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Li D, Franco S, Pennell PB. The impact of pregnancy-related hormonal and physiological changes on antiseizure medications: expert perspective. Expert Rev Clin Pharmacol 2024:1-9. [PMID: 38748860 DOI: 10.1080/17512433.2024.2356617] [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: 03/14/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Epilepsy is a disorder of recurrent, unprovoked seizures affecting approximately 15 million individuals of childbearing potential worldwide. Patients with epilepsy rely on regular daily therapy with antiseizure medications (ASMs). Furthermore, ASMs are also prescribed for other neuropsychiatric indications (e.g. bipolar disorder, pain, migraines) with over 2% of the pregnancies in the United States involving prenatal exposure to ASMs. AREAS COVERED ASM concentrations are affected by hormonal and physiological changes in pregnancy, including increases in renal and hepatic blood flow, decreased protein binding, and changes in enzyme activity. Clearance changes typically reverse within a few weeks after delivery. During pregnancy, many ASMs, such as lamotrigine, levetiracetam, and oxcarbazepine, should have serum concentrations monitored and doses increased to maintain the individualized target range for seizure control. ASMs metabolized via glucuronidation, primarily lamotrigine, undergo marked increases in clearance throughout pregnancy, requiring about 3-fold the pre-pregnancy daily dose by delivery. Postpartum, ASM doses are usually decreased over several weeks to prevent drug toxicity. EXPERT OPINION In the future, the development of a physiologically-based pharmacokinetic model for various ASMs may enable empiric dose adjustments in pregnancy without the difficulties of frequent therapeutic drug monitoring.
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Affiliation(s)
- Denise Li
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Susannah Franco
- Department of Pharmacy, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Page B Pennell
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Mesraoua B, Brigo F, Lattanzi S, Perucca E, Ali M, Asadi-Pooya AA. Safe delivery, perinatal outcomes and breastfeeding in women with epilepsy. Epilepsy Behav 2024; 156:109827. [PMID: 38759429 DOI: 10.1016/j.yebeh.2024.109827] [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: 01/05/2024] [Revised: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024]
Abstract
Safe delivery and optimal peripartum and postpartum care in women with epilepsy (WWE) is a major concern which has received limited attention in recent years. A diagnosis of epilepsy per se is not an indication for a planned cesarean section or induction of labor, even though epidemiological studies indicate that cesarean delivery is more common among WWE compared to the general population. Pregnancy in WWE is associated with an increased risk of obstetrical complications and increased perinatal morbidity and mortality, and these risks may be greater among WWE taking ASMs. Wherever feasible, pregnant WWE should be directed to specialist care. Risk minimization includes, when appropriate, dose adjustment to compensate for pregnancy-related changes in the pharmacokinetics of some ASMs. With respect to postpartum management, WWE should be advised that the benefits of breastfeeding outweigh the small risk of adverse drug reactions in the infant.
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Affiliation(s)
- Boulenouar Mesraoua
- Neurosciences Department, Hamad Medical Corporation and Weill Cornell Medical College, Doha, Qatar.
| | - Francesco Brigo
- Research Area Innovation, Research and Teaching Service (SABES- ASDAA), Bolzano-Bozen, Italy.
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
| | - Emilio Perucca
- Department of Medicine (Austin Health), University of Melbourne, and Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Musab Ali
- Neurosciences Department, Hamad Medical Corporation, Doha, Qatar.
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
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Ma M, Cheng Y, Hou X, Li Z, Wang M, Ma B, Cheng Q, Ding Z, Feng H. Serum biomarkers in patients with drug-resistant epilepsy: a proteomics-based analysis. Front Neurol 2024; 15:1383023. [PMID: 38585359 PMCID: PMC10995353 DOI: 10.3389/fneur.2024.1383023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
Objective To investigate the serum biomarkers in patients with drug-resistant epilepsy (DRE). Methods A total of 9 DRE patients and 9 controls were enrolled. Serum from DRE patients was prospectively collected and analyzed for potential serum biomarkers using TMT18-labeled proteomics. After fine quality control, bioinformatics analysis was conducted to find differentially expressed proteins. Pathway enrichment analysis identified some biological features shared by differential proteins. Protein-protein interaction (PPI) network analysis was further performed to discover the core proteins. Results A total of 117 serum differential proteins were found in our study, of which 44 were revised upwards and 73 downwards. The up-regulated proteins mainly include UGGT2, PDIA4, SEMG1, KIAA1191, CCT7 etc. and the down-regulated proteins mainly include ROR1, NIF3L1, ITIH4, CFP, COL11A2 etc. Pathway enrichment analysis identified that the upregulated proteins were mainly enriched in processes such as immune response, extracellular exosome, serine-type endopeptidase activity and complement and coagulation cascades, and the down-regulated proteins were enriched in signal transduction, extracellular exosome, zinc/calcium ion binding and metabolic pathways. PPI network analysis revealed that the core proteins nodes include PRDX6, CAT, PRDX2, SOD1, PARK7, GSR, TXN, ANXA1, HINT1, and S100A8 etc. Conclusion The discovery of these differential proteins enriched our understanding of serum biomarkers in patients with DRE and potentially provides guidance for future targeted therapy.
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Affiliation(s)
- Mian Ma
- Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Ying Cheng
- Suzhou Jinchang Street Bailian Community Health Service Center, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Xiaoxia Hou
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Zhisen Li
- Department of Radiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Meixia Wang
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Bodun Ma
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Qingzhang Cheng
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Zhiliang Ding
- Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Hongxuan Feng
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
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Thornton HF, Fantaneanu TA, Zhang T, Bercovici E, Hrazdil C, Ikeda KM, Kassiri J, Suller Marti A, Pana R, Rezazadeh A, Kobayashi E, Bui E. Real-world practices in reproductive health and counselling for women with epilepsy: A Canadian perspective. Epilepsy Behav 2024; 151:109623. [PMID: 38262329 DOI: 10.1016/j.yebeh.2024.109623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
Canadian women of reproductive potential living with epilepsy present unique care challenges due to the complex interplay of hormones, seizures, and medications. This study explores reproductive health practices and counselling for women with epilepsy. Through a questionnaire developed by the Canadian League Against Epilepsy women with epilepsy (WWE) workgroup, we are the first to report demographic and real-world practice characteristics of Canadian healthcare professionals providing care for WWE with specific focus on family planning, birth plans, and postpartum care counselling. Among respondents, 76.9% routinely reviewed contraception with patients and an intrauterine device (IUD) was the most popular recommended method (85.3%). With regards to preconception planning, 50% of respondents routinely had a preconception drug level prior to pregnancy. A significant proportion, 44.9%, reported not communicating a neurology-informed birth plan to obstetrical health practitioners. The majority recommended breastfeeding for WWE on anti-seizure medications (92.3%) and regularly provided safety counselling for women in the postpartum period (84.6%). Overall, our study demonstrates that Canadian practice patterns conform reasonably well to existing evidence and guidelines, although important gaps in care exist.
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Affiliation(s)
- Hayley F Thornton
- Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada.
| | - Tadeu A Fantaneanu
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ontario, Canada.
| | - Tinghua Zhang
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ontario, Canada.
| | - Eduard Bercovici
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Chantelle Hrazdil
- Division of Neurology, University of British Columbia, Vancouver Coastal Health, Vancouver, British Columbia, Canada.
| | - Kristin M Ikeda
- Division of Neurology, Department of Medicine, Dalhousie University, Nova Scotia Health, Canada.
| | - Janani Kassiri
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Ana Suller Marti
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Raluca Pana
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
| | - Arezoo Rezazadeh
- Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada; Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Eliane Kobayashi
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
| | - Esther Bui
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
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Cohen MJ, Meador KJ, Loring DW, Matthews AG, Brown C, Robalino CP, Birnbaum AK, Voinescu PE, Kalayjian LA, Gerard EE, Gedzelman ER, Hanna J, Cavitt J, Sam MC, French JA, Hwang ST, Pack AM, Pennell PB. Behavioral Outcomes and Neurodevelopmental Disorders Among Children of Women With Epilepsy. JAMA Neurol 2024; 81:19-29. [PMID: 37983058 PMCID: PMC10660252 DOI: 10.1001/jamaneurol.2023.4315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/21/2023] [Indexed: 11/21/2023]
Abstract
Importance The association of fetal exposure to antiseizure medications (ASMs) with outcomes in childhood are not well delineated. Objective To examine the association of fetal ASM exposure with subsequent adaptive, behavioral or emotional, and neurodevelopmental disorder outcomes at 2, 3, and 4.5 years of age. Design, Setting, and Participants The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational cohort study conducted at 20 epilepsy centers in the US. A total of 456 pregnant women with epilepsy or without epilepsy were enrolled from December 19, 2012, to January 13, 2016. Children of enrolled women were followed up with formal assessments at 2, 3, 4.5, and 6 years of age. Statistical analysis took place from August 2022 to May 2023. Exposures Exposures included mother's epilepsy status as well as mother's ASM blood concentration in the third trimester (for children of women with epilepsy). Women with epilepsy were enrolled regardless of ASM regimen. Main Outcomes and Measures The primary outcome was the Adaptive Behavior Assessment System, Third Edition (ABAS-3) General Adaptive Composite (GAC) score among children at 4.5 years of age. Children of women with epilepsy and children of women without epilepsy were compared, and the associations of ASM exposures with outcomes among exposed children were assessed. Secondary outcomes involved similar analyses of other related measures. Results Primary analysis included 302 children of women with epilepsy (143 boys [47.4%]) and 84 children of women without epilepsy (45 boys [53.6%]). Overall adaptive functioning (ABAS-3 GAC score at 4.5 years) did not significantly differ between children of women with epilepsy and children of women without epilepsy (parameter estimate [PE], 0.4 [95% CI, -2.5 to 3.4]; P = .77). However, in adjusted analyses, a significant decrease in functioning was seen with increasing third-trimester maximum ASM blood concentrations (PE, -7.8 [95% CI, -12.6 to -3.1]; P = .001). This decrease in functioning was evident for levetiracetam (PE, -18.9 [95% CI, -26.8 to -10.9]; P < .001) and lamotrigine (PE, -12.0 [95% CI, -23.7 to -0.3]; P = .04), the ASMs with sample sizes large enough for analysis. Results were similar with third-trimester maximum daily dose. Conclusions and Relevance This study suggests that adaptive functioning of children of women with epilepsy taking commonly used ASMs did not significantly differ from that of children of women without epilepsy, but there was an exposure-dependent association of ASMs with functioning. Thus, psychiatric or psychological screening and referral of women with epilepsy and their offspring are recommended when appropriate. Additional research is needed to confirm these findings.
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Affiliation(s)
- Morris J. Cohen
- Pediatric Neuropsychology International LLC, Augusta, Georgia
| | - Kimford J. Meador
- Department of Neurology & Neurological Sciences, Stanford University, Palo Alto, California
| | - David W. Loring
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Abigail G. Matthews
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Carrie Brown
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Chelsea P. Robalino
- Department of Biostatistics, The Emmes Company, Rockville, Maryland
- Department of Project Leadership, The Emmes Company, Rockville, Maryland
| | - Angela K. Birnbaum
- Epilepsy Research and Education Program, Experimental & Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis
| | - Paula E. Voinescu
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Elizabeth E. Gerard
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Evan R. Gedzelman
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Julie Hanna
- Adult Epilepsy, Minnesota Epilepsy Group, St Paul
| | - Jennifer Cavitt
- Division of Epilepsy, Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Maria C. Sam
- Department of Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Jacqueline A. French
- Department of Neurology and Comprehensive Epilepsy Center, New York University Comprehensive Epilepsy Center, New York
| | - Sean T. Hwang
- Department of Neurology, Northwell Health, Great Neck, New York
| | - Alison M. Pack
- Department of Neurology, Columbia University, New York, New York
| | - Page B. Pennell
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kacirova I, Urinovska R, Grundmann M. Therapeutic monitoring of lacosamide, perampanel, and zonisamide during breastfeeding. Epilepsy Res 2024; 199:107264. [PMID: 38041996 DOI: 10.1016/j.eplepsyres.2023.107264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 11/20/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE To provide additional information on the transport of the new anti-seizure medications lacosamide, perampanel, and zonisamide in breast milk and breastfed infants. METHODS Between 2013 and 2022, concentrations of anti-seizure medications were measured in six women with epilepsy (each drug in two patients) using high-performance liquid chromatography. Additionally, concentrations were determined after two consecutive pregnancies in women receiving lacosamide and one woman receiving zonisamide. In all cases, anti-seizure medication concentrations were measured in the maternal serum and breast milk, and five cases, in the infant serum. RESULTS For lacosamide, the ratios of breast milk/maternal serum concentration varied between 0.77 and 0.93, the ratios of infant/maternal serum concentrations were 0.16 and 0.35, and the ratios of infant serum/milk concentrations were 0.21 and 0.38. For perampanel, the ratios of breast milk/maternal serum concentration were 0.01 and 0.10 and the ratio of infant/maternal serum concentration was 0.36. For zonisamide, the ratios of breast milk/maternal serum concentration varied between 0.76 and 1.26, the ratios of infant/maternal serum concentrations between 0.44 and 0.85, and the ratios of infant serum/milk concentrations between 0.55 and 1.05. CONCLUSIONS Breastfeeding is recommended for women using lacosamide, perampanel, and zonisamide. However, the actual exposure can only be accurately evaluated by determining the serum concentration of anti-seizure medication in breastfed infants.
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Affiliation(s)
- Ivana Kacirova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
| | - Romana Urinovska
- Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic.
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Hasser C, Ameresekere M, Girgis C, Knapp J, Shah R. Striking the Balance: Bipolar Disorder in the Perinatal Period. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:3-15. [PMID: 38694148 PMCID: PMC11058914 DOI: 10.1176/appi.focus.20230020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
The authors reviewed the literature, published between 2018 and 2023, on treating bipolar disorder in the perinatal period in order to summarize current treatment perspectives. Mood episodes occur during pregnancy and there are high rates of both initial onset and recurrence in the postpartum period. Bipolar disorder itself is associated with higher risks of adverse pregnancy outcomes, including gestational hypertension, hemorrhage, cesarean delivery, and small for gestational age infants. A general principle of perinatal treatment includes maintaining psychiatric stability of the pregnant person while reducing medication exposure risk to the fetus. A variety of factors can compromise psychiatric stability, including rapid discontinuation of stabilizing medications, decreased efficacy due to physiologic changes of pregnancy, and exacerbation of underlying psychiatric illness. Psychosocial interventions include optimizing sleep, increasing support, and reducing stress. The American College of Obstetricians and Gynecologists recommends against discontinuing or withholding medications solely due to pregnancy or lactation status. Individualized treatment involves a discussion of the risks of undertreated bipolar disorder weighed against the risks of individual medication choice based on available evidence regarding congenital malformations, adverse neonatal and obstetrical events, and neurodevelopmental outcomes. Valproate is not a first-line treatment due to higher risks. Data are lacking on safety for many newer medications. The authors review current safety data regarding lithium, lamotrigine, and antipsychotics, which are the most commonly used treatments for managing bipolar disorder in the perinatal period. Due to physiologic changes during pregnancy, frequent therapeutic drug monitoring and dose adjustments are required.
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Affiliation(s)
- Caitlin Hasser
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Maithri Ameresekere
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Christina Girgis
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Jacquelyn Knapp
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
| | - Riva Shah
- Department of Psychiatry (Hasser, Knapp, Shah) and Department of Obstetrics and Gynecology (Knapp), School of Medicine, Oregon Health & Science University, Portland, Oregon; Portland VA Health Care System, Portland, Oregon (Hasser, Shah); Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston (Ameresekere); Edward Hines, Jr. VA Hospital, Hines, Illinois (Girgis); Department of Psychiatry, Stritch School of Medicine, Loyola University, Maywood, Illinois (Girgis)
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Lee SK. Issues of Women with Epilepsy and Suitable Antiseizure Drugs. J Epilepsy Res 2023; 13:23-35. [PMID: 38223363 PMCID: PMC10783964 DOI: 10.14581/jer.23005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/12/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Seizure aggravation in women with epilepsy (WWE) tends to occur at two specific times during the menstrual cycle: the perimenstrual phase and the ovulation period. Antiseizure drugs (ASDs), especially those that induce enzymes, can accelerate the metabolism of hormones in oral contraceptives, rendering them less effective. Estrogen in contraceptive pills increases the metabolism of lamotrigine. Physiological changes during pregnancy can significantly impact the pharmacokinetics of ASDs, potentially necessitating adjustments in dosage for women with epilepsy to maintain seizure control. The use of valproate in pregnant women is associated with the highest risk of major congenital malformations among ASDs. Risks of major congenital malformations associated with lamotrigine, levetiracetam, and oxcarbazepine were within the range reported in the general population. Exposure to valproate can lead to lower IQ in offspring. Reduced folic acid levels are linked to orofacial clefts, cardiovascular malformations, and urogenital and limb anomalies in WWE. Decreased folate levels are expected with the use of enzyme-inducing ASDs. However, a high dose of folate was associated with an increased risk of cancer in children of mothers with epilepsy. Most ASDs are generally considered safe for breastfeeding and should be encouraged. However, no single ASD is considered ideal for childbearing WWE. Lamotrigine and levetiracetam are relatively more suitable options for this situation.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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9
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Avachat C, Younis IR, Birnbaum AK. Characterization of the US Food and Drug Administration Post-Marketing Commitments and Requirements for Pregnancy and Lactation. Clin Pharmacol Ther 2023; 114:1238-1242. [PMID: 37750407 PMCID: PMC11006429 DOI: 10.1002/cpt.3059] [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: 05/24/2023] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
Enactment of the US Food and Drug Administration Amendments Act (FDAAA) in 2007 and the Pregnancy and Lactation Labeling Rule (PLLR) in 2015 are important milestones giving the FDA the authority to request studies in pregnant and lactating women. Our objective was to characterize trends of pregnancy and lactation-related postmarketing commitments (PMCs) and postmarketing requirements (PMRs) for new molecular entities approved by the FDA between 2000 and 2022. Approval letters of original New Drug Applications (NDAs, N = 488) for new molecular entities were obtained from the FDA website. NDAs with pregnancy and lactation-based PMCs/PMRs were identified, and data extracted. Data included: PMC/PMR timelines and attributes of requested study(ies) (type, design elements, and outcomes) when available. Fifty-nine NDAs included 92 PMCs/PMRs related to pregnancy and lactation. Forty-one NDAs had pregnancy-related PMRs/PMCs, 4 had lactation-related PMRs, and 14 had both. Most PMRs/PMCs were for nervous system medications (N = 33). Forty-seven NDAs specified safety data collection in infants in at least the first year of life. All pregnancy-related PMRs were issued after 2008, most PMCs (N = 8) were issued before 2008. Only one PMC requested a pharmacokinetic study in pregnant women. All lactation-related PMRs (N = 18) requested measurement of drug concentrations in breast milk with one also requiring measurement of maternal blood concentrations. Eighty-nine percent of lactation-related PMRs were requested after 2015. There was a steady increase in pregnancy and lactation-related PMRs following enactment of FDAAA and PLLR. Additions involved information collection pertaining to safety of the medication in pregnant and lactating women and children exposed to medications during pregnancy and breastfeeding.
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Affiliation(s)
- Charul Avachat
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Islam R Younis
- Department of Quantitative Clinical Pharmacology and Pharmacometrics, Merck & Co., Inc., Rahway, New Jersey, USA
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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10
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Langevin B, Gopalakrishnan M, Kuttamperoor J, Van Den Anker J, Murphy J, Arcaro KF, Daines D, Sylvetsky AC. The MILK study: Investigating intergenerational transmission of low-calorie sweeteners in breast milk. Contemp Clin Trials Commun 2023; 36:101212. [PMID: 37881407 PMCID: PMC10594547 DOI: 10.1016/j.conctc.2023.101212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/27/2023] [Accepted: 10/01/2023] [Indexed: 10/27/2023] Open
Abstract
Introduction Forty-four percent of lactating women in the United States consume beverages containing low calorie sweeteners (LCS), and the presence of LCS in the food supply has continued to increase in recent years. While LCS are approved by the United States Food and Drug Administration (FDA) and are believed to be safe for human consumption, intergenerational LCS transmission and the health impacts of early life LCS exposure are severely understudied. Methods and analysis In a tightly controlled, single site, prospective interventional study, mothers' plasma and breast milk, and infants' plasma will be collected from 40 mother-infant dyads over the course of 72 h, with rich sampling following maternal ingestion of a LCS sweetened beverage containing sucralose and acesulfame potassium (ace-K). Concentration-time data will be used to build maternal and infant pharmacokinetic models for future simulations and analysis. Conclusion This study aims to measure LCS concentrations in breast milk, maternal plasma, and infant plasma, to gain insight into infant exposure and inform recommendations for LCS consumption during breastfeeding.
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Affiliation(s)
- Brooke Langevin
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, USA
| | - Janae Kuttamperoor
- Department of Exercise and Nutrition Sciences, The George Washington University, Washington D.C., USA
| | - John Van Den Anker
- Division of Clinical Pharmacology, Children's National Medical Center, Washington D.C., USA
| | - Jeanne Murphy
- School of Nursing, The George Washington University, Washington D.C., USA
| | - Kathleen F. Arcaro
- Department of Veterinary and Animal Sciences, University of Massachusetts Amherst, Amherst, USA
| | - Dina Daines
- Department of Obstetrics and Gynecology, The George Washington University, Washington D.C., USA
| | - Allison C. Sylvetsky
- Department of Exercise and Nutrition Sciences, The George Washington University, Washington D.C., USA
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11
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Karceski S, Quinn H. Breastfeeding and Mothers With Epilepsy. Neurology 2023; 101:e2341-e2344. [PMID: 38012017 PMCID: PMC10727226 DOI: 10.1212/wnl.0000000000208021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 11/29/2023] Open
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Gerard EE, Meador KJ, Robalino CP, Brown CA, Matthews AG, Voinescu PE, Kalayjian LA, Gedzelman E, Hanna J, Cavitt J, Sam M, French JA, Pack AM, Hwang ST, Tsai JJ, Taylor C, Pennell PB. Initiation and Duration of Breastfeeding in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. Neurology 2023; 101:e2266-e2276. [PMID: 37816636 PMCID: PMC10727216 DOI: 10.1212/wnl.0000000000207812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/24/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Breastfeeding has important health benefits for both mother and child. We characterize breastfeeding initiation and duration in mothers with epilepsy relative to control mothers in a large prospective cohort. METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs study is a prospective, multicenter observational, US cohort study. Pregnant individuals with and without epilepsy, aged 14-45 years, were enrolled between December 19, 2012, and February 11, 2016. Exclusion criteria included intelligence quotient (IQ) <70, and gestational age >20 weeks at enrollment. Breastfeeding was assessed through electronic diary and at study visits until 2 years postpartum. Odds of initiating breastfeeding was compared between cohorts using unadjusted and adjusted logistic regression models. Duration of breastfeeding was compared between cohorts using the log-rank test. RESULTS Three hundred fifty-one pregnant individuals with epilepsy and 105 pregnant controls were enrolled. Breastfeeding data were available for 325 mothers with epilepsy and 98 controls. Study cohorts were similar demographically except race (p = 0.008); 84.9% of mothers with epilepsy and 71.4% of controls were White. The mean IQ was lower in mothers with epilepsy compared with that in controls (97.7 vs 104.2, p < 0.001). Breastfeeding was initiated by 74.8% mothers with epilepsy and 88.8% controls; this difference was significant in unadjusted logistic regression (odds ratio [OR] 0.4 [95% CI 0.2, 0.7], p = 0.004), but not in adjusted model (OR 0.5 [95% CI 0.2, 1.0], p = 0.051). Factors associated with breastfeeding were higher maternal education and IQ. There was no difference in duration of breastfeeding between mothers with and without epilepsy (median duration 8.5 months vs 9.9 months, p = 0.793). Among mothers with epilepsy, both convulsive seizures and all seizures that impair awareness during pregnancy were associated with lower breastfeeding initiation (OR 0.4 [95% CI 0.2, 0.8], p = 0.013) and (OR 0.4 [95% CI 0.2, 0.8], p = 0.003, respectively). Any peripartum seizures were associated with shorter breastfeeding duration (median 6 months vs 9.7 months, [p = 0.040]). DISCUSSION Mothers with epilepsy were less likely to initiate breastfeeding compared with controls; however, this difference was not significant when controlling for maternal IQ and education level. Continuation of breastfeeding once initiated was not different between mothers with and without epilepsy. Seizure control was associated with breastfeeding initiation and duration in mothers with epilepsy. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov identifier NCT01730170.
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Affiliation(s)
- Elizabeth E Gerard
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA.
| | - Kimford J Meador
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Chelsea P Robalino
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Carrie Anne Brown
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Abigail G Matthews
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - P Emanuela Voinescu
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Laura A Kalayjian
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Evan Gedzelman
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Julie Hanna
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jennifer Cavitt
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Maria Sam
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jacqueline A French
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Alison M Pack
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Sean T Hwang
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Jeffrey J Tsai
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Cora Taylor
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
| | - Page B Pennell
- From the Northwestern University (E.E.G.), Chicago, IL; Stanford University (K.J.M.), Palo Alto, CA; The Emmes Company, LLC, (C.P.R., C.A.B., A.G.M.), Rockville, MD; Harvard University (P.E.V.), Boston, MA; University of Southern California (L.A.K.), Los Angeles, CA; Emory University (E.G.), Atlanta, GA; Minnesota Epilepsy Group (J.H.), Minneapolis, MN; University of Cincinnati (J.C.), OH; Wake Forest University (M.S.), Winston-Salem, NC; New York University (J.A.F.); Columbia University (A.M.P.), New York, NY; Zucker School of Medicine at Hofstra Northwell (S.T.H.), Hempsted, NY; University of Washington (J.J.T.), Seattle, WA; Geisinger Medical Center (C.T.), Danville, PA; and University of Pittsburgh (P.B.P.), PA
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Reitan Riibe S, Heitmann K, Schjøtt J, Riedel B. Healthcare professionals' information need related to antiseizure medication use in breastfeeding patients with epilepsy. Retrospective analysis of enquiries to Norwegian medicines information and pharmacovigilance centers. Epilepsy Behav Rep 2023; 24:100629. [PMID: 37954010 PMCID: PMC10632412 DOI: 10.1016/j.ebr.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023] Open
Abstract
Background Safety information of antiseizure medication (ASM) during breastfeeding is scarce and conflicting. We aimed to identify characteristic traits of safety concerns among healthcare professionals by reviewing enquiries to the Norwegian Regional Medicines Information and Pharmacovigilance Centres (RELIS). Method Enquiries related to breastfeeding, epilepsy, and ASM identified by their ATC-numbers were retrieved from the RELIS database of question-and-answer pairs (QAPs) by combining indexed and Boolean database searches and manual inspection. 112 QAPs were analyzed retrospectively using descriptive statistics. Results Hospital-employed physicians and nurses were puzzled by ambiguous or conflicting drug information advice and called for general information about the compatibility of an ASM with breastfeeding, mainly related to lamotrigine and levetiracetam. Other enquiries were related to co-medication with other drugs, mainly antidepressants. Half of the enquiries were posed after birth, 12 of these motivated by suspected adverse events in the infants. Conclusion Healthcare professionals with acknowledged high competence in the topic were uncertain about the prevailing safety information of ASM during breastfeeding. The fear to harm the infant may lead to the decision not to recommend breastfeeding. Future information strategies should aim to reach these professions, and support their information need on this topic.
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Affiliation(s)
- Sunniva Reitan Riibe
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Sandnessjøen Helgeland Hospital, Prestmarkveien 1, 8800 Sandnessjøen, Norway
| | - Kristine Heitmann
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Haukeland University Hospital, 5021 Bergen, Norway
| | - Jan Schjøtt
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Haukeland University Hospital, 5021 Bergen, Norway
| | - Bettina Riedel
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
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Hope OA, Harris KM. Management of epilepsy during pregnancy and lactation. BMJ 2023; 382:e074630. [PMID: 37684052 DOI: 10.1136/bmj-2022-074630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Epilepsy is a group of neurological diseases characterized by susceptibility to recurrent seizures. Antiseizure medications (ASMs) are the mainstay of treatment, but many antiseizure medications with variable safety profiles have been approved for use. For women with epilepsy in their childbearing years, the safety profile is important for them and their unborn children, because treatment is often required to protect them from seizures during pregnancy and lactation. Since no large randomized controlled trials have investigated safety in this subgroup of people with epilepsy, pregnancy registries, cohort and case-control studies from population registries, and a few large prospective cohort studies have played an important role. Valproate, in monotherapy and polytherapy, has been associated with elevated risk of major congenital malformations and neurodevelopmental disorders in children born to mothers who took it. Topiramate and phenobarbital are also associated with elevated risks of congenital malformations and neurodevelopmental disorders, though the risks are lower than those of valproate. Lamotrigine and levetiracetam are relatively safe. Insufficient data exist to reach strong conclusions about the newest antiseizure medications such as eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Besides antiseizure medications, other treatments such as vagal nerve stimulation, responsive neurostimulation, and deep brain stimulation are likely safe. In general, breastfeeding does not appear to add any additional long term risks to the child. Creative ways of optimizing registry enrollment and data collection are needed to enhance patient safety.
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Affiliation(s)
- Omotola A Hope
- Houston Methodist Sugarland Neurology Associates, Houston, TX, USA
| | - Katherine Mj Harris
- Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, USA
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Uguz F, Sharma V, Boyce P, Clark CT, Galbally M, Koukopoulos A, Marsh W, Stevens A, Viguera A. Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors. J Clin Psychopharmacol 2023; 43:434-452. [PMID: 37683233 DOI: 10.1097/jcp.0000000000001740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
ABSTRACT Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.
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Affiliation(s)
- Faruk Uguz
- From the Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Verinder Sharma
- Schulich School of Medicine and Dentistry, The University of Western Ontario; Lawson Health Research Institute; Parkwood Institute Mental Health, Perinatal Mental Health Clinic, London Health Sciences Center, London, Ontario, Canada
| | - Philip Boyce
- Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Crystal T Clark
- Department of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Megan Galbally
- Department of Psychiatry, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Alexia Koukopoulos
- University Hospital Policlinico Umberto I, La Sapienza University of Rome; Centro Lucio Bini, Rome, Italy
| | - Wendy Marsh
- Department of Psychiatry, University of Massachusetts Medical School/UMass Memorial Medical Center, Worcester, MA.
| | - Anja Stevens
- Centre for Bipolar Disorders, Dimence Group, Deventer, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Psychiatry, the Netherlands
| | - Adele Viguera
- Cleveland Clinic, Cleveland Clinic Neurological Institute, Cleveland, OH
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Furugen A, Nishimura A, Umazume T, Ishikawa H, Narumi K, Kobayashi M. Simple and validated method to quantify lacosamide in human breast milk and plasma using UPLC/MS/MS and its application to estimate drug transfer into breast milk. J Pharm Health Care Sci 2023; 9:26. [PMID: 37653499 PMCID: PMC10472561 DOI: 10.1186/s40780-023-00295-w] [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: 04/28/2023] [Accepted: 07/05/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Epilepsy is a common neurological disorder. Lacosamide is a third-generation antiepileptic drug used to treat partial-onset seizures. Limited information is currently available on the transfer of lacosamide to breast milk. To facilitate studies on the safety of lacosamide use during breastfeeding, we aimed to develop a method to quantify lacosamide in human breast milk and plasma using ultra-performance liquid chromatography/tandem mass spectrometry. METHODS Fifty microliters of breast milk or plasma was used, and samples were prepared by protein precipitation using methanol containing lacosamide-d3 as an internal standard (IS). Chromatography was performed using an ACQUITY HSS T3 column with an isocratic flow of 10 mM ammonium acetate solution/methanol (70:30, v/v). Lacosamide and IS were detected by multiple reaction monitoring in positive ion electrospray mode. The run time was 3.5 min. RESULTS Calibration curves were linear and in the range of 0.5 to 100 ng/mL both in breast milk and plasma. The validation assessment indicated that precision, accuracy, matrix effects, selectivity, dilution integrity, and stability were acceptable. The developed method was successfully applied to quantify lacosamide in breast milk and plasma obtained from a volunteer who had been orally administered lacosamide twice a day (100 mg × 2). Relative infant dose of lacosamide was estimated to be 14.6% in breast milk at five time points. CONCLUSIONS We developed a simple and robust method to quantify of lacosamide in human breast milk and plasma. This method could be useful for in future studies investigating the safety of lacosamide use during breastfeeding.
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Affiliation(s)
- Ayako Furugen
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan
| | - Ayako Nishimura
- Department of Pharmacy, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan
| | - Takeshi Umazume
- Department of Obstetrics, Hokkaido University Hospital, Kita-14-Jo, Nishi-5-Chome, Kita-Ku, Sapporo, 060-8648, Japan
| | - Hina Ishikawa
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan
| | - Katsuya Narumi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan
| | - Masaki Kobayashi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12-Jo, Nishi-6-Chome, Kita-Ku, Sapporo, 060-0812, Japan.
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Bromley RL, Bullen P, Campbell E, Craig J, Ingham A, Irwin B, Jackson C, Kelly T, Morrow J, Rushton S, García-Fiñana M, Hughes DM, Winterbottom J, Wood A, Yates LM, Clayton-Smith J. Neurodevelopment of babies born to mothers with epilepsy: A prospective observational cohort study. Epilepsia 2023; 64:2454-2471. [PMID: 37403560 DOI: 10.1111/epi.17709] [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: 03/07/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Despite widespread monotherapy use of lamotrigine or levetiracetam during pregnancy, prospectively collected, blinded child development data are still limited. The NaME (Neurodevelopment of Babies Born to Mothers With Epilepsy) Study prospectively recruited a new cohort of women with epilepsy and their offspring for longitudinal follow-up. METHODS Pregnant women of <21 weeks gestation (n = 401) were recruited from 21 hospitals in the UK. Data collection occurred during pregnancy (recruitment, trimester 3) and at 12 and 24 months of age. The primary outcome was blinded assessment of infant cognitive, language, and motor development on the Bayley Scales of Infant and Toddler Development (3rd edition) at 24 months of age with supplementary parent reporting on the Vinelands Adaptive Behavior Scales (2nd edition). RESULTS There were 394 live births, with 277 children (70%) completing the Bayley assessment at 24 months. There was no evidence of an association of prenatal exposure to monotherapy lamotrigine (-.74, SE = 2.9, 95% confidence interval [CI] = -6.5 to 5.0, p = .80) or levetiracetam (-1.57, SE = 3.1, 95% CI = -4.6 to 7.7, p = .62) with poorer infant cognition, following adjustment for other maternal and child factors in comparison to nonexposed children. Similar results were observed for language and motor scores. There was no evidence of an association between increasing doses of either lamotrigine or levetiracetam. Nor was there evidence that higher dose folic acid supplementation (≥5 mg/day) or convulsive seizure exposure was associated with child development scores. Continued infant exposure to antiseizure medications through breast milk was not associated with poorer outcomes, but the number of women breastfeeding beyond 3 months was low. SIGNIFICANCE These data are reassuring for infant development following in utero exposure to monotherapy lamotrigine or levetiracetam, but child development is dynamic, and future follow-up is required to rule out later emerging effects.
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Affiliation(s)
- Rebecca L Bromley
- Division of Neuroscience, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust and Manchester Academic Health Sciences Centre, Manchester, UK
| | - Philip Bullen
- Obstetric and Fetal Medicine, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Ellen Campbell
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - John Craig
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Amy Ingham
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
| | - Beth Irwin
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Cerain Jackson
- Department of Neuropsychology, Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Teresa Kelly
- Obstetric and Fetal Medicine, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - James Morrow
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Sarah Rushton
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
| | - Marta García-Fiñana
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - David M Hughes
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Janine Winterbottom
- Department of Neurology, Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Amanda Wood
- School of Psychology, Deakin University, Burwood, Victoria, Australia
- Aston Institute for Health and Neurodevelopment, Aston University, Birmingham, UK
| | - Laura M Yates
- Department for Clinical Genetics, Nothern Genetics Service, Newcastle, UK
| | - Jill Clayton-Smith
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
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18
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Liu C, Pace S, Bromley R, Dobson R. Exposure to medication for neurological disease in pregnancy - time to consider the long-term implications? EClinicalMedicine 2023; 63:102157. [PMID: 37662523 PMCID: PMC10474373 DOI: 10.1016/j.eclinm.2023.102157] [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: 04/21/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023] Open
Abstract
A range of long-term neurological conditions may be diagnosed in young adulthood. These conditions are generally not curable, and most people need to take ongoing treatment for symptom control and/or disease modification. When chronic diseases are diagnosed before people have completed their families, there is a need to balance the potential benefits of treatment for the mother against potential risk(s) to the fetus from exposure to medications during pregnancy. Whilst available data regarding short-term fetal outcomes following treatment exposures during pregnancy is rapidly increasing, information regarding longer-term outcomes is more limited. The association of fetal exposure to valproate with serious long-term neurodevelopmental outcomes has highlighted the importance of capturing and evaluating long-term data. In this review we examine available evidence around the long-term effects of treatments used for the most common long-term neurological conditions diagnosed in early adulthood, namely epilepsy, migraine and neuroinflammatory disorders. We draw from existing literature across a range of diseases and discuss strategies to improve future knowledge.
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Affiliation(s)
- Chen Liu
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
| | - Samuel Pace
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Rebecca Bromley
- Division of Neuroscience, School of Biological Sciences, Faculty of Medicine, Biology and Health, University of Manchester, UK
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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19
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Meador KJ, Cohen MJ, Loring DW, Matthews AG, Brown C, Robalino CP, Birnbaum AK, Voinescu PE, Kalayjian LA, Gerard EE, Gedzelman ER, Hanna J, Cavitt J, Sam M, French JA, Hwang S, Pack AM, Pennell PB. Cognitive outcomes at age 3 years in children with fetal exposure to antiseizure medications (MONEAD study) in the USA: a prospective, observational cohort study. Lancet Neurol 2023; 22:712-722. [PMID: 37479375 PMCID: PMC10423009 DOI: 10.1016/s1474-4422(23)00199-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND The neurodevelopmental effects of fetal exposure to most antiseizure medications are unclear. We aimed to investigate the effects of fetal exposure to commonly used antiseizure medications on neuropsychological outcomes at age 3 years. METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational, multicentre cohort study at 20 specialty epilepsy centres in the USA. We have investigated pregnancy outcomes in women (aged 14-45 years) with and without epilepsy who were enrolled during pregnancy (≤20 weeks' gestational age), and their children. The primary outcome for children at age 3 years was a blindly assessed Verbal Index score, which was calculated by averaging scores on the Naming Vocabulary and Verbal Comprehension subtests of Differential Ability Scales-II, Expressive Communication and Auditory Comprehension subscales of Preschool Language Scale-5, and Peabody Picture Vocabulary Test-4. Children of women with and without epilepsy were compared, and the associations of medication exposures to outcomes in exposed children were assessed. The MONEAD study is registered with ClinicalTrials.gov, NCT0730170, and is ongoing. FINDINGS Between Dec 19, 2012, and Jan 13, 2016, 456 pregnant women (351 with epilepsy and 105 without epilepsy) were enrolled into the study. 345 children were born to women with epilepsy and 106 children were born to women without epilepsy. Verbal Index scores at age 3 years did not differ for children of women with epilepsy (n=284; adjusted least-square mean 102·7, 95% CI 101·4 to 103·9) versus those without epilepsy (n=87; 102·3, 99·8 to 104·7). Significant risk factors for reduced Verbal Index scores included maternal intelligence quotient, maternal education, post-birth anxiety, gestational age at enrolment, child's sex, and child's ethnicity. For Verbal Index scores, antiseizure medication exposure effects were not seen for maximum third trimester blood concentrations (n=258; adjusted parameter estimate -2·9, 95% CI -6·7 to 1·0). However, in secondary analyses, exposure-dependent effects were present on multiple cognitive measures, which varied by medication. INTERPRETATION We found no difference in neurodevelopmental outcomes between children with fetal exposure to newer antiseizure medications compared with unexposed children. However, some exposure-dependent antiseizure medication effects were seen in secondary analyses. The adverse effects of maternal post-birth anxiety emphasise the importance of screening mothers during pregnancy and postpartum and implementing interventions. Additional studies are needed to clarify the exposure-dependent effects. FUNDING National Institutes of Health, National Institute of Neurological Disorders and Stroke, and National Institute of Child Health and Development.
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Affiliation(s)
| | - Morris J Cohen
- Pediatric Neuropsychology International, Augusta, GA, USA
| | | | | | | | | | | | - Paula E Voinescu
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Julie Hanna
- Minnesota Epilepsy Group, Roseville, MN, USA
| | | | - Maria Sam
- Wake Forest University, Winston-Salem, NC, USA
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Sokou R, Parastatidou S, Iliodromiti Z, Lampropoulou K, Vrachnis D, Boutsikou T, Konstantinidi A, Iacovidou N. Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases. Nutrients 2023; 15:2822. [PMID: 37447149 DOI: 10.3390/nu15132822] [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: 05/24/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Elena Venizelou" Maternity Hospital, 11521 Athens, Greece
| | - Zoi Iliodromiti
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Katerina Lampropoulou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45110 Ioannina, Greece
| | - Dionysios Vrachnis
- Endocrinology Unit, 2nd Department of Obstetrics and Gynecology, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
| | - Aikaterini Konstantinidi
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, 3 D.Mantouvalou Str., Nikea, 18454 Piraeus, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece
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21
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Lopes das Neves P, Ventura R, Sobral-Pinho A, Silva E, Morgadinho A, Vitor J, Miranda M, Madureira B, Moniz Dionísio J, Pinheiro R, Delgado S, Carapinha D, Rego A, S Á F, Pelejão MR, Antunes F, Marques I, Brito da Silva V, Castro Sousa S, Peres J, Martins A, Tojal R. [Evaluation of the Knowledge of Women of Childbearing Age with Epilepsy about the Impact of Their Disease in Contraception, Pregnancy and Breastfeeding: A Multicenter Cross-Sectional Study]. ACTA MEDICA PORT 2023. [PMID: 36977340 DOI: 10.20344/amp.19156] [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: 10/06/2022] [Accepted: 01/31/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION The interaction of antiseizure medication with contraceptives, its potential teratogenicity and implications in pregnancy and breastfeeding are aspects to consider in the neurological care of women with epilepsy of childbearing age. To ensure the commitment in therapeutic decisions and the appropriate planning of maternity, it is essential that women are informed about the implications of their disease in these domains. The main aim of this study was to assess the knowledge of women of childbearing age with epilepsy concerning the impact of epilepsy in contraception, pregnancy and breastfeeding. As secondary aims we defined (1) the demographic, clinical and therapeutic characterization of this group of patients, (2) the identification of variables that correlated with the level of knowledge of women with epilepsy, and (3) the identification of preferential methods to acquire new knowledge about epilepsy. MATERIAL AND METHODS The study was observational, cross-sectional and multicentric, and was carried out in five hospitals of the Lisbon metropolitan area. After identifying all women of childbearing age with epilepsy followed in the epilepsy clinic of each center, we applied an electronic questionnaire based on a non-systematic review of the literature. RESULTS One hundred and fourteen participants were validated, with a median age of 33 years. Half of the participants were on monotherapy, and the majority had no seizures in the last six months. We identified important gaps in the participants' knowledge. Sections about complications and administration of antiseizure medication during pregnancy were the ones with the worst results. None of the clinical and demographic variables correlated with the final questionnaire score. Having had a previous pregnancy and the desire to breastfeed in a future pregnancy were positively correlated with the performance in breastfeeding section. Face-to-face discussion during medical outpatient visits was selected as the preferential method to learn about epilepsy, and the internet and social media were the least preferred ones. CONCLUSION The knowledge of women of childbearing age with epilepsy in the Lisbon metropolitan area concerning the impact of epilepsy in contraception, pregnancy and breastfeeding seems to have significant gaps. Medical teams should consider engaging in patient education particularly during outpatient clinics.
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Affiliation(s)
- Pedro Lopes das Neves
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Rita Ventura
- Serviço de Neurologia. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | - André Sobral-Pinho
- Serviço de Neurologia. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | - Elisa Silva
- Serviço de Neurologia. Hospital Garcia de Orta. Almada. Portugal
| | | | - Joana Vitor
- Serviço de Neurologia. Hospital Beatriz Ângelo. Loures. Portugal
| | - Miguel Miranda
- Serviço de Neurologia. Hospital de Cascais Dr. José de Almeida. Cascais. Portugal
| | - Beatriz Madureira
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Joana Moniz Dionísio
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Rita Pinheiro
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Sofia Delgado
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Duarte Carapinha
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - André Rego
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Francisca S Á
- Serviço de Neurologia. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | - Maria Rita Pelejão
- Serviço de Neurologia. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | | | - Inês Marques
- Serviço de Neurologia. Hospital Garcia de Orta. Almada. Portugal
| | | | - Sandra Castro Sousa
- Serviço de Neurologia. Hospital de Cascais Dr. José de Almeida. Cascais. Portugal
| | - João Peres
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - António Martins
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
| | - Raquel Tojal
- Serviço de Neurologia. Hospital Professor Doutor Fernando Fonseca. Amadora. Portugal
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Abstract
Epilepsy affects up to 15 million of people assigned female at birth of childbearing age globally. Up to 65% of these people with epilepsy and gestational capacity have an unplanned pregnancy. Seizure control during pregnancy is important for both the childbearer's and fetus' safety. There are multiple antiseizure medications (ASMs) that can be used to control epilepsy; however, each medication has its own teratogenic risk profile, which must be considered. The majority of these ASMs will require frequent plasma concentration monitoring during pregnancy with corresponding dosage adjustments. Dosages can be reduced back to prepregnancy levels within 3 weeks postpartum. Breastfeeding on ASMs is recommended.
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23
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McNulty ML. Gender Issues in Epileptic Patients. Neurol Clin 2023; 41:249-263. [PMID: 37030956 DOI: 10.1016/j.ncl.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Treatment approaches for epilepsy for both women and men are similar, however, there are special aspects that must be considered when caring for women with epilepsy. This includes how hormonal fluctuations may affect seizure frequency, contraception, and potential drug-drug interactions, and pregnancy planning to minimize and potentially mitigate any adverse neurodevelopmental outcomes and major congenital malformations. Adequate counseling for women across the lifespan can help prepare women for the future and optimize outcomes.
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Affiliation(s)
- Maggie L McNulty
- Department of Neurology, Rush University Medical Center, 1725 West Harrison Street Suite 885, Chicago, IL 60612, USA.
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Sha L, Yong X, Shao Z, Duan Y, Hong Q, Zhang J, Zhang Y, Chen L. Targeting adverse effects of antiseizure medication on offspring: current evidence and new strategies for safety. Expert Rev Neurother 2023; 23:141-156. [PMID: 36731825 DOI: 10.1080/14737175.2023.2176751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION For women with epilepsy of reproductive age, antiseizure medications (ASMs) are associated with an increased risk of offspring malformations. There are safety concerns for most anti-seizure medications in the perinatal period, and there is a clear need to identify safe medications. ASMs must transport through biological barriers to exert toxic effects on the fetus, and transporters play essential roles in trans-barrier drug transport. Therefore, it is vital to understand the distribution and properties of ASM-related transporters in biological barriers. AREAS COVERED This study reviews the structure, transporter distribution, and properties of the blood-brain, placental, and blood-milk barrier, and summarizes the existing evidence for the trans-barrier transport mechanism of ASMs and standard experimental models of biological barriers. EXPERT OPINION Ideal ASMs in the perinatal period should have the following characteristics: 1) Increased transport through the blood-brain barrier, and 2) Reduced transport of the placental and blood-milk barriers. Thus, only low-dose or almost no antiseizure medication could enter the fetus's body, which could decrease medication-induced fetal abnormalities. Based on the stimulated structure and molecular docking, we propose a development strategy for new ASMs targeting transporters of biological barriers to improve the perinatal treatment of female patients with epilepsy.
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Affiliation(s)
- Leihao Sha
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Xihao Yong
- Division of Nephrology and Kidney Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhenhua Shao
- Division of Nephrology and Kidney Research Institute, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yifei Duan
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Qiulei Hong
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Jifa Zhang
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
| | - Yunwu Zhang
- The current form, Fujian Provincial Key Laboratory of Neurodegenerative Disease and Aging Research, Institute of Neuroscience, School of Medicine, Xiamen University, Xiamen, 361102, China
| | - Lei Chen
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan
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Management of Anti-Seizure Medications during Pregnancy: Advancements in The Past Decade. Pharmaceutics 2022; 14:pharmaceutics14122733. [PMID: 36559227 PMCID: PMC9788450 DOI: 10.3390/pharmaceutics14122733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/24/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Management of seizures often involves continuous medication use throughout a patient's life, including when a patient is pregnant. The physiological changes during pregnancy can lead to altered drug exposure to anti-seizure medications, increasing patient response variability. In addition, subtherapeutic anti-seizure medication concentrations in the mother may increase seizure frequency, raising the risk of miscarriage and preterm labor. On the other hand, drug exposure increases can lead to differences in neurodevelopmental outcomes in the developing fetus. Established pregnancy registries provide insight into the teratogenicity potential of anti-seizure medication use. In addition, some anti-seizure medications are associated with an increased risk of major congenital malformations, and their use has declined over the last decade. Although newer anti-seizure medications are thought to have more favorable pharmacokinetics in general, they are not without risk, as they may undergo significant pharmacokinetic changes when an individual becomes pregnant. With known changes in metabolism and kidney function during pregnancy, therapeutic monitoring of drug concentrations helps to determine if and when doses should be changed to maintain similar seizure control as observed pre-pregnancy. This review concentrates on the results from research in the past decade (2010-2022) regarding risks of major congenital malformations, changes in prescribing patterns, and pharmacokinetics of the anti-seizure medications that are prescribed to pregnant patients with epilepsy.
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Therapeutic monitoring of serum concentrations of acyclovir and its metabolite 9-(carboxymethoxymethyl) guanine in routine clinical practice. Biomed Pharmacother 2022; 156:113852. [DOI: 10.1016/j.biopha.2022.113852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
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Yan R, Tuo J, Tai Z, Zhang H, Yang J, Yu C, Xu Z. Management of anti-seizure medications in lactating women with epilepsy. Front Neurol 2022; 13:1005890. [DOI: 10.3389/fneur.2022.1005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/28/2022] [Indexed: 11/18/2022] Open
Abstract
Epilepsy is a common neurological disease. At present, there are about 70 million epilepsy patients in the world, half of them are women, and 30–40% of women with epilepsy are of childbearing potential. Patients with epilepsy who are of childbearing potential face more challenges, such as seizures caused by hormonal fluctuations and the risk of adverse effects on the mother and baby from taking anti-seizure medications (ASMs). Breast milk is one of the best gifts that a mother can give her baby, and breastfeeding can bring more benefits to the baby. Compared with healthy people, people with epilepsy have more concerns about breastfeeding because they are worried that ASMs in their milk will affect the growth and development of the baby, and they are always faced with the dilemma of whether to breastfeed after childbirth. Regarding, whether women with epilepsy can breastfeed while taking ASMs, and whether breastfeeding will adversely affect the baby is still an important topic of concern for patients and doctors. This article reviews the existing research on breastfeeding-related issues in women with epilepsy to guide clinical practice, and improve the breastfeeding compliance of women with epilepsy.
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Meador KJ. Effects of Maternal Use of Antiseizure Medications on Child Development. Neurol Clin 2022; 40:755-768. [PMID: 36270689 PMCID: PMC9589915 DOI: 10.1016/j.ncl.2022.03.006] [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] [Indexed: 11/16/2022]
Abstract
Most children born to women with epilepsy (WWE) are normal, but have increased risks for malformations and poor neuropsychological outcomes. Antiseizure medications (ASMs) are among the most commonly prescribed teratogenic medications in women of childbearing age. However, WWE typically cannot avoid using ASMs during pregnancy. Teratogenic risks vary across ASMs. Valproate poses a special risk for anatomic and behavioral teratogenic risks compared with other ASMs. The risks for many ASMs remain uncertain. Women of childbearing potential taking ASMs should be taking folic acid. Breastfeeding while taking ASMs seems safe. WWE should receive informed consent outlining risks before conception.
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Affiliation(s)
- Kimford J Meador
- Department of Neurology & Neurological Sciences, Stanford University, Stanford University School of Medicine, 213 Quarry Road, MC 5979, Palo Alto, CA 94304-5979, USA.
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Al-Faraj AO, Pang TD. Breastfeeding recommendations for women taking anti-seizure medications. Epilepsy Behav 2022; 136:108769. [PMID: 35690572 DOI: 10.1016/j.yebeh.2022.108769] [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: 03/01/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
The literature regarding breastfeeding and effects of anti-seizure medication (ASM) exposure on the breastfed infant has been evolving rapidly over the last decade as new studies advance our understanding of the extent of medication exposure via breastfeeding and the long-term developmental outcomes of breastfed infants. Currently, strong evidence supports the safety of breastfeeding for women with epilepsy (WWE) taking most prescribed ASMs. In this review, we present a comprehensive overview of the data regarding ASM exposure in breastfed infants and neurodevelopmental outcomes in breastfed infants of mothers taking various ASMs. In addition, we present current breastfeeding recommendations and the reported adverse effects of various ASMs to facilitate decision making in the clinical care of WWE.
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Affiliation(s)
- Abrar O Al-Faraj
- Boston Medical Center, Boston University School of Medicine, United States.
| | - Trudy D Pang
- Beth Israel Deaconess Medical Center, Harvard Medical School, United States.
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Shi X, Wang Y, Zhang Y, Song C, Jiang Y, Zhao J, Xia L, Ma L, Jiang W. Effects of antiepileptic drugs polytherapy on pregnancy outcomes in women with epilepsy: An observation study in northwest China. Epilepsy Behav 2022; 135:108904. [PMID: 36095876 DOI: 10.1016/j.yebeh.2022.108904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/01/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The management of pregnant women with epilepsy (WWE) treated with antiepileptic drugs (AEDs) polytherapy poses a great challenge. The purpose of this study was to evaluate the major congenital malformations (MCMs) associated with AED polytherapy, to assess the impacts of polytherapy regimens on seizure control and breastfeeding, and to determine the potential predictors for pregnancy outcomes. METHODS This study was based on prospectively acquired data from a registry enrolling WWE in early pregnancy from Feb 2010 to July 2019, in which 123 pregnancies in 110 WWE were exposed to 27 different AED combinations. RESULTS There were 123 pregnancies in 110 WWE analyzed in our study. The live birth rate was 86.2 % and the risk of MCMs was 10.4 %. Multivariate analysis indicated that prenatal exposure to phenobarbital (odds ratio [OR], 17.424; 95 %CI, 1.510-201.067; P = 0.022) and topiramate (OR, 9.469; 95 %CI, 1.149-62.402; P = 0.036) was associated with increased risk of MCMs. Valproate (OR, 4.441; 95 %CI, 1.165-16.934; P = 0.029), phenobarbital (OR, 13.636; 95 %CI, 2.146-86.660; P = 0.006) and topiramate (OR, 7.527; 95 %CI, 1.764-32.118; P = 0.006) were significantly correlated with adverse pregnancy outcomes. Among 67 pregnancies in four combinations over 10 patients, 15 (22.4 %) remained seizure free through pregnancy, seizure frequency increased in 17 (25.4 %), decreased in 24 (35.8 %) women, in 26 (38.8 %) remained unchanged. Only 23.6 % of mothers undertook exclusive breastfeeding. Planned pregnancy was the only independent factor significantly associated with decreased risk of adverse pregnancy outcomes (OR, 0.139; 95 % CI, 0.051-0.382; P < 0.001). Notably, no adverse pregnancy outcome was recorded in pregnancies exposed to the combination of lamotrigine plus levetiracetam. CONCLUSION Prenatal exposure to the combinations containing valproate, phenobarbital, or topiramate was associated with increased risk of adverse pregnant outcomes. AED-related teratogenicity may be reduced by planned pregnancy in WWE exposed to polytherapy. Our findings also suggest the combination of lamotrigine and levetiracetam seems to be most desirable to balance seizure control and fetal safety.
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Affiliation(s)
- Xiaojing Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yaoyao Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Changgeng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Yongli Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Jingjing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Liang Xia
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Lei Ma
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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Kirkpatrick L, Waters J, O'Neal MA. Preventive Approaches in Women's Neurology: Prepartum, Pregnancy, and Postpartum. Semin Neurol 2022; 42:665-678. [PMID: 36216357 DOI: 10.1055/a-1958-0633] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Women's neurology is the subspecialty within neurology concerned with the distinct healthcare needs of women. In this article, we review current literature and expert management strategies regarding disease-specific neurologic concerns of women, with an emphasis on issues related to contraception, pregnancy, and lactation. Health conditions that we discuss in this article include epilepsy, headache, stroke, multiple sclerosis, and Chiari I malformation. Current findings on neurologic disease in women suggest that many women with neurologic disease can safely manage their disease during pregnancy and have healthy children, though pregnancy planning is important in many conditions to mitigate risks and effective contraceptive management is important when pregnancy prevention is desired.
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Affiliation(s)
- Laura Kirkpatrick
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Janet Waters
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Angela O'Neal
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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Jordan S, Bromley R, Damase-Michel C, Given J, Komninou S, Loane M, Marfell N, Dolk H. Breastfeeding, pregnancy, medicines, neurodevelopment, and population databases: the information desert. Int Breastfeed J 2022; 17:55. [PMID: 35915474 PMCID: PMC9343220 DOI: 10.1186/s13006-022-00494-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/27/2022] [Indexed: 11/16/2022] Open
Abstract
Background The pharmacoepidemiology of the long-term benefits and harms of medicines in pregnancy and breastfeeding has received little attention. The impact of maternal medicines on children is increasingly recognised as a source of avoidable harm. The focus of attention has expanded from congenital anomalies to include less visible, but equally important, outcomes, including cognition, neurodevelopmental disorders, educational performance, and childhood ill-health. Breastfeeding, whether as a source of medicine exposure, a mitigator of adverse effects or as an outcome, has been all but ignored in pharmacoepidemiology and pharmacovigilance: a significant ‘blind spot’. Whole-population data on breastfeeding: why we need them Optimal child development and maternal health necessitate breastfeeding, yet little information exists to guide families regarding the safety of medicine use during lactation. Breastfeeding initiation or success may be altered by medicine use, and breastfeeding may obscure the true relationship between medicine exposure during pregnancy and developmental outcomes. Absent or poorly standardised recording of breastfeeding in most population databases hampers analysis and understanding of the complex relationships between medicine, pregnancy, breastfeeding and infant and maternal health. The purpose of this paper is to present the arguments for breastfeeding to be included alongside medicine use and neurodevelopmental outcomes in whole-population database investigations of the harms and benefits of medicines during pregnancy, the puerperium and postnatal period. We review: 1) the current situation, 2) how these complexities might be accommodated in pharmacoepidemiological models, using antidepressants and antiepileptics as examples; 3) the challenges in obtaining comprehensive data. Conclusions The scarcity of whole-population data and the complexities of the inter-relationships between breastfeeding, medicines, co-exposures and infant outcomes are significant barriers to full characterisation of the benefits and harms of medicines during pregnancy and breastfeeding. This makes it difficult to answer the questions: ‘is it safe to breastfeed whilst taking this medicine’, and ‘will this medicine interfere with breastfeeding and/ or infants’ development’?
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Affiliation(s)
- Sue Jordan
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, Wales, UK.
| | - Rebecca Bromley
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Christine Damase-Michel
- Faculté de Médecine, Center for Epidemiology and Research in POPulation Health (CERPOP), Université Toulouse III, CHU Toulouse INSERM, Pharmacologie Médicale, Toulouse, France
| | - Joanne Given
- Faculty Life & Health Sciences, University of Ulster, Co Antrim, Newtownabbey, N Ireland, UK
| | - Sophia Komninou
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, Wales, UK
| | - Maria Loane
- Faculty Life & Health Sciences, University of Ulster, Co Antrim, Newtownabbey, N Ireland, UK
| | - Naomi Marfell
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, Wales, UK
| | - Helen Dolk
- Faculty Life & Health Sciences, University of Ulster, Co Antrim, Newtownabbey, N Ireland, UK
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The Use of Antiepileptic Drugs During Pregnancy and Fetal Outcomes. Neonatal Netw 2022; 41:226-231. [PMID: 35840331 DOI: 10.1891/nn-2021-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Epilepsy affects approximately 1 percent of the population and roughly 1 million women of childbearing age. Estimates suggest that 0.3-0.7 percent of pregnancies occur in women with epilepsy. Epilepsy itself increases the risk of congenital malformation and medications add to this risk. Also, approximately one-half of the use of medications for epilepsy are used for other indications, possibly increasing exposure in some women. As controlled trials with these medications are not performed during pregnancy, data has been accumulated primarily through databases and case studies. This review is intended to update the practitioner about the use and concerns of antiepileptic medications in the presnant woman and the potential effects on the fetus and neonate.
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Kacirova I, Grundmann M, Brozmanova H. Carbamazepine and carbamazepine-epoxide concentrations in mothers, colostrum, and breastfed newborns: Comparison with concentrations determined during delivery and in the mature milk period. Biomed Pharmacother 2022; 151:113176. [PMID: 35623166 DOI: 10.1016/j.biopha.2022.113176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/12/2022] [Accepted: 05/22/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To obtain information on the transport of carbamazepine and its active metabolite carbamazepine-epoxide from mother to colostrum and breastfed newborns. METHODS In this cohort study, carbamazepine and carbamazepine-epoxide concentrations in maternal serum (162 women), milk (i.e., colostrum) and breastfed newborn serum were analysed between the 1st and 5th days after delivery from November 1990 to February 2021. The measured concentrations were compared with the delivery and mature milk periods. The effect of the combination with both enzyme-inducing antiseizure medication and valproic acid was also evaluated. RESULTS Carbamazepine concentrations varied from 1.0 to 11.2 mg/L (epoxide 0.3-4.4 mg/L) in maternal serum, from 0.5 to 6.8 mg/L (epoxide 0.3-2.4 mg/L) in milk and from 0.5 to 4.7 mg/L (epoxide 0.3-1.7 mg/L) in newborn serum. The median milk/maternal serum concentration ratio of carbamazepine was 0.45 (epoxide 0.71), the median newborn/maternal serum concentration ratio of carbamazepine was 0.20 (epoxide 0.41), and the median newborn serum/milk concentration ratio of carbamazepine was 0.38 (epoxide 0.50). A highly significant correlation was found between the milk and maternal serum concentrations of both carbamazepine and carbamazepine-epoxide and between the milk and newborn serum concentrations of carbamazepine. CONCLUSIONS In the serum of breastfed newborns, only one concentration of carbamazepine reached the reference range used for the general epileptic population, and more than half was below the lower limit of quantification. Routine monitoring of serum carbamazepine concentrations is not required in breastfed newborns. However, observation of newborns is desirable, and if signs of potential adverse reactions are noted, the serum concentrations in newborns should be measured.
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Affiliation(s)
- Ivana Kacirova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic.
| | - Hana Brozmanova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
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Kacirova I, Grundmann M, Brozmanova H. Monitoring of lamotrigine concentrations in mothers, colostrum, and breastfed newborns during the early postpartum period. Biomed Pharmacother 2022; 151:113167. [PMID: 35617804 DOI: 10.1016/j.biopha.2022.113167] [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: 03/28/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE To analyse the concentrations of lamotrigine in maternal serum, colostrum, and serum of breastfed newborns, and to evaluate the effect of comedication with enzyme-inducing antiseizure medication and valproic acid. METHODS This cohort study collected data from 158 women and 143 breastfed newborns. Maternal serum, milk (i.e., colostrum), and newborn serum samples were collected between the 2nd and 5th postnatal days, and lamotrigine concentrations were measured by high-performance liquid chromatography. RESULTS The median lamotrigine concentrations were 2.7 mg/L in maternal serum, 1.4 mg/L in milk, and 1.7 mg/L in newborn serum. The median milk/maternal serum concentration ratio was 0.60, the median newborn/maternal serum concentration ratio was also 0.60, and the median newborn serum/milk concentration ratio was 1.00. A significant correlation was observed between milk and maternal serum concentrations and between newborn serum and milk concentrations, maternal serum concentrations, maternal daily dose, and dose related to maternal body weight. CONCLUSIONS Exposure to lamotrigine in breastfed newborns is lower than exposure during pregnancy. However, by the same dose by the same mother, lamotrigine concentrations in both maternal serum and milk increase significantly after delivery. This finding, together with the immature function of eliminating enzymes in newborns, may be the reason for reaching concentrations in the reference range used for the general epileptic population in breastfed newborns. Therapeutic monitoring of breastfed newborns serum concentrations of lamotrigine is not mandatory; however, if signs of possible adverse events are noted, newborn serum concentrations should be analysed.
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Affiliation(s)
- Ivana Kacirova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic.
| | - Hana Brozmanova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 700 30 Ostrava, Czech Republic
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La Neve A, Falcicchio G, Trojano M, Boero G. Seizure medication and planned pregnancy: balancing the risks and outcomes. Expert Rev Neurother 2022; 22:527-539. [PMID: 35726788 DOI: 10.1080/14737175.2022.2093107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The therapeutic management of women with epilepsy (WWE) of childbearing age can be complicated by the need to balance maternal/fetal risks related to seizure occurrence during gestation with the potential teratogenic risks related to the use of anti-seizure medications (ASMs). AREAS COVERED The authors review clinical evidence on seizure-related and ASM-related risks during pregnancy. Current regulatory indications are discussed, evaluating their impact on clinical practice, and ethical implications of pharmacological decisions are debated. EXPERT OPINION If properly informed about the maternal/fetal risks carried by different pharmacological choices, WWE can become the final decision makers regarding their care in every phase of their life. Over the coming years, analysis of aggregated pregnancy registry data on the structural impact, on the fetus, of low doses of valproate and of newer ASMs, together with analysis of the main population study data on functional (cognitive and behavioral) outcomes, could lead to huge advances, making choosing an ASM a less complex process for the clinician and a less painful decision for the woman. Future objectives should include identification of the potential role of the pharmacogenomic profile of WWE in determining the risk of fetal malformations.
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Affiliation(s)
- Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Giovanni Boero
- Complex Structure of Neurology, SS Annunziata Hospital, Taranto, Italy
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Shawahna R, Zaid L. Caring for women with epilepsy in Palestine: A qualitative study of the current status. Epilepsy Behav 2022; 130:108689. [PMID: 35398722 DOI: 10.1016/j.yebeh.2022.108689] [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: 01/01/2022] [Revised: 03/26/2022] [Accepted: 03/26/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This qualitative study was conducted to explore the current status of caring for women with epilepsy (WWE) in the Palestinian healthcare system. METHODS This study used an explorative qualitative design. A purposive sampling technique was used to recruit the participants. Semi-structured in-depth interviews were conducted with neurologists (n = 6), gynecologists (n = 5), psychiatrists (n = 3), an internist (n = 1), and clinical pharmacists (n = 5). The interpretive description methodology was used to thematically analyze the qualitative data. RESULTS A total of 745 min (12.4 h) of interview time were analyzed. The qualitative data collected in this study were categorized under 3 major themes and multiple subthemes. The 3 major themes were: (1) diagnosis and care for patients with epilepsy, (2) general issues in caring for patients with epilepsy, and (3) consideration of women's issues in the pharmacotherapy of epilepsy. Formally adopted protocols/criteria for the diagnosis and care for WWE were lacking. CONCLUSION Findings of this qualitative study showed a need to formally adopt uniform guidelines that can guide the diagnosis and care of WWE in the Palestinian healthcare system. The findings of this study might be informative to healthcare providers, decision-makers in healthcare authorities, WWE, and patient advocacy groups who could be interested in improving and benchmarking healthcare services provided to WWE. Future studies are still needed to quantitatively measure adherence to the international guidelines in caring for WWE.
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Affiliation(s)
- Ramzi Shawahna
- Department of Physiology, Pharmacology and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine; An-Najah BioSciences Unit, Centre for Poisons Control, Chemical and Biological Analyses, An-Najah National University, Nablus, Palestine.
| | - Lina Zaid
- Master of Pharmacology Program, Faculty of Graduate Studies, An-Najah National University, Nablus, Palestine
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Kohn E, Dinavitser N, Berlin M, Brandriss N, Bar-Chaim A, Gueta I, Keidar R, Livne A, Stepensky D, Berkovitch M, Masarwi M. Magnitude of Lamotrigine Exposure Through Breastfeeding. Breastfeed Med 2022; 17:341-348. [PMID: 35049332 DOI: 10.1089/bfm.2021.0304] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Importance: Lamotrigine use during breastfeeding has significantly increased in the recent years, whereas breast milk lamotrigine pharmacokinetics data are still sparse. Objectives: To assess lamotrigine exposure in breastfed infants by monitoring maternal serum and breast milk concentrations. Methods: Breastfeeding women treated with lamotrigine were recruited to this study. Maternal trough breast milk and serum samples were collected, and additional breast milk samples were collected 1, 3, 6, 9, 12 hours after lamotrigine consumption. Trough breast milk/serum ratios (M/S ratio) and breast milk area under the curve (AUC) values were calculated. Results: Twenty-one breastfeeding women were recruited to this study, and the final dataset was based on the samples collected from 17 women. Lamotrigine trough serum and mother's milk concentrations were 5.1 ± 3.3 mg/L and 3.1 ± 1.9 mg/L, respectively (mean ± standard deviation). The trough M/S ratio of lamotrigine was 0.66 ± 0.22. The lamotrigine breast milk average AUC was 41.7 ± 24.6 mg·h/L. The estimated infant dose of lamotrigine was 0.52 ± 0.31 mg/kg/day and 0.26 ± 0.15 mg/kg/day for fully and partially breastfed infants, respectively. Significant correlation was found between the maternal lamotrigine serum trough concentrations and the breast milk parameters: trough breast milk concentrations (Spearman's rho = 0.986, p < 0.0001) and breast milk AUC values (Spearman's rho = 0.941, p < 0.0001). No significant correlation was found between the maternal lamotrigine daily dose and serum trough concentrations, breast milk trough concentrations, and breast milk AUC values (Spearman's rho = 0.294, 0.285, and 0.438, p = 0.252, 0.396, and 0.078, respectively). Conclusion and Relevance: High correlation between the maternal lamotrigine trough serum concentrations and the breast milk AUC values was found, implying that monitoring the maternal lamotrigine serum concentrations can be useful for prediction of exposure of infants to lamotrigine through the breast milk. The trial was registered in the Israeli trials registry MOH_2021-09-05_010243 at September 5, 2021 Retrospectively registered https://my.health.gov.il/CliniTrials.
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Affiliation(s)
- Elkana Kohn
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Natalie Dinavitser
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Maya Berlin
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Nurit Brandriss
- Biochemistry Laboratory, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Adina Bar-Chaim
- Biochemistry Laboratory, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Itai Gueta
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine A, Sheba Medical Center, Tel Hashomer, Israel
| | - Rimona Keidar
- Neonatal Intensive Care Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Ayelet Livne
- Neonatal Intensive Care Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - David Stepensky
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Majdi Masarwi
- Pharmacy Department, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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Abstract
PURPOSE OF REVIEW Issues pertaining to women with epilepsy have advanced with a better understanding of multidirectional influences among hormones, seizures, and antiseizure medications, as well as pregnancy-related concerns around fertility, seizure destabilization, and antiseizure medication-associated teratogenicity. This article highlights important developments in this field and reviews best practices in the management of women with epilepsy. RECENT FINDINGS Important external hormonal influences may impact women with epilepsy particularly in the context of gender-affirming medications, hormonal replacement therapy, and fertility therapies. Fertility for women with epilepsy is influenced by multiple variables; however, in the absence of preexisting fertility issues, epilepsy per se is not associated with significantly impaired fertility. Once women with epilepsy are pregnant, the majority have a stable course. Antiseizure medication use in pregnancy is associated with major congenital malformations 2 to 5 times that of the general population and is highest with high-dose (≥1500 mg or greater total daily) valproate. Carefully considered changes in drug choice and dose may mitigate these risks. Therapeutic drug monitoring plays an important role in pregnancy care, and under expert supervision, women with epilepsy in pregnancy have similar seizure risks as women with epilepsy who are not pregnant. As women with epilepsy age, bone health and menopause may further be impacted by seizures and antiseizure medications. SUMMARY The care of women with epilepsy is a multifaceted discipline that recognizes the life-long impact of sex and gender influences on epilepsy care.
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King A, Gerard EE. Contraception, fecundity, and pregnancy in women with epilepsy: an update on recent literature. Curr Opin Neurol 2022; 35:161-168. [PMID: 35191408 PMCID: PMC9230745 DOI: 10.1097/wco.0000000000001039] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Caring for women with epilepsy requires specialized knowledge about potential teratogenicity of antiseizure medications, interactions with hormonal contraception, and pregnancy outcomes. RECENT FINDINGS There has been an improvement in understanding the cognitive outcomes of infants exposed in utero in recent years. Folic acid supplementation helps mitigate the cognitive teratogenicity of antiseizure medications. Recent updates provide reassurance that seizure frequency tends to remain stable throughout pregnancy. There is conflicting evidence about the fecundity impact of epilepsy and antiseizure medications in women with epilepsy. SUMMARY Recent research highlights the importance of early counseling about the risks and interactions of contraception, pregnancy, and antiseizure medications. More research is needed to understand fertility in women with epilepsy.
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Affiliation(s)
- Alexa King
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Huang W, Shao W, Ji Y, Li H, Chen J, Lin Z. Covalent organic framework-based solid phase microextraction coupled with electrospray ionization mass spectrometry for sensitive screening and quantitative evaluation of carbamazepine and its metabolite in mice. Talanta 2022; 243:123341. [PMID: 35247819 DOI: 10.1016/j.talanta.2022.123341] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 12/26/2022]
Abstract
Carbamazepine (CBZ) and its metabolite carbamazepine-10,11-epoxide (CBZEP) play vital role in the treatment of epilepsy. It is of great importance to develop a method for rapid and sensitive monitoring of CBZ and CBZEP due to their narrow therapeutic index. Herein, an imine-linked-based covalent organic framework was synthesized by using 1,3,5-tris (4-aminophenyl) benzene (TPB) and 1,3,5-triformylbenzene (TFB) (denoted as TPB-TFB-COF),and applied as a solid-phase microextraction (SPME) probe for extracting CBZ and CBZEP. The TPB-TFB-COF showed large surface areas (371 m2 g-1), high regular porosity (1.23 nm) and extraordinary stability, which rendered it an ideal adsorbent for highly efficient enrichment of CBZ and CBZEP. Accordingly, an attractive strategy of the combination of the TPB-TFB-COF-based SPME probe and electrospray ionization mass spectrometry system (ESI/MS) was proposed for rapid screening and sensitive monitoring of CBZ and CBZEP. Under the optimized parameters, the developed method exhibited good linearity for CBZ and CBZEP in the range of 4-1000 μg L-1 with correlation coefficient (r) no less than 0.9953, and the corresponding limits of detection (LODs) were 0.4 and 2.5 μg L-1, respectively. Moreover, high enrichment factors (EFs, 202-351 folds) and satisfactory relative standard deviations (RSDs) of one probe (3.3-5.1%) and probe-to-probe (4.8-5.6%) were obtained. By using the proposed method, sensitive screening and quantitative evaluation of CBZ and CBZEP in mice whole blood and tissue homogenates were successfully achieved, indicating the promising applicability of the TPB-TFB-COF-SPME-AMIS as a powerful tool for drug monitoring.
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Affiliation(s)
- Weini Huang
- Ministry of Education Key Laboratory of Analytical Science for Food Safety and Biology, Fujian Provincial Key Laboratory of Analysis and Detection Technology for Food Safety, College of Chemistry, Fuzhou University, Fuzhou, Fujian, 350108, China
| | - Wenya Shao
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou, 350122, China
| | - Yin Ji
- Ministry of Education Key Laboratory of Analytical Science for Food Safety and Biology, Fujian Provincial Key Laboratory of Analysis and Detection Technology for Food Safety, College of Chemistry, Fuzhou University, Fuzhou, Fujian, 350108, China
| | - Heming Li
- Ministry of Education Key Laboratory of Analytical Science for Food Safety and Biology, Fujian Provincial Key Laboratory of Analysis and Detection Technology for Food Safety, College of Chemistry, Fuzhou University, Fuzhou, Fujian, 350108, China
| | - Jiajing Chen
- Ministry of Education Key Laboratory of Analytical Science for Food Safety and Biology, Fujian Provincial Key Laboratory of Analysis and Detection Technology for Food Safety, College of Chemistry, Fuzhou University, Fuzhou, Fujian, 350108, China
| | - Zian Lin
- Ministry of Education Key Laboratory of Analytical Science for Food Safety and Biology, Fujian Provincial Key Laboratory of Analysis and Detection Technology for Food Safety, College of Chemistry, Fuzhou University, Fuzhou, Fujian, 350108, China.
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Contraception and Reproductive Health Care for Adolescent and Young Adult Women with Epilepsy. J Pediatr 2022; 241:229-236. [PMID: 34728232 DOI: 10.1016/j.jpeds.2021.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/16/2021] [Accepted: 10/27/2021] [Indexed: 11/21/2022]
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Abstract
PURPOSE OF REVIEW Seizure disorders are the most frequent major neurologic complication in pregnancy, affecting 0.3% to 0.8% of all gestations. Women of childbearing age with epilepsy require special care related to pregnancy. This article provides up-to-date information to guide practitioners in the management of epilepsy in pregnancy. RECENT FINDINGS Ongoing multicenter pregnancy registries and studies continue to provide important information on issues related to pregnancy in women with epilepsy. Valproate poses a special risk for malformations and cognitive/behavioral impairments. A few antiseizure medications pose low risks (eg, lamotrigine, levetiracetam), but the risks for many antiseizure medications remain uncertain. Although pregnancy rates differ, a prospective study found no difference in fertility rates between women with epilepsy who were attempting to get pregnant and healthy controls. During pregnancy, folic acid supplementation is important, and a dose greater than 400 mcg/d during early pregnancy (ie, first 12 weeks) is associated with better neurodevelopmental outcome in children of women with epilepsy. Breastfeeding is not harmful and should be encouraged in women with epilepsy even when they are on antiseizure medication treatment. SUMMARY Women with epilepsy should be counseled early and regularly about reproductive health. Practitioners should discuss the risks of various obstetric complications; potential anatomic teratogenicity and neurodevelopmental dysfunction related to fetal antiseizure medication exposure; and a plan of care during pregnancy, delivery, and postpartum. Women with epilepsy should also be reassured that the majority of pregnancies are uneventful.
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Affiliation(s)
- Yi Li
- Clinical Assistant Professor of Neurology and Neurological Sciences, Stanford University, Palo Alto, California
| | - Kimford J. Meador
- Stanford, University School of Medicine, Stanford Neuroscience Health, Center, 213 Quarry Rd, MC 5979, Palo Alto, CA 94304
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Epilepsy in Pregnancy—Management Principles and Focus on Valproate. Int J Mol Sci 2022; 23:ijms23031369. [PMID: 35163292 PMCID: PMC8836209 DOI: 10.3390/ijms23031369] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
Abstract
An estimated 60 million people worldwide suffer from epilepsy, half of whom are women. About one-third of women with epilepsy are of childbearing age. The childbirth rate in women with epilepsy is about 20–40% lower compared to that of the general population, which may be partly due to a lower number of these women being in relationships. Lower fertility in women with epilepsy may be linked to the disease itself, but it is mainly a result of the treatment provided. Valproate, as an antiepileptic drug inhibiting histone deacetylases, may affect the expression of genes associated with cell cycle control and cellular differentiation. Evidently, this drug is associated with the risk of malformations although other antiepileptic drugs (AEDs) may also trigger birth defects, however, to a lower degree. Valproate (and to a certain degree other AEDs) may induce autism spectrum disorders and attention deficit hyperactivity disorder. The main mechanism responsible for all negative effects of prenatal exposure to valproate seems inhibition of histone deacetylases. Animal studies show a reduction in the expression of genes involved in social behavior and an increase in hippocampal cytokines. Valproate-induced oxidative stress may also contribute to neural tube defects. Interestingly, paternal exposure to this AED in mice may trigger neurodevelopmental disorders as well although a population-based cohort study does not confirm this effect. To lower the risk of congenital malformations and neurodevelopmental disorders, a single AED at the optimal dose and supplementation with folic acid is recommended. VPA should be avoided in women of childbearing age and especially during pregnancy.
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Kacirova I, Grundmann M, Brozmanova H. Valproic Acid Concentrations in Mothers, Colostrum and Breastfed Infants during the Early Postpartum Period: Comparison with Concentrations Determined during Delivery and in the Mature Milk Period. Pharmaceutics 2021; 13:pharmaceutics13122074. [PMID: 34959355 PMCID: PMC8708593 DOI: 10.3390/pharmaceutics13122074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
To obtain information on the transport of valproic acid from mothers to colostrum and breastfed infants, in this cohort study, valproic acid concentrations in maternal serum (90 subjects), colostrum and the serum of breastfed infants were analyzed in years 1993–2018, between the 2nd and 5th postnatal days. Valproic acid concentrations ranged from 4.3 to 66.5 mg/L (mean 31.2 ± 13.6 mg/L) in maternal serum, from 0.5 to 5.9 mg/L (mean 1.1 ± 1.2 mg/L) in milk, and from 0.5 to 42.9 mg/L (mean 15.4 ± 9.4 mg/L) in infant serum. The milk/maternal serum concentration ratio ranged from 0.01 to 0.22 (mean 0.04 ± 0.04), and the infant/maternal serum concentration ratio ranged from 0.01 to 1.61 (mean 0.51 ± 0.28). A significant correlation was found between serum concentrations of breastfed infants and milk concentrations, maternal serum concentrations, maternal daily dose, and dose related to maternal body weight. Valproic acid concentrations in milk and infant serum did not reach the lower limit of the reference range used for the general epileptic population, and three-quarters of the concentrations in milk were lower than the lower limit of quantification. Routine monitoring of serum concentrations of breastfed infants is not necessary. If signs of potential adverse reactions are noted, serum concentrations of the infants should be measured.
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Affiliation(s)
- Ivana Kacirova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic; (I.K.); (H.B.)
- Department of Laboratory Medicine, Institute of Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic; (I.K.); (H.B.)
- Department of Laboratory Medicine, Institute of Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic
- Correspondence: ; Tel.: +420-59-737-4389
| | - Hana Brozmanova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic; (I.K.); (H.B.)
- Department of Laboratory Medicine, Institute of Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic
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Bermeo-Ovalle A. Like Mother, Like Child. Keeping Control of Seizures During Pregnancy. Epilepsy Curr 2021; 21:252-254. [PMID: 34690559 PMCID: PMC8512916 DOI: 10.1177/15357597211012026] [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] [Indexed: 12/02/2022] Open
Abstract
Changes in Seizure Frequency and Antiepileptic Therapy During Pregnancy Pennell PB, French JA, May RC, et al. N Engl J Med.
2020;383(26):2547-2556. doi:10.1056/NEJMoa2008663 Background: Among women with epilepsy, studies regarding changes in seizure frequency during
pregnancy have been limited by the lack of an appropriate nonpregnant comparator
group to provide data on the natural course of seizure frequency in both groups. Methods: In this prospective, observational, multicenter cohort study, we compared the
frequency of seizures during pregnancy through the peripartum period (the first 6
weeks after birth) (epoch 1) with the frequency during the postpartum period (the
following 7.5 months after pregnancy; epoch 2). Nonpregnant women with epilepsy were
enrolled as controls and had similar follow-up during an 18-month period. The
primary outcome was the percentage of women who had a higher frequency of seizures
that impaired awareness during epoch 1 than during epoch 2. We also compared changes
in the doses of antiepileptic drugs that were administered in the 2 groups during
the first 9 months of epoch 1. Results: We enrolled 351 pregnant women and 109 controls with epilepsy. Among the 299
pregnant women and 93 controls who had a history of seizures that impaired awareness
and who had available data for the 2 epochs, seizure frequency was higher during
epoch 1 than during epoch 2 in 70 (23%) pregnant women and in 23 (25%) controls
(odds ratio, 0.93; 95% CI, 0.54-1.60). During pregnancy, the dose of an
antiepileptic drug was changed at least once in 74% of pregnant women and in 31% of
controls (odds ratio, 6.36; 95% CI, 3.82-10.59). Conclusions: Among women with epilepsy, the percentage who had a higher incidence of seizures
during pregnancy than during the postpartum period was similar to that in women who
were not pregnant during the corresponding epochs. Changes in doses of antiepileptic
drugs occurred more frequently in pregnant women than in nonpregnant women during
similar time periods. (Funded by the National Institutes of Health; MONEAD ClinicalTrials.gov number, NCT01730170.).
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Meador KJ, Cohen MJ, Loring DW, May RC, Brown C, Robalino CP, Matthews AG, Kalayjian LA, Gerard EE, Gedzelman ER, Penovich PE, Cavitt J, Hwang S, Sam M, Pack AM, French J, Tsai JJ, Pennell PB. Two-Year-Old Cognitive Outcomes in Children of Pregnant Women With Epilepsy in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. JAMA Neurol 2021; 78:927-936. [PMID: 34096986 DOI: 10.1001/jamaneurol.2021.1583] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The neurodevelopmental risks of fetal exposure are uncertain for many antiseizure medications (ASMs). Objective To compare children at 2 years of age who were born to women with epilepsy (WWE) vs healthy women and assess the association of maximum ASM exposure in the third trimester and subsequent cognitive abilities among children of WWE. Design, Setting, and Participants The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is a prospective, observational, multicenter investigation of pregnancy outcomes that enrolled women from December 19, 2012, to January 13, 2016, at 20 US epilepsy centers. Children are followed up from birth to 6 years of age, with assessment at 2 years of age for this study. Of 1123 pregnant women assessed, 456 were enrolled; 426 did not meet criteria, and 241 chose not to participate. Data were analyzed from February 20 to December 4, 2020. Main Outcomes and Measures Language domain score according to the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), which incorporates 5 domain scores (language, motor, cognitive, social-emotional, and general adaptive), and association between BSID-III language domain and ASM blood levels in the third trimester in children of WWE. Analyses were adjusted for multiple potential confounding factors, and measures of ASM exposure were assessed. Results The BSID-III assessments were analyzed in 292 children of WWE (median age, 2.1 [range, 1.9-2.5] years; 155 female [53.1%] and 137 male [46.9%]) and 90 children of healthy women (median age, 2.1 [range, 2.0-2.4] years; 43 female [47.8%] and 47 male [52.2%]). No differences were found between groups on the primary outcome of language domain (-0.5; 95% CI, -4.1 to 3.2). None of the other 4 BSID-III domains differed between children of WWE vs healthy women. Most WWE were taking lamotrigine and/or levetiracetam. Exposure to ASMs in children of WWE showed no association with the language domain. However, secondary analyses revealed that higher maximum observed ASM levels in the third trimester were associated with lower BSID-III scores for the motor domain (-5.6; 95% CI, -10.7 to -0.5), and higher maximum ASM doses in the third trimester were associated with lower scores in the general adaptive domain (-1.4; 95% CI, -2.8 to -0.05). Conclusions and Relevance Outcomes of children at 2 years of age did not differ between children of WWE taking ASMs and children of healthy women. Trial Registration ClinicalTrials.gov Identifier: NCT01730170.
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Affiliation(s)
- Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Morris J Cohen
- Pediatric Neuropsychology International, Augusta, Georgia
| | - David W Loring
- Department of Neurology, Emory University, Atlanta, Georgia
| | | | | | | | | | - Laura A Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | | | - Jennifer Cavitt
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Maria Sam
- Department of Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Alison M Pack
- Department of Neurology, Columbia University, New York, New York
| | | | - Jeffrey J Tsai
- Department of Neurology, University of Washington, Seattle
| | - Page B Pennell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Al-Faraj AO, Pandey S, Herlihy MM, Pang TD. Factors affecting breastfeeding in women with epilepsy. Epilepsia 2021; 62:2171-2179. [PMID: 34289107 DOI: 10.1111/epi.17003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE This study aimed to compare rates of breastfeeding initiation and maintenance in women with epilepsy (WWE) with those of the general population and to identify factors affecting breastfeeding patterns in WWE. METHODS We retrospectively reviewed data for the following variables in pregnant WWE (n = 102) and healthy women without epilepsy (n = 112): demographic characteristics (age, race, ethnicity), epilepsy type (focal or generalized onset), antiseizure medication(s), psychiatric comorbidities, postpartum seizure control, breastfeeding counseling, and lactation consultation. Fisher exact test and logistic regression analyses were performed to compare the rates of breastfeeding initiation and continuation in pregnant WWE with those of healthy pregnant women and to determine factors associated with rates of breastfeeding initiation and maintenance. RESULTS The rate of breastfeeding initiation in WWE was significantly lower than in healthy women without epilepsy (50.9% vs. 87.6%), and WWE were less likely to maintain breastfeeding at 6 weeks (38.2%) and 3 months (36%) postpartum. Nearly half (53%) of WWE received antepartum breastfeeding counseling by their neurologists, and these women had higher odds of breastfeeding initiation and continuation (odds ratio [OR] = 2.53, 95% confidence interval [CI] = 1.14-5.72, p = .02). Postpartum consultation with a board-certified lactation consultant was associated with higher odds of breastfeeding continuation at 6 weeks (OR = 5.43, 95% CI = 1.39-27.23, p = .02) and at 3 months (OR = 4.9, 95% CI = 1.34-20.87, p = .019). Women taking levetiracetam were more likely to initiate and continue breastfeeding than those taking lamotrigine (OR = 6.22, 95% CI = 2.15-20.20, p = .001). SIGNIFICANCE The initiation rate and duration of breastfeeding were significantly lower in WWE than in healthy women without epilepsy and were significantly associated with several factors. Identification of potential barriers to breastfeeding in WWE may lead to development of intervention strategies that can improve breastfeeding rates in WWE to maximize positive health outcomes for WWE and their infants.
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Affiliation(s)
- Abrar O Al-Faraj
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Samiksha Pandey
- Boston University School of Medicine, Boston, Massachusetts, USA.,Beaumont Health-Royal Oak, Royal Oak, Michigan, USA
| | - Mary M Herlihy
- Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Trudy D Pang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Dinavitser N, Kohn E, Berlin M, Brandriss N, Bar-Chaim A, Keidar R, Livne A, Stepensky D, Berkovitch M, Sheinberg R. Levetiracetam in lactation: How much is excreted into human breast milk? Br J Clin Pharmacol 2021; 88:199-205. [PMID: 34131926 DOI: 10.1111/bcp.14940] [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: 11/11/2020] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 11/30/2022] Open
Abstract
AIMS In breastfeeding women, anti-epileptic therapy can lead to infant toxicities, even with newer anti-epileptic drugs such as levetiracetam. This study assessed levetiracetam breastmilk excretion and its correlation with the maternal oral dose and serum concentrations. METHODS Women with epilepsy treated with levetiracetam were recruited to this study and completed a questionnaire. Levetiracetam concentrations were determined in serial breastmilk samples (pre-dose to 12 h post-dose period) and in a single pre-dose maternal serum sample. RESULTS Twenty breastfeeding women and 21 infants (one woman with twins; 16 fully and five partially breastfed infants) participated in this study. The trough breastmilk/serum ratio of levetiracetam was 0.98 ± 0.20. The infant levetiracetam daily dose was 5.39 ± 1.96 and 2.70 ± 0.98 mg. kg-1. d-1 , and the relative infant dose (RID) was 13.8 ± 3.1% and 6.9 ± 1.6% in the fully and partially breastfed infants, respectively. Substantial correlations between the levetiracetam dose, maternal serum and breastmilk trough concentrations, and breastmilk AUC values were found. Three women reported somnolence in their fully breastfed infants, which resolved shortly after switching to partial breastfeeding. All the infants gained weight according to their age. CONCLUSIONS Infant levetiracetam exposure via the breastmilk was close to the safety thresholds (trough breastmilk/serum ratio slightly below 1, RID > 10% in fully breastfed infants), and infant somnolescence reports could be related to exposure of the infants to levetiracetam via breastmilk. Further studies are warranted to reveal the short- and long-term safety of levetiracetam in breastfeeding.
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Affiliation(s)
- Natalie Dinavitser
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Elkana Kohn
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Maya Berlin
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nurit Brandriss
- Biochemistry Laboratory, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Adina Bar-Chaim
- Biochemistry Laboratory, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rimona Keidar
- Neonatal Intensive Care Unit, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ayelet Livne
- Neonatal Intensive Care Unit, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Stepensky
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Revital Sheinberg
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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