Valproate use in women aged 15-44 years: an observational study in general practice

The valproate prescription pattern for female mental healthcare users of reproductive age

Background

Sodium valproate (valproate) that is used both as an anti-epileptic and a mood stabiliser is teratogenic in pregnancy. A Dear Health Care Professional Letter (DHCPL) issued in December 2015 recommended the avoidance of sodium valproate prescription in women of childbearing age (WOCBA) and pregnant women.

Aim

This study aimed to describe the prescription pattern of valproate in female mental healthcare users (MHCUs).

Setting

Regional hospital psychiatry department in King Dinizulu Hospital Complex, Durban, KwaZulu-Natal.

Methods

This was a descriptive, retrospective chart review of female in- and out-patient aged 12-55 years who were receiving a valproate prescription for mental illness between 01 January 2018 and 31 December 2020.

Results

Of the 158 females who received valproate during the study period, 15 (9.5%) had it tapered off while 143 (90.5%) were continued. Only 19% of all the patients had documented counselling regarding valproate, 19 (12%) had documented contraceptive use, and six (3.8%) continued its use at any point during pregnancy. The most frequently prescribed dose range was 800 mg - 1499 mg/day (n = 111, 70.7%) and the most common psychiatric indication was a psychotic disorder.

Conclusion

This study showed that prescription of valproate in female MHCUs still occurs in practice in a referral centre in South Africa despite the guidelines outlining management of those of reproductive age on valproate. The prescription pattern and monitoring of valproate were poorly documented in relation to the guideline.

Contribution

This study highlights the lack of adherence to recommendations regarding the prescription of valproate in WOCBA and the need for improved documentation of the indications, consent and counselling.

A Case Report of a 5-Year-Old Girl with Self-Limited Epilepsy with Autonomic Seizures

BACKGROUND

Self-limited epilepsy with autonomic seizures (SeLEAS), formerly known as Panayiotopoulos syndrome (PS), is a common multifocal autonomic childhood epileptic syndrome. SeLEAS affects 6% of children in between the ages of 1 and 15 years who have had one or more afebrile seizures in their lifetime.

CASE

A 5-year-old girl was admitted to the paediatric emergency room (ER) of our hospital due to a reported episode of vomiting during her sleep, followed by central cyanosis perorally of sort duration (<5'), a right turn of her head, and gaze fixation with right eye deviation. She was dismissed after a one-day hospitalization free of symptoms. A month later, the patient was admitted to the paediatric ER of a tertiary health unit due to a similar episode. The patient underwent EEG, which revealed pathologic paroxysmal abnormalities of high-amplitude sharp waves and spike-wave complexes in temporal-occipital areas of the left hemisphere, followed by enhancement of focal abnormalities in temporal-occipital areas of the left hemisphere during sleep. The patient was diagnosed with SeLEAS and started levetiracetam.

CONCLUSIONS

SeLEAS can be easily misdiagnosed as many physicians may not be very familiar with this disease, and, on the other hand, the autonomic manifestations can be easily disregarded as seizures. The physician must always be alert and search beneath the symptoms to find the cause rather than only treat them.

The long-term outcomes of patients with negative prolonged ambulatory electroencephalography tests: A cross-sectional follow-up study

Background

Ambulatory electroencephalography (AEEG) recording is an essential aid for detecting interictal discharges and providing a clinical diagnosis. This study aimed to describe long-term outcomes among a cohort of patients who yielded negative results on AEEG at the time of assessment and identify factors associated with contemporary quality of life (QOL) and ultimate epilepsy diagnosis.

Methods

This cross-sectional telephone follow-up study was conducted in June-November 2021 at the Neurology Department in a metropolitan hospital in Sydney, Australia.

Results

In total, 47 of 105 eligible (45%) participants were enrolled. Overall, 21 (45%) participants had been diagnosed with epilepsy at a 12-year follow-up. Taking anti-seizure medication, having experienced a seizure event, and having marriage and education-related characteristics were associated with an epilepsy diagnosis. QOL was found to be associated with age, employment status and history of experience of a seizure event. QOL and an epilepsy diagnosis were not shown to be statistically related.

Conclusions

Nearly half of the participants had received an epilepsy diagnosis at long-term follow-up, despite having tested negative on AEEG at the time of assessment. Prolonged AEEG testing is an important tool to aid the diagnostic process. However, clinical examination, including accurate history taking, is vital in establishing an epilepsy diagnosis.

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.

Analysing patient-generated data to understand behaviours and characteristics of women with epilepsy of childbearing years: A prospective cohort study

BACKGROUND

Women with epilepsy (WWE) are vulnerable in pregnancy, with increased risks to mother and baby including teratogenic risks, especially from valproate. The free EpSMon mobile-phone app allows self-monitoring to afford patient-centred feedback on seizure related risks, such as sudden death in epilepsy (SUDEP) to its users. We sought to generate insights into various seizure related risks and its treatments in WWE of childbearing age (16 to 60 years ) using EpSMon.

METHODS

The study utilizes a prospective real-world cohort of 5.5 years. Patient reported data on demographics, medication taken, diagnoses, seizure types and recognised biological, psychological, and social factors of seizure related harm were extracted. Data was stratified according to frequent and infrequent users and those scoring lower and higher risk scores. Multivariate logistic regression and different statistical tests were conducted.

FINDINGS

Data from 2158 WWE of childbearing age encompassing 4016 self-assessments were analysed. Overall risk awareness was 25.3% for pregnancy and 54.1% for SUDEP. Frequent users were more aware of pregnancy risks but not of SUDEP. Repeated EpSMon use increased SUDEP awareness but not pregnancy risks. Valproate was used by 11% of WWE, ranging from 6.5% of younger to 31.5% of older women.

CONCLUSIONS

The awareness to risks to pregnancy, SUDEP and valproate is low. Valproate is being used by a significant minority. It is imperative risk communication continues for WWE based on their individual situation and need. This is unlikely to be delivered by current clinical models. Digital solutions hold promise but require work done to raise implementation and acceptability.

Perampanel for the treatment of patients with myoclonic seizures in clinical practice: Evidence from the PERMIT study

PURPOSE

To investigate the effectiveness, safety and tolerability of perampanel (PER) in treating myoclonic seizures in clinical practice, using data from the PERaMpanel pooled analysIs of effecTiveness and tolerability (PERMIT) study.

METHODS

PERMIT was a pooled analysis of 44 real-world studies from 17 countries, in which patients with focal and generalised epilepsy were treated with PER. This post-hoc analysis included patients with myoclonic seizures at baseline. Retention and effectiveness were assessed after 3, 6, and 12 months; effectiveness was additionally assessed at the last visit (last observation carried forward). Effectiveness assessments included responder rate (≥50% seizure frequency reduction from baseline) and seizure freedom rate (no seizures since at least the prior visit). Safety and tolerability were assessed by evaluating adverse events (AEs) and discontinuation due to AEs.

RESULTS

156 patients had myoclonic seizures (59.0% female; mean age, 32.1 years; idiopathic generalised epilepsy, 89.1%; Juvenile Myoclonic Epilepsy, 63.1%; monthly median myoclonic seizure frequency [interquartile range], 1.7 [1.0-10.0]; mean [standard deviation] prior antiseizure medications, 2.9 [2.6]). Retention was assessed for 133 patients (mean time, 12.1 months), effectiveness for 142, and safety/tolerability for 156. Responder and seizure freedom rates were, respectively, 89.5% and 68.8% at 12 months, and 85.9% and 63.4% at the last visit. Incidence of AEs was 46.8%, the most frequent being dizziness/vertigo (19.2%), irritability (18.6%) and somnolence (9.6%). AEs led to discontinuation of 14.0% of patients over 12 months.

CONCLUSION

PER was associated with reduction in myoclonic seizure frequency in patients with myoclonic seizures treated in everyday clinical practice.