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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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Schoretsanitis G, Deligiannidis KM, Kasperk N, Schmidt CT, Kittel-Schneider S, Ter Horst P, Berlin M, Kohn E, Poels EMP, Zutshi D, Tomson T, Spigset O, Paulzen M. The impact of pregnancy on the pharmacokinetics of antiseizure medications: A systematic review and meta-analysis of data from 674 pregnancies. Prog Neuropsychopharmacol Biol Psychiatry 2024; 133:111030. [PMID: 38762161 DOI: 10.1016/j.pnpbp.2024.111030] [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: 02/06/2024] [Revised: 05/04/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE Increasing evidence suggests that the physiological changes of pregnancy may impact pharmacokinetics of antiseizure medications (ASM), and this may affect treatment outcomes. The aim of this study was to quantify the pregnancy impact on the ASM pharmacokinetics. METHODS A systematic literature search was conducted in PubMed/EMBASE in November 2022 and updated in August 2023 for studies comparing levels of ASM in the same individuals during pregnancy and in the preconception/postpartum period. Alteration ratios between the 3rd trimester and baseline were estimated. We also performed a random-effects meta-analysis calculating between-timepoint differences in mean differences (MDs) and 95% confidence intervals (95%CIs) for dose-adjusted plasma concentrations (C/D ratios). Study quality was assessed using the ClinPK guidelines. RESULTS A total of 65 studies investigating 15 ASMs in 674 pregnancies were included. The largest differences were reported for lamotrigine, oxcarbazepine and levetiracetam (alteration ratio 0.42, range 0.07-2.45, 0.42, range 0.08-0.82 and 0.52, range 0.04-2.77 respectively): accordingly, C/D levels were lower in the 3rd trimester for lamotrigine, levetiracetam and the main oxcarbazepine metabolite monohydroxycarbazepine (MD = -12.33 × 10-3, 95%CI = -16.08 to -8.58 × 10-3 (μg/mL)/(mg/day), p < 0.001, MD = -7.16 (μg/mL)/(mg/day), 95%CI = -9.96 to -4.36, p < 0.001, and MD = -4.87 (μg/mL)/(mg/day), 95%CI = -9.39 to -0.35, p = 0.035, respectively), but not for oxcarbazepine (MD = 1.16 × 10-3 (μg/mL)/(mg/day), 95%CI = -2.55 to 0.24 × 10-3, p = 0.10). The quality of studies was acceptable with an average rating score of 11.5. CONCLUSIONS Data for lamotrigine, oxcarbazepine (and monohydroxycarbazepine) and levetiracetam demonstrate major changes in pharmacokinetics during pregnancy, suggesting the importance of therapeutic drug monitoring to assist clinicians in optimizing treatment outcomes.
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Affiliation(s)
- Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry at the Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.
| | - Kristina M Deligiannidis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; The Departments of Obstetrics & Gynecology and Molecular Medicine at the Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Department of Psychiatry at the Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.
| | - Nicholas Kasperk
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Aachen, Germany.
| | - Chiara Theresa Schmidt
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Aachen, Germany.
| | - Sarah Kittel-Schneider
- Department of Psychiatry and Neurobehavioural Science, University College Cork, Acute Mental Health Unit, Cork University Hospital, Wilton, Cork, Ireland.
| | - Peter Ter Horst
- Department of Clinical Pharmacy, Isala Medical Centre, Dokter van Heesweg 2, 8025 AB Zwolle, the Netherlands.
| | - Maya Berlin
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Faculty of Medical and Health Sciences, Tel-Aviv University, Tel-Aviv, Israel.
| | - Elkana Kohn
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Faculty of Medical and Health Sciences, Tel-Aviv University, Tel-Aviv, Israel.
| | - Eline M P Poels
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Deepti Zutshi
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI, USA.
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Aachen, Germany; Alexianer Hospital Aachen, Aachen, Germany.
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Duan Y, Yang X, Zhang M, Qi X, Jin Y, Wang Z, Chen L. Adaptive Dosage Strategy of Levetiracetam in Chinese Epileptic Patients: Focus on Pregnant Women. J Pharm Sci 2024; 113:1385-1394. [PMID: 38176454 DOI: 10.1016/j.xphs.2023.12.025] [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: 08/16/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/06/2024]
Abstract
There is presently no efficient dose individualization strategy for the use of antiseizure medications in epileptic pregnant patients. This study aimed to develop a population pharmacokinetics model for levetiracetam and propose a tailored adaptive individualized dosage strategy for epileptic pregnant patients. A total of 322 levetiracetam plasma concentrations from 238 patients with epilepsy were included, including 216 women with epilepsy (20.83% of whom were pregnant). The levetiracetam plasma concentration was measured using a validated ultra-performance liquid chromatography-tandem mass spectrometry assay, and the data were modeled using a nonlinear mixed-effects model. The resultant model served as the basis for simulating the dosage adjustment strategy. A one-compartment model with first-order elimination best described the pharmacokinetic data of levetiracetam. The apparent clearance (CL/F) was 3.43 L/h (95% CI 3.30-3.56) and the apparent volume of distribution was 43.7 L (95% CI 40.4-47.0) for a typical individual of 57.2 kg. Pregnancy and body weight were found to be significant covariates of CL/F of levetiracetam. The recommended regimen of levetiracetam could be predicted by the population pharmacokinetic model based on body weight, gestational age, and the daily dose of levetiracetam taken before pregnancy.
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Affiliation(s)
- Yifei Duan
- Department of Neurology, West China Hospital, Sichuan University
| | - Ximeng Yang
- Department of Neurology, West China Hospital, Sichuan University
| | - Mengyu Zhang
- Department of Neurology, West China Hospital, Sichuan University; Clinical Trial Center, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University
| | - Xiaohui Qi
- Department of Neurology, West China Hospital, Sichuan University; Clinical Trial Center, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University
| | - Ying Jin
- Department of Neurology, West China Hospital, Sichuan University; Clinical Trial Center, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University
| | - Zhenlei Wang
- Department of Neurology, West China Hospital, Sichuan University; Clinical Trial Center, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University.
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University.
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Shahla M, Aytan M. Clinical characteristics, seizure control, and delivery outcomes in pregnant women with focal and generalized epilepsies. Seizure 2024; 117:67-74. [PMID: 38335875 DOI: 10.1016/j.seizure.2024.01.017] [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: 12/12/2023] [Revised: 01/13/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE To prospectively investigate the course of epilepsy and assess seizure control during pregnancy in women with focal epilepsy (FE) compared with generalized epilepsy (GE), to ascertain the effects of epilepsy and its types on delivery and neonatal outcomes, and to compare adverse outcomes between pregnancies complicated by epilepsy and normal pregnancies. METHODS 124 pregnant women with epilepsy (WWE) were enrolled in a prospective study. Obstetric and neonatal outcomes were compared with those of 277 healthy women in the control group. RESULTS Occurrence of seizures during pregnancy was more often in FE (77.1 %) compared with GE (50.0 %) (Odds ratio [OR] 2.08; 95 % confidence interval [CI] 0.97-4.46, p = 0.06); the overall seizure freedom was significantly higher in women with GE compared with women with FE (p = 0.0038). Poor seizure control one year prior to the pregnancy and nonadherence to treatment were significantly associated with presence of seizures during pregnancy (p < 0.0001). Compared with pregnancies of women without epilepsy, WWE were at increased risk of cesarean section (CS) (p < 0.0001) and preterm birth (p = 0.03). Offspring of mothers with epilepsy were at higher risks of Apgar scores at 5 min ≤7 (p < 0.0001) and perinatal hypoxia (p = 0.03) compared with infants of unaffected women. Seizures during pregnancy were significantly correlated with the higher rate of CS, Apgar scores at 5 min ≤7, and perinatal hypoxia (p = 0.0069; p = 0.0098; and p = 0.0045, respectively). The risks of adverse outcomes were not significantly increased in women with FE compared to women with GE. CONCLUSION Epileptic seizures in pregnancy are associated with increased risks of adverse delivery and neonatal outcomes. Hence, early assessment of seizure disorder, adequate seizure control prior to and during pregnancy, and effective treatment are required to prevent potential seizure-related complications and improve maternal and fetal outcomes.
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Affiliation(s)
- Melikova Shahla
- Department of Neurology, Azerbaijan Medical University, Secretary General of Azerbaijan League Against Epilepsy, Mardanov Gardaslar 100, Baku, Azerbaijan.
| | - Mammadbayli Aytan
- Department of Neurology, Azerbaijan Medical University, The President of Azerbaijan League Against Epilepsy, Mardanov Gardaslar 100, Baku, Azerbaijan.
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Goo Y, der Nederlanden AM, Bleasel A, Alffenaar JW, Kim HY. Dose Monitoring of Lamotrigine Monotherapy in Pregnancy: Are Pregnant Women with Epilepsy Currently Optimally Managed? A Systematic Review. Ther Drug Monit 2024; 46:181-194. [PMID: 38366344 DOI: 10.1097/ftd.0000000000001186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Lamotrigine monotherapy is the first-line treatment for epilepsy in pregnant women. However, altered pharmacokinetics during pregnancy can lead to suboptimal drug levels and increased seizure risk. This systematic review aimed to evaluate current therapeutic drug monitoring (TDM) strategies for lamotrigine monotherapy in pregnant women with epilepsy and provide guidance for monitoring and dose adjustments. METHODS A systematic search was performed using the Ovid-MEDLINE, Ovid-EMBASE, and Ovid-Cochrane Central Register of Controlled Trials databases. Studies were included if data on lamotrigine dosing, concentration, TDM strategies, efficacy, or safety were available. RESULTS Eleven studies were analyzed, revealing heterogeneity in outcomes with selective reporting of TDM strategies; however, clear similarities were observed. Blood samples were collected every 1-3 months during pregnancy to maintain prepregnancy baseline drug levels. Lamotrigine's apparent and relative clearance increased across trimesters, particularly in the second and third trimesters, coinciding with a period of increased seizure frequency and required dose adjustments. Details on dose adjustments were limited. Some studies have proposed using the threshold of the ratio to the target concentration to predict increased seizure risk. No distinct association was observed between adverse newborn outcomes and lamotrigine dose or serum concentration. Few maternal adverse effects have been reported after delivery, confirming the necessity of empirical postpartum tapering. CONCLUSIONS Further studies are required to establish evidence-based standardized protocols encompassing all aspects of TDM. Early interventions, such as empirical dose increases during pregnancy and postpartum tapering, and routine monitoring from preconception to the postpartum period may enhance seizure control, reducing the risk of breakthrough seizures for the mother and unborn child.
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Affiliation(s)
- Yeonkyung Goo
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Andrew Bleasel
- Neurology Department, Westmead Hospital, Westmead, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia ; and
| | - Jan-Willem Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Hannah Yejin Kim
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
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Gu C, Zhang Y, Yuan F, Huang K, Lin Z, Chen Q, Chen Y, Wu Y, Wang D, Wang S. Effect of a Declined Plasma Concentration of Valproic Acid Induced by Meropenem on the Antiepileptic Efficacy of Valproic Acid. J Clin Lab Anal 2024; 38:e25025. [PMID: 38563451 PMCID: PMC11073810 DOI: 10.1002/jcla.25025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/23/2024] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE This study aimed to indicate whether a declined plasma concentration of valproic acid (VPA) induced by co-administration of meropenem (MEPM) could affect the antiepileptic efficacy of VPA. METHODS We retrospectively reviewed data of hospitalized patients who were diagnosed with status epilepticus or epilepsy between 2010 and 2019. Patients co-administered VPA and MEPM during hospitalization were screened and assigned to the exposure group, while those co-administerd VPA and other broad-spectrum antibiotics were allocated to the control group. RESULTS The exposure group and control group included 50 and 11 patients, respectively. With a similar dosage of VPA, the plasma concentration of VPA significantly decreased during co-administration (24.6 ± 4.3 μg/mL) compared with that before co-administration (88.8 ± 13.6 μg/mL, p < 0.0001), and it was partly recovered with the termination of co-administration (39.8 ± 13.2 μg/mL, p = 0.163) in the exposure group. The inverse probability of treatment weighting estimated the treatment efficacy via changes in seizure frequency, seizure duration, and concomitant use of antiepileptic drugs, which were not significantly different between the exposure and control groups. In the exposure group, there was no significant differences in seizure frequency between the periods of before-during and before-after (p = 0.074 and 0.153, respectively). Seizure duration during VPA-MEPM co-administration was not significantly different from that before co-administration (p = 0.291). CONCLUSIONS In this study, the reduced plasma concentration of VPA induced by the co-administration of MEPM did not affect the antiepileptic efficacy of VPA. This conclusion should be interpreted with caution, and more research is warranted. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR2000034567. Registered on 10 July 2020.
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Affiliation(s)
- Chunping Gu
- Department of Pharmacy, Nanfang Hospital, Southern Medical UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of New Drug Design and EvaluationGuangzhouChina
| | - Yongfang Zhang
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Fumiao Yuan
- Department of Pharmacy, Nanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Kaibin Huang
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Zhenzhou Lin
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Qiong Chen
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Yan Chen
- Department of Pharmacy, Nanfang Hospital, Southern Medical UniversityGuangzhouChina
| | - Yongming Wu
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Dongmei Wang
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Shengnan Wang
- Neurology Department, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
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He Z, Liu C, Lin L, Feng G, Wu G. Real-world safety of Levetiracetam: Mining and analysis of its adverse drug reactions based on FAERS database. Seizure 2024; 117:253-260. [PMID: 38537425 DOI: 10.1016/j.seizure.2024.03.009] [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: 01/23/2024] [Revised: 03/17/2024] [Accepted: 03/20/2024] [Indexed: 05/01/2024] Open
Abstract
INTRODUCTION Levetiracetam is a relatively new and widely utilized anti-seizure medication; however, limited information is available regarding its adverse effects. This study aims to thoroughly investigate, evaluate, and present evidence on the safety profile of Levetiracetam, relying on data from the FDA Adverse Event Reporting System (FAERS) database to facilitate informed clinical decision-making. METHODS We employed various statistical measures, including Reporting Odds Ratio (ROR), Proportionate Reporting Ratio (PRR), and analysis by the Medicines and Healthcare Products Regulatory Agency (MHRA), to identify signals of adverse reactions associated with Levetiracetam. Positive signals consistent with Designated Medical Event (DME) were singled out for focused comparison and discussion. RESULTS The analysis of 26,182 adverse events linked to Levetiracetam as the primary suspected drug revealed 692 positive signals spanning 22 System Organ Classes (SOCs). Nervous system disorders were the most frequently reported, followed by psychiatric disorders, and general disorders and administration site conditions. 11 positive signals consistent with Preferred Terms (PTs) in DME were identified, predominantly concentrated in 6 SOCs. Among these, rhabdomyolysis, Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS) exhibited relatively large values of A, ROR, and Chi-squared. Additionally, PTs related to spontaneous abortion, drug interaction, urethral atresia, ventricular septal defect, and atrial septal defect showed significant strength. CONCLUSIONS The study indicates that Levetiracetam carries a potential risk of causing rhabdomyolysis, SJS, TEN, DRESS as well as spontaneous abortion. Signals related to drug interaction, urethral atresia, ventricular septal defect, and atrial septal defect warrant heightened attention in clinical use.
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Affiliation(s)
- Zhimin He
- School of Pharmacy, Wenzhou Medical University, Wenzhou, 325035, PR China
| | - Cuimin Liu
- Department of Pharmacy, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, PR China
| | - Lin Lin
- Department of Pharmacy, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, PR China; School of Pharmacy, Wenzhou Medical University, Wenzhou, 325035, PR China
| | - Guowen Feng
- Department of Pharmacy, Langzhong People's Hospital, Nanchong, Sichuan, 637400, PR China.
| | - Gang Wu
- Department of Pharmacy, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, 317000, PR China.
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Chen Y, Ke M, Fang W, Jiang Y, Lin R, Wu W, Huang P, Lin C. Physiologically based pharmacokinetic modeling to predict maternal pharmacokinetics and fetal carbamazepine exposure during pregnancy. Eur J Pharm Sci 2024; 194:106707. [PMID: 38244810 DOI: 10.1016/j.ejps.2024.106707] [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: 08/23/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/22/2024]
Abstract
Carbamazepine is an antiepileptic drug commonly used in pregnant women, during which the physiological changes may affect its efficacy. The aim of this study was to establish a physiologically based pharmacokinetic (PBPK) model of carbamazepine and its active metabolite carbamazepine-10,11-epoxide, and simulate maternal and fetal pharmacokinetic changes of carbamazepine and carbamazepine-10,11-epoxide in different trimesters and propose dose adjustment. We established pregnancy PBPK models for carbamazepine and carbamazepine-10,11-epoxide in PK-Sim® and Mobi® and validated the models with observed data from clinical reports. The placental transfer parameters obtained using different methods were also imported into the model and compared with the observed data to establish and validate fetal pharmacokinetic curves. The simulated results showed that mean steady-state trough plasma concentration of carbamazepine decreased by 27, 43.1, and 52 % during the first, second, and third trimesters, respectively. Therefore, to achieve an optimum therapeutic concentration, administering at least 1.4, 1.8, and 2.1 times the baseline dose of carbamazepine in the first, second, and third trimesters, respectively can be used as a dose reference. In conclusion, this study established and validated a pregnancy PBPK model of carbamazepine and carbamazepine-10,11-epoxide to assess exposure in pregnant women and fetuses, which provided a reference for the dosage adjustment of carbamazepine during pregnancy.
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Affiliation(s)
- Yuying Chen
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Meng Ke
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Weipeng Fang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Yaojie Jiang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Rongfang Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Wanhong Wu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Pinfang Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Cuihong Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, People's Republic of China; Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, People's Republic of 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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10
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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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11
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Wei LY, Xu ZYR, Lai ZZ, Dong N, Sang YW, Guo Y. Association of oxcarbazepine concentration with seizure frequency in pregnant women with epilepsy. Epilepsy Behav Rep 2023; 25:100640. [PMID: 38235017 PMCID: PMC10792750 DOI: 10.1016/j.ebr.2023.100640] [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: 10/02/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024] Open
Abstract
The management of epilepsy during pregnancy presents particular challenges for neurologists worldwide. Currently, there are no clear recommendations for oxcarbazepine (OXC) specific target concentration during pregnancy. We conducted this retrospective observational cohort study on pregnant women with epilepsy (WWE) who received OXC monotherapy or polytherapy, at the epilepsy outpatient clinic of a tertiary hospital in eastern China. Sixteen pregnancies of 16 WWE were split into the seizure-free group or the non-seizure-free group, according to whether they had been seizure free for more than one year prior to conception or not. There was a significantly decrease in OXC concentration throughout pregnancy, as indicated by the concentration/dose ratio and the ratio of target concentration (RTC). The second trimester of pregnancy was the period when seizure deterioration occurred the most, particularly in the non-seizure-free group. Lower RTC_OXC was identified to be a risk factor for increasing seizure frequency in both the total group and the non-seizure-free group in both univariate and multivariate analysis, with a threshold of 0.575 for differentiating patients at high-risk and low-risk for seizure deterioration. In conclusion, this study suggested an OXC concentration threshold of 0.575 during pregnancy for assisting neurologists in OXC drug monitoring and dose adaptation.
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Affiliation(s)
- Lin-yan Wei
- Department of General Practice and International Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Zheng-yan-ran Xu
- Department of Neurology, Epilepsy Center, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Zhen-zhen Lai
- Department of Neurology, Tiantai People's Hospital, Taizhou, China
| | - Na Dong
- Department of Special Inspection, Shaoxing People's Hospital, Shaoxing, China
| | - Yi-wen Sang
- Department of Laboratory Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Guo
- Department of General Practice and International Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Department of Neurology, Epilepsy Center, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Key Laboratory of Intelligent Preventive Medicine, Hangzhou, China
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12
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Barry JM, French JA, Pennell PB, Karanam A, Harden CL, Birnbaum AK. Empiric dosing strategies to predict lamotrigine concentrations during pregnancy. Pharmacotherapy 2023; 43:998-1006. [PMID: 37475496 PMCID: PMC10948204 DOI: 10.1002/phar.2856] [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: 02/13/2023] [Revised: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Maintaining seizure control with lamotrigine is complicated by altered pharmacokinetics and existence of subpopulations in whom clearance increases or remains constant during pregnancy. OBJECTIVE Our objective was to characterize the potential for particular dosing scenarios to lead to increased seizure risk or toxicity. METHODS Lamotrigine pharmacokinetic parameters obtained from our previous study were applied to a one-compartment model structure with subpopulations (75:25%) exhibiting different clearance changes. A single-patient simulation was conducted with typical pharmacokinetic parameter values from each subpopulation. Population-level simulations (N = 48,000) included six dosing scenarios and considered four preconception doses using the R package mrgsolve (Metrum Research Group). Thresholds for efficacy and toxicity were selected as drug concentration that are 65% lower than preconception concentrations and doubling of preconception concentrations, respectively. RESULTS Individual simulation results demonstrated that without dose increases, concentrations fell below 0.65 at 6-8 weeks in the high clearance change (HC) subpopulation, depending on preconception clearance. While no simulated dosing regimen allowed all women in both subpopulations to maintain preconception concentrations, some regimens provided a more balanced risk profile than others. Predicted concentrations suggested potential increased seizure risk for 7%-100% of women in the HC group depending on preconception dose and subpopulation. Additionally, in 63% of dosing scenarios for women with low clearance change (LC), there was an increased risk of toxicity (34%-100% of women). SIGNIFICANCE A substantial percentage of simulated individuals had concentrations low enough to potentially increase seizure risk or high enough to create toxicity. Early clearance changes indicate possible subpopulation categorization if therapeutic drug monitoring is conducted in the first trimester. An arbitrary "one-size-fits-all" philosophy may not work well for lamotrigine dosing adjustments during pregnancy and reinforces the need for therapeutic drug monitoring until a patient is determined to be in the LC or HC group.
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Affiliation(s)
- Jessica M Barry
- Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | - Jacqueline A French
- Department of Neurology, New York University Comprehensive Epilepsy Center, New York, New York
| | - Page B Pennell
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ashwin Karanam
- Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | | | - Angela K Birnbaum
- Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
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Lesné L, Desdoits-Lethimonier C, Hug E, Costet N, Raffenne L, Toupin M, Evrard B, Kugathas I, Lavoué V, Chalmel F, Jégou B, Mazaud-Guittot S. Antiepileptic drugs are endocrine disruptors for the human fetal testis ex vivo. Toxicol Sci 2023; 195:169-183. [PMID: 37505509 DOI: 10.1093/toxsci/kfad076] [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: 07/29/2023] Open
Abstract
Valproic acid (VPA) has long been the most widely used antiepileptic drug (AED) for the treatment of epilepsy, bipolar psychiatric disorders, and migraine. However, long-term VPA treatment has several adverse effects on the male reproductive system notably on endocrine functions and/or spermatic parameters. In utero exposure of the fetus to VPA is well known to be associated with a higher risk of several congenital malformations including those of male reproductive organs. Subsequent generations of AEDs, such as carbamazepine (CARB) and lamotrigine (LAM), are considered safer and are currently recommended for women of child-bearing age with epilepsy. Because anomalies of the male genital tract mostly result from endocrine imbalance during fetal life, we hypothesized that AEDs could directly impair testis differentiation. We thus aimed at identifying and characterizing the effects of VPA, CARB, and LAM on the differentiation and function of the different testicular cell types, and at understanding the mechanisms underlying these effects. By using ex vivo culture of first-trimester human fetal testes, we show that VPA induces multiple endocrine disruptive effects, compared with the milder ones caused by CARB and LAM. AED also subtly altered the germ cell lineage in distinct manners. Transcriptomic analysis of VPA-induced alterations highlighted a very broad range of effects on the fetal testis. Overall, our results show that AEDs can behave as endocrine disruptors for the human fetal testis ex vivo. This is consistent with, and likely underlies, the VPA-induced male genital tract masculinization abnormalities observed in patients.
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Affiliation(s)
- Laurianne Lesné
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Christèle Desdoits-Lethimonier
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Elisa Hug
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Nathalie Costet
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Léo Raffenne
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Maryne Toupin
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Bertrand Evrard
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Indusha Kugathas
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Vincent Lavoué
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Frédéric Chalmel
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
| | - Bernard Jégou
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
- EHESP-School of Public Health, 35043 Rennes, France
| | - Séverine Mazaud-Guittot
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, 35000 Rennes, France
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14
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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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15
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Du Y, Fang W, Huang W, Xu Q, Gong J, Xia N, Zhu Z, Wang X, Zheng R, Xu H. Changes in seizure frequency and anti-seizure medication therapy during pregnancy and one year postpregnancy. Epilepsy Behav 2023; 144:109256. [PMID: 37244219 DOI: 10.1016/j.yebeh.2023.109256] [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: 03/25/2023] [Revised: 04/29/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
Seizure control in women with epilepsy (WWE) during pregnancy is a vital concern. The aim of this study was to compare changes in seizure frequency and anti-seizure medication (ASM ) therapy in WWE in a real-world setting over three epochs (prepregnancy, pregnancy, and postpregnancy). We screened WWE who were pregnant between 1 January 2010 and 31 December 2020 from the epilepsy follow-up registry database of a tertiary hospital in China. We reviewed and collected follow-up data for the following time periods: 12 months before pregnancy (epoch 1), throughout pregnancy and the first 6 weeks postpartum (epoch 2), and from 6 weeks to 12 months postpartum (epoch 3). Seizures were classified into two categories: tonic‒clonic/focal to bilateral tonic‒clonic seizures and non-tonic‒clonic seizures. The main indicator was the seizure-free rate over the three epochs. Using epoch 1 as a reference, we also compared the percentage of women with an increased seizure frequency, as well as changes in ASM treatment, in epochs 2 and 3. Ultimately, 271 eligible pregnancies in 249 women were included. The seizure-free rates in epoch 1, epoch 2, and epoch 3 were 38.4%, 34.7%, and 43.9%, respectively (P = 0.09). The top three ASMs used in the three epochs were lamotrigine, levetiracetam, and oxcarbazepine. Using epoch 1 as a reference, the percentages of women with increased frequencies of tonic‒clonic/focal to bilateral tonic‒clonic seizures in epoch 2 and epoch 3 were 17.0% and 14.8%, respectively, while the percentages of women with an increased frequency of non-tonic‒clonic seizures in epoch 2 and epoch 3 were 31.0% and 21.8% (P = 0.02). The percentage of women whose ASM dosages were increased in epoch 2 was higher than that in epoch 3 (35.8% vs. 27.3%, P = 0.03). The seizure frequency during pregnancy may not differ significantly from that during prepregnancy and postpregnancy if WWE are treated according to the guidelines.
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Affiliation(s)
- Yanru Du
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Wenqiang Fang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Wenting Huang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Qi Xu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Jiaoni Gong
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Niange Xia
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Zhenguo Zhu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Xinshi Wang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Rongyuan Zheng
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Huiqin Xu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
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16
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Li Y, Wang ML, Guo Y, Cao YF, Zhao MM, Zhao LM. Population pharmacokinetics and dosing regimen optimization of levetiracetam in epilepsy during pregnancy. Br J Clin Pharmacol 2023; 89:1152-1161. [PMID: 36260320 DOI: 10.1111/bcp.15572] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/14/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022] Open
Abstract
AIMS The pharmacokinetics of levetiracetam (LEV) significantly changed during pregnancy. It is a great challenge to predict the adjusted doses of LEV to reach the preconception target concentrations. This study aimed to establish a population pharmacokinetic model of LEV in women with epilepsy (WWE) during pregnancy to analyse the factors of pharmacokinetic variability and to develop a model-based individualized dosing regimen. METHODS A total of 166 concentration-time points from 37 WWE during pregnancy treated with LEV were collected to analyse LEV pharmacokinetics with nonlinear mixed-effects modelling. The dosing regimen was optimized by Monte Carlo simulations based on the final model. RESULTS The LEV pharmacokinetics in pregnant WWE were best described by a 1-compartment model of first-order absorption and elimination. The population typical value of apparent clearance (CL/F) in the final model was estimated to be 3.82 L/h (95% confidence interval 3.283-4.357 L/h) with a relative standard error of 7.2%. Both total body weight (TBW) and trimester of pregnancy were significantly associated with LEV-CL/F during pregnancy; LEV-CL/F increased by 42.72% when TBW increased from 55 to 65 kg from the first trimester to the second trimester. Monte Carlo simulations showed that dosing regimens for LEV should be individualized based on the patient's TBW and trimester of pregnancy to maximize the likelihood of achieving the therapeutic range. CONCLUSION This first population pharmacokinetic study of LEV in WWE during pregnancy supports the use of a weight-based and pregnancy-based dosing regimen and can lay a foundation for further optimizing the individualized dosing regimens.
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Affiliation(s)
- Ying Li
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ming-Lu Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yang Guo
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yun-Feng Cao
- Shanghai Institute for Biomedical and Pharmaceutical Technologies, NHC Key Laboratory of Reproduction Regulation, Shanghai, China
| | - Ming-Ming Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Li-Mei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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17
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Chen J, You X, Wu W, Guo G, Lin R, Ke M, Huang P, Lin C. Application of PBPK modeling in predicting maternal and fetal pharmacokinetics of levetiracetam during pregnancy. Eur J Pharm Sci 2023; 181:106349. [PMID: 36496167 DOI: 10.1016/j.ejps.2022.106349] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/13/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022]
Abstract
Levetiracetam is currently being used to treat epilepsy in pregnant women. The plasma concentration of levetiracetam drops sharply during pregnancy, and the inability of pregnant women to maintain therapeutic concentrations can lead to seizures. This study aimed to predict the changes in fetal and maternal plasma exposure to levetiracetam during pregnancy and provide advice on dose adjustment. The physiology-based pharmacokinetics (PBPK) model was developed using PK-Sim and Mobi software, and validated following comparison of the observed plasma concentration and pharmacokinetic parameters. The levetiracetam PBPK model for mother and the fetus at various stages of pregnancy was successfully established and verified. Predictions indicated that the area under the steady-state concentration-time curve for levetiracetam decreased to 83, 62, and 67% of baseline values in the first, second, and third trimesters, respectively. Based on PBPK predictions, the recommended dose of levetiracetam is 1.2, 1.6, and 1.5 times the baseline dose in the first, second, and third trimesters, respectively, not exceeding 4000 mg/day in the third trimester due to fetal safety. The levetiracetam PBPK model for pregnancy was successfully developed and validated, and could provide alternative levetiracetam dosing regimens across the stages of pregnancy.
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Affiliation(s)
- Jiarui Chen
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Xiang You
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Wanhong Wu
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Guimu Guo
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Rongfang Lin
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Meng Ke
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Pinfang Huang
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China
| | - Cuihong Lin
- Department of Pharmacy, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong M. Rd, Fuzhou 350005, PR China.
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18
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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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19
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Schelhaas M, Wegner I, Edens M, Wammes-Van Der Heijden E, Touw D, Ter Horst P. Association of Levetiracetam Concentration With Seizure Frequency in Pregnant Women With Epilepsy. Neurology 2023; 100:e172-e181. [PMID: 36257713 DOI: 10.1212/wnl.0000000000201348] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 08/19/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pharmacologic treatment of epilepsy in pregnant women is balancing between risks for the mother and fetus. Levetiracetam (LEV) is considered to be safe during pregnancy because of its low teratogenic potential and lack of drug-drug interaction with other antiseizure medications (ASMs). Recent studies have shown decline of ASM concentrations during pregnancy because of physiologically based pharmacokinetic changes. In this study, we established this decrease in LEV concentration during pregnancy. In addition, we aimed at investigating the effect of the low LEV levels during pregnancy and developing a target value for the level during pregnancy. METHODS Pregnant patients using levetiracetam were studied in this retrospective cohort study. Blood samples were monthly collected through venous puncture or the dried blood spot method. ASM serum concentrations were determined at least 6 months before conception and for each month of pregnancy. Seizure frequency and ASM dosages during pregnancy were obtained from patient records. Patients were divided into 2 groups: a seizure-free group and a non-seizure-free group, which contained pregnancies in which the mother had experienced an epileptic seizure more than 12 months and less than 12 months before pregnancy, respectively. RESULTS We found decreased concentration/dose ratios in 29 pregnancies throughout all months of pregnancy. In the non-seizure-free group, it was found that low LEV concentrations were associated with seizure increase frequency (p = 0.022). For this group, the cutoff value with the highest sum of sensitivity and specificity was 0.466. DISCUSSION All in all, we recommend therapeutic drug monitoring for all pregnant patients on LEV as the concentrations of LEV significantly decrease throughout most months of pregnancy. However, this decrease in LEV concentration was only significantly correlated with seizure deterioration in patients who had a seizure in the year preceding the pregnancy. Therefore, we suggest more careful monitoring of non-seizure-free patients as they are at higher risk for experiencing an increase of seizure frequency. For this group, we advise physicians to keep LEV concentration above 65% of the preconceptional concentration. For seizure-free patients, we recommend an LEV threshold value of approximately 46% of the preconceptional concentration.
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Affiliation(s)
- Meike Schelhaas
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Ilse Wegner
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Mireille Edens
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Elisabeth Wammes-Van Der Heijden
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Daniel Touw
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - Peter Ter Horst
- From the Isala (M.S.B., P.T.H.), Department of Clinical Pharmacy, Zwolle, The Netherlands; Stichting Epilepsie Instellingen Nederland (M.S.B., I.W.), Zwolle, The Netherlands; Isala (M.E.), Isala Academy, Zwolle, The Netherlands; Viecuri (E.W.-V.D.H.), Department of Clinical Pharmacy, Venlo, The Netherlands; and University of Groningen (P.D.P.), University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
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20
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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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21
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Vajda FJE, O'Brien TJ, Graham J, Hitchcock AA, Perucca P, Lander CM, Eadie MJ. Seizure control in successive pregnancies in Australian women with epilepsy. Acta Neurol Scand 2022; 146:610-614. [PMID: 35986483 DOI: 10.1111/ane.13688] [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: 06/10/2022] [Revised: 08/02/2022] [Accepted: 08/07/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To investigate control of epileptic seizures during pairs of successive pregnancies in antiseizure medication (ASM)-treated women with epilepsy. MATERIALS AND METHODS Analysis of seizure freedom rates during 436 pairs of successive pregnancies in Australian women with epilepsy, in nearly all instances long-standing epilepsy. RESULT There was a higher rate of seizure-free second pregnancies compared with first paired pregnancies (63.1% vs. 51.4%; Relative Risk (R.R.) = 1.2277; 95% CI 1.0930, 1.3789) and of seizure-free pre-pregnancy years before second as compared with first paired pregnancies in the same women (63.6% vs. 52.4%; R.R. = 1.2616; 95% CI 1.1337, 1.4040). In 108 women whose ASM therapy was unaltered throughout both of their pregnancies, the seizure-freedom rate was higher in the second of the paired pregnancies (82.4% vs. 69.4%; R.R. = 1.1867, 95% CI 1.0189, 1.3821). CONCLUSIONS Altered ASM therapy after the first of a pair of successive pregnancies did not fully account for the better overall seizure control in the corresponding second pregnancies. Some additional factor may have been in operation, possibly a greater preparedness to undertake a further pregnancy if seizures were already fully controlled.
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Affiliation(s)
- Frank J E Vajda
- Departments of Medicine and Neurosciences, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Janet Graham
- Departments of Medicine and Neurosciences, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Alison A Hitchcock
- Departments of Medicine and Neurosciences, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Piero Perucca
- Departments of Medicine and Neurosciences, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia.,Comprehensive Epilepsy Program, Austin Health, Heidelberg, Victoria, Australia
| | - Cecilie M Lander
- Royal Brisbane and Women's Hospital and School of Medicine and Biomedical Science, University of Queensland, Brisbane, Queensland, Australia
| | - Mervyn J Eadie
- Royal Brisbane and Women's Hospital and School of Medicine and Biomedical Science, University of Queensland, Brisbane, Queensland, Australia
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22
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Coppola P, Kerwash E, Nooney J, Omran A, Cole S. Pharmacokinetic data in pregnancy: A review of available literature data and important considerations in collecting clinical data. Front Med (Lausanne) 2022; 9:940644. [PMID: 36267613 PMCID: PMC9577026 DOI: 10.3389/fmed.2022.940644] [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: 05/10/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022] Open
Abstract
Pregnancy-related physiological changes can alter the absorption, distribution, metabolism and excretion of medicines which may affect the safety and efficacy of the medicines administered in pregnancy. Pharmacokinetic data can thus be instrumental in supporting dose adjustments required in this population. This review considers the availability of published pharmacokinetic data for over 200 medicines of interest for use in pregnancy in the UK, to identify whether sufficient data currently exists, in principle, for any medicine or group of medicines to support dose adjustments to maintain maternal health through pregnancy. Very limited data was found for many of the medicines of interest. Nevertheless, well documented, large changes of exposure for some drugs, where data is available, highlights the urgent need to collect more data of good quality to inform appropriate doses, when needed, in this population. In addition, clinical study methodology can have an impact on the usefulness of the data and key clinical design aspects are highlighted for consideration in future clinical study design.
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Affiliation(s)
- Paola Coppola
- Medicines and Healthcare Regulatory Agency, London, United Kingdom
| | - Essam Kerwash
- Medicines and Healthcare Regulatory Agency, London, United Kingdom
| | - Janet Nooney
- Medicines and Healthcare Regulatory Agency, London, United Kingdom
| | - Amro Omran
- Medicines and Healthcare Regulatory Agency, London, United Kingdom
| | - Susan Cole
- Medicines and Healthcare Regulatory Agency, London, United Kingdom
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23
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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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24
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Epilepsy Complicating Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00344-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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25
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Hophing L, Kyriakopoulos P, Bui E. Sex and gender differences in epilepsy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:235-276. [PMID: 36038205 DOI: 10.1016/bs.irn.2022.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Sex and gender differences in epilepsy are important influencing factors in epilepsy care. In epilepsy, the hormonal differences between the sexes are important as they impact specific treatment considerations for patients at various life stages particularly during early adulthood with establishment of the menstrual cycle, pregnancy, perimenopause and menopause. Choice of antiseizure medication may have direct consequences on hormonal cycles, hormonal contraception, pregnancy and fetal risk of major congenital malformation. Conversely hormones whether intrinsic or extrinsically administered may have direct impact on antiseizure medications and seizure control. This chapter explores these important influences on the management of persons with epilepsy.
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Affiliation(s)
- Lauren Hophing
- Krembil Brain Institute, University Health Network, University of Toronto, Toronto, Canada
| | | | - Esther Bui
- Krembil Brain Institute, University Health Network, University of Toronto, Toronto, Canada.
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26
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P A B, G SS, Thomas G, K P A. Dosage Optimization of Lamotrigine in Pregnancy: A Pharmacometric Approach using Modeling and Simulation. J Clin Pharmacol 2022; 62:1557-1565. [PMID: 35739074 DOI: 10.1002/jcph.2111] [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: 03/03/2022] [Accepted: 06/10/2022] [Indexed: 11/05/2022]
Abstract
Lamotrigine is the most widely used anti-epileptic drug in pregnancy due to its low teratogenicity. However, there is an increased metabolism & clearance of Lamotrigine in pregnancy contributing to suboptimal drug therapy and poor disease control, prompting the need for pro-active dosage adjustments. The present study aimed to develop a pharmacometric model-based framework for recommending optimal dosage regimen for Lamotrigine in pregnancy. A systematic review was performed to obtain the literature aggregate data on clearance of Lamotrigine in pregnancy. The data was incorporated into simulations using PUMAS software for estimating the plasma concentrations at preconception stage and three trimesters. Simulated drug-exposures for different doses were investigated to ascertain plasma concentrations similar to the pre-conception and above minimum effective concentration. The simulated mean steady state trough plasma concentrations (mg/L) of Lamotrigine in non-pregnant and pregnant women at 3 trimesters decreased significantly (p<0.001) viz. 4.31±1.14, 3.17± 0.93, 2.14±0.86, 1.51±0.65 respectively. The simulation studies revealed that 150mg, 175mg, 225mg and 250mg twice daily doses, in pre-conception stage and three trimesters respectively achieve the target concentrations. Thus, the model-informed dosage regimen of Lamotrigine proposed in this study shall be considered to initiate the dosing in pregnant women, however the safety and efficacy of the drug have to be assured through therapeutic drug monitoring, in order to avoid therapeutic failure of Lamotrigine in pregnancy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Bhavatharini P A
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, The Nilgiris, Tamil Nadu, 643001, India
| | - Shri Sanghavi G
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, The Nilgiris, Tamil Nadu, 643001, India
| | - Grace Thomas
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, The Nilgiris, Tamil Nadu, 643001, India
| | - Arun K P
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, The Nilgiris, Tamil Nadu, 643001, India
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Nucera B, Brigo F, Trinka E, Kalss G. Treatment and care of women with epilepsy before, during, and after pregnancy: a practical guide. Ther Adv Neurol Disord 2022; 15:17562864221101687. [PMID: 35706844 PMCID: PMC9189531 DOI: 10.1177/17562864221101687] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/03/2022] [Indexed: 01/16/2023] Open
Abstract
Women with epilepsy (WWE) wishing for a child represent a highly relevant subgroup of epilepsy patients. The treating epileptologist needs to delineate the epilepsy syndrome and choose the appropriate anti-seizure medication (ASM) considering the main goal of seizure freedom, teratogenic risks, changes in drug metabolism during pregnancy and postpartum, demanding for up-titration during and down-titration after pregnancy. Folic acid or vitamin K supplements and breastfeeding are also discussed in this review. Lamotrigine and levetiracetam have the lowest teratogenic potential. Data on teratogenic risks are also favorable for oxcarbazepine, whereas topiramate tends to have an unfavorable profile. Valproate needs special emphasis. It is most effective in generalized seizures but should be avoided whenever possible due to its teratogenic effects and the negative impact on neuropsychological development of in utero-exposed children. Valproate still has its justification in patients not achieving seizure freedom with other ASMs or if a woman decides to or cannot become pregnant for any reason. When valproate is the most appropriate treatment option, the patient and caregiver must be fully informed of the risks associated with its use during pregnancies. Folate supplementation is recommended to reduce the risk of major congenital malformations. However, there is insufficient information to address the optimal dose and it is unclear whether higher doses offer greater protection. There is currently no general recommendation for a peripartum vitamin K prophylaxis. During pregnancy most ASMs (e.g. lamotrigine, oxcarbazepine, and levetiracetam) need to be increased to compensate for the decline in serum levels; exceptions are valproate and carbamazepine. Postpartum, baseline levels are reached relatively fast, and down-titration is performed empirically. Many ASMs in monotherapy are (moderately) safe for breastfeeding and women should be encouraged to do so. This review provides a practically oriented overview of the complex management of WWE before, during, and after pregnancy.
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Affiliation(s)
- Bruna Nucera
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria
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Beghin D. [Impact of pregnancy on drug pharmacokinetics: What implication in clinical practice?]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:422-425. [PMID: 35219913 DOI: 10.1016/j.gofs.2022.02.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Abstract
Physiological changes that occur during pregnancy in the maternal body can lead to alterations in the response to drugs in the mother. Pregnancy modifies the volume of distribution of drugs, their binding to plasma proteins, the activity of their metabolizing enzymes, and their elimination. However, to date, due to the dynamic and complex processes involved, adjustments to the dosage regimen during pregnancy remain impossible to standardize. Knowledge of these modifications will help to better understand the possible loss of drug efficacy during pregnancy, as well as anticipating the clinical and plasma monitoring of drugs with a low therapeutic margin.
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Affiliation(s)
- D Beghin
- Centre de référence sur les agents tératogènes (CRAT), DMU ESPRIT (épidémiologie et biostatistique, santé publique, pharmacie, pharmacologie, recherche, information médicale, thérapeutique et médicaments), GHU AP-HP Sorbonne université, site Trousseau 26, avenue Dr Netter, 75571 Paris cedex 12, France.
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29
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Pennell PB, Karanam A, Meador KJ, Gerard E, Kalayjian L, Penovich P, Matthews A, McElrath TM, Birnbaum AK. Antiseizure Medication Concentrations During Pregnancy: Results From the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) Study. JAMA Neurol 2022; 79:370-379. [PMID: 35157004 PMCID: PMC8845026 DOI: 10.1001/jamaneurol.2021.5487] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE During pregnancy in women with epilepsy, lower blood concentrations of antiseizure medications can have adverse clinical consequences. OBJECTIVE To characterize pregnancy-associated concentration changes for several antiseizure medications among women with epilepsy. DESIGN, SETTING, AND PARTICIPANTS Enrollment in this prospective, observational cohort study, Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD), occurred from December 19, 2012, to February 11, 2016, at 20 US sites. Enrolled cohorts included pregnant women with epilepsy and nonpregnant control participants with epilepsy. Inclusion criteria were women aged 14 to 45 years, an intelligence quotient greater than 70 points, and, for the cohort of pregnant women, a fetal gestational age younger than 20 weeks. A total of 1087 women were assessed for eligibility; 397 were excluded and 230 declined. Data were analyzed from May 1, 2014, to June 30, 2021. EXPOSURE Medication plasma concentrations in women taking monotherapy or in combination with noninteracting medications. The cohort of pregnant women was monitored through 9 months post partum, with similar time points for control participants. MAIN OUTCOMES AND MEASURES Dose-normalized concentrations were calculated as total or unbound plasma medication concentrations divided by total daily dose. Phlebotomy was performed during 4 pregnancy study visits and 3 postpartum visits for the pregnant women and 7 visits over 18 months for control participants. The primary hypothesis was to test pregnancy changes of dose-normalized concentrations from nonpregnant postpartum samples compared with those of control participants. RESULTS Of the 351 pregnant women and 109 control participants enrolled in MONEAD, 326 pregnant women (median [range] age, 29 [19-43] years) and 104 control participants (median [range] age, 29 [16-43] years) met eligibility criteria for this analysis. Compared with postpartum values, dose-normalized concentrations during pregnancy were decreased by up to 56.1% for lamotrigine (15.60 μg/L/mg to 6.85 μg/L/mg; P < .001), 36.8% for levetiracetam (11.33 μg/L/mg to 7.16 μg/L/mg; P < .001), 17.3% for carbamazepine (11.56 μg/L/mg to 7.97 μg/L/mg; P = .03), 32.6% for oxcarbazepine (11.55 μg/L/mg to 7.79 μg/L/mg; P < .001), 30.6% for unbound oxcarbazepine (6.15 μg/L/mg to 4.27 μg/L/mg; P < .001), 39.9% for lacosamide (26.14 μg/L/mg to 15.71 μg/L/mg; P < .001), and 29.8% for zonisamide (40.12 μg/L/mg to 28.15 μg/L/mg; P < .001). No significant changes occurred for unbound carbamazepine, carbamazepine-10,11-epoxide, and topiramate, although a decrease was observed for topiramate (29.83 μg/L/mg to 13.77 μg/L/mg; P = .18). Additionally, compared with dose-normalized concentrations from control participants, pregnancy dose-normalized median (SE) concentrations decreased significantly by week of gestational age: carbamazepine, -0.14 (0.06) μg/L/mg (P = .02); carbamazepine unbound, -0.04 (0.01) μg/L/mg (P = .01); lacosamide, -0.23 (0.07) μg/L/mg (P < .001); lamotrigine, -0.20 (0.02) μg/L/mg (P < .001); levetiracetam, -0.06 (0.03) μg/L/mg (P = .01); oxcarbazepine, -0.14 (0.04) μg/L/mg (P < .001); oxcarbazepine unbound, -0.11 (0.03) μg/L/mg (P < .001); and zonisamide, -0.53 (0.14) μg/L/mg (P < .001) except for topiramate (-0.35 [0.20] μg/L/mg per week) and carbamazepine-10,11-epoxide (0.02 [0.01] μg/L/mg). CONCLUSIONS AND RELEVANCE Study results suggest that therapeutic drug monitoring should begin early in pregnancy and that increasing doses of these anticonvulsants may be needed throughout the course of pregnancy.
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Affiliation(s)
- Page B Pennell
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashwin Karanam
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis
| | - Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Gerard
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Laura Kalayjian
- Department of Neurology, University of Southern California, Los Angeles
| | | | | | - Thomas M McElrath
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis
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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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Ershadi F, Mousavi Mirzaei SM, Tabrizi N, Roshanravan B, Sahebnasagh A, Avan R. Evaluation of family planning methods in married women with epilepsy. Epilepsy Behav 2022; 129:108618. [PMID: 35257991 DOI: 10.1016/j.yebeh.2022.108618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/13/2022] [Accepted: 02/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epilepsy is one of the most common neurologic unit diseases that have different prevalence in different parts of the world. Antiepileptic drugs (AEDs) are associated with major fertility risks for women of childbearing age. Due to the fact that studies on family planning methods in married women with epilepsy (WWE) have not been conducted in Iran, the aim of this study was to evaluate the family planning methods in married WWE in Birjand, Iran. METHODS An analytical-descriptive study was performed on 126 married WWE hospitalized in the neurology ward or referred to Vali-e-Asr specialized and sub-specialized clinic in Birjand. Demographic information of patients as well as data on the type of used AED, and various methods of family planning were collected in a questionnaire. Data analysis was performed using Chi-square and Fisher tests. All of the above analyses were considered at a significance level of less than 5% by SPSS v.19 software. RESULTS The mean age of the patients was 33.41 ± 9.15 years. The mean age of experiencing the first seizure and the onset of menstruation were 24.82 and 13.79 years, respectively. Fifty (35.5%), 38 (27%), 15 (10.6%), 14 (9.9%), and 14 (9.9%) patients used sodium valproate, carbamazepine, phenytoin, levetiracetam, and lamotrigine, respectively. The results showed that 72 sexually active patients (70.6%) used family planning methods, of which 43 patients (59.7%) used withdrawal method, 20 patients (27.8%) used condoms, and 6 patients (8.3%) used oral contraceptive pills (OCP). Eight patients (9.6%) had a history of unintended pregnancy and 3 patients (3.6%) had a history of abortion. CONCLUSION It is recommended to apply effective family planning methods in married WWE to prevent unintended pregnancies and the subsequent adverse effects in the fetus, considering the fact that a significant percentage of WWE did not use effective family planning methods and 8 cases of unintended pregnancies were reported. Because of high consumption of valproate in women of childbearing age in our study and concerning issue about its fetal malformation, it is recommended to reduce the administration of valproate in this population. Moreover, regarding the low consumption of folic acid, especially for women of childbearing age and pregnant WWE who are taking AED, the necessary recommendations should be made by our physicians.
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Affiliation(s)
- Faranak Ershadi
- Medical Student, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Nasim Tabrizi
- Department of Neurology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Babak Roshanravan
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Razieh Avan
- Department of Clinical Pharmacy, School of Pharmacy, Medical Toxicology and Drug Abuse Research Center, Birjand University of Medical Sciences, Birjand, Iran.
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Voinescu PE, Ehlert AN, Bay CP, Allien S, Pennell PB. Variations in Seizure Frequency During Pregnancy and Postpartum by Epilepsy Type. Neurology 2022; 98:e802-e807. [PMID: 34893557 PMCID: PMC8883510 DOI: 10.1212/wnl.0000000000013056] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 10/25/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To assess whether increased seizure frequency during pregnancy and postpartum is influenced by epilepsy type, seizure location, and antiseizure medications. METHODS Clinical data were collected in a longitudinal prospective database of pregnant women with epilepsy at Brigham and Women's Hospital. Within each individual participant, baseline seizure frequency was calculated for the 9 months before conception, and whether seizure frequency increased during pregnancy or the postpartum period was determined. Seizure frequency was calculated for each 4-week interval during pregnancy. Generalized estimating equations for logistic regression were applied. RESULTS Ninety-nine patients contributing 114 pregnancies were included from 2013 to 2018. Increased seizure frequency occurred more often during pregnancies of women with focal vs generalized epilepsy (21.1% vs 5.3%, odds ratio [OR] 4.70, 95% confidence interval [CI] 1.00-22.00; p = 0.0497). Among women with focal epilepsy, increased seizure frequency occurred more often in those with frontal lobe epilepsy (OR 8.00, 95% CI 2.19-29.21; p = 0.0017). There was no difference in seizure worsening in the postpartum period between the focal and generalized (11.1% vs 9.1%; p = 0.4478) or frontal and other focal (18.8% vs 6.0%; p = 0.1478) epilepsy groups. Pregnancies on polytherapy had higher odds of seizure worsening compared to monotherapy (OR 8.36, 95% CI 2.07-33.84; p = 0.0029), regardless of the medication or epilepsy type. A lack of preconception seizure freedom was also associated with increased seizure frequency during pregnancy (OR 6.418; p = 0.0076). DISCUSSION Women with focal epilepsy have higher likelihood of seizure worsening during pregnancy compared to women with generalized epilepsy; frontal lobe epilepsy poses an especially elevated risk. Polytherapy and lack of preconception seizure freedom are additional predictors for an increased likelihood of seizure worsening.
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Affiliation(s)
- P Emanuela Voinescu
- From the Department of Neurology (P.E.V., S.A., P.B.P.), Division of Epilepsy, Department of Medicine (P.E.V., P.B.P.), Division of Women's Health, Department of Radiology (C.P.B.), and Center for Clinical Investigation (C.P.B.), Brigham and Women's Hospital; Harvard Medical School (P.E.V., C.P.B., P.B.P.); T.H. Chan School of Public Health (A.N.E.), Harvard University; OptumRx (A.N.E.), Boston, MA; and Department of Neurology (P.B.P.), University of Pittsburgh, PA.
| | - Alexa N Ehlert
- From the Department of Neurology (P.E.V., S.A., P.B.P.), Division of Epilepsy, Department of Medicine (P.E.V., P.B.P.), Division of Women's Health, Department of Radiology (C.P.B.), and Center for Clinical Investigation (C.P.B.), Brigham and Women's Hospital; Harvard Medical School (P.E.V., C.P.B., P.B.P.); T.H. Chan School of Public Health (A.N.E.), Harvard University; OptumRx (A.N.E.), Boston, MA; and Department of Neurology (P.B.P.), University of Pittsburgh, PA
| | - Camden P Bay
- From the Department of Neurology (P.E.V., S.A., P.B.P.), Division of Epilepsy, Department of Medicine (P.E.V., P.B.P.), Division of Women's Health, Department of Radiology (C.P.B.), and Center for Clinical Investigation (C.P.B.), Brigham and Women's Hospital; Harvard Medical School (P.E.V., C.P.B., P.B.P.); T.H. Chan School of Public Health (A.N.E.), Harvard University; OptumRx (A.N.E.), Boston, MA; and Department of Neurology (P.B.P.), University of Pittsburgh, PA
| | - Stephanie Allien
- From the Department of Neurology (P.E.V., S.A., P.B.P.), Division of Epilepsy, Department of Medicine (P.E.V., P.B.P.), Division of Women's Health, Department of Radiology (C.P.B.), and Center for Clinical Investigation (C.P.B.), Brigham and Women's Hospital; Harvard Medical School (P.E.V., C.P.B., P.B.P.); T.H. Chan School of Public Health (A.N.E.), Harvard University; OptumRx (A.N.E.), Boston, MA; and Department of Neurology (P.B.P.), University of Pittsburgh, PA
| | - Page B Pennell
- From the Department of Neurology (P.E.V., S.A., P.B.P.), Division of Epilepsy, Department of Medicine (P.E.V., P.B.P.), Division of Women's Health, Department of Radiology (C.P.B.), and Center for Clinical Investigation (C.P.B.), Brigham and Women's Hospital; Harvard Medical School (P.E.V., C.P.B., P.B.P.); T.H. Chan School of Public Health (A.N.E.), Harvard University; OptumRx (A.N.E.), Boston, MA; and Department of Neurology (P.B.P.), University of Pittsburgh, PA
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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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Yin X, Liu Y, Guo Y, Zhao L, Li G, Tan X. Pharmacokinetic changes for newer antiepileptic drugs and seizure control during pregnancy. CNS Neurosci Ther 2022; 28:658-666. [PMID: 35037389 PMCID: PMC8981429 DOI: 10.1111/cns.13796] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate pharmacokinetic changes in newer antiepileptic drugs (AEDs) and assess seizure frequencies and risk factors of increased seizures during pregnancy in women with epilepsy (WWE). Methods A total of 56 pregnancies in 53 WWE who received newer antiepileptic drugs (AEDs) were enrolled. Data on seizure activity and types, daily dose, and AEDs blood levels were derived from routine clinical follow‐up. Changes in AEDs clearance were compared between each trimester and nonpregnant baseline. The ratio of AED levels of each trimester to their targets (nonpregnant baseline) concentrations (RTC) was compared between patients with and without an increased seizure. A binary logistic regression was used to investigate the risk factors contributing to seizure worsening during pregnancy. Results Increased clearances of LTG, LEV, and OXC were observed in all trimesters versus nonpregnant baseline. The peak changes in the clearance of LTG (3.42‐fold baseline clearance) (p < 0.001) and LEV (2.78‐fold) (p < 0.001) occurred in the second trimester during pregnancy, followed by oxcarbazepine (2.11‐fold) in the third trimester (p < 0.03). Plasma concentrations of LTG and LEV during pregnancy were significantly decreased compared to baseline levels, except for OXC. However, no significant differences in RTC values were observed between patients with and without seizure worsening. Some risk factors as seizures for the prior nine months could significantly affect seizure frequency during pregnancy. Conclusion We found substantial changes in the pharmacokinetics of multiple newer AEDs in WWE, reinforcing the need for therapeutic drug monitoring (TDM) during pregnancy. We would encourage at least one monitoring every trimester and probably more frequently for women with poorly seizure control before pregnancy, and AEDs dose adjustment should keep up with clearance changes. In addition, a well‐controlled seizure nine months before pregnancy could lower the risks of seizure during pregnancy, highlighting the importance of pre‐pregnancy counseling and seizure management before pregnancy.
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Affiliation(s)
- Xiaotong Yin
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Yan Liu
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Yang Guo
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Guofei Li
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Xiaoping Tan
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
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Yang H, Fan Y, Zhu Z, Wu H, Chen Z, Hu X, Wu T, Zhang M. Strategies for the Emergency Treatment of Pregnant Women with Neurological Symptoms during the COVID-19 Pandemic. Aging Dis 2022; 14:290-298. [PMID: 37008058 PMCID: PMC10017149 DOI: 10.14336/ad.2022.0718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022] Open
Abstract
Coronavirus disease-19 (COVID-19) has been spreading all over the world for more than two years. Though several kinds of vaccines are currently available, emergence of new variants, spike mutations and immune escape have raised new challenges. Pregnant women are vulnerable to respiratory infections due to their altered immune defence and surveillance functions. Besides, whether pregnant persons should receive a COVID-19 vaccine is still under debate because limited data are available on the efficacy and safety of receiving a vaccine during pregnancy. Physiological features and lack of effective protection making pregnant women at high risk of getting infected. Another concern is that pregnancy may trigger the onset of underlying existing neurological disease, which is highly similar to those neurological symptoms of pregnant women caused by COVID-19. These similarities interfere with diagnosis and delay timely and effective management. Therefore, providing efficient emergency support for pregnant women suffering from neurological symptoms caused by COVID-19 remains a challenge among neurologists and obstetricians. To improve the diagnosis and treatment efficiency of pregnant women with neurological symptoms, we propose an emergency management framework based on the clinicians' experience and available resources. This emergency care system aimed at addressing the conundrums faced by the emergency guarantee system under COVID-19 pandemic and could serve as a potential multisystem project for clinical practice and medical education.
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Affiliation(s)
- Haojun Yang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yishu Fan
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Ziqing Zhu
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Haiyue Wu
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Zhuohui Chen
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xinhang Hu
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Tong Wu
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Mengqi Zhang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Correspondence should be addressed to: Dr. Mengqi Zhang, Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China. .
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Abstract
[Box: see text]
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37
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Craig JJ, Scott S, Leach JP. Epilepsy and pregnancy: identifying risks. Pract Neurol 2021; 22:98-106. [PMID: 34887343 DOI: 10.1136/practneurol-2019-002304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 11/04/2022]
Abstract
Pregnancy is a time of physical, physiological and psychological challenge. For women with epilepsy, as well as its potential for joy and fulfilment, pregnancy may bring additional risks and difficulties. Clinicians must anticipate and prevent these complications, ensuring that pregnancy, delivery and motherhood proceed without obstetric or medical complications, using available evidence to balance individual risks of undertreatment and overtreatment. Here we review epilepsy management in pregnancy, identifying some of the known effects of epilepsy and its treatment on gestation, fetal malformation, delivery, and neurocognitive and behavioural development. We outline strategies to reduce obstetric and fetal complications in women with epilepsy, while recognising the sometimes competing need to maintain or improve seizure control. We reinforce the importance of identifying those at highest risk, who may require additional measures or safeguards.
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Affiliation(s)
- John J Craig
- Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Shona Scott
- Department of Clinical Neurosciences, University of Edinburgh Division of Medical and Radiological Sciences, Edinburgh, UK
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Eadie MJ. Pregnancy and the Control of Epileptic Seizures: A Review. Neurol Ther 2021; 10:455-468. [PMID: 33988822 PMCID: PMC8571455 DOI: 10.1007/s40120-021-00252-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/15/2021] [Indexed: 10/27/2022] Open
Abstract
Over the past 50 years, published studies have provided quantitative data on the control of epileptic seizures during pregnancy. The studies have varied in quality, and particularly in the ways in which seizure control has been assessed. However, most studies have shown that seizure occurrence rates are more likely to worsen than improve during pregnancy, though in most pregnancies the rates have been unaltered. Nearly all of the studies have involved women with antiseizure medication-treated epilepsy, but there is a little evidence that seizure control also tends to worsen in pregnancies of women with untreated epilepsy. The factors likely to contribute to the seizure worsening are (i) patient non-compliance, (ii) increased antiseizure medication clearance during pregnancy resulting in lower circulating drug concentrations relative to dose, (iii) the effects of the higher female sex hormone levels during pregnancy, oestrogens being pro-epileptogenic and progesterone anti-epileptogenic, and (iv) reluctance to use the potential teratogen valproate in women capable of pregnancy, depriving them of the most effective drug for certain types of epilepsy. Compliance can be encouraged, but at the present time only one other factor is readily correctable, i.e. the increased drug clearance. This can be compensated for by raising antiseizure medication dosage during pregnancy, guided by measurement of circulating drug concentrations. This course of action appears to reduce the chance of seizure disorder worsening during pregnancy, but so far it has not provided a complete solution to the issue.
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Affiliation(s)
- Mervyn J Eadie
- School of Medicine and Biomedical Science, University of Queensland, Brisbane, QLD, 4027, Australia.
- , 4th Floor, Ladhope Chambers, 131 Wickham Terrace, Brisbane, 4000, Australia.
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Vajda FJE, Brien TJO, Graham JE, Hitchcock AA, Perucca P, Lander CM, Eadie MJ. The control of treated generalized and focal epilepsies during pregnancy. Epilepsy Behav 2021; 125:108406. [PMID: 34775246 DOI: 10.1016/j.yebeh.2021.108406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To examine factors contributing to failure to achieve full seizure control during pregnancy in women with anti-seizure medication (ASM) treated generalized epilepsy compared with focal epilepsy. RESULTS Full seizure control was not attained in 51.4% of 1223 pregnancies of women with focal epilepsies in the Australian Pregnancy Register, and in 38.7% of 1026 pregnancies in women with generalized epilepsy (P < 0.05). For convulsive seizures only, the corresponding figures of 20.8% and 22.9% were reasonably similar. Where seizures had occurred in the pre-pregnancy year, 82.5% of the focal epilepsy pregnancies were seizure affected, and 70.1% of the generalized epilepsy ones (P < 0.05). Where the pre-pregnancy year was seizure free, the corresponding figures were 22.6% and 16.4% (P < 0.05), a roughly four-fold lower rate. Maternal age, epilepsy onset age, and epilepsy duration also differed between the focal and generalized epilepsy pregnancies. Multivariate regression analysis showed that generalized epilepsy and younger maternal age were associated with statistically significant decreased risks of seizure-affected pregnancy, and having seizure-affected pre-pregnancy years with an increased risk. However, for convulsive seizures only, the risk of seizure-affected pregnancy appeared increased in generalized epilepsy. CONCLUSIONS The risk of seizure-affected pregnancy appears lower in women with generalized epilepsy, independently of pre-pregnancy seizure control, itself a major determinant of the risk. The risk of having only convulsive seizures in pregnancy was not lower in generalized epilepsy than in focal epilepsy. ASM therapy seemed less effective in controlling focal than generalized epileptic seizures during pregnancy.
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Affiliation(s)
- Frank J E Vajda
- Departments of Medicine and Neurosciences, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia; Department of Neuroscience, Monash University, Melbourne, VIC 3004, Australia.
| | - Terence J O' Brien
- Department of Neuroscience, Monash University, Melbourne, VIC 3004, Australia; Department of Neurology, Alfred Health, Melbourne, VIC 3004, Australia.
| | - Janet E Graham
- Departments of Medicine and Neurosciences, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia.
| | - Alison A Hitchcock
- Departments of Medicine and Neurosciences, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia.
| | - Piero Perucca
- Departments of Medicine and Neurosciences, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria 3050, Australia; Department of Neuroscience, Monash University, Melbourne, VIC 3004, Australia; Department of Neurology, Alfred Health, Melbourne, VIC 3004, Australia; Department of Medicine, Austin Health, the University of Melbourne, Heidelberg, VIC 3084, Australia; Comprehensive Epilepsy Program, Austin Health, Heidelberg, VIC 3084, Australia.
| | - Cecilie M Lander
- Royal Brisbane and Women's Hospital and School of Medicine and Biomedical Science, University of Queensland, Brisbane, QLD 4027, Australia.
| | - Mervyn J Eadie
- Royal Brisbane and Women's Hospital and School of Medicine and Biomedical Science, University of Queensland, Brisbane, QLD 4027, Australia.
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Lai W, He S, Zhou D, Chen L. Managing reproductive problems in women with epilepsy of childbearing age. ACTA EPILEPTOLOGICA 2021. [DOI: 10.1186/s42494-021-00062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractGirls and women constitute nearly 50% of all epilepsy cases. Apart from the disease symptoms, epilepsy and antiseizure medications (ASMs) may also affect the reproductive function, pregnancy and even the health of their offspring. Therefore, it is very important to identify and summarize the problems and risks for women with epilepsy (WWE) of childbearing age, and offer internationally recognized methods through multidisciplinary collaboration. In this review, we summarize the reproduction-related problems with WWE and propose multidisciplinary management by epileptologists, gynecologists and obstetricians, as well as other experts, from preconception to delivery. Large, multicenter registries are needed to advance our knowledge on new ASMs and their effects on WWE and their offspring.
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Levetiracetam, lamotrigine and carbamazepine: which monotherapy during pregnancy? Neurol Sci 2021; 43:1993-2001. [PMID: 34468899 PMCID: PMC8860795 DOI: 10.1007/s10072-021-05542-2] [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: 03/31/2021] [Accepted: 07/31/2021] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Epilepsy treatment during pregnancy is still challenging. The study is aimed at comparing the efficacy and safety of carbamazepine (CBZ), lamotrigine (LTG) and levetiracetam (LEV) monotherapies during pregnancy in women with focal (FE) or generalized (GE) epilepsy. METHODS A multicentre retrospective study was conducted to evaluate seizures frequency and seizure freedom (SF) rate during 3 months before pregnancy, each trimester of gestation and post-partum period in women on monotherapy with CBZ, LTG and LEV. RESULTS Fifty-seven pregnancies (45 FE, 12 GE) on monotherapy (29 CBZ, 11 LTG, 17 LEV) were included. A significant reduction of seizure frequency was found in the first trimester of pregnancy as compared with that one before pregnancy (p = 0.004), more evident in GE (p = 0.003) and in LEV group (p = 0.004). The SF rate significantly increased in the first trimester in comparison to that one before pregnancy and persisted in the post-partum period in the whole sample (p < 0.001) and in women on LEV (p = 0.004). Besides, 88.57% of SF women before pregnancy remained unchanged during gestation and the post-partum period. One major heart malformation in CBZ and no major malformations in LTG and LEV groups were found. CONCLUSIONS A better clinical outcome during pregnancy emerged since the first trimester in comparison to the before-pregnancy period, mostly evident in women with GE and LEV therapy, reinforcing the hypothesis of a protective role of pregnancy versus seizures. SF before pregnancy represents a significant predictive factor of good clinical outcome during gestation and the post-partum period. Compared to CBZ, LTG and LEV showed a better safety profile.
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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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Aícua‐Rapún I, André P, Rossetti AO, Décosterd LA, Buclin T, Novy J. Seizure freedom and plasma levels of newer generation antiseizure medications. Acta Neurol Scand 2021; 144:202-208. [PMID: 33950522 DOI: 10.1111/ane.13450] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Contrary to older antiseizure medications (ASM), correlation between plasma levels and seizure freedom is not well defined for newer generation ASM. We assessed correlations between efficacy and newer generation ASM plasma levels in patients with epilepsy. MATERIALS AND METHODS Plasma medication levels were measured over two years in consecutive patients taking lamotrigine, levetiracetam, oxcarbazepine, topiramate, zonisamide, lacosamide, perampanel or pregabalin. Seizure freedom was defined as three times the longest inter-seizure pre-treatment interval, or at least one year. Each medication level was stratified according to its position in relation to its proposed reference range (below or in lower half vs upper half or above). RESULTS 168 patients on stable therapy were included. ASM plasma levels of seizure-free patients were lower than those with ongoing seizures; 45/48 (93.7%) were in the lower half or below the reference ranges, compared to 86/106 (81.1%; p = .004). Lamotrigine plasma levels were significantly lower in seizure-free patients (median 2.4 mg/L range 0.4-6.5 mg/L, none above 6.5 mg/L) compared with those with ongoing seizures (5 mg/L, 0.5-14.2 mg/L; p < .0001). Levetiracetam showed similar results (7.2 mg/L, 1.6-15.1 mg/L; none above 15.1 mg/L in seizure-free patients vs 16.4 mg/L, 0.6-47.7 mg/L; p = .005). Demographics, epilepsy type and polytherapy did not influence the results. CONCLUSIONS Efficacy of newer generation ASMs seems to be reached at the lower part or at times even below the reference ranges in drug responsive patients; this could inform regarding titrations of these treatments.
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Affiliation(s)
- Irene Aícua‐Rapún
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital (CHUV) University of Lausanne Lausanne Switzerland
| | - Pascal André
- Clinical Pharmacology Service Lausanne University Hospital (CHUV) University of Lausanne Lausanne Switzerland
| | - Andrea O. Rossetti
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital (CHUV) University of Lausanne Lausanne Switzerland
| | - Laurent A. Décosterd
- Laboratory of Clinical Pharmacology Lausanne University Hospital (CHUV) University of Lausanne Lausanne Switzerland
| | - Thierry Buclin
- Clinical Pharmacology Service Lausanne University Hospital (CHUV) University of Lausanne Lausanne Switzerland
| | - Jan Novy
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital (CHUV) University of Lausanne Lausanne Switzerland
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Mostacci B, Troisi S, Bisulli F, Zenesini C, Licchetta L, Provini F, Avoni P, Rombini A, Vignatelli L, Tinuper P. Seizure worsening in pregnancy in women with sleep-related hypermotor epilepsy (SHE): A historical cohort study. Seizure 2021; 91:258-262. [PMID: 34246880 DOI: 10.1016/j.seizure.2021.06.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/06/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Data on seizure course during pregnancy in women with epilepsy are limited. In particular, little is known about the causes underlying possible seizure worsening in this population. We therefore set out to explore worsening, in pregnancy, of sleep-related hypermotor epilepsy (SHE), a syndrome in which seizures are known to be triggered by sleep fragmentation, a condition common in pregnancy. METHODS From a cohort of consecutive patients with epilepsy who had one or more deliveries between January 2008 and March 2018, we retrospectively compared the rates of seizure worsening during pregnancy in SHE versus other epilepsies (NSHE). Worsening was defined as an increase in seizure frequency compared with the rate for the year prior to conception, including seizure recurrence after a year of seizure freedom, and/or new occurrence of tonic-clonic seizures. RESULTS We considered data on 11 pregnancies in women with SHE and 104 pregnancies in women with NSHE. Seizures worsened in six SHE pregnancies (54.5%) versus 18 NSHE ones (17.3%) (OR adjusted for preconception seizure frequency and polytherapy = 5.7, 95% CI = 1.6-20.8, p = 0.019). CONCLUSIONS Women with SHE have a higher risk of seizure worsening in pregnancy. This finding should be considered from the perspective of patient counseling.
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Affiliation(s)
- Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy.
| | - Serena Troisi
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Federico II University Hospital, Naples, Italy
| | - Francesca Bisulli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Corrado Zenesini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy
| | - Laura Licchetta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Federica Provini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Patrizia Avoni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Annalisa Rombini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Luca Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy
| | - Paolo Tinuper
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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Sharma SR, Sharma N, Hussain M, Mobing H, Hynniewta Y. Levetiracetam Use During Pregnancy in Women With Active Epilepsy: A Hospital-Based, Retrospective Study from a Tertiary Care Hospital in North Eastern INDIA. Neurol India 2021; 69:692-697. [PMID: 34169870 DOI: 10.4103/0028-3886.319234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background and Purpose Epilepsy during pregnancy is a therapeutic challenge. Since the 1990s, the number of licensed antiepileptic drugs has substantially increased, but safety data on managing epilepsy during conception, pregnancy, and postpartum period use of newer generation antiepileptic drugs and birth defects are limited. We analyzed efficacy and safety of levetiracetam during pregnancy in northeast Indian women with active epilepsy (WWAE) which is being presented here. Design Hospital based retrospective study. Patients and Methods A retrospective analysis was conducted based on clinical records at a tertiary care teaching hospital and referral center in Northeast India between June 2008 through June 2018 without any personal identifying information. The Obstetric data from pregnancy register was supplemented with detailed neurologic data retrieved from medical records. Results Of 103 women with active epilepsy, 47 (45.6%) received levetiracetam as monotherapy and 56 (54.4%) as polytherapy. During pregnancy, the seizure frequency was unchanged, or the change was better in the majority (61.1%) of the patients. With one twin pregnancy, there were 96 live births, 5 spontaneous abortions, 2 induced abortions, 1 stillbirth. However, the rate of small for gestational age was higher in WWAE, Apgar score at 5 min was lower in infants of WWAE, and the need for care in the neonatal ward and neonatal intensive care was higher. Seven of 103 exposed pregnancies had a major congenital malformation (6.79%), all 7 were exposed to other antiepileptic drugs. Generalized epilepsy accounted for 57.2%. Conclusion Pregnancy course is uncomplicated and neonatal outcome is good in the majority of women with active epilepsy with proper antenatal and neurologic care. Levetiracetam taken in monotherapy can be considered as safer alternative for women with epilepsy of childbearing age. Long-term follow-up of neuropsychological and cognitive development of the children of WWAE is still needed.
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Affiliation(s)
- Shri Ram Sharma
- Department of Neurology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Nalini Sharma
- Department of Obstetrics and Gynecology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Masaraf Hussain
- Department of Neurology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Hibung Mobing
- Department of Neurology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Yasmeen Hynniewta
- Department of Pediatric Medicine, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
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Arfman IJ, Wammes-van der Heijden EA, Ter Horst PGJ, Lambrechts DA, Wegner I, Touw DJ. Therapeutic Drug Monitoring of Antiepileptic Drugs in Women with Epilepsy Before, During, and After Pregnancy. Clin Pharmacokinet 2021; 59:427-445. [PMID: 31912315 DOI: 10.1007/s40262-019-00845-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
During pregnancy, the pharmacokinetics of an antiepileptic drug is altered because of changes in the clearance capacity and volume of distribution. These changes may have consequences for the frequency of seizures during pregnancy and fetal exposure to antiepileptic drugs. In 2009, a review was published providing guidance for the dosing and therapeutic drug monitoring of antiepileptic drugs during pregnancy. Since that review, new drugs have been licensed and new information about existing drugs has been published. With this review, we aim to provide an updated narrative overview of changes in the pharmacokinetics of antiepileptic drugs in women during pregnancy. In addition, we aim to formulate advice for dose modification and therapeutic drug monitoring of antiepileptic drugs. We searched PubMed and the available literature on the pharmacokinetic changes of antiepileptic drugs and seizure frequency during pregnancy published between January 2007 and September 2018. During pregnancy, an increase in clearance and a decrease in the concentrations of lamotrigine, levetiracetam, oxcarbazepine's active metabolite licarbazepine, topiramate, and zonisamide were observed. Carbamazepine clearance remains unchanged during pregnancy. There is inadequate or no evidence for changes in the clearance or concentrations of clobazam and its active metabolite N-desmethylclobazam, gabapentin, lacosamide, perampanel, and valproate. Postpartum elimination rates of lamotrigine, levetiracetam, and licarbazepine resumed to pre-pregnancy values within the first few weeks after pregnancy. We advise monitoring of antiepileptic drug trough concentrations twice before pregnancy. This is the reference concentration. We also advise to consider dose adjustments guided by therapeutic drug monitoring during pregnancy if the antiepileptic drug concentration decreases 15-25% from the pre-pregnancy reference concentration, in the presence of risk factors for convulsions. If the antiepileptic drug concentration changes more than 25% compared with the reference concentration, dose adjustment is advised. Monitoring of levetiracetam, licarbazepine, lamotrigine, and topiramate is recommended during and after pregnancy. Monitoring of clobazam, N-desmethylclobazam, gabapentin, lacosamide, perampanel, and zonisamide during and after pregnancy should be considered. Because of the risk of teratogenic effects, valproate should be avoided during pregnancy. If that is impossible, monitoring of both total and unbound valproate is recommended. More research is needed on the large number of unclear pregnancy-related effects on the pharmacokinetics of antiepileptic drugs.
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Affiliation(s)
- Inge J Arfman
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - Danielle A Lambrechts
- Academic Center for Epileptology Kempenhaeghe and Maastricht UMC+, Sterkselseweg 65, 5591, Heeze, VE, The Netherlands
| | - Ilse Wegner
- SEIN-Stichting Epilepsie Instellingen Nederland, Zwolle, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
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Abstract
During pregnancy, there are several physiological changes during each trimester that can affect the absorption, distribution, metabolism, and elimination of drugs. Although there is a potential need to understand the pharmacokinetics and pharmacodynamics of drugs in pregnant patients, therapeutic drug monitoring is not well established for various drug classes due to ethical and safety concerns regarding the neonate. Potential risks from in utero drug exposure to the fetus may impact growth and development and may cause malformations or teratogenesis. The clinician must consider the benefits of drug treatment for the pregnant mother versus the risk to the fetus, before prescribing medications during pregnancy. The objective of this review is to aid clinicians, pharmacists, and laboratorians in understanding the pharmacokinetic and pharmacodynamic changes during pregnancy, to provide drug class recommendations for monitoring therapy throughout pregnancy via therapeutic drug monitoring, and to highlight the recent directives of governing agencies on maternal and fetal health.
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Dehydroepiandrosterone (DHEA) Serum Levels Indicate Cerebrospinal Fluid Levels of DHEA and Estradiol (E2) in Women at Term Pregnancy. Reprod Sci 2021; 28:2823-2829. [PMID: 33772479 PMCID: PMC8523509 DOI: 10.1007/s43032-021-00541-2] [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: 08/31/2020] [Accepted: 03/09/2021] [Indexed: 11/29/2022]
Abstract
Neuroactive steroids such as dehydroepiandrosterone (DHEA), estradiol (E2), and progesterone (P4) are associated with structural and functional changes in the central nervous system (CNS). Measurement of steroid levels in the CNS compartments is restricted in accessibility. Consequently, there is only limited human data on the distributional equilibrium for steroid levels between peripheral and central compartments. While some neuroactive steroids including DHEA and E2 have been reported to convey excitatory and proconvulsant properties, the opposite was demonstrated for P4. We aimed to elucidate the correlation between peripheral and central DHEA, E2, and P4 levels in women at term pregnancy. CSF and serum samples of 27 healthy pregnant women (22–39 years) at term pregnancy were collected simultaneously under combined spinal and epidural anesthesia and used for DHEA ELISA and E2, and P4 ECLIA. All three neuroactive steroids were detected at markedly lower levels in CSF compared to their corresponding serum concentrations (decrease, mean ± SD, 97.66 ± 0.83%). We found a strong correlation for DHEA between its serum and the corresponding CSF levels (r = 0.65, p = 0.003). Serum and CSF levels of E2 (r = 0.31, p = 0.12) appeared not to correlate in the investigated cohort. DHEA serum concentration correlated significantly with E2 (r = 0.58, p = 0.0016) in CSF. In addition, a strong correlation was found between DHEA and E2, both measured in CSF (r = 0.65, p = 0.0002). Peripheral DHEA levels might serve as an indicator for central nervous levels of the neuroactive steroids DHEA and E2 in pregnant women.
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Kacirova I, Grundmann M, Brozmanova H. Umbilical Cord, Maternal Milk, and Breastfed Infant Levetiracetam Concentrations Monitoring at Delivery and during Early Postpartum Period. Pharmaceutics 2021; 13:398. [PMID: 33802733 PMCID: PMC8002441 DOI: 10.3390/pharmaceutics13030398] [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: 02/22/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 11/22/2022] Open
Abstract
(1) To obtain objective information about levetiracetam transplacental passage and its transport into colostrum, mature milk, and breastfed infants, we analyzed data from women treated for epilepsy between October 2006 and January 2021; (2) in this cohort study, maternal, umbilical cord, milk, and infant serum concentrations were measured at delivery, 2-4 days postpartum (colostrum) and 7-31 days postpartum (mature milk). Paired umbilical cord serum, maternal serum, breastfed infant serum, and milk concentrations were used to assess the ratios of umbilical cord/maternal serum, milk/maternal serum, and infant/maternal serum concentrations. The influence of combined treatment with enzyme-inducing antiseizure medication carbamazepine was assessed; (3) the umbilical cord/maternal serum concentration ratio ranged between 0.75 and 1.78 (mean 1.10 ± 0.33), paired maternal and umbilical cord serum concentrations were not significantly different, and a highly significant correlation was found between both concentrations. The mean milk/maternal serum concentration ratio was 1.14 ± 0.27 (2-4 days postpartum) and 1.04 ± 0.24 (7-31 days postpartum) while the mean infant/maternal serum concentration ratio was markedly lower (0.19 ± 0.13 and 0.14 ± 0.05, respectively); (4) levetiracetam was found in the umbilical cord at a concentration similar to those in maternal serum. All of the breastfed infant serum concentrations were below the reference range used for the general epileptic population.
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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 Clinical Pharmacology, Department of Laboratory Medicine, 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.)
| | - Hana Brozmanova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic; (I.K.); (H.B.)
- Department of Clinical Pharmacology, Department of Laboratory Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic
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Dupont S, Vercueil L. Epilepsy and pregnancy: What should the neurologists do? Rev Neurol (Paris) 2021; 177:168-179. [PMID: 33610349 DOI: 10.1016/j.neurol.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 02/08/2023]
Abstract
Epilepsy is one of the most common chronic disorders affecting women of childbearing age. Unfortunately, many women with epilepsy (WWE) still report not receiving key information about pregnancy. They obviously need information about epilepsy and pregnancy prior to conception with a particular emphasis on effective birth control (i.e. contraception), necessity to plan pregnancy, antiepileptic drugs optimization, and folate supplementation. The risks associated with use of antiepileptic drugs during pregnancy have to be balanced against fetal and maternal risks associated with uncontrolled seizures. This report reviews evidence-based counseling and management strategies concerning maternal and fetal risks associated with seizures, teratogenic risks associated with antiepileptic drug exposure with a special emphasis on developmental and behavioural outcomes of children exposed to intra utero antiepileptic drugs.
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Affiliation(s)
- S Dupont
- Epilepsy and Rehabilitation Unit, Hôpital de la Pitié-Salpêtrière, AP-HP, Paris, France; Centre de Recherche de l'Institut du Cerveau et de la Moëlle Épinière (ICM), UMPC-UMR 7225 CNRS-UMRS 975 INSERM, Paris, France; Université Paris Sorbonne, Paris, France.
| | - L Vercueil
- EFSN, University Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences (GIN), 38000 Grenoble, France
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