Valproate MHRA Guidance: Limitations and Opportunities

New valproate regulations, informed choice and seizure risk

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child-bearing women is not disputed, the data in males are based on animal models, case reports, and one commissioned, unpublished, non-peer reviewed report unavailable to the UK public, stakeholder charities or professionals.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.

Valproate pregnancy prevention scheme: what are the barriers to enrolling patients and how do we meet them?

Background

The UK Medicines Health products Regulation Agency instructs that valproate prescriptions should be restricted in women of childbearing age to those consenting to the Pregnancy Prevention Programme (PPP). We assessed the compliance and barriers to the valproate PPP.

Methods

We retrospectively audited NHS Grampian's compliance with PPP guidelines among women of childbearing potential prescribed valproate between October 2017 and March 2018. Additionally, we prospectively reviewed new valproate prescriptions from February 2019 to March 2022 and compared this with our retrospective data to assess the effectiveness of our identification process using descriptive statistics.

Results

We identified 351 women retrospectively and 80 women prospectively. Epilepsy, migraine and psychiatry were the main indications. There was a decline in valproate use over the years, particularly for epilepsy. Initially, only 132 (37.6%) met the PPP requirement, and eventually, 81 (23%) stopped the medication. Despite efforts, 38 (10.8%) had contact with secondary care but still did not meet PPP and 100 (28.5%) had no documentation or referral to secondary care. Patients not meeting PPP lacked capacity, most commonly with severe learning difficulties. Women treated for psychiatric purposes were less likely to meet PPP than other indications.

Conclusions

A significant proportion of women continue valproate treatment without meeting the PPP requirement. This is linked to their indication for prescription and their comorbidities. Collaborative input from relevant specialities and primary care is required to fully achieve PPP if a national valproate database is to be established.

Are female bipolar patients of reproductive age aware of the teratogenic risk of sodium valproate? A qualitative study

Background

Sodium valproate is considered the most teratogenic of all anticonvulsant drugs. Internationally, new regulations require women to sign risk assessment forms if initiated on it.

Aim

This study aimed to explore patients’ awareness of the teratogenic risk of sodium valproate.

Setting

Weskoppies Psychiatric Hospital, Tshwane, Gauteng.

Methods

We conducted a qualitative study comprising 23 semi-structured interviews with female bipolar patients of reproductive age at a tertiary psychiatric hospital in South Africa.

Results

Patient psychoeducation and self-education is improving as many patients were aware of the risk of teratogenicity of sodium valproate either by being educated or by searching online after developing an interest. Our study identified the need for female patients to be educated about contraceptive use when starting on sodium valproate to avoid pregnancy.

Conclusion

Our study shows that patients are becoming more aware of the teratogenic risk of sodium valproate. This suggests that consultations focusing on the issues of conception and the use of sodium valproate in women of childbearing potential has improved.

Valproate prescribing practices for women with intellectual disability across Europe

BACKGROUND

Valproate (VPA) is a known teratogen associated with greater risk of major congenital malformations and other neurodevelopmental sequelae than all other licensed antiepileptic medicines. To reduce the potential for VPA-related teratogenicity, the European Medicines Agency issued recommendations in 2018. Over two-thirds of women/girls with intellectual disability (ID) may have treatment-resistant epilepsy that could benefit from VPA treatment.

AIMS

This investigation compared VPA prescribing practice for women/girls with ID between European countries, specifically evaluating the practice in the UK with that in other countries.

METHODS

An expert working group with representation from key stake-holding organizations developed a survey for dissemination to relevant professionals across Europe.

RESULTS

Seventy one responses were received (27 UK, 44 Europe). Clinicians in the UK were more likely to report that they are working to mandatory regulations compared with European respondents (P = .015). European respondents were less likely to be aware of user-independent contraception options (P = .06). In The UK, VPA regulations were more likely to be applied to women with ID than in Europe (P = .024).

CONCLUSION

There is heterogeneity in the application of VPA regulations across Europe for women/girls with ID. In both the UK and Europe, the regulations lack suitable adjustments for specific ID-related factors.

Understanding and Responding to Prescribing Patterns of Sodium Valproate-Containing Medicines in Pregnant Women and Women of Childbearing Age in Western Cape, South Africa

INTRODUCTION

Growing evidence of the teratogenic potential of sodium valproate (VPA) has changed prescribing practices across the globe; however, the impact of this research and the consequent dissemination of a Dear Health Care Professional Letter (DHCPL) in December 2015, recommending avoidance of the teratogen VPA in women of childbearing age (WOCBA) and pregnant women in South Africa, is unknown. We explored trends and reasons for VPA use among pregnant women and WOCBA in the public sector in Western Cape Province from 1 January 2015 to 31 December 2017.

METHODS

Using the provincial health information exchange that collates routine electronic health data via unique patient identifiers, we analysed clinical and pharmacy records from 2015 to 2017 to determine prescription patterns of VPA and other antiepileptic drug (AED) and mood-stabilising medicine (MSM) use in WOCBA and pregnant women. Senior clinicians and policy makers were consulted to understand the determinants of VPA use.

RESULTS

At least one VPA prescription was dispensed to between 8205 (0.79%) and 9425 (0.94%) WOBCA from a cohort of approximately 1 million WOCBA attending provincial health care facilities per year. Prescriptions were more likely in HIV-infected women compared with HIV-uninfected women (1.1-1.3% vs. 0.7-0.9%; p < 0.001). VPA use in WOCBA remained stable at 0.8-0.9% over the review period despite the 2016 DHCPL. VPA was the most prescribed AED/MSM, constituting 43.2-45.5% of all WOCBA taking at least one such agent, while lamotrigine, the other recommended first-line agent, was only prescribed in 7.8-8.9% of WOCBA. Over 3 years, approximately 663 pregnancies were exposed to VPA, with a steady rise in the number of exposures each year (n = 204, 214 and 245, respectively).

CONCLUSION

Despite warnings, VPA remained the most frequently prescribed AED or MSM in WOCBA. Contributing factors are described.

Valproate risk form-Surveying 215 clinicians involving 4775 encounters

OBJECTIVES

Annual completion of a Valproate Risk Acknowledgement Form (RAF) is mandated in the United Kingdom due to neurodevelopmental risks of in utero valproate exposure. The number of women of childbearing potential taking valproate, the uptake of the RAF within this population and their clinical outcomes is not known or monitored. This study surveyed responses of clinicians administering the RAF to women of childbearing potential taking valproate medications.

MATERIALS AND METHODS

Study design-national online survey distributed to clinical specialists throughout the United Kingdom via their national organizations. Participants-clinicians qualified to counsel and administer the valproate RAF (as defined by the Medicines and Healthcare products Regulatory Agency). Main outcome measures-quantitative and qualitative responses regarding identification, uptake, effects and reactions to the RAF. Trial registration-registered at the Clinical Governance and Audit Committee at Royal Free London NHS Foundation Trust Hospital.

RESULTS

215 respondents covering more than 4775 patient encounters were captured. Most patients continued on valproate, 90% with epilepsy as the indication. Respondents reported that seizure control deteriorated when switched to levetiracetam (33%) and lamotrigine (43%), compared to 7% when continuing valproate (P < .001).

CONCLUSIONS

33%-43% of clinicians reported seizure control deterioration in women changed to alternatives to valproate. Informed consent requires women considering a change are given this information. Systematic capture of data automated through online RAFs and linked to patient outcomes is needed. There remains little data on valproate given for indications other than epilepsy.

Treatment decisions in women of childbearing age on valproate

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.

A perspective on cannabinoids for treating epilepsy: Do they really change the landscape?

With the licensing of cannabidiol for drug resistant seizures in Dravet and Lennox Gastaut syndromes in the United states in 2018, interest in the potential for cannabis-based-medicinal products to meet currently unmet needs for people with epilepsy continues to grow. This review summarizes current knowledge and discusses the implications for future research and practice. Both cannabidiol and tetrahydrocannabinol, the main components, have been extensively studied in animal models, with multimodal mechanisms of action proposed. Only pure cannabidiol formulations have been rigorously evaluated in controlled trials thus far, with modest but significant improvements in motor seizures. Adverse effects include diarrhoea, somnolence and reduced appetite, with mostly acceptable tolerability, but a not insignificant (up to 1 in 23) risk of serious adverse events. Recognized drug interactions include with valproate (increased risk of hepatotoxicity) and clobazam (contributing to somnolence, increased secretions, probably chest infections, and potentially efficacy). Whilst there is public (and producer) interest in products also containing tetrahydrocannabinol, clinicians have justifiable concerns about exposing a group already vulnerable to mental health and neurobehavioural comorbidities to the associated additional risks in these domains. Artisanal preparations, with often inconsistent/unknown constituents are frequently used but not recommended. A gulf exists between the actual evidence, including a lack of comparative studies and public beliefs, fuelled by media and anecdote. Continued education of the public, policymakers, researchers and healthcare providers about what is and isn't yet known, together with on-going good quality research is essential to mitigate against future potential risks, particularly in relation to vulnerable populations. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.

Valproate utilisation trends among girls and women from 2013 to 2018

PURPOSE

To evaluate the change in the number of female valproate users in Lithuania from 2013 to 2018 and determine the presumed impact of two distinct European Medicines Agency (EMA) regulatory interventions on the observed trend.

METHOD

An interrupted time series analysis was performed using reimbursement data from the National Health Register Fund to detect changes in user trends after a selected regulatory event in time.

RESULTS

The absolute number of female patients under 50 using valproate is seen decreasing over time. After an EMA regulatory procedure in 2014, there was only a delayed decrease in female valproate users under 15 (a change in trend of -4.83, 95%CI = -9.45 to -0.22, P = 0.041, a decrease in level 15 months post-intervention of -40.06, 95%CI = -79.26 to -0.86, P = 0.046). An increase in new prescriptions for patients with epilepsy was noted post-intervention (change in trend 13.75, 95%CI = 6.03-21.48, P = 0.004). The EMA referral procedure in 2017-2018 was followed by a lasting decrease in female valproate users of reproductive age and older (level effect 3 months post-intervention: -201.28, 95%CI = -310.61 to -91.96, P = 0.001 and -170.60, 95%CI = -287.73 to -53.48, P = 0.007, respectively). However, the rate of new initiations on valproate for patients with either epilepsy or mood disorders remained constant.

CONCLUSIONS

The number of female patients under 50 using valproate is decreasing over time. The 2018 EMA referral procedure was followed by a notable reduction in female valproate users.