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Angus-Leppan H, Arkell R, Watkins L, Heaney D, Cooper P, Shankar R. New valproate regulations, informed choice and seizure risk. J Neurol 2024:10.1007/s00415-024-12436-8. [PMID: 38896265 DOI: 10.1007/s00415-024-12436-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 06/21/2024]
Abstract
Valproate is the most effective medication for generalised epilepsies, and several specific epilepsy syndromes. For some people, it will be the only medication to establish seizure remission, and withdrawing it carries risks of seizure recurrence and Sudden Unexpected Death in Epilepsy (SUDEP). It is also of proven efficacy for bipolar disorder and migraine prevention. Guidelines based on observational and epidemiological studies stress that maternal valproate related teratogenicity and neurodevelopmental effects are significantly higher than for other antiseizure medications (ASMs). It should, therefore, only be used if other medications are ineffective and after balancing the teratogenicity risk. Regulatory restrictions have changed prescribing practices and reduced valproate use. The number of other medications that must be trialled in the different conditions for which valproate has effectiveness and the consequences of the lack of efficacy of those drugs leading to significant harm including death remains unexplored. Risk minimisation measures (RMMs) for valproate, chiefly Pregnancy Prevention practices (PPP), consider foetal risk and not risk to people living with epilepsy. In the United Kingdom (UK), limitations relating to valproate use in all people < 55 years commenced in January 2024. While the evidence in child-bearing women is not disputed, the data in males are based on animal models, case reports, and one commissioned, unpublished, non-peer reviewed report unavailable to the UK public, stakeholder charities or professionals. Evidence suggests that 30-40% of people switching from valproate have breakthrough seizures. Thus, an estimated 21,000-28000 people in the UK will imminently be exposed to the potential hazards of breakthrough seizures, including death. There is little government investment in monitoring the effects of these changes to valproate prescribing on patient health and quality of life. This review summarises the history of valproate regulation, evidence underpinning it and argues how the latest regulations in the UK do not align with the country's medical regulatory bodies ethical principles nor with the Montgomery principles of informed patient choice and autonomy. It dissects how such regulations infringe Common Law principles, nor give due regard for patient outcomes beyond reproduction. The paper looks to provide recommendations to redress these concerns while appreciating the core need for such governance to emerge in the first place.
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Affiliation(s)
- Heather Angus-Leppan
- University of East London, Stratford, E15 4LZ, UK.
- National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, Queen Square, London, WC1N 3BG, UK.
- Royal Free London, Pond Street, London, NW3 2QG, UK.
| | - Rachel Arkell
- University of East London, Stratford, E15 4LZ, UK
- Kent Law School, University of Kent, Canterbury, CT2 7NS, UK
- Centre for Reproductive Research and Communication, British Pregnancy Advisory Service (BPAS), London, UK
| | - Lance Watkins
- University of South Wales, Pontypridd, UK
- University of Plymouth, Plymouth, UK
| | - Dominic Heaney
- National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, Queen Square, London, WC1N 3BG, UK
| | - Paul Cooper
- University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Greater Manchester, Salford Royal Hospital, Stott Lane, Salford, M6 8HD, UK
| | - Rohit Shankar
- Peninsula School of Medicine, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, UK
- University of Plymouth, Plymouth, UK
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Rugg-Gunn F, Hunt D. The prescription of valproate: risk of harm. Lancet Neurol 2024; 23:557-558. [PMID: 38760090 DOI: 10.1016/s1474-4422(24)00141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/27/2024] [Indexed: 05/19/2024]
Affiliation(s)
- Fergus Rugg-Gunn
- Department of Clinical and Experimental Epilepsy, National Hospital for Neurology and Neurosurgery, Institute of Neurology, University College London, London, UK
| | - David Hunt
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh EH16 4TJ, UK.
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Martin M, Braillon A. Sperm epigenetic mechanisms in autism spectrum disorders. The valproate case illustrates an enduring and systemic failure. Mol Psychiatry 2024; 29:1163-1164. [PMID: 38182807 DOI: 10.1038/s41380-023-02401-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 12/16/2023] [Accepted: 12/22/2023] [Indexed: 01/07/2024]
Affiliation(s)
- Marine Martin
- Association to Help Parents of Children Suffering from Anti-Convulsant Syndrome (APESAC), 8 rue Ramon Saguardia, 66450, Pollestres, France
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