
| | - Julie W Dreier
- National Center for Register-Based Research, Aarhus University, Denmark.,Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
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Twenty-year trends in the use of anti-seizure medication among pregnant women in the Netherlands. Epilepsy Behav 2022; 127:108549. [PMID: 35042161 DOI: 10.1016/j.yebeh.2021.108549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/30/2021] [Accepted: 12/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anti-seizure medications (ASMs) are used to treat conditions such as epilepsy and bipolar disorder. Some of these drugs are associated with an increased risk of congenital malformations and adverse developmental outcomes. OBJECTIVES To examine trends in use of ASMs among pregnant women in the Netherlands according to medication safety profile. METHODS Using population-based data from the PHARMO Perinatal Research Network, we assessed trends in use of ASMs among pregnant women in the Netherlands between 1999 and 2019, stratified by medication safety profile. Individual treatment patterns were also assessed. RESULTS In total, 671,709 pregnancies among 446,169 women were selected, of which 2405 (3.6 per 1000) were ASM-exposed. Over the study period, a significant increase was observed for use of known safest ASMs (0.7-18.0 per 10,000 pregnancies) as well as for those with uncertain risk (5.3-13.4 per 10,000 pregnancies). Use of ASMs with higher risk of congenital malformations decreased significantly (24.8-14.5 per 10,000 pregnancies), except for topiramate (0-6.7 per 10,000 pregnancies). Switches between ASM safety risk categories before and during pregnancy were uncommon; women rather discontinued treatment or switched within the same category. There was no clear change for the proportion using polytherapy during pregnancy (12% overall), however a non-significant trend toward inclusion of known safest ASMs was observed over time (1.9-3.6%). CONCLUSIONS Over the last two decades, there has been an increase in use of known safest ASMs among pregnant women, together with a trend toward newer ASMs with uncertain risk. Only a small proportion of women switched to a safer alternative before or during pregnancy. Altogether, this highlights the need for an expansion of ASM risk knowledge and communication to healthcare providers and women of reproductive age to improve preconception counseling.
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Cauldwell M, Bredaki E, Dassan P, Dhanjal MK, Kaler M, Madipola N, Mahmud M, Paviour D, Senvar N, de Silva R, Watt-Coote I, Williams D, Yulia A, Steer PJ. Maternal and fetal outcomes in women with cerebrovascular malformations in pregnancy: A multicentre retrospective cohort study. BJOG 2021; 129:1151-1157. [PMID: 34882960 DOI: 10.1111/1471-0528.17046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine maternal, obstetric and neonatal outcomes in a cohort of women with cerebrovascular malformations (CVMs) that include arterial venous malformations (AVMs) and cavernomas. DESIGN Retrospective cohort study. SETTING Six specialist centres managing pregnant women with neurological disorders. POPULATION Sixty-three women with CVMs in 83 pregnancies of ≥20 completed weeks' gestation. METHODS Retrospective case notes review. MAIN OUTCOME MEASURES Neurological outcomes including rates of acute cerebral bleeding in pregnancy and reported seizures during pregnancy. Maternal outcomes included number of women with a livebirth and the proportion of women being delivered by caesarean section. RESULTS Most women had a good pregnancy outcome with high rates of vaginal delivery (73%) at term. There were no maternal deaths. Six women had an acute cerebral bleed, all of whom were delivered by planned caesarean section. In total, ten women had seizures in pregnancy (of whom four also had a bleed). Six (7%) babies were admitted to a neonatal unit. There was no significant difference in outcomes between women with AVMs and those with cavernomas. CONCLUSION In the majority of cases, pregnancy outcomes were favourable, with most women having a vaginal delivery. All cases of cerebral bleeds that occurred were at a remove from the peripartum period. TWEETABLE ABSTRACT Women with cerebrovascular malformations have high rates of vaginal delivery.
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Affiliation(s)
- Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Emma Bredaki
- UCL EGA Institute for Women's Health, London, UK
| | - Pooja Dassan
- Department of Neurology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mandish K Dhanjal
- Directorate of Maternity, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mandeep Kaler
- Department of Obstetrics and Gynaecology, Royal London Hospital, Whitechapel, London, UK
| | - Nissanka Madipola
- Department of Obstetrics and Gynaecology, Queen's Hospital Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Mohammad Mahmud
- Department of Neurology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Dominic Paviour
- Department of Neurology, Queen's Hospital Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Naz Senvar
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Rajith de Silva
- Department of Neurology, Queen's Hospital Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Ingrid Watt-Coote
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | | | - Angela Yulia
- UCL EGA Institute for Women's Health, London, UK
| | - Philip J Steer
- Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, London, UK
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Effectiveness of patient decision aids in women considering psychotropic medication use during pregnancy: a literature review. Arch Womens Ment Health 2021; 24:569-578. [PMID: 33751206 DOI: 10.1007/s00737-021-01118-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/26/2021] [Indexed: 10/22/2022]
Abstract
Women face complicated decisions regarding psychotropic medication use during pregnancy. Patient decision aids (PDAs) could be a valuable tool to assist with decision-making. The objective of this review was to evaluate the effectiveness of PDAs in this population. A systematic search of the literature was conducted using PRISMA guidelines. Three major databases were searched to identify articles published between 2006 and June 2020. Studies were included if they evaluated use of a PDA for women considering medication for mental illness during pregnancy. A total of 4629 titles were returned from the search; however, only three studies met inclusion criteria and were selected for analysis. Two were pilot randomised controlled trials in women considering antidepressant use during pregnancy, and one was a non-randomised study in women considering medication for the treatment of opioid use disorder (OUD). The PDAs had good acceptability across all three studies. The randomised trials assessed knowledge, decisional conflict, depression, and anxiety, with non-significant trends towards reduced decisional conflict and anxiety in the PDA groups. PDAs have the potential to assist women with mental illnesses to make decisions regarding medication use during pregnancy; however, current evidence is too limited to evaluate the effectiveness of PDAs for this population.
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11
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Clinical characteristics and outcomes in pregnant women with epilepsy. Epilepsy Behav 2020; 112:107433. [PMID: 32919204 DOI: 10.1016/j.yebeh.2020.107433] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Epilepsy in pregnancy can lead to substantial maternal and neonatal morbidity and mortality. Early intervention in pregnant women with epilepsy (WWE), accurate assessment of the severity of their condition, and effective treatment are required to improve maternal and neonatal prognosis. Many obstetricians lack experience in monitoring and treating pregnant WWE. AIMS The aim of this study was to describe the demographic and clinical characteristics of pregnant WWE and examine maternal and neonatal outcomes. METHODS Medical records of 75 pregnant women with a history of epilepsy who delivered at Beijing Tiantan Hospital, China between January 2006 and December 2019 were retrospectively reviewed. Pregnant women with a history of epilepsy were matched 1:2 with a control group of 150 pregnant women without epilepsy who delivered at Beijing Tiantan Hospital during the same time period. Information including type and frequency of epilepsy and seizures, maternal complications, medication, delivery mode, newborn weight, and newborn Apgar score were recorded. In subgroup analyses, pregnant WWE were stratified according to presence or absence of seizures during pregnancy and generalized seizure vs. nongeneralized seizure. RESULTS The incidence of anemia, hypertensive disorder of pregnancy, premature rupture of membranes (PROM), cesarean section, and postpartum hemorrhage was significantly higher (p < 0.05), and mean newborn weight and newborn Apgar score were significantly lower (p < 0.05) in pregnant WWE compared with pregnant women without epilepsy. The incidence of premature delivery was significantly higher (p < 0.05), and mean newborn weight was significantly lower (p < 0.05) in pregnant WWE with seizures vs. without seizures. Mean newborn weight was significantly lower (p = 0.01) in pregnant WWE with nongeneralized seizures vs. generalized seizures. CONCLUSION Pregnant WWE are at high risk of anemia, gestational hypertension, PROM, cesarean section, postpartum hemorrhage, and low newborn weight and Apgar score. Women with epilepsy who experience seizures during pregnancy are at high risk of preterm birth and having low birth weight infants. Pregnant WWE who experience nongeneralized seizures are at high risk of having low birth weight infants. These data emphasize the need to routinely monitor fetal weight on ultrasound and offer appropriate intervention. These findings highlight the need for healthcare providers to take a multidisciplinary approach to the management of pregnant WWE. SYNOPSIS Pregnant WWE are at high risk of obstetric complications. Women with epilepsy who experience seizures during pregnancy are at high risk of preterm birth and having low birth weight infants. Pregnant WWE who experience nongeneralized seizures are at high risk of having low birth weight infants. These data highlight the need for healthcare providers to take a multidisciplinary approach to the management of pregnant WWE.
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Harris L, Lowes O, Angus‐Leppan H. Treatment decisions in women of childbearing age on valproate. Acta Neurol Scand 2020; 141:287-293. [PMID: 31883101 DOI: 10.1111/ane.13211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/19/2019] [Accepted: 12/23/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There are little data on the understanding and participation of women of childbearing age in decisions about their choice of antiepileptic drugs (AEDs). Valproate carries a risk of major congenital malformations, developmental and behavioural delay. For some, valproate is the only medication to prevent potentially life-threatening seizures. MATERIALS & METHODS This was a cross-sectional study of two groups of women of childbearing age; 50 taking valproate and 50 controls. Each patient completed a patient questionnaire and structured telephone interview assessing understanding of the risks and benefits of AEDs in relation to pregnancy. Analysis used unpaired two-tailed t test and chi-squared test, with Bonferroni correction. Follow-up at 12 months showed that 8% of the women taking valproate had switched to other medication. RESULTS Hundred patients participated in the study, 89 on AEDs for epilepsy, 4 for migraine, and 7 for both. 55% of participants stated they were not involved in decision-making. More patients in the valproate group were informed about (64% vs 42%, P < .005), and expressed understanding of (64%vs 32%, P < .001), the risks involved with treatment. 59% of all patients wanted more information. The minority of women surveyed took folic acid (37%) or used contraceptives (29%). Valproate was used following failure of other AEDs to control seizures in 80%. DISCUSSION This in-depth survey suggests more information is needed for women taking AEDs, using a range of formats. Women taking valproate are better informed than those on levetiracetam or lamotrigine. Information provision on the use of folic acid and contraception needs improvement.
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Affiliation(s)
| | - Olivia Lowes
- University Hospital Coventry and Warwickshire Coventry UK
| | - Heather Angus‐Leppan
- Clinical Neurosciences Royal Free London NHS Foundation Trust University College London London UK
- Institute of Neurology University College London London UK
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Bansal R, Suri V, Chopra S, Aggarwal N, Sikka P, Saha SC, Kharbanda PS, Kumar P. Change in antiepileptic drug prescription patterns for pregnant women with epilepsy over the years: Impact on pregnancy and fetal outcomes. Indian J Pharmacol 2019; 51:93-97. [PMID: 31142944 PMCID: PMC6533923 DOI: 10.4103/ijp.ijp_78_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS AND OBJECTIVES: The objectives of the study were: (1) to determine if there is a change in pattern of antiepileptic drug (AED) prescription during pregnancy in women with epilepsy (WWE) attending a tertiary care institute in North India and (2) to determine if change in AED prescription pattern has resulted in improved fetal and maternal outcomes in WWE. PATIENTS AND METHODS: The current study was a retrospective analysis of records of WWE attending a medical and surgical disorder clinic of obstetrics and gynecology department of a tertiary care teaching hospital in North India. We retrospectively collected data of all the patients during the 5-year period from 2011 to 2015 (Group A) (n = 177) and compared it with our previously published data during the years 1987–1994 (Group B) (n = 219). RESULTS: There was significantly higher use of (i) levetiracetam (LEV) in Group A compared to Group B when women on monotherapy were compared (P<0.0001) and (ii) LEV (P<0.0001), clobazam (P<0.0001) and lamotrigine (P=0.0004) in Group A compared to Group B when women on polytherapy were compared. A significantly higher (P=0.02) number of women were using more than two antiepileptic drugs simultaneously in Group A compared to Group B. There was a significantly higher incidence (P = 0.001) of small for gestational age babies in Group A. CONCLUSION: Although there is an increase in the use of newer AEDs in WWE during pregnancy in North Indian population, it has not resulted in improved maternal and fetal outcomes. (2) to determine if change in AED prescription pattern has resulted in improved fetal and maternal outcomes in WWE.
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Affiliation(s)
- Ramandeep Bansal
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Seema Chopra
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Aggarwal
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pooja Sikka
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhas Chandra Saha
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Praveen Kumar
- Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hurault-Delarue C, Morris JK, Charlton R, Gini R, Loane M, Pierini A, Puccini A, Neville A, Snowball J, Damase-Michel C. Prescription of antiepileptic medicines including valproate in pregnant women: A study in three European countries. Pharmacoepidemiol Drug Saf 2019; 28:1510-1518. [PMID: 31517430 DOI: 10.1002/pds.4897] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/20/2019] [Accepted: 08/24/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To study patterns of antiepileptic drugs (AED) prescribing, particularly valproate, during pregnancy over a 10-year period in the UK, Italy, and France. METHODS Data on pregnancies conceived after 1 January 2007 with outcomes before 31 December 2016 were extracted from four European electronic health care databases (380 499 in the United Kingdom (UK), 66 681 in France, and 649 918 in Italy [355 767 in Emilia Romagna and 294 151 in Tuscany]). Prevalence of AEDs with an ATC code starting N03A and clobazam (N05BA09) were stratified by country and calendar year. RESULTS AED prescribing during pregnancy varied from 3.0 (2.8-3.1) per 1000 pregnancies in Emilia Romagna to 7.8 (7.5-8.0) in the UK, 5.9 (5.6-6.1) in Tuscany, and 6.3 (5.7-6.9) in France. Lamotrigine was commonly prescribed in all regions with a third of women exposed to an AED during pregnancy taking lamotrigine in the UK and France. Valproate was prescribed to 28.6% of AED exposed pregnant women in Tuscany, 21.6% in France, 16.7% in Emilia Romagna, and 11.9% in the UK. Over the study period, the prevalence of AED prescribing increased in the UK mainly due to increases in pregabalin and gabapentin, declined in France mainly related to decreases in clonazepam, and remained constant in Italy. Valproate prescriptions declined to a prevalence <1 per 1000 pregnancies in 2015 to 2016 in the UK, France, and Emilia Romagna. CONCLUSIONS Variations in AED prescribing during pregnancy indicate the potential for further reductions, particularly of valproate. Increases in pregabalin/gabapentin prescribing, for which risks are not well known, are a cause for concern.
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Affiliation(s)
- Caroline Hurault-Delarue
- Pharmacologie Faculté de Médecine, Université Paul-Sabatier Toulouse III CHU Toulouse, UMR INSERM, Toulouse, 1027, France
| | - Joan K Morris
- Population Health Research Institute, St George's, University of London, St George's, University of London, London, UK
| | - Rachel Charlton
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Rosa Gini
- Agenzia Regionale di Sanità della Toscana, Florence, Italy
| | - Maria Loane
- Centre for Maternal, Fetal and Infant Research, INHR, Ulster University, Newtowanbbey, UK
| | - Anna Pierini
- Institute of Clinical Physiology-National Research Council (IFC-CNR)/Fondazione Toscana "Gabriele Monasterio", Pisa, Italy
| | - Aurora Puccini
- Drug Policy Service, Emilia Romagna Region Health Authority, Bologna, Italy
| | - Amanda Neville
- IMER (Emilia Romagna Registry of Birth Defects), Centre for Clinical and Epidemiological Research, University of Ferrara and Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Julia Snowball
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Christine Damase-Michel
- Pharmacologie Faculté de Médecine, Université Paul-Sabatier Toulouse III CHU Toulouse, UMR INSERM, Toulouse, 1027, France
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Charlton R, Damase‐Michel C, Hurault‐Delarue C, Gini R, Loane M, Pierini A, Puccini A, Neville A, Snowball J, Morris JK. Did advice on the prescription of sodium valproate reduce prescriptions to women? An observational study in three European countries between 2007 and 2016. Pharmacoepidemiol Drug Saf 2019; 28:1519-1528. [DOI: 10.1002/pds.4881] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 06/17/2019] [Accepted: 07/22/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Rachel Charlton
- Department of Pharmacy and PharmacologyUniversity of Bath Bath UK
| | - Christine Damase‐Michel
- Pharmacologie Faculté de MédecineUniversité Toulouse III, CHU Toulouse, INSERM UMR1027 France
| | | | - Rosa Gini
- Agenzia regionale di sanità della Toscana Italy
| | - Maria Loane
- Institute of Nursing and Health ResearchUlster University Co Antrim Northern Ireland
| | - Anna Pierini
- Institute of Clinical Physiology ‐ National Research Council (IFC‐CNR)/Fondazione Toscana “Gabriele Monasterio” Pisa Italy
| | - Aurora Puccini
- Drug Policy ServiceEmilia Romagna Region Health Authority Bologna Italy
| | - Amanda Neville
- IMER (Emilia Romagna Registry of Birth Defects), Centre for Clinical and Epidemiological ResearchUniversity of Ferrara and Azienda Ospedaliero‐Universitaria di Ferrara Ferrara Italy
| | - Julia Snowball
- Department of Pharmacy and PharmacologyUniversity of Bath Bath UK
| | - Joan K. Morris
- Centre for Environmental and Preventive MedicineQueen Mary University of London London UK
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Allotey J, Fernandez-Felix BM, Zamora J, Moss N, Bagary M, Kelso A, Khan R, van der Post JAM, Mol BW, Pirie AM, McCorry D, Khan KS, Thangaratinam S. Predicting seizures in pregnant women with epilepsy: Development and external validation of a prognostic model. PLoS Med 2019; 16:e1002802. [PMID: 31083654 PMCID: PMC6513048 DOI: 10.1371/journal.pmed.1002802] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/11/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Seizures are the main cause of maternal death in women with epilepsy, but there are no tools for predicting seizures in pregnancy. We set out to develop and validate a prognostic model, using information collected during the antenatal booking visit, to predict seizure risk at any time in pregnancy and until 6 weeks postpartum in women with epilepsy on antiepileptic drugs. METHODS AND FINDINGS We used datasets of a prospective cohort study (EMPiRE) of 527 pregnant women with epilepsy on medication recruited from 50 hospitals in the UK (4 November 2011-17 August 2014). The model development cohort comprised 399 women whose antiepileptic drug doses were adjusted based on clinical features only; the validation cohort comprised 128 women whose drug dose adjustments were informed by serum drug levels. The outcome was epileptic (non-eclamptic) seizure captured using diary records. We fitted the model using LASSO (least absolute shrinkage and selection operator) regression, and reported the performance using C-statistic (scale 0-1, values > 0.5 show discrimination) and calibration slope (scale 0-1, values near 1 show accuracy) with 95% confidence intervals (CIs). We determined the net benefit (a weighted sum of true positive and false positive classifications) of using the model, with various probability thresholds, to aid clinicians in making individualised decisions regarding, for example, referral to tertiary care, frequency and intensity of monitoring, and changes in antiepileptic medication. Seizures occurred in 183 women (46%, 183/399) in the model development cohort and in 57 women (45%, 57/128) in the validation cohort. The model included age at first seizure, baseline seizure classification, history of mental health disorder or learning difficulty, occurrence of tonic-clonic and non-tonic-clonic seizures in the 3 months before pregnancy, previous admission to hospital for seizures during pregnancy, and baseline dose of lamotrigine and levetiracetam. The C-statistic was 0.79 (95% CI 0.75, 0.84). On external validation, the model showed good performance (C-statistic 0.76, 95% CI 0.66, 0.85; calibration slope 0.93, 95% CI 0.44, 1.41) but with imprecise estimates. The EMPiRE model showed the highest net proportional benefit for predicted probability thresholds between 12% and 99%. Limitations of this study include the varied gestational ages of women at recruitment, retrospective patient recall of seizure history, potential variations in seizure classification, the small number of events in the validation cohort, and the clinical utility restricted to decision-making thresholds above 12%. The model findings may not be generalisable to low- and middle-income countries, or when information on all predictors is not available. CONCLUSIONS The EMPiRE model showed good performance in predicting the risk of seizures in pregnant women with epilepsy who are prescribed antiepileptic drugs. Integration of the tool within the antenatal booking visit, deployed as a simple nomogram, can help to optimise care in women with epilepsy.
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Affiliation(s)
- John Allotey
- Barts Research Centre for Women’s Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Multidisciplinary Evidence Synthesis Hub, Queen Mary University of London, London, United Kingdom
| | - Borja M. Fernandez-Felix
- CIBER Epidemiology and Public Health, Madrid, Spain
- Clinical Biostatistics Unit, Hospital Ramón y Cajal, Madrid, Spain
| | - Javier Zamora
- Barts Research Centre for Women’s Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- CIBER Epidemiology and Public Health, Madrid, Spain
- Clinical Biostatistics Unit, Hospital Ramón y Cajal, Madrid, Spain
- * E-mail:
| | - Ngawai Moss
- Patient and Public Involvement, Katie’s Team, Katherine Twining Network, Queen Mary University of London, London, United Kingdom
| | - Manny Bagary
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrew Kelso
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Rehan Khan
- Department of Obstetrics and Gynaecology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Joris A. M. van der Post
- Department of Obstetrics and Gynaecology, University of Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - Ben W. Mol
- Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | | | - Dougall McCorry
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Khalid S. Khan
- Barts Research Centre for Women’s Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Multidisciplinary Evidence Synthesis Hub, Queen Mary University of London, London, United Kingdom
| | - Shakila Thangaratinam
- Barts Research Centre for Women’s Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Multidisciplinary Evidence Synthesis Hub, Queen Mary University of London, London, United Kingdom
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Strongman H, Williams R, Meeraus W, Murray‐Thomas T, Campbell J, Carty L, Dedman D, Gallagher AM, Oyinlola J, Kousoulis A, Valentine J. Limitations for health research with restricted data collection from UK primary care. Pharmacoepidemiol Drug Saf 2019; 28:777-787. [PMID: 30993808 PMCID: PMC6618795 DOI: 10.1002/pds.4765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/30/2018] [Accepted: 02/14/2019] [Indexed: 11/12/2022]
Abstract
Purpose UK primary care provides a rich data source for research. The impact of proposed data collection restrictions is unknown. This study aimed to assess the impact of restricting the scope of electronic health record (EHR) data collection on the ability to conduct research. The study estimated the consequences of restricted data collection on published Clinical Practice Research Datalink studies from high impact journals or referenced in clinical guidelines. Methods A structured form was used to systematically analyse the extent to which individual studies would have been possible using a database with data collection restrictions in place: (1) retrospective collection of specified diseases only; (2) retrospective collection restricted to a 6‐ or 12‐year period; (3) prospective and retrospective collection restricted to non‐sensitive data. Outcomes were categorised as unfeasible (not reproducible without major bias); compromised (feasible with design modification); or unaffected. Results Overall, 91% studies were compromised with all restrictions in place; 56% studies were unfeasible even with design modification. With restrictions on diseases alone, 74% studies were compromised; 51% were unfeasible. Restricting collection to 6/12 years had a major impact, with 67 and 22% of studies compromised, respectively. Restricting collection of sensitive data had a lesser but marked impact with 10% studies compromised. Conclusion EHR data collection restrictions can profoundly reduce the capacity for public health research that underpins evidence‐based medicine and clinical guidance. National initiatives seeking to collect EHRs should consider the implications of restricting data collection on the ability to address vital public health questions.
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Affiliation(s)
| | | | | | | | | | - Lucy Carty
- Clinical Practice Research Datalink (CPRD)MHRALondonUK
| | - Daniel Dedman
- Clinical Practice Research Datalink (CPRD)MHRALondonUK
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Abstract
PURPOSE OF REVIEW As the number of patients diagnosed with epilepsy continues to rise and the pharmacological and device-based treatment options for epilepsy increase, determining when to stop antiepileptic drug (AED) treatment continues to be an important issue for patient management and counseling. RECENT FINDINGS This review focuses on outcomes following AED withdrawal in seizure-free adults with epilepsy. Practical considerations are also discussed because, despite the importance of this topic, relatively little progress has been made in the past year regarding the identification of patients whose risk for recurrent seizures after AED withdrawal is no higher than that of the general population. SUMMARY Although articles in the past year have updated the debates about whether and when to discontinue AEDs in seizure-free adults and have suggested potential utility for electroencephalograms as a prognostic tool for AED reduction as well as for an AED withdrawal risk calculator, decisions about AED withdrawal should still be based on the known risks and consequences of seizure recurrence and be made following well documented discussions between doctor and patient/carer.
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Kinney MO, Morrow J, Patterson CC, Campbell E, Russell A, Smithson HW, Parsons L, Morrison PJ, Bromley R, Liggan B, Delanty N, Irwin B, Hunt SJ, Craig JJ. Changing antiepilepsy drug-prescribing trends in women with epilepsy in the UK and Ireland and the impact on major congenital malformations. J Neurol Neurosurg Psychiatry 2018; 89:1320-1323. [PMID: 29661925 DOI: 10.1136/jnnp-2017-317368] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 03/14/2018] [Accepted: 03/24/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES After 20 years of data collection, pregnancy registers have informed prescribing practice. Various populations show trends for a reduction in valproate prescribing, which is associated with an increased risk of anatomical teratogenesis and neurodevelopmental effects in those exposed in utero. Our aim was to determine if any shifts in prescribing trends have occurred in the UK and Ireland Epilepsy and Pregnancy Register cohort and to assess if there had been any change in the overall major congenital malformation (MCM) rate over time. METHODS The UK and Ireland Epilepsy and Pregnancy Register, a prospective, observational, registration and follow-up study established in 1996, was used to determine the changes in antiepileptic drugs (AEDs) utilised during pregnancy and the MCM rate between 1996 and 2016. Linear regression analysis was used to assess changes in AED utilisation, and Poisson regression was used for the analysis of trends in the MCM rates. RESULTS Outcome data for 9247 pregnancies showed a stable percentage of monotherapy to polytherapy prescribing habits over time. After Bonferroni correction, statistically significant (p<0.003) changes were found in monotherapy prescribing with increases in lamotrigine and levetiracetam and decreases in valproate and carbamazepine use. Between 1996 and 2016, the total MCM rate showed a 2.1% reduction per year (incidence risk ratio 0.979 (95% CIs 0.956 to 1.002) but Poisson regression analysis showed that this was not statistically significant p=0.08). CONCLUSION Significant changes are seen in the prescribing habits in this cohort over 20 years, but a statistically significant change in the MCM rate was not detected. This work should be replicated on a larger scale to determine if significant changes are occurring in the MCM rate, which would allow a robust economic estimate of the benefits of improvements in prescribing practice and the personal effect of such changes.
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Affiliation(s)
- Michael O Kinney
- Department of Neurology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, County Antrim, UK
| | - James Morrow
- Department of Neurology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, County Antrim, UK
| | - Chris C Patterson
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Belfast, Northern Ireland, UK
| | - Ellen Campbell
- Department of Neurology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, County Antrim, UK
| | - Aline Russell
- Department of Clinical Neurophysiology, Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
| | - Henry W Smithson
- Department of General Practice, University College Cork Ireland, Cork, Ireland
| | - Linda Parsons
- Neurology Department, Luton and Dunstable Hospitals NHS Trust, Luton, UK
| | - Patrick J Morrison
- Department of Medical Genetics, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Rebecca Bromley
- Royal Manchester Children's Hospital, Central Manchester University Foundation NHS Trust, Manchester, UK.,The Institute of Human Development, The University of Manchester, Manchester, UK
| | - Brenda Liggan
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Norman Delanty
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Beth Irwin
- Department of Neurology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, County Antrim, UK
| | - Stephen J Hunt
- Department of Neurology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, County Antrim, UK
| | - John J Craig
- Department of Neurology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, County Antrim, UK
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21
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Affiliation(s)
- Kim Morley
- Independent and supplementary prescriber, and MSc Candidate, Maternity and Neurology Services, Hampshire Hospitals Foundation Trust
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22
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Blotière PO, Weill A, Dalichampt M, Billionnet C, Mezzarobba M, Raguideau F, Dray-Spira R, Zureik M, Coste J, Alla F. Development of an algorithm to identify pregnancy episodes and related outcomes in health care claims databases: An application to antiepileptic drug use in 4.9 million pregnant women in France. Pharmacoepidemiol Drug Saf 2018; 27:763-770. [PMID: 29763992 PMCID: PMC6055607 DOI: 10.1002/pds.4556] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/20/2018] [Accepted: 04/12/2018] [Indexed: 11/27/2022]
Abstract
Purpose Access to claims databases provides an opportunity to study medication use and safety during pregnancy. We developed an algorithm to identify pregnancy episodes in the French health care databases and applied it to study antiepileptic drug (AED) use during pregnancy between 2007 and 2014. Methods The algorithm searched the French health care databases for discharge diagnoses and medical procedures indicative of completion of a pregnancy. To differentiate claims associated with separate pregnancies, an interval of at least 28 weeks was required between 2 consecutive pregnancies resulting in a birth and 6 weeks for terminations of pregnancy. Pregnancy outcomes were categorized into live births, stillbirths, elective abortions, therapeutic abortions, spontaneous abortions, and ectopic pregnancies. Outcome dates and gestational ages were used to calculate pregnancy start dates. Results According to our algorithm, live birth was the most common pregnancy outcome (73.9%), followed by elective abortion (17.2%), spontaneous abortion (4.2%), ectopic pregnancy (1.1%), therapeutic abortion (1.0%), and stillbirth (0.4%). These results were globally consistent with French official data. Among 7 559 701 pregnancies starting between 2007 and 2014, corresponding to 4 900 139 women, 6.7 per 1000 pregnancies were exposed to an AED. The number of pregnancies exposed to older AEDs, comprising the most teratogenic AEDs, decreased throughout the study period (−69.4%), while the use of newer AEDs increased (+73.4%). Conclusions We have developed an algorithm that allows identification of a large number of pregnancies and all types of pregnancy outcomes. Pregnancy outcome and start dates were accurately identified, and maternal data could be linked to neonatal data.
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Affiliation(s)
- Pierre-Olivier Blotière
- Department of Studies in Public Health, French National Health Insurance (CNAMTS), Paris, France.,Université de Lorraine, université Paris-Descartes, Apemac, EA 4360, Nancy, France
| | - Alain Weill
- Department of Studies in Public Health, French National Health Insurance (CNAMTS), Paris, France
| | - Marie Dalichampt
- Department of Studies in Public Health, French National Health Insurance (CNAMTS), Paris, France
| | - Cécile Billionnet
- Department of Studies in Public Health, French National Health Insurance (CNAMTS), Paris, France
| | - Myriam Mezzarobba
- Department of Studies in Public Health, French National Health Insurance (CNAMTS), Paris, France
| | - Fanny Raguideau
- Department of Epidemiology of Health Products, The French National Agency for Medicines and Health Products Safety, Saint-Denis, France
| | - Rosemary Dray-Spira
- Department of Epidemiology of Health Products, The French National Agency for Medicines and Health Products Safety, Saint-Denis, France
| | - Mahmoud Zureik
- Department of Epidemiology of Health Products, The French National Agency for Medicines and Health Products Safety, Saint-Denis, France
| | - Joël Coste
- Department of Studies in Public Health, French National Health Insurance (CNAMTS), Paris, France
| | - François Alla
- Université de Lorraine, université Paris-Descartes, Apemac, EA 4360, Nancy, France.,Université Bordeaux et CHU Bordeaux, CIC-EC 1401, Inserm U1219, Bordeaux, France
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Richards N, Reith D, Stitely M, Smith A. Antiepileptic drug exposure in pregnancy and pregnancy outcome from national drug usage data. BMC Pregnancy Childbirth 2018; 18:84. [PMID: 29625554 PMCID: PMC5889580 DOI: 10.1186/s12884-018-1728-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 03/29/2018] [Indexed: 01/01/2023] Open
Abstract
Background Antiepileptic drugs (AEDs) are used by pregnant women to manage conditions such as epilepsy and bipolar disorder even though they pose a risk to the developing foetus. This study aimed to determine the overall use of AEDs by women during their childbearing years and women who are pregnant and the association between AED use and rates of pregnancy termination and spontaneous abortion. Methods Retrospective population based cohort study using administrative databases in New Zealand between 2008 and 2014. Women who had been pregnant were identified by the National Minimum Dataset and were linked to the Pharmaceutical Collection to obtain information on use of AEDs. Women aged between 15 and 45 years dispensed AEDs were identified in the Pharmaceutical Collection. Results There was an increase in the number of women of child-bearing potential prescribed AEDs, from 9 women per 1000 women in 2008 to 11.4 women per 1000 women in 2014. Women who had been dispensed an AED had an increased rate of spontaneous abortion 8.97 spontaneous abortions per 100 pregnancies, compared with, 6.31 per 100 pregnancies (risk ratio 1.42, 95% CI 1.40 to 1.44), and a decreased rate of pregnancy termination, 18.51 terminations per 100 pregnancies compared with 19.58 per 100 pregnancies (risk ratio 1.95, 95% CI 0.94–0.96). Conclusion Use of newer AEDs is increasing in women of child-bearing potential in New Zealand leading to an overall increase in AED use in this group despite a fall in the use of older AEDs. AED use is this study was associated with an increased risk of spontaneous abortion and decreased rate of pregnancy termination, however confounding by indication could not be excluded.
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Affiliation(s)
- Noni Richards
- School of Pharmacy, University of Otago, 18 Frederick St, Dunedin, New Zealand.
| | - David Reith
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Michael Stitely
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Alesha Smith
- School of Pharmacy, University of Otago, 18 Frederick St, Dunedin, New Zealand.,bpacnz, 10 George St, Dunedin, New Zealand
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Thomas RH. Valproate: life-saving, life-changing. Clin Med (Lond) 2018; 18. [PMID: 29700085 PMCID: PMC6334031 DOI: 10.7861/clinmedicine.18-2s-s1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Antiepileptic medications, and valproate principally, are commonly prescribed teratogens. There is significant concern that we are not doing enough to educate clinicians and potential parents about the risks of valproate in pregnancy. There is clear advice from the Medicines and Healthcare products Regulatory Agency and the International League Against Epilepsy about the risks of valproate exposure in utero Reviews and guidelines that are focused on fetal risk, however, fall short in being able to fully replicate the complexity of a real clinical decision. Valproate is certainly life-changing if your child is one of the 10% with a major malformation or 30-40% with a neurodevelopmental disorder, but valproate is also potentially life-saving in the context of ensuring the best possible seizure control for some mothers with epilepsy. There are significant knowledge gaps regarding the risks to mothers who elect to take another drug, or to mother and baby if she comes off medication entirely. We also should be doing more to reduce rates of sudden unexpected death in epilepsy (SUDEP), which is recognised as a key target when evaluating all maternal deaths.
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Affiliation(s)
- Rhys H Thomas
- ARoyal Victoria Infirmary and intermediate clinical lecturer, Newcastle University, Newcastle, UK,Address for correspondence: Dr Rhys Thomas, Institute of Neuroscience, Henry Wellcome Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne NE2 4HH, UK.
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25
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Abstract
Antiepileptic medications, and valproate principally, are commonly prescribed teratogens. There is significant concern that we are not doing enough to educate clinicians and potential parents about the risks of valproate in pregnancy. There is clear advice from the Medicines and Healthcare products Regulatory Agency and the International League Against Epilepsy about the risks of valproate exposure in utero Reviews and guidelines that are focused on fetal risk, however, fall short in being able to fully replicate the complexity of a real clinical decision. Valproate is certainly life-changing if your child is one of the 10% with a major malformation or 30-40% with a neurodevelopmental disorder, but valproate is also potentially life-saving in the context of ensuring the best possible seizure control for some mothers with epilepsy. There are significant knowledge gaps regarding the risks to mothers who elect to take another drug, or to mother and baby if she comes off medication entirely. We also should be doing more to reduce rates of sudden unexpected death in epilepsy (SUDEP), which is recognised as a key target when evaluating all maternal deaths.
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Affiliation(s)
- Rhys H Thomas
- Royal Victoria Infirmary and intermediate clinical lecturer, Newcastle University, Newcastle, UK
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26
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Grigoriadis S, Peer M. The Perinatal Treatment Conundrum. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:514-516. [PMID: 28777922 PMCID: PMC5546671 DOI: 10.1177/0706743717717693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sophie Grigoriadis
- 1 Department of Psychiatry, Women's Mood and Anxiety Clinic: Reproductive Transitions, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Miki Peer
- 2 Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario
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Leong C, Raymond C, Château D, Dahl M, Alessi-Severini S, Falk J, Bugden S, Katz A. Psychotropic Drug Use before, during, and after Pregnancy: A Population-Based Study in a Canadian Cohort (2001-2013). CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:543-550. [PMID: 28545329 PMCID: PMC5546669 DOI: 10.1177/0706743717711168] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe the extent of increase in use and the rate of continuation versus discontinuation of psychotropic agents before, during, and after pregnancy. METHODS Rates of psychotropic use (antidepressants, anxiolytic/sedative-hypnotics, antiepileptics, antipsychotics, lithium, stimulants) among women with a hospital-recorded pregnancy outcome were assessed using databases at the Manitoba Centre for Health Policy. Rate of use was defined as ≥1 prescription over the total number of pregnancies in the 3-12 months before pregnancy, 0-3 months before pregnancy, during pregnancy, or 3 months after pregnancy. Continued use was defined as ≥2 prescriptions with gap ≤14 days. Poisson regression was used to analyze trends. RESULTS Over the study period, a psychotropic drug was used before, during, or after pregnancy in 41,923 of 224,762 pregnancies. From 2001 to 2013, psychotropic use increased 1.5-fold from 11.1% to 16.2% ( p < 0.0001) in the 3-12 months before pregnancy, 1.6-fold from 6.4% to 10.5% ( p < 0.0001) in the 3 months before pregnancy, 1.8-fold from 3.3% to 6.0% ( p < 0.0001) during pregnancy, and 1.5-fold from 6.2% to 9.5% ( p < 0.0001) in the 3 months postpartum. Among the 13,579 women who received at least 1 psychotropic agent in the 3 months prior to pregnancy, 38.5% stopped the agent prior to pregnancy and only 10.3% continued use throughout pregnancy. Continued use throughout pregnancy was higher (56.9%) among the 6693 women who received at least 2 prescriptions for a psychotropic agent and were at least 80% adherent in the 3 months prior to pregnancy. CONCLUSION The use of psychotropic agents increased over 12 years. The safety of continuing versus discontinuing these agents during pregnancy remains uncertain, but we observed a decrease in psychotropic drug use during the pregnancy period.
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Affiliation(s)
- Christine Leong
- 1 College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Colette Raymond
- 2 Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Dan Château
- 2 Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Matthew Dahl
- 2 Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Silvia Alessi-Severini
- 1 College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Jamie Falk
- 1 College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Shawn Bugden
- 1 College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Alan Katz
- 2 Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
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Petersen I, Collings SL, McCrea RL, Nazareth I, Osborn DP, Cowen PJ, Sammon CJ. Antiepileptic drugs prescribed in pregnancy and prevalence of major congenital malformations: comparative prevalence studies. Clin Epidemiol 2017; 9:95-103. [PMID: 28243149 PMCID: PMC5317245 DOI: 10.2147/clep.s118336] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study was to examine the prevalence of major congenital malformations associated with antiepileptic drug (AED) treatment in pregnancy. PATIENTS AND METHODS Using data from The Health Improvement Network, we identified women who have given live birth and their offspring. Four subgroups were selected based on the AED treatment in early pregnancy, valproate, carbamazepine, lamotrigine and women not receiving AED treatment. We compared the prevalence of major congenital malformations within children of these four groups and estimated prevalence ratios (PRs) using Poisson regression adjusted for maternal age, sex of child, quintiles of Townsend deprivation score and indication for treatment. RESULTS In total, 240,071 women were included in the study. A total of 229 women were prescribed valproate in pregnancy, 357 were prescribed lamotrigine and 334 were prescribed carbamazepine and 239,151 women were not prescribed AEDs. Fifteen out of 229 (6.6%) women prescribed valproate gave birth to a child with a major congenital malformation. The figures for lamotrigine, carbamazepine and women not prescribed AEDs were 2.7%, 3.3% and 2.2%, respectively. The prevalence of major congenital malformation was similar for women prescribed lamotrigine or carbamazepine compared to women with no AED treatment in pregnancy. For women prescribed valproate in polytherapy, the prevalence was fourfold higher. After adjustments, the effect of estimates attenuated, but the prevalence remained two- to threefold higher in women prescribed valproate. CONCLUSION The results of our study suggest that lamotrigine and carbamazepine are safer treatment options than valproate in pregnancy and should be considered as alternative treatment options for women of childbearing potential and in pregnancy.
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Affiliation(s)
- Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK; Department of Clinical Epidemiology, Aarhus University, Aarhus N, Denmark
| | - Shuk-Li Collings
- Department of Primary Care and Population Health, University College London, London, UK; OXON Epidemiology, London, UK
| | - Rachel L McCrea
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
| | - David P Osborn
- Division of Psychiatry, University College London, London, UK
| | - Phil J Cowen
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Cormac J Sammon
- Department of Primary Care and Population Health, University College London, London, UK
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Petersen I, McCrea RL, Sammon CJ, Osborn DPJ, Evans SJ, Cowen PJ, Freemantle N, Nazareth I. Risks and benefits of psychotropic medication in pregnancy: cohort studies based on UK electronic primary care health records. Health Technol Assess 2017; 20:1-176. [PMID: 27029490 DOI: 10.3310/hta20230] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although many women treated with psychotropic medication become pregnant, no psychotropic medication has been licensed for use in pregnancy. This leaves women and their health-care professionals in a treatment dilemma, as they need to balance the health of the woman with that of the unborn child. The aim of this project was to investigate the risks and benefits of psychotropic medication in women treated for psychosis who become pregnant. OBJECTIVE(S) (1) To provide a descriptive account of psychotropic medication prescribed before pregnancy, during pregnancy and up to 15 months after delivery in UK primary care from 1995 to 2012; (2) to identify risk factors predictive of discontinuation and restarting of lithium (multiple manufacturers), anticonvulsant mood stabilisers and antipsychotic medication; (3) to examine the extent to which pregnancy is a determinant for discontinuation of psychotropic medication; (4) to examine prevalence of records suggestive of adverse mental health, deterioration or relapse 18 months before and during pregnancy, and up to 15 months after delivery; and (5) to estimate absolute and relative risks of adverse maternal and child outcomes of psychotropic treatment in pregnancy. DESIGN Retrospective cohort studies. SETTING Primary care. PARTICIPANTS Women treated for psychosis who became pregnant, and their children. INTERVENTIONS Treatment with antipsychotics, lithium or anticonvulsant mood stabilisers. MAIN OUTCOME MEASURES Discontinuation and restarting of treatment; worsening of mental health; acute pre-eclampsia/gestational hypertension; gestational diabetes; caesarean section; perinatal death; major congenital malformations; poor birth outcome (low birthweight, preterm birth, small for gestational age, low Apgar score); transient poor birth outcomes (tremor, agitation, breathing and muscle tone problems); and neurodevelopmental and behavioural disorders. DATA SOURCES Clinical Practice Research Datalink database and The Health Improvement Network primary care database. RESULTS Prescribing of psychotropic medication was relatively constant before pregnancy, decreased sharply in early pregnancy and peaked after delivery. Antipsychotic and anticonvulsant treatment increased over the study period. The recording of markers of worsening mental health peaked after delivery. Pregnancy was a strong determinant for discontinuation of psychotropic medication. However, between 40% and 76% of women who discontinued psychotropic medication before or in early pregnancy restarted treatment by 15 months after delivery. The risk of major congenital malformations, and neurodevelopmental and behavioural outcomes in valproate (multiple manufacturers) users was twice that in users of other anticonvulsants. The risks of adverse maternal and child outcomes in women who continued antipsychotic use in pregnancy were not greater than in those who discontinued treatment before pregnancy. LIMITATIONS A few women would have received parts of their care outside primary care, which may not be captured in this analysis. Likewise, the analyses were based on prescribing data, which may differ from usage. CONCLUSIONS Psychotropic medication is prescribed before, during and after pregnancy. Many women discontinue treatment before or during early pregnancy and then restart again in late pregnancy or after delivery. Our results support previous associations between valproate and adverse child outcomes but we found no evidence of such an association for antipsychotics. FUTURE WORK Future research should focus on (1) curtailing the use of sodium valproate; (2) estimating the benefits of psychotropic drug use in pregnancy; and (3) investigating the risks associated with lifestyle choices that are more prevalent among women using psychotropic drugs. FUNDING DETAILS The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
| | - Rachel L McCrea
- Department of Primary Care and Population Health, University College London, London, UK
| | - Cormac J Sammon
- Department of Primary Care and Population Health, University College London, London, UK
| | | | - Stephen J Evans
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Phillip J Cowen
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
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30
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Weston J, Bromley R, Jackson CF, Adab N, Clayton‐Smith J, Greenhalgh J, Hounsome J, McKay AJ, Tudur Smith C, Marson AG. Monotherapy treatment of epilepsy in pregnancy: congenital malformation outcomes in the child. Cochrane Database Syst Rev 2016; 11:CD010224. [PMID: 27819746 PMCID: PMC6465055 DOI: 10.1002/14651858.cd010224.pub2] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is evidence that certain antiepileptic drugs (AEDs) are teratogenic and are associated with an increased risk of congenital malformation. The majority of women with epilepsy continue taking AEDs throughout pregnancy; therefore it is important that comprehensive information on the potential risks associated with AED treatment is available. OBJECTIVES To assess the effects of prenatal exposure to AEDs on the prevalence of congenital malformations in the child. SEARCH METHODS We searched the Cochrane Epilepsy Group Specialized Register (September 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 11), MEDLINE (via Ovid) (1946 to September 2015), EMBASE (1974 to September 2015), Pharmline (1978 to September 2015), Reprotox (1983 to September 2015) and conference abstracts (2010-2015) without language restriction. SELECTION CRITERIA We included prospective cohort controlled studies, cohort studies set within pregnancy registries and randomised controlled trials. Participants were women with epilepsy taking AEDs; the two control groups were women without epilepsy and women with epilepsy who were not taking AEDs during pregnancy. DATA COLLECTION AND ANALYSIS Three authors independently selected studies for inclusion. Five authors completed data extraction and risk of bias assessments. The primary outcome was the presence of a major congenital malformation. Secondary outcomes included specific types of major congenital malformations. Where meta-analysis was not possible, we reviewed included studies narratively. MAIN RESULTS We included 50 studies, with 31 contributing to meta-analysis. Study quality varied, and given the observational design, all were at high risk of certain biases. However, biases were balanced across the AEDs investigated and we believe that the results are not explained by these biases.Children exposed to carbamazepine (CBZ) were at a higher risk of malformation than children born to women without epilepsy (N = 1367 vs 2146, risk ratio (RR) 2.01, 95% confidence interval (CI) 1.20 to 3.36) and women with untreated epilepsy (N = 3058 vs 1287, RR 1.50, 95% CI 1.03 to 2.19). Children exposed to phenobarbital (PB) were at a higher risk of malformation than children born to women without epilepsy (N = 345 vs 1591, RR 2.84, 95% CI 1.57 to 5.13). Children exposed to phenytoin (PHT) were at an increased risk of malformation compared with children born to women without epilepsy (N = 477 vs 987, RR 2.38, 95% CI 1.12 to 5.03) and to women with untreated epilepsy (N = 640 vs 1256, RR 2.40, 95% CI 1.42 to 4.08). Children exposed to topiramate (TPM) were at an increased risk of malformation compared with children born to women without epilepsy (N = 359 vs 442, RR 3.69, 95% CI 1.36 to 10.07). The children exposed to valproate (VPA) were at a higher risk of malformation compared with children born to women without epilepsy (N = 467 vs 1936, RR 5.69, 95% CI 3.33 to 9.73) and to women with untreated epilepsy (N = 1923 vs 1259, RR 3.13, 95% CI 2.16 to 4.54). There was no increased risk for major malformation for lamotrigine (LTG). Gabapentin (GBP), levetiracetam (LEV), oxcarbazepine (OXC), primidone (PRM) or zonisamide (ZNS) were not associated with an increased risk, however, there were substantially fewer data for these medications.For AED comparisons, children exposed to VPA had the greatest risk of malformation (10.93%, 95% CI 8.91 to 13.13). Children exposed to VPA were at an increased risk of malformation compared with children exposed to CBZ (N = 2529 vs 4549, RR 2.44, 95% CI 2.00 to 2.94), GBP (N = 1814 vs 190, RR 6.21, 95% CI 1.91 to 20.23), LEV (N = 1814 vs 817, RR 5.82, 95% CI 3.13 to 10.81), LTG (N = 2021 vs 4164, RR 3.56, 95% CI 2.77 to 4.58), TPM (N = 1814 vs 473, RR 2.35, 95% CI 1.40 to 3.95), OXC (N = 676 vs 238, RR 3.71, 95% CI 1.65 to 8.33), PB (N = 1137 vs 626, RR 1.59, 95% CI 1.11 to 2.29, PHT (N = 2319 vs 1137, RR 2.00, 95% CI 1.48 to 2.71) or ZNS (N = 323 vs 90, RR 17.13, 95% CI 1.06 to 277.48). Children exposed to CBZ were at a higher risk of malformation than those exposed to LEV (N = 3051 vs 817, RR 1.84, 95% CI 1.03 to 3.29) and children exposed to LTG (N = 3385 vs 4164, RR 1.34, 95% CI 1.01 to 1.76). Children exposed to PB were at a higher risk of malformation compared with children exposed to GBP (N = 204 vs 159, RR 8.33, 95% CI 1.04 to 50.00), LEV (N = 204 vs 513, RR 2.33, 95% CI 1.04 to 5.00) or LTG (N = 282 vs 1959, RR 3.13, 95% CI 1.64 to 5.88). Children exposed to PHT had a higher risk of malformation than children exposed to LTG (N = 624 vs 4082, RR 1.89, 95% CI 1.19 to 2.94) or to LEV (N = 566 vs 817, RR 2.04, 95% CI 1.09 to 3.85); however, the comparison to LEV was not significant in the random-effects model. Children exposed to TPM were at a higher risk of malformation than children exposed to LEV (N = 473 vs 817, RR 2.00, 95% CI 1.03 to 3.85) or LTG (N = 473 vs 3975, RR 1.79, 95% CI 1.06 to 2.94). There were no other significant differences, or comparisons were limited to a single study.We found significantly higher rates of specific malformations associating PB exposure with cardiac malformations and VPA exposure with neural tube, cardiac, oro-facial/craniofacial, and skeletal and limb malformations in comparison to other AEDs. Dose of exposure mediated the risk of malformation following VPA exposure; a potential dose-response association for the other AEDs remained less clear. AUTHORS' CONCLUSIONS Exposure in the womb to certain AEDs carried an increased risk of malformation in the foetus and may be associated with specific patterns of malformation. Based on current evidence, LEV and LTG exposure carried the lowest risk of overall malformation; however, data pertaining to specific malformations are lacking. Physicians should discuss both the risks and treatment efficacy with the patient prior to commencing treatment.
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Affiliation(s)
- Jennifer Weston
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Rebecca Bromley
- University of ManchesterInstitute of Human Development6th Floor, Genetic Medicine, St Mary's HospitalOxford RoadManchesterUKM13 9WL
| | - Cerian F Jackson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Naghme Adab
- Walsgrave Hospital, University Hospitals Coventry and Warwickshire NHS TrustDepartment of Neurology, A5 CorridorClifford Bridge RoadCoventryWarwickshireUKCV2 2DX
| | - Jill Clayton‐Smith
- University of ManchesterInstitute of Human Development6th Floor, Genetic Medicine, St Mary's HospitalOxford RoadManchesterUKM13 9WL
| | - Janette Greenhalgh
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Juliet Hounsome
- University of LiverpoolLiverpool Reviews and Implementation GroupSherrington BuildingAshton StreetLiverpoolUKL69 3GE
| | - Andrew J McKay
- Institute of Child Health, Alder Hey HospitalClinical Trials UnitEaton RoadWest DerbyLiverpoolMerseysideUKL12 2AP
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsShelley's CottageBrownlow StreetLiverpoolUKL69 3GS
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
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Bromley R. The treatment of epilepsy in pregnancy: The neurodevelopmental risks associated with exposure to antiepileptic drugs. Reprod Toxicol 2016; 64:203-10. [PMID: 27312074 DOI: 10.1016/j.reprotox.2016.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/12/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022]
Abstract
A number of antiepileptic drugs (AEDs) have been confirmed as teratogens due to their association with an increased malformation rate. The majority of research to date does not find an association between prenatal exposure to monotherapy carbamazepine, lamotrigine or phenytoin and neurodevelopmental outcome in comparison to control children and noted higher abilities in comparison to children exposed to valproate; but further work is needed before conclusions can be drawn. Data for levetiracetam was limited to one study, as was the evidence for topiramate. Sodium valproate exposure appeared to carry a dose dependent risk to the developing brain, with evidence of reduced levels of IQ, poorer verbal abilities and increased rate of autistic spectrum disorder both in comparison to control children and children exposed to other AEDs. The severity of the neurodevelopmental deficits associated with prenatal exposure to valproate highlight the critical need to consider neurodevelopmental outcomes as a central aspect of teratological research.
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Affiliation(s)
- R Bromley
- Institute of Human Development, Faculty of Medical & Human Sciences, University of Manchester, United Kingdom; Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, United Kingdom.
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O'Keeffe AG, Nazareth I, Petersen I. Time trends in the prescription of statins for the primary prevention of cardiovascular disease in the United Kingdom: a cohort study using The Health Improvement Network primary care data. Clin Epidemiol 2016; 8:123-32. [PMID: 27313477 PMCID: PMC4890684 DOI: 10.2147/clep.s104258] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Statins are widely prescribed for the primary prevention of cardiovascular disease. Guidelines exist for statin prescriptions, but there is little recent analysis concerning prescription trends over time and how these vary with respect to demographic variables. Methods and results Using The Health Improvement Network primary care database, statin therapy initiation and statin prescription prevalence rates were calculated using data from 7,027,711 individuals across the UK for the years 1995 to 2013, overall and stratified by sex, age group, and socioeconomic deprivation level (Townsend score). Statin therapy initiation rates rose sharply from 1995 (0.51 per 1,000 person-years) up to 2006 (19.83 per 1,000 person-years) and thereafter declined (10.76 per 1,000 person-years in 2013). Males had higher initiation rates than females and individuals aged 60–85 years had higher initiation rates than younger or more elderly age groups. Initiation rates were slightly higher as social deprivation level increased, after accounting for age and sex. Prescription prevalence increased sharply from 1995 (2.36 per 1,000 person-years) to 2013 (128.03 per 1,000 person-years) with males generally having a higher prevalence rate, over time, than females. Prevalence rates over time were generally higher for older age groups but were similar with respect to social deprivation level. Conclusion The uptake of statins within UK primary care has increased greatly over time with statins being more commonly prescribed to older patients in general and, in recent years, males appear to have been prescribed statins at higher rates than females. After accounting for age and sex, the statin therapy initiation rate increases with the level of social deprivation.
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Affiliation(s)
- Aidan G O'Keeffe
- Department of Statistical Science, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
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Abstract
Approximately 50% of all pregnancies in women with epilepsy (WWE) occur unplanned. This is worrying, given the increased occurrence of obstetrical complications in WWE, including the risk of seizures and their possible consequences for both the mother and the unborn child. Hormonal contraception is usually regarded as highly effective, but it is subject to numerous bidirectional drug interactions with several antiepileptic drugs. These interactions may lead to loss of seizure control or contraceptive failure. Further concerns are loss of bone mineral density and increased seizure activity due to hormonal effects. Many physicians lack sufficient knowledge regarding these issues, and most WWE have never received adequate counseling. Moreover, several studies show that a large proportion of WWE do not take their medicines regularly. This article reviews all of these issues and offers practical recommendations for the management of contraception in WWE.
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Affiliation(s)
- Arne Reimers
- Department of Clinical Pharmacology, St Olavs University Hospital.,Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Stevenson F, Hamilton S, Pinfold V, Walker C, Dare CRJ, Kaur H, Lambley R, Szymczynska P, Nicolls V, Petersen I. Decisions about the use of psychotropic medication during pregnancy: a qualitative study. BMJ Open 2016; 6:e010130. [PMID: 26817641 PMCID: PMC4735167 DOI: 10.1136/bmjopen-2015-010130] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To understand the perspectives of women with severe mental illness concerning the use of psychotropic medicines while pregnant. DESIGN Interviews conducted by female peer researchers with personal experience of making or considering decisions about using psychotropic medicines in pregnancy, supported by professional researchers. PARTICIPANTS 12 women who had had a baby in the past 5 years and had taken antipsychotics or mood-stabilisers for severe mental illness within the 12-month period immediately prior to that pregnancy. Recruitment to the study was via peer networks and the women interviewed came from different regions of England. SETTING Interviews were arranged in places where women felt comfortable and that accommodated their childcare needs including their home, local library and the research office. RESULTS The views expressed demonstrated complex attempts to engage with decision-making about the use of psychotropic medicines in pregnancy. In nearly all cases, the women expressed the view that healthcare professionals had access to limited information leaving women to rely on experiential and common sense evidence when making decisions about medicine taking during pregnancy. CONCLUSIONS The findings complement existing work using electronic health records by providing explanations for the discontinuation of psychotropic medicines in pregnancy. Further work is necessary to understand health professionals' perspectives on the provision of services and care to women with severe mental illness during pregnancy.
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Affiliation(s)
- Fiona Stevenson
- Department of Primary Care and Population Health, UCL, London, UK
| | | | | | | | | | | | | | - Paulina Szymczynska
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | | | - Irene Petersen
- Department of Primary Care and Population Health, UCL, London, UK
- Department of Clinical Epidemiology, Aarhus, Denmark
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Charlton R, Garne E, Wang H, Klungsøyr K, Jordan S, Neville A, Pierini A, Hansen A, Engeland A, Gini R, Thayer D, Bos J, Puccini A, Nybo Andersen AM, Dolk H, de Jong-van den Berg L. Antiepileptic drug prescribing before, during and after pregnancy: a study in seven European regions. Pharmacoepidemiol Drug Saf 2015; 24:1144-54. [PMID: 26272314 DOI: 10.1002/pds.3847] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 06/26/2015] [Accepted: 07/08/2015] [Indexed: 11/07/2022]
Abstract
PURPOSE The aim of this study was to explore antiepileptic drug (AED) prescribing before, during and after pregnancy as recorded in seven population-based electronic healthcare databases. METHODS Databases in Denmark, Norway, the Netherlands, Italy (Emilia Romagna/Tuscany), Wales and the Clinical Practice Research Datalink, representing the rest of the UK, were accessed for the study. Women with a pregnancy starting and ending between 2004 and 2010, which ended in a delivery, were identified. AED prescriptions issued (UK) or dispensed (non-UK) at any time during pregnancy and the 6 months before and after pregnancy were identified in each of the databases. AED prescribing patterns were analysed, and the choice of AEDs and co-prescribing of folic acid were evaluated. RESULTS In total, 978 957 women with 1 248 713 deliveries were identified. In all regions, AED prescribing declined during pregnancy and was lowest during the third trimester, before returning to pre-pregnancy levels by 6 months following delivery. For all deliveries, the prevalence of AED prescribing during pregnancy was 51 per 10 000 pregnancies (CI95 49-52%) and was lowest in the Netherlands (43/10 000; CI95 33-54%) and highest in Wales (60/10 000; CI95 54-66%). In Denmark, Norway and the two UK databases lamotrigine was the most commonly prescribed AED; whereas in the Italian and Dutch databases, carbamazepine, valproate and phenobarbital were most frequently prescribed. Few women prescribed with AEDs in the 3 months before pregnancy were co-prescribed with high-dose folic acid: ranging from 1.0% (CI95 0.3-1.8%) in Emilia Romagna to 33.5% (CI95 28.7-38.4%) in Wales. CONCLUSION The country's differences in prescribing patterns may suggest different use, knowledge or interpretation of the scientific evidence base. The low co-prescribing of folic acid indicates that more needs to be done to better inform clinicians and women of childbearing age taking AEDs about the need to offer and receive complete preconception care.
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Affiliation(s)
- Rachel Charlton
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Ester Garne
- Paediatric department, Hospital Lillebaelt, Kolding, Denmark
| | - Hao Wang
- Pharmacoepidemiology and Pharmacoeconomics unit, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Kari Klungsøyr
- Medical Birth Registry of Norway, The Norwegian Institute of Public Health, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sue Jordan
- Department of Nursing, College of Human and Health Sciences, Swansea University, Swansea, Wales, UK
| | - Amanda Neville
- IMER (Emilia Romagna Registry of Birth Defects), Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Anna Pierini
- Institute of Clinical Physiology - National Research Council (IFC-CNR), Pisa, Italy
| | - Anne Hansen
- Paediatric department, Hospital Lillebaelt, Kolding, Denmark.,Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Engeland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Pharmacoepidemiology, The Norwegian Institution of Public Health, Oslo, Norway
| | - Rosa Gini
- The Regional Agency for Public Health of Tuscany, Tuscany, Italy
| | - Daniel Thayer
- Centre for Health Information, Research and Evaluation, Swansea University, Swansea, Wales, UK
| | - Jens Bos
- Pharmacoepidemiology and Pharmacoeconomics unit, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Aurora Puccini
- Drug Policy Service, Emilia Romagna Region Health Authority, Bologna, Italy
| | - Anne-Marie Nybo Andersen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Helen Dolk
- Institute of Nursing, University of Ulster, Ulster, Northern Ireland, United Kingdom
| | - Lolkje de Jong-van den Berg
- Pharmacoepidemiology and Pharmacoeconomics unit, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
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Ban L, Fleming KM, Doyle P, Smeeth L, Hubbard RB, Fiaschi L, Tata LJ. Congenital Anomalies in Children of Mothers Taking Antiepileptic Drugs with and without Periconceptional High Dose Folic Acid Use: A Population-Based Cohort Study. PLoS One 2015; 10:e0131130. [PMID: 26147467 PMCID: PMC4492893 DOI: 10.1371/journal.pone.0131130] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/27/2015] [Indexed: 11/18/2022] Open
Abstract
Background Antenatal antiepileptic drug (AED) use has been found to be associated with increased major congenital anomaly (CA) risks. However whether such AED-associated risks were different according to periconceptional high dose (5mg daily) folic acid supplementation is still unclear. Methods We included 258,591 singleton live-born children of mothers aged 15-44 years in 1990-2013 from The Health Improvement Network, a large UK primary care database. We identified all major CAs according to the European Surveillance of Congenital Anomalies classification. Absolute risks and adjusted odds ratios (aOR) were calculated comparing children of mothers prescribed AEDs to those without such prescriptions, stratified by folic acid prescriptions around the time of conception (one month before conception to two months post-conception). Results CA risk was 476/10,000 in children of mothers with first trimester AEDs compared with 269/10,000 in those without AEDs equating to an aOR of 1.82, 95% confidence interval 1.30-2.56. The highest system-specific risks were for heart anomalies (198/10,000 and 79/10,000 respectively, aOR 2.49,1.47-4.21). Sodium valproate and lamotrigine were both associated with increased risks of any CA (aOR 2.63,1.46-4.74 and aOR 2.01,1.12-3.59 respectively) and system-specific risks. Stratification by folic acid supplementation did not show marked reductions in AED-associated risks (e.g. for CAs overall aOR 1.75, 1.01-3.03 in the high dose folic acid group and 1.94, 95%CI 1.21-3.13 in the low dose or no folic acid group); however, the majority of mothers taking AEDs only initiated high dose folic acid from the second month of pregnancy. Conclusions Children of mothers with AEDs in the first trimester of pregnancy have a 2-fold increased risk of major CA compared to those unexposed. We found no evidence that prescribed high dose folic acid supplementation reduced such AED-associated risks. Although statistical power was limited, prescribing of folic acid too late for it to be effective during the organogenic period or selective prescribing to those with more severe morbidity may explain these findings.
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Affiliation(s)
- Lu Ban
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Kate M. Fleming
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Pat Doyle
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Liam Smeeth
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Richard B. Hubbard
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Linda Fiaschi
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, United Kingdom
| | - Laila J. Tata
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, United Kingdom
- * E-mail:
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Petersen I, McCrea RL, Lupattelli A, Nordeng H. Women's perception of risks of adverse fetal pregnancy outcomes: a large-scale multinational survey. BMJ Open 2015; 5:e007390. [PMID: 26033946 PMCID: PMC4458601 DOI: 10.1136/bmjopen-2014-007390] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine pregnant women and new mothers' perception of risks in pregnancy. DESIGN, SETTINGS AND PARTICIPANTS This was a large-scale multinational survey including 9113 pregnant women and new mothers from 18 countries in Europe, North America and Australia. MAIN OUTCOMES Risk perception scores (0-10) for harmful effects to the fetus were derived for: (1) medicines (over-the-counter medicine and prescribed medicine), (2) food substances (eggs and blue veined cheese), (3) herbal substances (ginger and cranberries) (4) alcohol and tobacco, and (5) thalidomide. RESULTS Overall, 80% (6453/8131) of women perceived the risk of giving birth to a child with a birth defect to be ≤ 5 of 100 births. The women rated cranberries and ginger least harmful (mean risk perception scores 1.1 and 1.5 of 10, respectively) and antidepressants, alcohol, smoking and thalidomide as most harmful (7.6, 8.6, 9.2 and 9.4 out of 10, respectively). The perception varied with age, level of education, pregnancy status, profession and geographical region. Noticeably, 70% had not heard about thalidomide, but of those who had (2692/9113), the risk perception scores were 0.4-0.5 points lower in women below 25 years compared to women aged 26-30 years. CONCLUSIONS In general, women perceived the risks of giving birth to a child with birth defects low, but there were substantial disparities between women's perceived risks and the actual risks when it comes to over-the-counter agents against nausea and prescribed medication. The study revealed that few women knew of thalidomide, suggesting that the general awareness among women of the teratogenic effects of thalidomide is declining, but it has left a general scepticism about safety of medication in pregnancy. This may have some severe consequences if women are left without medical treatments in pregnancy.
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Affiliation(s)
- Irene Petersen
- Department of Primary Care and Population Health, UCL, London, UK
| | - Rachel L McCrea
- Department of Primary Care and Population Health, UCL, London, UK
| | - Angela Lupattelli
- Department of PharmacoEpidemiology and Drug Safety Research Group, School of Pharmacy, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- Department of PharmacoEpidemiology and Drug Safety Research Group, School of Pharmacy, University of Oslo, Oslo, Norway
- Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway
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Rubinchik-Stern M, Shmuel M, Eyal S. Antiepileptic drugs alter the expression of placental carriers: An in vitro study in a human placental cell line. Epilepsia 2015; 56:1023-32. [DOI: 10.1111/epi.13037] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Miriam Rubinchik-Stern
- Institute for Drug Research; School of Pharmacy; The Hebrew University; Jerusalem Israel
| | - Miri Shmuel
- Institute for Drug Research; School of Pharmacy; The Hebrew University; Jerusalem Israel
| | - Sara Eyal
- Institute for Drug Research; School of Pharmacy; The Hebrew University; Jerusalem Israel
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Taylor CL, Stewart R, Ogden J, Broadbent M, Pasupathy D, Howard LM. The characteristics and health needs of pregnant women with schizophrenia compared with bipolar disorder and affective psychoses. BMC Psychiatry 2015; 15:88. [PMID: 25886140 PMCID: PMC4406022 DOI: 10.1186/s12888-015-0451-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/19/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Most women with psychotic disorders and bipolar disorders have children but their pregnancies are at risk of adverse psychiatric and fetal outcome. The extent of modifiable risk factors - both clinical and socio-demographic - is unclear as most studies have used administrative data or recruited from specialist tertiary referral clinics. We therefore aimed to investigate the socio-demographic and clinical characteristics of an epidemiologically representative cohort of pregnant women with affective and non-affective severe mental illness. METHODS Women with severe mental illness were identified from a large electronic mental health case register in south London, and a data linkage with national maternity Hospital Episode Statistics identified pregnancies in 2007-2011. Data were extracted using structured fields, text searching and natural language processing applications. RESULTS Of 456 pregnant women identified, 236 (51.7%) had schizophrenia and related disorders, 220 (48.3%) had affective psychosis or bipolar disorder. Women with schizophrenia and related disorders were younger, less likely to have a partner in pregnancy, more likely to be black, to smoke or misuse substances and had significantly more time in the two years before pregnancy in acute care (inpatient or intensive home treatment) compared with women with affective disorders. Both groups had high levels of domestic abuse in pregnancy (recorded in 18.9%), were from relatively deprived backgrounds and had impaired functioning measured by the Health of the Nation Outcome Scale. Women in the affective group were more likely to stop medication in the first trimester (39% versus 25%) whereas women with non-affective psychoses were more likely to switch medication. CONCLUSIONS A significant proportion of women, particularly those with non-affective psychoses, have modifiable risk factors requiring tailored care to optimize pregnancy outcomes. Mental health professionals need to be mindful of the possibility of pregnancy in women of childbearing age and prescribe and address modifiable risk factors accordingly.
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Affiliation(s)
- Clare L Taylor
- Section of Women's Mental Health/Women's Health Academic Centre, Department of Health Service and Population Research, King's College London, Institute of Psychiatry, London, UK.
| | - Robert Stewart
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, London, UK.
| | - Jack Ogden
- Section of Women's Mental Health/Women's Health Academic Centre, Department of Health Service and Population Research, King's College London, Institute of Psychiatry, London, UK.
| | | | | | - Louise M Howard
- Section of Women's Mental Health/Women's Health Academic Centre, Department of Health Service and Population Research, King's College London, Institute of Psychiatry, London, UK.
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McCrea RL, Nazareth I, Evans SJW, Osborn DPJ, Pinfold V, Cowen PJ, Petersen I. Lithium prescribing during pregnancy: a UK primary care database study. PLoS One 2015; 10:e0121024. [PMID: 25793580 PMCID: PMC4368741 DOI: 10.1371/journal.pone.0121024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 01/27/2015] [Indexed: 11/18/2022] Open
Abstract
Background Women taking lithium must decide whether to continue the medication if they conceive or plan to conceive. Little is known about the extent of prescribing of lithium during pregnancy. Aims To determine: 1) the prevalence of lithium prescribing during pregnancy and 2) to assess whether pregnancy is associated with discontinuation of lithium. Method First, we identified women receiving any lithium prescriptions before and during pregnancy using The Health Improvement Network (THIN) primary care database. Subsequently, we used a Kaplan-Meier plot to compare time to last prescription in women prescribed lithium continuously three months before pregnancy and a comparison group of non-pregnant women. Finally, we described the characteristics of the women prescribed lithium in pregnancy. Results Very few women were prescribed lithium during pregnancy; out of 458,761 pregnancies, we identified 47 (0.01%) in which lithium was prescribed after the 6th week of pregnancy (when the pregnancy was likely to be known). In our study of discontinuation, we found pregnant women were more likely to stop lithium than those who were not pregnant. Of the 52 women who were being continuously prescribed lithium three months before pregnancy, only 17 (33%) continued receiving prescriptions beyond the 6th week of pregnancy. However, most of these 17 women continued treatment throughout pregnancy. Conclusions Pregnancy was strongly associated with discontinuation of lithium. Further evidence on the risks of lithium is needed so that women can weight these against the risk of a deterioration in maternal mental health.
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Affiliation(s)
- Rachel L. McCrea
- University College London, Department of Primary Care and Population Health, London, United Kingdom
| | - Irwin Nazareth
- University College London, Department of Primary Care and Population Health, London, United Kingdom
| | | | - David P. J. Osborn
- University College London, Division of Psychiatry, London, United Kingdom
| | | | - Phil J. Cowen
- University of Oxford, University Department of Psychiatry, Oxford, United Kingdom
| | - Irene Petersen
- University College London, Department of Primary Care and Population Health, London, United Kingdom
- * E-mail:
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O'Keeffe AG, Petersen I, Nazareth I. Initiation rates of statin therapy for the primary prevention of cardiovascular disease: an assessment of differences between countries of the UK and between regions within England. BMJ Open 2015; 5:e007207. [PMID: 25748418 PMCID: PMC4360592 DOI: 10.1136/bmjopen-2014-007207] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To investigate the extent to which variation exists in the initiation rate of statin therapy for the primary prevention of cardiovascular disease between countries of the UK and between different regions within England. DESIGN Cohort study using data from a large UK primary care database. SETTING UK PARTICIPANTS 4,820,885 individuals from 554 general practices during the period 2004-2012. MAIN OUTCOME MEASURES Rate of statin therapy initiation per 1000 person-years. RESULTS Relative to a fixed English rate of 1 initiation per 1000 person-years and accounting for gender, age and social deprivation level, the rate was similar for Scotland at 0.92 (95% CI 0.84 to 1.00) and rates for Northern Ireland and Wales were higher at 1.40 (95% CI 1.20 to 1.62) and 1.18 (95% CI 1.05 to 1.32), respectively. Within England, the regions could be classified into three groups with respect to statin therapy initiation rates (relative to a rate of 1 initiation per 1000 person-years for London): the South Central 0.73 (95% CI 0.64 to 0.83), South West 0.80 (95% CI 0.71 to 0.91), East of England 0.81 (95% CI 0.71 to 0.94) and South East Coast 0.83 (95% CI 0.73 to 0.95); strategic health authorities had similar low rates followed by the East Midlands 0.88 (95% CI 0.73 to 1.05), West Midlands 0.96 (95% CI 0.84 to 1.09), North East 0.96 (95% CI 0.79 to 1.16), Yorkshire and Humber 0.97 (95% CI 0.81 to 1.17) and London strategic health authorities. North West England exhibited the highest rate of statin therapy initiation of 1.16 (95% CI 1.02 to 1.31). CONCLUSIONS Considerable variation in the rate of statin therapy initiation was observed between the four countries of the UK and between different geographical regions within England.
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Affiliation(s)
- Aidan G O'Keeffe
- Department of Statistical Science, University College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
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Vajda FJE, O'Brien TJ, Lander CM, Graham J, Eadie MJ. The teratogenicity of the newer antiepileptic drugs - an update. Acta Neurol Scand 2014; 130:234-8. [PMID: 25040242 DOI: 10.1111/ane.12280] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the risk of teratogenicity from maternal intake of the more widely used newer antiepileptic drugs, especially lamotrigine, levetiracetam and topiramate. MATERIALS AND METHODS Use of confidence interval and regression methods to compare risks of foetal malformation in pregnancies in women exposed (n = 1572) and in women with epilepsy not exposed (n = 153) to antiepileptic drugs in the first trimester. RESULTS Compared with the foetal malformation rate in women with epilepsy who were untreated in the first trimester (3.3%), the malformation rates for lamotrigine (4.6%), levetiracetam (2.4%) and topiramate (2.4%), all in monotherapy, were not statistically significantly different. However, the malformation rates for topiramate as part of polytherapy (14.1%) and for valproate in both monotherapy (13.8%) and polytherapy (10.2%) were statistically significantly higher. Regression analysis of combined monotherapy and polytherapy data showed no statistically significant increased risk of teratogenesis associated with lamotrigine or levetiracetam, but a statistically significant and dose-related risk for first trimester topiramate (P = 0.01) and valproate (P < 0.0001) exposure. CONCLUSIONS Evidence from this and other studies suggests that lamotrigine and levetiracetam have low risk for teratogenesis, but that topiramate exposure early in pregnancy may be associated with dose-related anatomical teratogenesis, as valproate is already known to be.
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Affiliation(s)
- F. J. E. Vajda
- Departments of Medicine and Neurology; Royal Melbourne Hospital; University of Melbourne; Parkville Vic. Australia
| | - T. J. O'Brien
- Departments of Medicine and Neurology; Royal Melbourne Hospital; University of Melbourne; Parkville Vic. Australia
| | - C. M. Lander
- Department of Neurology; Royal Brisbane and Women's Hospital; University of Queensland; Brisbane Qld Australia
| | - J. Graham
- Departments of Medicine and Neurology; Royal Melbourne Hospital; University of Melbourne; Parkville Vic. Australia
| | - M. J. Eadie
- School of Medicine and Biomedical Sciences; University of Queensland; Brisbane Qld Australia
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Petersen I, McCrea RL, Osborn DJP, Evans S, Pinfold V, Cowen PJ, Gilbert R, Nazareth I. Discontinuation of antipsychotic medication in pregnancy: a cohort study. Schizophr Res 2014; 159:218-25. [PMID: 25171856 DOI: 10.1016/j.schres.2014.07.034] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/23/2014] [Accepted: 07/27/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Women prescribed antipsychotics face the dilemma on whether to continue medication in pregnancy in terms of balancing risks and benefits. Previous research on other psychotropic medications suggests that many women discontinue treatment in early pregnancy. However, very limited evidence exists on discontinuation of antipsychotic medication. METHODS We identified 495,953 pregnant women from THIN primary care database. Kaplan-Meier plots were used to examine time to last antipsychotic prescription. Poisson regression was used to examine characteristics of those who stopped treatment during pregnancy. RESULTS There has been an overall increase in prevalence of antipsychotic prescribing since 2007. However, antipsychotics were more likely to be stopped in pregnant than non-pregnant women. Only 107/279 (38%) of women on atypical antipsychotics and 39/207 (19%) of women on typical antipsychotics before pregnancy still received treatment at the start of third trimester. Older women were more likely to continue typical antipsychotic treatment in pregnancy (35+ versus <25 years risk ratio: 3.09 [95% CI 1.76, 5.44]). Likewise, those who received typical antipsychotics for longer periods before were most likely to continue treatment in pregnancy (12+ versus <6 months: RR: 3.12 [95% CI 1.97, 4.95]). For atypical antipsychotics length and dose of prior prescribing were also associated with continuation in pregnancy. CONCLUSIONS Pregnancy was a major determinant of cessation of antipsychotics. Only 38% of women on atypical and 19% on typical antipsychotics were still prescribed the drug in the third trimester. Duration of prior treatment, maternal age as well as dose was significantly associated with continued treatment of antipsychotics in pregnancy.
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Affiliation(s)
- Irene Petersen
- Department of Primary Care and Population Health, UCL, Rowland Hill St., London NW3 2PF, United Kingdom.
| | - Rachel L McCrea
- Department of Primary Care and Population Health, UCL, Rowland Hill St., London NW3 2PF, United Kingdom
| | - David J P Osborn
- Division of Psychiatry, UCL, Charles Bell House, Riding House Street, London W1W 7EJ, United Kingdom
| | - Stephen Evans
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Vanessa Pinfold
- The McPin Foundation, 32-36 Loman Street, London SE1 0EH, United Kingdom
| | - Phil J Cowen
- University Department of Psychiatry, Warneford Hospital, Oxford OX37JX, United Kingdom
| | - Ruth Gilbert
- Centre of Paediatric Epidemiology and Biostatistics, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom
| | - Irwin Nazareth
- Department of Primary Care and Population Health, UCL, Rowland Hill St., London NW3 2PF, United Kingdom
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Welch CA, Petersen I, Bartlett JW, White IR, Marston L, Morris RW, Nazareth I, Walters K, Carpenter J. Evaluation of two-fold fully conditional specification multiple imputation for longitudinal electronic health record data. Stat Med 2014; 33:3725-3737. [PMID: 24782349 DOI: 10.1002/sim.6184.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 01/08/2014] [Accepted: 04/03/2014] [Indexed: 05/21/2023]
Abstract
Most implementations of multiple imputation (MI) of missing data are designed for simple rectangular data structures ignoring temporal ordering of data. Therefore, when applying MI to longitudinal data with intermittent patterns of missing data, some alternative strategies must be considered. One approach is to divide data into time blocks and implement MI independently at each block. An alternative approach is to include all time blocks in the same MI model. With increasing numbers of time blocks, this approach is likely to break down because of co-linearity and over-fitting. The new two-fold fully conditional specification (FCS) MI algorithm addresses these issues, by only conditioning on measurements, which are local in time. We describe and report the results of a novel simulation study to critically evaluate the two-fold FCS algorithm and its suitability for imputation of longitudinal electronic health records. After generating a full data set, approximately 70% of selected continuous and categorical variables were made missing completely at random in each of ten time blocks. Subsequently, we applied a simple time-to-event model. We compared efficiency of estimated coefficients from a complete records analysis, MI of data in the baseline time block and the two-fold FCS algorithm. The results show that the two-fold FCS algorithm maximises the use of data available, with the gain relative to baseline MI depending on the strength of correlations within and between variables. Using this approach also increases plausibility of the missing at random assumption by using repeated measures over time of variables whose baseline values may be missing.
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Affiliation(s)
- Catherine A Welch
- Department of Primary Care and Population Health, University College London (UCL), London, U.K
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Vajda FJE, O'Brien T, Lander C, Graham J, Eadie M. The efficacy of the newer antiepileptic drugs in controlling seizures in pregnancy. Epilepsia 2014; 55:1229-34. [DOI: 10.1111/epi.12711] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Frank J. E. Vajda
- Departments of Medicine and Neurology; Royal Melbourne Hospital; University of Melbourne; Parkville Victoria Australia
| | - Terrence O'Brien
- Departments of Medicine and Neurology; Royal Melbourne Hospital; University of Melbourne; Parkville Victoria Australia
| | - Cecilie Lander
- Department of Neurology; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Janet Graham
- Departments of Medicine and Neurology; Royal Melbourne Hospital; University of Melbourne; Parkville Victoria Australia
| | - Mervyn Eadie
- School of Medicine and Biomedical Science; University of Queensland; Brisbane Queensland Australia
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Welch CA, Petersen I, Bartlett JW, White IR, Marston L, Morris RW, Nazareth I, Walters K, Carpenter J. Evaluation of two-fold fully conditional specification multiple imputation for longitudinal electronic health record data. Stat Med 2014; 33:3725-37. [PMID: 24782349 PMCID: PMC4285297 DOI: 10.1002/sim.6184] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 01/08/2014] [Accepted: 04/03/2014] [Indexed: 12/02/2022]
Abstract
Most implementations of multiple imputation (MI) of missing data are designed for simple rectangular data structures ignoring temporal ordering of data. Therefore, when applying MI to longitudinal data with intermittent patterns of missing data, some alternative strategies must be considered. One approach is to divide data into time blocks and implement MI independently at each block. An alternative approach is to include all time blocks in the same MI model. With increasing numbers of time blocks, this approach is likely to break down because of co-linearity and over-fitting. The new two-fold fully conditional specification (FCS) MI algorithm addresses these issues, by only conditioning on measurements, which are local in time. We describe and report the results of a novel simulation study to critically evaluate the two-fold FCS algorithm and its suitability for imputation of longitudinal electronic health records. After generating a full data set, approximately 70% of selected continuous and categorical variables were made missing completely at random in each of ten time blocks. Subsequently, we applied a simple time-to-event model. We compared efficiency of estimated coefficients from a complete records analysis, MI of data in the baseline time block and the two-fold FCS algorithm. The results show that the two-fold FCS algorithm maximises the use of data available, with the gain relative to baseline MI depending on the strength of correlations within and between variables. Using this approach also increases plausibility of the missing at random assumption by using repeated measures over time of variables whose baseline values may be missing.
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Affiliation(s)
- Catherine A Welch
- Department of Primary Care and Population Health, University College London (UCL), London, U.K
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47
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48
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Pearlstein T. Use of Psychotropic Medication during Pregnancy and the Postpartum Period. WOMENS HEALTH 2013; 9:605-15. [DOI: 10.2217/whe.13.54] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Women with active psychiatric disorders who become pregnant face treatment dilemmas. Although results from studies are inconsistent, small but significant, risks on birth outcomes occur with exposure to untreated disorders, as well as to psychotropic medications. Prenatal antidepressant medication exposure may increase the risk for spontaneous miscarriage, preterm birth, cardiac malformations, persistent pulmonary hypertension of the newborn and postnatal adaptation syndrome. The use of valproate is contraindicated during pregnancy due to teratogenicity and neurocognitive delay and deficits. This review of selected studies will highlight some of the current issues with the use of psychotropic medications during pregnancy and the postpartum period.
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Affiliation(s)
- Teri Pearlstein
- Alpert Medical School of Brown University, Women's Medicine Collaborative, 146 West River Street, Providence, RI 02904, USA, Tel.: +1 401 793 7020, Fax: +1 401 793 7407,
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Piskorska B, Miziak B, Czuczwar SJ, Borowicz KK. Safety issues around misuse of antiepileptics. Expert Opin Drug Saf 2013; 12:647-57. [DOI: 10.1517/14740338.2013.796363] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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50
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Goodridge DMG, Shorvon SD. The contribution of British general practice to our knowledge of epilepsy and its effects on people. Br Med Bull 2013; 108:115-30. [PMID: 24133115 DOI: 10.1093/bmb/ldt030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION British general practice is a good base for epidemiological research which is evidenced by the study of epilepsy. SOURCES OF DATA A comprehensive search of PubMed using various keywords for articles on epilepsy research performed in British general practice. AREAS OF AGREEMENT Studies in the setting of general practice have contributed significantly to knowledge in the field of epilepsy, especially in relation to epidemiology, studies of prognosis and treatment patterns and psychosocial aspects. AREAS OF CONTROVERSY The extent to which epilepsy can be managed in general practice. GROWING POINTS The importance of primary care research and the importance of collaborative studies between general practice, hospital and university departments. AREAS TIMELY FOR DEVELOPING RESEARCH The effects of interventions at general practice level on seizure control, morbidity and mortality.
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