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Honybun E, Cockle E, Malpas CB, O'Brien TJ, Vajda FJ, Perucca P, Rayner G. Neurodevelopmental and Functional Outcomes Following In Utero Exposure to Antiseizure Medication: A Systematic Review. Neurology 2024; 102:e209175. [PMID: 38531021 DOI: 10.1212/wnl.0000000000209175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 12/04/2023] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To undertake a systematic review of the available literature to examine the relationship between prenatal antiseizure medication (ASM) exposure and adverse postnatal neurodevelopmental outcomes, focusing on social, emotional, behavioral, and adaptive domains of human function, and the frequency of neurodevelopmental and psychiatric disorders in ASM-exposed offspring. METHODS Electronic searches of MEDLINE, PsychINFO, and EMBASE were conducted and limited to studies published between 1990 and 2023 in English. Studies were eligible if they prospectively or retrospectively reported neurodevelopmental outcomes of ASM-exposed offspring. The Newcastle-Ottawa scale was used to conduct methodologic quality assessments of included studies, and a narrative synthesis integrated the review findings. RESULTS Forty-three studies were included. Valproate has been consistently associated with a 2- to 4-fold increased risk of autism spectrum disorder (ASD), 2- to 5-fold increased risk of intellectual disability (ID), and poor adaptive functioning. Growing evidence indicates that topiramate is associated with a 2-fold increased risk of ASD and 3- to 4-fold increased risk of ID. The risks of adverse neurodevelopmental outcomes for valproate and topiramate seem to be dose dependent. Phenobarbital has been suggested to be associated with deleterious neurodevelopmental effects, but data are limited. Levetiracetam has recently been linked with an increased risk of attention deficit hyperactivity disorder and anxiety disorders in a single study. Carbamazepine has been associated with variable neurodevelopmental outcomes. Lamotrigine seems to be "safe" in terms of postnatal neurodevelopment. Data for oxcarbazepine, phenytoin, and clonazepam are limited but seem to have little-to-no risk of adverse outcomes. Evidence for the remaining ASMs, including gabapentin, pregabalin, lacosamide, zonisamide, clobazam, perampanel, ethosuximide, or brivaracetam, is lacking. Several methodologic limitations impeded data synthesis, including heterogeneity in outcome measures and small samples of monotherapy exposures. DISCUSSION The findings of this review support the conclusion that valproate and topiramate use during pregnancy is associated with a significantly increased risk of neurodevelopmental effects on the fetus. Apart from lamotrigine, which seems to be free of adverse neurodevelopmental effects, data for the other ASMs are mixed or inadequate to draw definite conclusions. Further research into the neurodevelopmental effects of prenatal exposure to ASMs, including most newer agents, is much needed.
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Affiliation(s)
- Eliza Honybun
- From the Melbourne School of Psychological Sciences (E.H., C.B.M., G.R.), The University of Melbourne; Epilepsy Research Centre (E.H., P.P., G.R.), Department of Medicine, Austin Hospital, The University of Melbourne; Department of Neuroscience (E.C., C.B.M., T.J.O.B., F.J.V., P.P., G.R.), Central Clinical School, Monash University; Department of Neurology (E.C., C.B.M., T.J.O.B., P.P., G.R.), The Alfred Hospital; Department of Neurology (C.B.M., T.J.O.B., F.J.V., P.P.), Royal Melbourne Hospital; Department of Medicine (C.B.M., T.J.O.B., F.J.V.), Royal Melbourne Hospital, The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health; and Department of Clinical Neuropsychology (G.R.), Austin Health, Melbourne, Australia
| | - Emily Cockle
- From the Melbourne School of Psychological Sciences (E.H., C.B.M., G.R.), The University of Melbourne; Epilepsy Research Centre (E.H., P.P., G.R.), Department of Medicine, Austin Hospital, The University of Melbourne; Department of Neuroscience (E.C., C.B.M., T.J.O.B., F.J.V., P.P., G.R.), Central Clinical School, Monash University; Department of Neurology (E.C., C.B.M., T.J.O.B., P.P., G.R.), The Alfred Hospital; Department of Neurology (C.B.M., T.J.O.B., F.J.V., P.P.), Royal Melbourne Hospital; Department of Medicine (C.B.M., T.J.O.B., F.J.V.), Royal Melbourne Hospital, The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health; and Department of Clinical Neuropsychology (G.R.), Austin Health, Melbourne, Australia
| | - Charles B Malpas
- From the Melbourne School of Psychological Sciences (E.H., C.B.M., G.R.), The University of Melbourne; Epilepsy Research Centre (E.H., P.P., G.R.), Department of Medicine, Austin Hospital, The University of Melbourne; Department of Neuroscience (E.C., C.B.M., T.J.O.B., F.J.V., P.P., G.R.), Central Clinical School, Monash University; Department of Neurology (E.C., C.B.M., T.J.O.B., P.P., G.R.), The Alfred Hospital; Department of Neurology (C.B.M., T.J.O.B., F.J.V., P.P.), Royal Melbourne Hospital; Department of Medicine (C.B.M., T.J.O.B., F.J.V.), Royal Melbourne Hospital, The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health; and Department of Clinical Neuropsychology (G.R.), Austin Health, Melbourne, Australia
| | - Terence J O'Brien
- From the Melbourne School of Psychological Sciences (E.H., C.B.M., G.R.), The University of Melbourne; Epilepsy Research Centre (E.H., P.P., G.R.), Department of Medicine, Austin Hospital, The University of Melbourne; Department of Neuroscience (E.C., C.B.M., T.J.O.B., F.J.V., P.P., G.R.), Central Clinical School, Monash University; Department of Neurology (E.C., C.B.M., T.J.O.B., P.P., G.R.), The Alfred Hospital; Department of Neurology (C.B.M., T.J.O.B., F.J.V., P.P.), Royal Melbourne Hospital; Department of Medicine (C.B.M., T.J.O.B., F.J.V.), Royal Melbourne Hospital, The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health; and Department of Clinical Neuropsychology (G.R.), Austin Health, Melbourne, Australia
| | - Frank J Vajda
- From the Melbourne School of Psychological Sciences (E.H., C.B.M., G.R.), The University of Melbourne; Epilepsy Research Centre (E.H., P.P., G.R.), Department of Medicine, Austin Hospital, The University of Melbourne; Department of Neuroscience (E.C., C.B.M., T.J.O.B., F.J.V., P.P., G.R.), Central Clinical School, Monash University; Department of Neurology (E.C., C.B.M., T.J.O.B., P.P., G.R.), The Alfred Hospital; Department of Neurology (C.B.M., T.J.O.B., F.J.V., P.P.), Royal Melbourne Hospital; Department of Medicine (C.B.M., T.J.O.B., F.J.V.), Royal Melbourne Hospital, The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health; and Department of Clinical Neuropsychology (G.R.), Austin Health, Melbourne, Australia
| | - Piero Perucca
- From the Melbourne School of Psychological Sciences (E.H., C.B.M., G.R.), The University of Melbourne; Epilepsy Research Centre (E.H., P.P., G.R.), Department of Medicine, Austin Hospital, The University of Melbourne; Department of Neuroscience (E.C., C.B.M., T.J.O.B., F.J.V., P.P., G.R.), Central Clinical School, Monash University; Department of Neurology (E.C., C.B.M., T.J.O.B., P.P., G.R.), The Alfred Hospital; Department of Neurology (C.B.M., T.J.O.B., F.J.V., P.P.), Royal Melbourne Hospital; Department of Medicine (C.B.M., T.J.O.B., F.J.V.), Royal Melbourne Hospital, The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health; and Department of Clinical Neuropsychology (G.R.), Austin Health, Melbourne, Australia
| | - Genevieve Rayner
- From the Melbourne School of Psychological Sciences (E.H., C.B.M., G.R.), The University of Melbourne; Epilepsy Research Centre (E.H., P.P., G.R.), Department of Medicine, Austin Hospital, The University of Melbourne; Department of Neuroscience (E.C., C.B.M., T.J.O.B., F.J.V., P.P., G.R.), Central Clinical School, Monash University; Department of Neurology (E.C., C.B.M., T.J.O.B., P.P., G.R.), The Alfred Hospital; Department of Neurology (C.B.M., T.J.O.B., F.J.V., P.P.), Royal Melbourne Hospital; Department of Medicine (C.B.M., T.J.O.B., F.J.V.), Royal Melbourne Hospital, The University of Melbourne; Bladin-Berkovic Comprehensive Epilepsy Program (P.P.), Department of Neurology, Austin Health; and Department of Clinical Neuropsychology (G.R.), Austin Health, Melbourne, Australia
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Gallitelli V, Franco R, Guidi S, Puri L, Parasiliti M, Vidiri A, Eleftheriou G, Perelli F, Cavaliere AF. Depression Treatment in Pregnancy: Is It Safe, or Is It Not? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:404. [PMID: 38673317 PMCID: PMC11049910 DOI: 10.3390/ijerph21040404] [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: 02/16/2024] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
Prenatal depression carries substantial risks for maternal and fetal health and increases susceptibility to postpartum depression. Untreated depression in pregnancy is correlated with adverse outcomes such as an increased risk of suicidal ideation, miscarriage and neonatal growth problems. Notwithstanding concerns about the use of antidepressants, the available treatment options emphasize the importance of specialized medical supervision during gestation. The purpose of this paper is to conduct a brief literature review on the main antidepressant drugs and their effects on pregnancy, assessing their risks and benefits. The analysis of the literature shows that it is essential that pregnancy be followed by specialized doctors and multidisciplinary teams (obstetricians, psychiatrists and psychologists) who attend to the woman's needs. Depression can now be treated safely during pregnancy by choosing drugs that have no teratogenic effects and fewer side effects for both mother and child. Comprehensive strategies involving increased awareness, early diagnosis, clear guidelines and effective treatment are essential to mitigate the impact of perinatal depression.
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Affiliation(s)
- Vitalba Gallitelli
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | - Rita Franco
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | - Sofia Guidi
- Division of Gynecology and Obstetrics, IRCSS Azienda Ospedaliera-Universitaria of Bologna, 40138 Bologna, Italy;
| | - Ludovica Puri
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | - Marco Parasiliti
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | - Annalisa Vidiri
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
| | | | - Federica Perelli
- Azienda USL Toscana Centro, Gynecology and Obstetrics Department, Santa Maria Annunziata Hospital, 50012 Florence, Italy;
| | - Anna Franca Cavaliere
- Division of Gynecology and Obstetrics, Isola Tiberina Gemelli Hospital, 00186 Rome, Italy; (V.G.); (L.P.); (M.P.); (A.V.); (A.F.C.)
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Hernández-Díaz S, Straub L, Bateman BT, Zhu Y, Mogun H, Wisner KL, Gray KJ, Lester B, McDougle CJ, DiCesare E, Pennell PB, Huybrechts KF. Risk of Autism after Prenatal Topiramate, Valproate, or Lamotrigine Exposure. N Engl J Med 2024; 390:1069-1079. [PMID: 38507750 PMCID: PMC11047762 DOI: 10.1056/nejmoa2309359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
BACKGROUND Maternal use of valproate during pregnancy has been associated with an increased risk of neurodevelopmental disorders in children. Although most studies of other antiseizure medications have not shown increased risks of these disorders, there are limited and conflicting data regarding the risk of autism spectrum disorder associated with maternal topiramate use. METHODS We identified a population-based cohort of pregnant women and their children within two health care utilization databases in the United States, with data from 2000 through 2020. Exposure to specific antiseizure medications was defined on the basis of prescription fills from gestational week 19 until delivery. Children who had been exposed to topiramate during the second half of pregnancy were compared with those unexposed to any antiseizure medication during pregnancy with respect to the risk of autism spectrum disorder. Valproate was used as a positive control, and lamotrigine was used as a negative control. RESULTS The estimated cumulative incidence of autism spectrum disorder at 8 years of age was 1.9% for the full population of children who had not been exposed to antiseizure medication (4,199,796 children). With restriction to children born to mothers with epilepsy, the incidence was 4.2% with no exposure to antiseizure medication (8815 children), 6.2% with exposure to topiramate (1030 children), 10.5% with exposure to valproate (800 children), and 4.1% with exposure to lamotrigine (4205 children). Propensity score-adjusted hazard ratios in a comparison with no exposure to antiseizure medication were 0.96 (95% confidence interval [CI], 0.56 to 1.65) for exposure to topiramate, 2.67 (95% CI, 1.69 to 4.20) for exposure to valproate, and 1.00 (95% CI, 0.69 to 1.46) for exposure to lamotrigine. CONCLUSIONS The incidence of autism spectrum disorder was higher among children prenatally exposed to the studied antiseizure medications than in the general population. However, after adjustment for indication and other confounders, the association was substantially attenuated for topiramate and lamotrigine, whereas an increased risk remained for valproate. (Funded by the National Institute of Mental Health.).
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Affiliation(s)
- Sonia Hernández-Díaz
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Loreen Straub
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Brian T Bateman
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Yanmin Zhu
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Helen Mogun
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Katherine L Wisner
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Kathryn J Gray
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Barry Lester
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Christopher J McDougle
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Elyse DiCesare
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Page B Pennell
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
| | - Krista F Huybrechts
- From the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (L.S., Y.Z., H.M., E.D., K.F.H.), the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital (K.J.G.), and the Department of Psychiatry, Harvard Medical School (C.J.M.), Boston, and the Lurie Center for Autism, Massachusetts General Hospital, Lexington (C.J.M.) - all in Massachusetts; the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.); the Asher Center for the Study and Treatment of Depressive Disorders, Department of Psychiatry and Behavioral Sciences, and the Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.L.W.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University, and Women and Infants Hospital, Providence, RI (B.L.); and the Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh (P.B.P.)
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Kumaravel J, Sarma P, Suri V, Singh P, Prakash A, Medhi B. Therapeutic Drug Monitoring of Levetiracetam in Different Trimesters of Pregnant Women with Epilepsy in a Tertiary Care Center: A Prospective Study. Neurol India 2024; 72:358-363. [PMID: 38691482 DOI: 10.4103/ni.ni_439_22] [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: 05/04/2022] [Accepted: 04/16/2023] [Indexed: 05/03/2024]
Abstract
BACKGROUND Levetiracetam is the most commonly used antiepileptic drug in pregnant women due to its low teratogenic risk profile, favorable pharmacokinetic characteristics, and safety profile. Serum levels of levetiracetam vary in epilepsy during pregnancy. Therefore, the aim of the study was to evaluate the serum levels of levetiracetam during different trimesters of pregnancy by using therapeutic drug monitoring (TDM). MATERIALS AND METHODS This was a single-center, prospective study. Pregnant women with epilepsy on levetiracetam were enrolled after getting written informed consent from them. Serum trough levels of levetiracetam were estimated at all trimesters by high-performance liquid chromatography (HPLC). RESULTS The study included 16 participants with mean ± standard deviation (SD) age of 27.75 ± 4 years. There were nine (56.2%) participants with generalized seizure disorder and seven (43.8%) participants of focal seizure disorder. Among 16 patients, 10 (62.5%) participants were on levetiracetam alone and six (37.5%) participants were on levetiracetam combined with other antiepileptic drugs. In a total of 48 trough samples, 45 sample concentrations were below the therapeutic range of 12-46 mg/l and three sample concentrations were within the therapeutic range. There was a statistically significant difference in the concentration-dose ratio (CDR) of levetiracetam between the third and first trimesters (P-value 0.018). CONCLUSION There was a statistically significant difference in serum levetiracetam concentration between the third and first trimesters. A well-conducted, intensive pharmacokinetic sampling study in PWWE with a control group is needed in future to evaluate the whole pharmacokinetic profile of levetiracetam and to correlate the clinical outcome.
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Affiliation(s)
- J Kumaravel
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Phulen Sarma
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Parampreet Singh
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Prakash
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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5
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Khanom S, Astill D, Astill N, Cozens J, Mann B, Garratt J, Bromley RL. The lived experience of young adults with Fetal Valproate Spectrum Disorder, and the perspective of their parents: A qualitative study. Epilepsy Behav 2024; 152:109680. [PMID: 38335859 DOI: 10.1016/j.yebeh.2024.109680] [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: 12/22/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND While research has investigated the physical and neurodevelopmental consequences following prenatal exposure to valproate, our understanding of individuals with a formal diagnosis of Fetal Valproate Spectrum Disorder (FVSD), particularly in the context of adulthood, remains limited. AIM To investigate how symptoms and challenges of FVSD present in adulthood. METHODS 30 people took part in the study, including 13 young adults aged between 21 and 37 years, 15 mothers, and 2 fathers. In all cases, valproate had been used for the treatment of maternal epilepsy. Data were collected using semi-structured interviews and analysed using thematic analysis. RESULTS Six broad themes were identified: 1. Health and development, 2. Employment, 3. Daily living and independence, 4. Social skills and relationships, 5. Access to services, and 6. Impact on families. Individuals with FVSD live with an array of physical, mental, and developmental challenges that extend well beyond childhood, significantly altering their life course and that of their families. Challenges in obtaining employment, achieving independent living, and navigating social and romantic relationships become increasingly significant as individuals with FVSD age. Despite their persistent need for support, services for adults with FVSD are either limited or entirely absent. Recommendations from families were provided regarding optimized support systems. CONCLUSION This study highlights the lifelong physical, cognitive, emotional, social and behavioural symptoms associated with FVSD. Young adults and their parents desire further research regarding the condition along with improved support and health services in adulthood.
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Affiliation(s)
- S Khanom
- Division of Neuroscience, Faculty of Biology, Medicine and Health, the University of Manchester, Manchester, UK; Paediatric Psychosocial Department, Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - D Astill
- Foetal Anti-Convulsant Syndrome New Zealand, Auckland, New Zealand
| | - N Astill
- Foetal Anti-Convulsant Syndrome New Zealand, Auckland, New Zealand
| | - J Cozens
- Organisation of Anti-Convulsant Syndromes, Caerphilly, Wales, UK
| | - B Mann
- Organisation of Anti-Convulsant Syndromes, Caerphilly, Wales, UK
| | - J Garratt
- Foetal Anti-Convulsant Syndrome New Zealand, Auckland, New Zealand
| | - R L Bromley
- Division of Neuroscience, Faculty of Biology, Medicine and Health, the University of Manchester, Manchester, UK; Paediatric Psychosocial Department, Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
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6
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Bromley RL, Bullen P, Campbell E, Craig J, Ingham A, Irwin B, Jackson C, Kelly T, Morrow J, Rushton S, García-Fiñana M, Hughes DM, Winterbottom J, Wood A, Yates LM, Clayton-Smith J. Neurodevelopment of babies born to mothers with epilepsy: A prospective observational cohort study. Epilepsia 2023; 64:2454-2471. [PMID: 37403560 DOI: 10.1111/epi.17709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Despite widespread monotherapy use of lamotrigine or levetiracetam during pregnancy, prospectively collected, blinded child development data are still limited. The NaME (Neurodevelopment of Babies Born to Mothers With Epilepsy) Study prospectively recruited a new cohort of women with epilepsy and their offspring for longitudinal follow-up. METHODS Pregnant women of <21 weeks gestation (n = 401) were recruited from 21 hospitals in the UK. Data collection occurred during pregnancy (recruitment, trimester 3) and at 12 and 24 months of age. The primary outcome was blinded assessment of infant cognitive, language, and motor development on the Bayley Scales of Infant and Toddler Development (3rd edition) at 24 months of age with supplementary parent reporting on the Vinelands Adaptive Behavior Scales (2nd edition). RESULTS There were 394 live births, with 277 children (70%) completing the Bayley assessment at 24 months. There was no evidence of an association of prenatal exposure to monotherapy lamotrigine (-.74, SE = 2.9, 95% confidence interval [CI] = -6.5 to 5.0, p = .80) or levetiracetam (-1.57, SE = 3.1, 95% CI = -4.6 to 7.7, p = .62) with poorer infant cognition, following adjustment for other maternal and child factors in comparison to nonexposed children. Similar results were observed for language and motor scores. There was no evidence of an association between increasing doses of either lamotrigine or levetiracetam. Nor was there evidence that higher dose folic acid supplementation (≥5 mg/day) or convulsive seizure exposure was associated with child development scores. Continued infant exposure to antiseizure medications through breast milk was not associated with poorer outcomes, but the number of women breastfeeding beyond 3 months was low. SIGNIFICANCE These data are reassuring for infant development following in utero exposure to monotherapy lamotrigine or levetiracetam, but child development is dynamic, and future follow-up is required to rule out later emerging effects.
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Affiliation(s)
- Rebecca L Bromley
- Division of Neuroscience, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust and Manchester Academic Health Sciences Centre, Manchester, UK
| | - Philip Bullen
- Obstetric and Fetal Medicine, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Ellen Campbell
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - John Craig
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Amy Ingham
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
| | - Beth Irwin
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Cerain Jackson
- Department of Neuropsychology, Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Teresa Kelly
- Obstetric and Fetal Medicine, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - James Morrow
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Sarah Rushton
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
| | - Marta García-Fiñana
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - David M Hughes
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Janine Winterbottom
- Department of Neurology, Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Amanda Wood
- School of Psychology, Deakin University, Burwood, Victoria, Australia
- Aston Institute for Health and Neurodevelopment, Aston University, Birmingham, UK
| | - Laura M Yates
- Department for Clinical Genetics, Nothern Genetics Service, Newcastle, UK
| | - Jill Clayton-Smith
- Manchester Centre for Genomic Medicine, St. Mary's Hospital, University of Manchester, Manchester, UK
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
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7
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Abstract
Epilepsy affects up to 15 million of people assigned female at birth of childbearing age globally. Up to 65% of these people with epilepsy and gestational capacity have an unplanned pregnancy. Seizure control during pregnancy is important for both the childbearer's and fetus' safety. There are multiple antiseizure medications (ASMs) that can be used to control epilepsy; however, each medication has its own teratogenic risk profile, which must be considered. The majority of these ASMs will require frequent plasma concentration monitoring during pregnancy with corresponding dosage adjustments. Dosages can be reduced back to prepregnancy levels within 3 weeks postpartum. Breastfeeding on ASMs is recommended.
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8
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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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9
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Meador KJ. Effects of Maternal Use of Antiseizure Medications on Child Development. Neurol Clin 2022; 40:755-768. [PMID: 36270689 PMCID: PMC9589915 DOI: 10.1016/j.ncl.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most children born to women with epilepsy (WWE) are normal, but have increased risks for malformations and poor neuropsychological outcomes. Antiseizure medications (ASMs) are among the most commonly prescribed teratogenic medications in women of childbearing age. However, WWE typically cannot avoid using ASMs during pregnancy. Teratogenic risks vary across ASMs. Valproate poses a special risk for anatomic and behavioral teratogenic risks compared with other ASMs. The risks for many ASMs remain uncertain. Women of childbearing potential taking ASMs should be taking folic acid. Breastfeeding while taking ASMs seems safe. WWE should receive informed consent outlining risks before conception.
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Affiliation(s)
- Kimford J Meador
- Department of Neurology & Neurological Sciences, Stanford University, Stanford University School of Medicine, 213 Quarry Road, MC 5979, Palo Alto, CA 94304-5979, USA.
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10
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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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11
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Alsfouk BA. Neurodevelopmental outcomes in children exposed prenatally to levetiracetam. Ther Adv Drug Saf 2022; 13:20420986221088419. [PMID: 35387387 PMCID: PMC8977694 DOI: 10.1177/20420986221088419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 03/02/2022] [Indexed: 11/15/2022] Open
Abstract
Some old antiseizure medications (ASMs) pose teratogenic risks, including major
congenital malformations and neurodevelopmental delay. Therefore, the use of new
ASMs in pregnancy is increasing, particularly lamotrigine and levetiracetam.
This is likely due to evidence of low risk of anatomical teratogenicity for both
lamotrigine and levetiracetam. Regarding neurodevelopmental effects, lamotrigine
is the most frequently investigated new ASM with information available for
children up to 14 years of age. However, fewer data are available for the
effects of levetiracetam on cognitive and behavioral development, with smaller
cohorts and shorter follow-up. The aim of the present review was to explicate
neurodevelopmental outcomes in children exposed prenatally to levetiracetam to
support clinical decision-making. The available data do not indicate an
increased risk of abnormal neurodevelopmental outcomes in children exposed
prenatally to levetiracetam. Findings demonstrated comparable outcomes for
levetiracetam versus controls and favorable outcomes for
levetiracetam versus valproate on global and specific cognitive
abilities, and behavioral problems. In addition, the available evidence shows no
significant dose-effect association for levetiracetam on neurodevelopmental
outcomes. However, this evidence cannot be determined definitively due to the
limited numbers of exposures with relatively short follow-up. Therefore, further
research is required.
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Affiliation(s)
- Bshra A. Alsfouk
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O Box 84428, Riyadh 11671, Saudi Arabia
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12
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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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13
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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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14
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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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15
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Knight R, Wittkowski A, Bromley RL. Neurodevelopmental outcomes in children exposed to newer antiseizure medications: A systematic review. Epilepsia 2021; 62:1765-1779. [PMID: 34128227 DOI: 10.1111/epi.16953] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 01/16/2023]
Abstract
As prenatal exposure to certain older antiseizure medications (ASMs) has been linked with poorer neurodevelopmental outcomes in children, the use of newer ASMs throughout pregnancy has increased. The current review aimed to delineate the impact of in utero exposure to these newer ASMs on child neurodevelopment. A systematic search of MEDLINE, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature Plus, and PsycINFO was conducted, limiting results to articles available in English and published after the year 2000. Studies investigating neurodevelopmental outcomes following in utero exposure to the following ASMs were eligible for inclusion in the review: eslicarbazepine, gabapentin, lacosamide, lamotrigine, levetiracetam, oxcarbazepine, perampanel, topiramate, and zonisamide. Thirty-five publications were identified, and a narrative synthesis was undertaken. Methodological quality was variable, with distinct patterns of strengths/weaknesses attributable to design. Most studies examined lamotrigine exposure and reported nonsignificant effects on child neurodevelopment. Comparatively fewer high-quality studies were available for levetiracetam, limiting conclusions regarding findings to date. Data for topiramate, gabapentin, and oxcarbazepine were so limited that firm conclusions could not be drawn. Concerningly, no studies investigated eslicarbazepine, lacosamide, perampanel, or zonisamide. Exposure to certain newer ASMs, such as lamotrigine and levetiracetam, does not thus far appear to impact certain aspects of neurodevelopment, but further delineation across the different neurodevelopmental domains and dosage levels is required. A lack of data cannot be inferred to represent safety of newer ASMs, which are yet to be investigated.
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Affiliation(s)
- Rebecca Knight
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, UK
| | - Anja Wittkowski
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, UK
| | - Rebecca Louise Bromley
- Division of Evolution and Genomic Science, University of Manchester, Manchester, UK.,Royal Manchester Children's Hospital, Manchester Academic Health Sciences, Manchester, UK
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Mermi Dibek D, Öztura İ, Baklan B. Our reasons for converting to valproic acid treatment in female patients with genetic generalized epilepsy: a retrospective, single-centre study. Neurol Sci 2021; 43:517-523. [PMID: 33890162 DOI: 10.1007/s10072-021-05261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/16/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIM Valproic acid (Na valproate) is a broad-spectrum anti-seizure medication used in children and adolescents. It is thought to have fewer adverse effects; however, recent studies have restricted its use in women of reproductive age due to the teratogenic impacts on cognition. Although alternative drugs have been used to treat patients in clinical follow-up, some patients have to return to using valproic acid. Our study aimed to determine the rate of return to valproic acid treatment in female patients with follow-up in our centre and the reasons for the return. MATERIALS AND METHODS Female patients with genetic generalized epilepsy who were followed up in our centre were included in the study. Patient data were retrospectively obtained from file records. The patients were grouped by seizure subgroups, antiepileptic treatment used, electroencephalography characteristics, and seizure treatment response. RESULTS Sixty-three (31.7%) of the 199 patients had to return to VPA treatment. When the reasons for the discontinuation of other drugs were examined, non-response to treatment was found in 80.0% of patients, adverse medication effects in 18.3%, and 1.7% continued voluntarily. Patients who are JAE subtypes were more likely to return to VPA treatment than GTCS alone subtypes. A total of 7.4% of patients converted to VPA therapy had continued myoclonic seizures compared with 20.4% of patients treated with alternative drugs. CONCLUSION VPA treatment is not used as the first choice in females of reproductive age; however, some patients will only achieve seizure control with valproate, especially those with myoclonic seizures and JAE.
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Affiliation(s)
- Dilara Mermi Dibek
- Department of Neurology, Clinical Neurophysiology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey.
| | - İbrahim Öztura
- Department of Neurology, Clinical Neurophysiology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Barış Baklan
- Department of Neurology, Clinical Neurophysiology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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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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18
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19
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Reynolds EH, Green R. Valproate and folate: Congenital and developmental risks. Epilepsy Behav 2020; 108:107068. [PMID: 32375098 DOI: 10.1016/j.yebeh.2020.107068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 01/08/2023]
Abstract
Increasing awareness of the congenital and developmental risks associated with the use of sodium valproate (VPA) has led to recent European guidelines designed to avoid the use of this drug in pregnancy if effective alternative treatments are available. In the general population, it is well established that periconceptual folic acid reduces the risk of neural tube defects (NTDs) and possibly other congenital abnormalities. We here review the evidence 1) that VPA interferes with one-carbon metabolism, including the transport of methylfolate into the brain and the placenta by targeting folate receptors; 2) that VPA effects on the folate metabolic system contribute to congenital and developmental problems associated with VPA exposure; and 3) that genetic factors, notably polymorphisms related to one-carbon metabolism, contribute to the vulnerability to these VPA-induced risks. Based on these facts, we propose that the standard periconceptual use of 400 μg of folic acid may not adequately protect against VPA or other antiepileptic drug (AED)-induced congenital or developmental risks. Pending definitive studies to determine appropriate dose, we recommend up to 5 mg of folic acid periconceptually in at-risk women with the caveat that the addition of supplementary vitamin B12 may also be prudent because vitamin B12 deficiency is common in pregnancy in some countries and is an additional risk factor for developmental abnormalities.
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Affiliation(s)
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California Davis, USA
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20
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Blotière PO, Miranda S, Weill A, Mikaeloff Y, Peyre H, Ramus F, Mahmoud Z, Coste J, Dray-Spira R. Risk of early neurodevelopmental outcomes associated with prenatal exposure to the antiepileptic drugs most commonly used during pregnancy: a French nationwide population-based cohort study. BMJ Open 2020; 10:e034829. [PMID: 32513880 PMCID: PMC7282331 DOI: 10.1136/bmjopen-2019-034829] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To assess the association between prenatal exposure to monotherapy with the antiepileptic drugs (AEDs) most commonly used during pregnancy and the risk of various neurodevelopmental outcomes compared with lamotrigine. DESIGN Nationwide population-based cohort study. SETTING French national healthcare databases. PARTICIPANTS Children born alive between 2011 and 2014 and prenatally exposed to AED monotherapy. PRIMARY AND SECONDARY OUTCOME MEASURES Outcomes included neurodevelopmental disorders (NDD), defined by International Classification of Diseases, 10th Revision codes F70-F98-pervasive developmental disorders (PDD, F84) and mental retardation (MR, F70-F79) were studied separately-and visits to speech therapists. The reference group comprised children prenatally exposed to lamotrigine. Children were followed until outcome, loss to follow-up, death or 31 December 2016. We performed inverse probability of treatment weighting analyses using the propensity score, which included maternal and infant characteristics. Hazard ratios (HRs) were calculated using Cox models. RESULTS The cohort comprised 9034 children, 2916 of which were exposed to lamotrigine, 1627 to pregabalin, 1246 to clonazepam, 991 to valproic acid (VPA), 621 to levetiracetam, 502 to carbamazepine, 477 to topiramate, 378 to gabapentin and 143 to oxcarbazepine. None of these AEDs, except VPA, was associated with an increased risk of any of the four neurodevelopmental outcomes investigated. Exposure to VPA was associated with increased risks of NDDs (HR=2.7, 95% CI (1.8 to 4.0)), PDD (HR=4.4 (2.1 to 9.3)), MR (HR=3.1 (1.5 to 6.2)) and visits to speech therapists (HR=1.5 (1.1 to 1.9)), with a dose-response relationship. CONCLUSIONS No increased risk of any of the neurodevelopmental outcomes investigated in this study was observed with prenatal exposure to levetiracetam, pregabalin, oxcarbazepine, topiramate, gabapentin, clonazepam or carbamazepine, compared with lamotrigine. However, this study corroborates the well-known association between maternal use of VPA during pregnancy and the risk of neurodevelopmental disorders in the offspring. Longer follow-up is necessary to confirm these findings.
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Affiliation(s)
- Pierre-Olivier Blotière
- Department of Public Health Studies, French National Health Insurance (CNAM), Paris, France
- Apemac, EA 4360, Université de Lorraine, Université Paris-Descartes, Nancy, France
| | - Sara Miranda
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, Saint-Denis, France
| | - Alain Weill
- Department of Public Health Studies, French National Health Insurance (CNAM), Paris, France
| | - Yann Mikaeloff
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Unité de Rééducation Neurologique Infantile, Bicêtre, France
- CESP, Faculté de médecine-Université Paris-Sud, Faculté de médecine-UVSQ, INSERM, Université Paris-Saclay, Villejuif, France
| | - Hugo Peyre
- Laboratoire de Sciences Cognitives et Psycholinguistique, Ecole Normale Supérieure, EHESS, CNRS, PSL University, Paris, France
- Department of Child and Adolescent Psychiatry, Robert Debré Hospital, APHP, Paris, France
- INSERM UMR 1141, Paris Diderot University, Paris, France
| | - Franck Ramus
- Laboratoire de Sciences Cognitives et Psycholinguistique, Ecole Normale Supérieure, EHESS, CNRS, PSL University, Paris, France
| | - Zureik Mahmoud
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, Saint-Denis, France
- Versailles Saint-Quentin-en-Yvelines University, Versailles, France
| | - Joël Coste
- Department of Public Health Studies, French National Health Insurance (CNAM), Paris, France
- Biostatistics and Epidemiology Unit, Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris, and Paris Descartes University, Paris, France
| | - Rosemary Dray-Spira
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, Saint-Denis, France
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21
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Huber-Mollema Y, van Iterson L, Oort FJ, Lindhout D, Rodenburg R. Neurocognition after prenatal levetiracetam, lamotrigine, carbamazepine or valproate exposure. J Neurol 2020; 267:1724-1736. [PMID: 32112258 PMCID: PMC7293688 DOI: 10.1007/s00415-020-09764-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/14/2020] [Accepted: 02/14/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To examine neurocognitive functioning of children exposed prenatally to carbamazepine, lamotrigine, levetiracetam or valproate monotherapy. METHODS In a prospective observational study, children aged 6 or 7 years, identified from the European Registry of Antiepileptic Drugs and Pregnancy database in The Netherlands, were assessed using the Wechsler Intelligence Scale for Children and the developmental neuropsychological assessment. Maternal IQ was measured using Wechsler Adult Intelligence Scale. Assessors were blinded to drug exposures. RESULTS One hundred and sixty-one children (one set of twins and 21 sibling pairs) of 139 mothers were included. As a group, children achieved average scores on neurocognitive outcomes. Children exposed to valproate (n = 22) performed lower on all six neurocognitive domains, especially language, than those exposed to carbamazepine (n = 32), lamotrigine (n = 82) or levetiracetam (n = 25). After controlling for maternal IQ and drug dose, the verbal IQ of valproate-exposed children was on average 9.1 points lower than those exposed to carbamazepine (95% confidence interval [CI] 1.3-17.0; p = 0.023), 10.3 lower than lamotrigine-exposed children (CI 3.4-17.3; p = 0.004) and 13.4 lower than levetiracetam-exposed children (CI 5.2-21.6; p = 0.002). No significant dose-effect was found. Virtually no significant differences were found between lamotrigine and levetiracetam or lamotrigine and carbamazepine exposed children. CONCLUSIONS Consistent with previous research, valproate-exposed children experienced more problems compared to three other common antiepileptic drugs, while children exposed to lamotrigine, carbamazepine or levetiracetam revealed little to no problems. This illustrates the need for systematic follow-up of prenatally exposed children, to support pre-pregnancy counseling and treatment decisions in women of reproductive age.
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Affiliation(s)
- Yfke Huber-Mollema
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
- Research Institute of Child Development and Education, University of Amsterdam, 15776, 1001 NG Amsterdam, The Netherlands
| | - Loretta van Iterson
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Frans J. Oort
- Research Institute of Child Development and Education, University of Amsterdam, 15776, 1001 NG Amsterdam, The Netherlands
| | - Dick Lindhout
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roos Rodenburg
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
- Research Institute of Child Development and Education, University of Amsterdam, 15776, 1001 NG Amsterdam, The Netherlands
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22
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Josephson CB, Engbers JDT, Jette N, Patten SB, Singh S, Sajobi TT, Marshall D, Agha-Khani Y, Federico P, Mackie A, Macrodimitris S, McLane B, Pillay N, Sharma R, Wiebe S. Prediction Tools for Psychiatric Adverse Effects After Levetiracetam Prescription. JAMA Neurol 2020; 76:440-446. [PMID: 30688969 DOI: 10.1001/jamaneurol.2018.4561] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance Levetiracetam is a commonly used antiepileptic drug, yet psychiatric adverse effects are common and may lead to treatment discontinuation. Objective To derive prediction models to estimate the risk of psychiatric adverse effects from levetiracetam use. Design, Setting, and Participants Retrospective open cohort study. All patients meeting the case definition for epilepsy after the Acceptable Mortality Reporting date in The Health Improvement Network (THIN) database based in the United Kingdom (inclusive January 1, 2000, to May 31, 2012) who received a first-ever prescription for levetiracetam were included. Of 11 194 182 patients registered in THIN, this study identified 7400 presumed incident cases (66.1 cases per 100 000 persons) over a maximum of 12 years' follow-up. The index date was when patients received their first prescription code for levetiracetam, and follow-up lasted 2 years or until an event, loss to follow-up, or censoring. The analyses were performed on April 22, 2018. Exposure A presumed first-ever prescription for levetiracetam. Main Outcomes and Measures The outcome of interest was a Read code for any psychiatric sign, symptom, or disorder as reached through consensus by 2 authors. This study used regression techniques to derive 2 prediction models, one for the overall population and one for those without a history of a psychiatric sign, symptom, or disorder during the study period. Results Among 1173 patients with epilepsy receiving levetiracetam, the overall median age was 39 (interquartile range, 25-56) years, and 590 (50.3%) were female. A total of 14.1% (165 of 1173) experienced a psychiatric symptom or disorder within 2 years of index prescription. The odds of reporting a psychiatric symptom were significantly elevated for women (odds ratio [OR], 1.41; 95% CI, 0.99-2.01; P = .05) and those with a preexposure history of higher social deprivation (OR, 1.15; 95% CI, 1.01-1.31; P = .03), depression (OR, 2.20; 95% CI, 1.49-3.24; P < .001), anxiety (OR, 1.74; 95% CI, 1.11-2.72; P = .02), or recreational drug use (OR, 2.02; 95% CI, 1.20-3.37; P = .008). The model performed well after stratified k = 5-fold cross-validation (area under the curve [AUC], 0.68; 95% CI, 0.58-0.79). There was a gradient in risk, with probabilities increasing from 8% for 0 risk factors to 11% to 17% for 1, 17% to 31% for 2, 30% to 42% for 3, and 49% when all risk factors were present. For those free of a preexposure psychiatric code, a second model performed comparably well after k = 5-fold cross-validation (AUC, 0.72; 95% CI, 0.54-0.90). Specificity was maximized using threshold cutoffs of 0.10 (full model) and 0.14 (second model); a score below these thresholds indicates safety of prescription. Conclusions and Relevance This study derived 2 simple models that predict the risk of a psychiatric adverse effect from levetiracetam. These algorithms can be used to guide prescription in clinical practice.
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Affiliation(s)
- Colin B Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | | | - Nathalie Jette
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Scott B Patten
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Shaily Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Deborah Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Yahya Agha-Khani
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paolo Federico
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Sophie Macrodimitris
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Brienne McLane
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Neelan Pillay
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ruby Sharma
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Samuel Wiebe
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Betcher HK, Wisner KL. Psychotropic Treatment During Pregnancy: Research Synthesis and Clinical Care Principles. J Womens Health (Larchmt) 2019; 29:310-318. [PMID: 31800350 DOI: 10.1089/jwh.2019.7781] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Psychiatric illnesses are common in women of childbearing age. The perinatal period is a particularly high-risk time for depression, bipolar, and anxiety disorders. Methods: The scope of the public health problem of perinatal mental disorders is discussed followed by an examination of the specific research methods utilized for the study of birth and developmental outcomes associated with maternal mental illness and its treatment. The evidence on exposure to common psychotropics during pregnancy and breastfeeding is reviewed. Results: Selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitor medications are not associated with higher rates of birth defects or long-term changes in mental development after adjustment for confounding factors associated with underlying psychiatric illness. Lithium exposure is associated with an increased risk for fetal cardiac malformations, but this risk is lower than previously thought (absolute risk of Ebstein's anomaly 6/1,000). Antipsychotics, other than risperidone and potentially paliperidone, have not been associated with an increase in birth defects; olanzapine and quetiapine have been linked with an elevated risk of gestational diabetes. Due to the dramatic physiological changes of pregnancy and enhanced hepatic metabolism, drug doses may need to be adjusted during pregnancy to sustain efficacy. Untreated maternal psychiatric illness also carries substantial risks for the mother, fetus, infant, and family. Conclusions: The goal of perinatal mental health treatment is to optimally provide pharmacotherapy to mitigate the somatic and psychosocial burdens of maternal psychiatric disorders. Regular symptom monitoring during pregnancy and postpartum and medication dose adjustments to sustain efficacy constitutes good practice.
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Affiliation(s)
- Hannah K Betcher
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Katherine L Wisner
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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24
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Turner K, Zambrelli E, Bassanese G, Vignoli A, Valvassori Bolgè M, Baldi C, Franza A, Canevini MP. Effects of postpartum depression on the behaviour of children born to mothers with epilepsy. Seizure 2019; 73:31-38. [PMID: 31715519 DOI: 10.1016/j.seizure.2019.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 10/19/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Postpartum depression (PPD) is a non-psychotic depressive disorder that begins within 4 weeks of childbirth. This study aimed to evaluate the prevalence of PPD by screening mothers with the Edinburgh Postnatal Depression Scale (EPDS), to assess the behavioural outcome of children born to mothers with and without epilepsy and to investigate the relationship between PPD and children's behavioural problems. METHOD We enrolled 80 pregnancies of women with epilepsy, who filled in EPDS after birth, and afterward we asked them to complete the Child Behavior Checklist (CBCL). RESULTS 23.8% of patients presented PPD. Children, when the CBCL were completed, had a mean age of 6.05 ± 3.07 years. The CBCL results indicate the occurrence of at least one behavioural issue in 25.0% (20/80) of children. CBCL scores revealed a higher prevalence of behavioural disturbances with regards to the CBCL Total (P = 0.016), internalizing (P = 0.014) and somatic problems (P = 0.048) in patients with PPD vs. patients without PPD. We found an association between mothers' EPDS total score and children's CBCL global score (P = 0.034), internalizing score (P = 0.021), anxiety problems (P = 0.05), affective problems (P = 0.027) and withdrawn/depressed (P = 0.05). We recorded a statistically higher malformation rate in patients with PPD (P = 0.005) compared to the general population. CONCLUSIONS Children born from mothers with epilepsy have an increased risk for emotional disorders. These findings highlight the importance of screening for emotional distress and providing adequate interventions to children born to women with epilepsy.
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Affiliation(s)
- Katherine Turner
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy.
| | - Elena Zambrelli
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy
| | - Giulia Bassanese
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy
| | - Aglaia Vignoli
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy; Department of Health Sciences, University of Milan, Italy
| | - Maria Valvassori Bolgè
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy
| | - Cristina Baldi
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy
| | - Albertina Franza
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy
| | - Maria Paola Canevini
- Epilepsy Center-Child Neuropsychiatry Unit, ASST Santi Paolo Carlo, San Paolo Hospital, Milan, Italy; Department of Health Sciences, University of Milan, Italy
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Rajizadeh MA, Afarinesh MR, Zarif M, Mirasadi A, Esmaeilpour K. Does caffeine therapy improve cognitive impairments in valproic acid rat model of autism? TOXIN REV 2019. [DOI: 10.1080/15569543.2019.1680563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Mohammad Amin Rajizadeh
- Neuroscience Research Center, Institute of neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Reza Afarinesh
- Neuroscience Research Center, Institute of neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Zarif
- Neuroscience Research Center, Institute of neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Alaa Mirasadi
- Neuroscience Research Center, Institute of neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Khadijeh Esmaeilpour
- Neuroscience Research Center, Institute of neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
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Pennell PB, Meador KJ. Reducing birth defects in women with epilepsy: Research leading to results. Neurology 2019; 93:375-376. [PMID: 31391246 DOI: 10.1212/wnl.0000000000007999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Page B Pennell
- From Brigham and Women's Hospital and Harvard Medical School (P.B.P.), Boston, MA; and Stanford University (K.J.M.), CA.
| | - Kimford J Meador
- From Brigham and Women's Hospital and Harvard Medical School (P.B.P.), Boston, MA; and Stanford University (K.J.M.), CA
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Abstract
Juvenile myoclonic epilepsy (JME) is both a frequent and a very characteristic epileptic syndrome with female preponderance. Treatment of JME in women of childbearing potential must consider multiple factors such as desire for pregnancy, use of contraception, seizure control and previously used antiepileptic drugs (AEDs). Approximately 85% of cases are well controlled with valproate, which remains the reference AED in JME but is nowadays considered unsafe for the expecting mother and her fetus. The prescription of valproate is now severely restricted in women of childbearing potential but may still be considered, at the lowest possible dose and when pregnancies can be reliably planned, with temporary alternatives to valproate prescribed before fertilization. Alternatives have emerged, especially lamotrigine and levetiracetam, but also topiramate, zonisamide, and recently perampanel, but none of these AEDs can be considered fully safe in the context of pregnancy. In special settings, benzodiazepines and barbiturates may be useful. In some cases, combination therapy, especially lamotrigine and levetiracetam, may be useful or even required. However, lamotrigine may have the potential to aggravate JME, with promyoclonic effects. Carbamazepine, oxcarbazepine and phenytoin must be avoided. Valproate, levetiracetam, zonisamide, topiramate if the daily dose is ≤ 200 mg and perampanel if the daily dose is ≤ 10 mg do not affect combined hormonal contraception. Lamotrigine ≥ 300 mg/day has been shown to decrease levonorgestrel levels by 20% but does not compromise combined hormonal contraception. Patients with JME taking oral contraceptive should be counselled on the fact that the estrogenic component can reduce concentrations of lamotrigine by over 50%, putting patients at risk of increased seizures. Pregnancy is a therapeutic challenge, and the risk/benefit ratio for the mother and fetus must be considered when choosing the appropriate drug. Lamotrigine (< 325 mg daily in the European Registry of Antiepileptic Drugs in Pregnancy) and levetiracetam seem to be comparatively safer in pregnancy than other AEDs, especially topiramate and valproate. Plasma concentration of lamotrigine and levetiracetam decreases significantly during pregnancy, and dosage adjustments may be necessary. With persisting generalized tonic-clonic seizures, the combination of lamotrigine and levetiracetam offer the chance of seizure control and lesser risks of major congenital malformations. The risk of malformation increases when valproate or topiramate are included in the drug combination. In one study, the relative risk of autism and autism spectrum disorders (ASD) in children born to women with epilepsy (WWE) treated with valproate were, respectively, 5.2 for autism and 2.9 for ASD versus 2.12 for autism and 1.6 for ASD in WWE not treated with valproate. More studies are needed to assess the risk of autism with AEDs other than valproate. The current knowledge is that the risk appears to be double that in the general population. In patients with JME, valproate remains an essential and life-changing agent. The consequences of a lifetime of poorly controlled epilepsy need to be balanced against the teratogenic risks of valproate during limited times in a woman's life. The management of JME in WWE should include lifestyle interventions, with avoidance of sleep deprivation, and planned pregnancy.
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Whelehan A, Delanty N. Therapeutic strategies for treating epilepsy during pregnancy. Expert Opin Pharmacother 2018; 20:323-332. [PMID: 30526135 DOI: 10.1080/14656566.2018.1550073] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Counseling for women with epilepsy of childbearing potential surrounding pregnancy issues is of the utmost importance and should be done when antiepileptic medications are prescribed and reviewed regularly at clinic visits. Physicians must be familiar with risks associated with antiepileptic medication, and endeavor to minimize risks to a fetus while selecting best medications for epilepsy type. AREAS COVERED The authors discuss the role of folic acid, updated evidence relating to the occurrence of major congenital malformations and neurocognitive risks associated with antiepileptic medication. They also examine the rationale for monitoring drug levels, optimum delivery strategies, and evidence for the safety of breastfeeding while taking antiepileptic medication. EXPERT OPINION Valproate carries the highest known teratogenic risk in pregnancy and should only be prescribed to women of child-bearing potential in a specialist setting. There is a need for the ongoing register collection of risks associated with newer AEDs which lack substantial (major) data. Choosing these newer medications can create a dilemma for physicians, particularly when seizures are not well controlled or where treatment options are limited. The authors advocate a multidisciplinary team approach to managing women with epilepsy so that pregnancies in such women can be well managed in an optimum and individualized fashion.
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Affiliation(s)
- Anna Whelehan
- a Department of Neurology , Beaumont Hospital , Dublin , Ireland
| | - Norman Delanty
- a Department of Neurology , Beaumont Hospital , Dublin , Ireland.,b Department of Molecular and Cellular Therapeutics and Future Neuro , Royal College of Surgeons in Ireland , Dublin , Ireland
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Husebye ESN, Gilhus NE, Riedel B, Spigset O, Daltveit AK, Bjørk MH. Verbal abilities in children of mothers with epilepsy: Association to maternal folate status. Neurology 2018; 91:e811-e821. [PMID: 30068633 PMCID: PMC6133626 DOI: 10.1212/wnl.0000000000006073] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 05/24/2018] [Indexed: 12/12/2022] Open
Abstract
Objective To examine the effect of maternal folic acid supplementation and maternal plasma folate and antiepileptic drug (AED) concentrations on language delay in AED-exposed children of mothers with epilepsy. Methods Children of mothers with and without epilepsy enrolled from 1999 to 2008 in the Norwegian Mother and Child Cohort study were included. Information on medical history, AED use, and folic acid supplementation during pregnancy was collected from parent-completed questionnaires. Maternal plasma folate and maternal plasma and umbilical cord AED concentrations were measured in blood samples from gestational weeks 17 to 19 and immediately after birth, respectively. Language development at 18 and 36 months was evaluated by the Ages and Stages Questionnaires. Results A total of 335 AED-exposed children of mothers with epilepsy and 104,222 children of mothers without epilepsy were surveyed. For those with no maternal periconceptional folic acid supplementation, the fully adjusted odds ratio (OR) for language delay in AED-exposed children compared to the controls at 18 months was 3.9 (95% confidence interval [CI] 1.9–7.8, p < 0.001) and at 36 months was 4.7 (95% CI 2.0–10.6, p < 0.001). When folic supplementation was used, the corresponding ORs for language delay were 1.7 (95% CI 1.2–2.6, p = 0.01) and 1.7 (95% CI 0.9–3.2, p = 0.13), respectively. The positive effect of folic acid supplement use on language delay in AED-exposed children was significant only when supplement was used in the period from 4 weeks before the pregnancy and until the end of the first trimester. Conclusion Folic acid use early in pregnancy may have a preventive effect on language delay associated with in utero AED exposure.
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Affiliation(s)
- Elisabeth Synnøve Nilsen Husebye
- From the Department of Clinical Medicine (E.S.N.H., N.E.G., M.H.B.), Section for Neurology, Department of Clinical Science (B.R.), and Department of Global Public Health and Primary Care (A.K.D.), University of Bergen; Department of Neurology (E.S.N.H., N.E.G., M.H.B.) and Laboratory of Clinical Biochemistry (B.R.), Section of Clinical Pharmacology, Haukeland University Hospital, Bergen; Department of Clinical Pharmacology (O.S.), St. Olav University Hospital; Department of Clinical and Molecular Medicine (O.S.), Norwegian University of Science and Technology, Trondheim; and Department of Health Registries (A.K.D.), Norwegian Institute of Public Health, Bergen, Norway.
| | - Nils Erik Gilhus
- From the Department of Clinical Medicine (E.S.N.H., N.E.G., M.H.B.), Section for Neurology, Department of Clinical Science (B.R.), and Department of Global Public Health and Primary Care (A.K.D.), University of Bergen; Department of Neurology (E.S.N.H., N.E.G., M.H.B.) and Laboratory of Clinical Biochemistry (B.R.), Section of Clinical Pharmacology, Haukeland University Hospital, Bergen; Department of Clinical Pharmacology (O.S.), St. Olav University Hospital; Department of Clinical and Molecular Medicine (O.S.), Norwegian University of Science and Technology, Trondheim; and Department of Health Registries (A.K.D.), Norwegian Institute of Public Health, Bergen, Norway
| | - Bettina Riedel
- From the Department of Clinical Medicine (E.S.N.H., N.E.G., M.H.B.), Section for Neurology, Department of Clinical Science (B.R.), and Department of Global Public Health and Primary Care (A.K.D.), University of Bergen; Department of Neurology (E.S.N.H., N.E.G., M.H.B.) and Laboratory of Clinical Biochemistry (B.R.), Section of Clinical Pharmacology, Haukeland University Hospital, Bergen; Department of Clinical Pharmacology (O.S.), St. Olav University Hospital; Department of Clinical and Molecular Medicine (O.S.), Norwegian University of Science and Technology, Trondheim; and Department of Health Registries (A.K.D.), Norwegian Institute of Public Health, Bergen, Norway
| | - Olav Spigset
- From the Department of Clinical Medicine (E.S.N.H., N.E.G., M.H.B.), Section for Neurology, Department of Clinical Science (B.R.), and Department of Global Public Health and Primary Care (A.K.D.), University of Bergen; Department of Neurology (E.S.N.H., N.E.G., M.H.B.) and Laboratory of Clinical Biochemistry (B.R.), Section of Clinical Pharmacology, Haukeland University Hospital, Bergen; Department of Clinical Pharmacology (O.S.), St. Olav University Hospital; Department of Clinical and Molecular Medicine (O.S.), Norwegian University of Science and Technology, Trondheim; and Department of Health Registries (A.K.D.), Norwegian Institute of Public Health, Bergen, Norway
| | - Anne Kjersti Daltveit
- From the Department of Clinical Medicine (E.S.N.H., N.E.G., M.H.B.), Section for Neurology, Department of Clinical Science (B.R.), and Department of Global Public Health and Primary Care (A.K.D.), University of Bergen; Department of Neurology (E.S.N.H., N.E.G., M.H.B.) and Laboratory of Clinical Biochemistry (B.R.), Section of Clinical Pharmacology, Haukeland University Hospital, Bergen; Department of Clinical Pharmacology (O.S.), St. Olav University Hospital; Department of Clinical and Molecular Medicine (O.S.), Norwegian University of Science and Technology, Trondheim; and Department of Health Registries (A.K.D.), Norwegian Institute of Public Health, Bergen, Norway
| | - Marte Helene Bjørk
- From the Department of Clinical Medicine (E.S.N.H., N.E.G., M.H.B.), Section for Neurology, Department of Clinical Science (B.R.), and Department of Global Public Health and Primary Care (A.K.D.), University of Bergen; Department of Neurology (E.S.N.H., N.E.G., M.H.B.) and Laboratory of Clinical Biochemistry (B.R.), Section of Clinical Pharmacology, Haukeland University Hospital, Bergen; Department of Clinical Pharmacology (O.S.), St. Olav University Hospital; Department of Clinical and Molecular Medicine (O.S.), Norwegian University of Science and Technology, Trondheim; and Department of Health Registries (A.K.D.), Norwegian Institute of Public Health, Bergen, Norway
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Lacey AS, Pickrell WO, Thomas RH, Kerr MP, White CP, Rees MI. Educational attainment of children born to mothers with epilepsy. J Neurol Neurosurg Psychiatry 2018; 89:736-740. [PMID: 29588327 DOI: 10.1136/jnnp-2017-317515] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/29/2018] [Accepted: 02/24/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Small prospective studies have identified that children exposed to valproate in utero have poorer scores on cognitive testing. We wanted to identify whether children exposed to antiepileptic drugs (AEDs) in utero have poorer school performance. METHODS We used anonymised, linked, routinely collected healthcare records to identify children born to mothers with epilepsy. We linked these children to their national attainment Key Stage 1 (KS1) tests in mathematics, language and science at the age of 7 and compared them with matched children born to mothers without epilepsy, and with the national KS1 results. We used the core subject indicator (CSI) as an outcome measure (the proportion of children achieving a minimum standard in all subjects) and the results in individual subjects. RESULTS We identified 440 children born to mothers with epilepsy with available KS1 results. Compared with a matched control group, fewer children with mothers being prescribed sodium valproate during pregnancy achieved the national minimum standard in CSI (-12.7% less than the control group), mathematics (-12.1%), language (-10.4%) and in science (-12.2%). Even fewer children with mothers being prescribed multiple AEDs during pregnancy achieved a national minimum standard: CSI (by -20.7% less than the control group), mathematics (-21.9%), language (-19.3%) and science (-19.4%). We did not observe any significant difference in children whose mothers were prescribed carbamazepine or were not taking an AED when compared with the control group. CONCLUSIONS In utero exposure to AEDs in combination, or sodium valproate alone, is associated with a significant decrease in attainment in national educational tests for 7-year-old children compared with both a matched control group and the all-Wales national average. These results give further support to the cognitive and developmental effects of in utero exposure to sodium valproate as well as multiple AEDs, which should be balanced against the need for effective seizure control for women during pregnancy.
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Affiliation(s)
- Arron S Lacey
- Wales Epilepsy Research Network, Swansea University Medical School, Swansea University, Swansea, UK.,Farr Institute, Swansea University Medical School, Swansea, UK
| | - William Owen Pickrell
- Wales Epilepsy Research Network, Swansea University Medical School, Swansea University, Swansea, UK
| | - Rhys H Thomas
- Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Mike P Kerr
- Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Cathy P White
- Morriston Hospital, Abertawe Bro-Morgannwg University Hospital Trust, Swansea, UK
| | - Mark I Rees
- Wales Epilepsy Research Network, Swansea University Medical School, Swansea University, Swansea, UK
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Bansal R, Jain G, Kharbanda P, Goyal M, Suri V. Maternal and neonatal complications during pregnancy in women with epilepsy. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.ijep.2016.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractEpilepsy is the commonest serious neurological problem faced by obstetricians and gynaecologists. Epidemiological studies estimate epilepsy to complicate 0.3–0.7% of all pregnancies.1 2 The importance of epilepsy in pregnancy lies in the fact that many women with epilepsy (WWE) have to go through their pregnancy while taking antiepileptic (AED) drugs. Both the seizures and AEDs can have harmful effects on the mother as well the foetus. Thus, during pregnancy, the clinician faces dual challenge of controlling seizures as well as preventing teratogenicity of AEDs.1 In this review we discuss the possible impact of seizures as well as AEDs on mother as well as the child. We try to answer some of the commonest questions which are relevant to successful management of pregnancy and ensuring birth of a healthy baby.
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Affiliation(s)
- R. Bansal
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - G. Jain
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - P. Kharbanda
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - M. Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - V. Suri
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
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A Systematic Appraisal of Neurosurgical Seizure Prophylaxis: Guidance for Critical Care Management. J Neurosurg Anesthesiol 2017; 28:233-49. [PMID: 26192247 DOI: 10.1097/ana.0000000000000206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Clinical decisions are often made in the presence of some uncertainty. Health care should be based on a combination of scientific evidence, clinical experience, economics, patient value judgments, and preferences. Seizures are not uncommon following brain injury, surgical trauma, hemorrhage, altered brain metabolism, hypoxia, or ischemic events. The impact of seizures in the immediate aftermath of injury may be a prolonged intensive care stay or compounding of the primary injury. The aim of brain injury management is to limit the consequences of the secondary damage. The original intention of seizure prophylaxis was to limit the incidence of early-onset seizures. However, clinical trials have been equivocal on this point, and there is concern about the adverse effects of antiepileptic drug therapy. This review of the literature raises concerns regarding the arbitrary division of seizures into early onset (7 d) and late onset (8 d and beyond). In many cases it would appear that seizures present within 24 hours of the injury or after 7 days, which would be outside of the scope of current seizure prophylaxis guidance. There also does not appear to be a pathophysiological reason to divide brain injury-related seizures into these timeframes. Therefore, a solution to the conundrum is to reevaluate current practice. Prophylaxis could be offered to those receiving intensive care for the primary brain injury, where the impact of seizure would be detrimental to the management of the brain injury, or other clinical judgments where prophylaxis is prudent. Neurosurgical seizure management can then focus attention on which agent has the best adverse effect profile and the duration of therapy. The evidence seems to support levetiracetam as the most appropriate agent. Although previous reviews have identified an increase cost associated with the use of levetiracetam, current cost comparisons with phenytoin demonstrate a marginal price differential. The aim of this review is to assimilate the applicable literature regarding seizure prophylaxis. The final guidance is a forum upon which further clinical research could evaluate a new seizure prophylaxis paradigm.
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Abstract
Bipolar disorder is associated with high morbidity and mortality. The management of bipolar disorder includes a broad approach involving psychoeducation, psychological therapies and psychotropic medication. The management of bipolar disorder in pregnancy is challenging; there is an increase in the rate of relapse of bipolar disorder in the perinatal period and treatment decisions are complex as clinicians are required to weigh up the risks of untreated illness versus unwanted treatment effects on both the mother and the developing fetus. Whilst depressive relapses are more common, women are also at an increased risk of postpartum psychosis, which is a psychiatric emergency that almost always requires inpatient treatment. This paper discusses the limited evidence base regarding the safety of psychotropic medication in the perinatal period, including challenges in perinatal mental health research and the lack of robust evidence. The general principles of prescribing in pregnancy, the importance of preconception counselling, and the risks and benefits associated with antipsychotics, mood stabilisers and antidepressants are addressed.
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Affiliation(s)
- Sarah C Jones
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK.,National Centre for Mental Health, MRC Centre for Psychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Ian Jones
- National Centre for Mental Health, MRC Centre for Psychiatric Genetics and Genomics, Cardiff University, Cardiff, UK.
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Fujimura K, Mitsuhashi T, Takahashi T. Adverse effects of prenatal and early postnatal exposure to antiepileptic drugs: Validation from clinical and basic researches. Brain Dev 2017; 39:635-643. [PMID: 28450094 DOI: 10.1016/j.braindev.2017.03.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 03/19/2017] [Accepted: 03/28/2017] [Indexed: 12/20/2022]
Abstract
Epilepsy requires the long-term administration of antiepileptic drugs (AEDs), and thus, we must consider the effects of prenatal AED exposure on fetus when treating female patients of child bearing age. Large prospective clinical researches in humans have demonstrated the following: (1) prenatal exposure to valproic acid (VPA), carbamazepine, and phenobarbital increases the risk of congenital malformations in a dose-dependent manner and (2) prenatal exposure to VPA increases the risk of higher brain function impairments including intellectual disabilities and autistic spectrum disorders in the offspring. Furthermore, basic researches in animals have shown that prenatal exposure to specific AEDs causes microscopic structural abnormalities in the fetal brain. Specifically, prenatal exposure to VPA has been reported to inhibit the differentiation of neural progenitor cells during the early to middle phases of neuronogenesis, leading to increased number of projection neurons in the superficial layers of postnatal neocortices in mice. It is indispensable to prescribe AEDs that are associated with lower risk of congenital malformations and impairment of higher brain functions as well as to administer them at requisite minimum doses.
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Affiliation(s)
- Kimino Fujimura
- Department of Pediatrics, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Takayuki Mitsuhashi
- Department of Pediatrics, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Takao Takahashi
- Department of Pediatrics, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Ornoy A, Weinstein-Fudim L, Ergaz Z. Antidepressants, Antipsychotics, and Mood Stabilizers in Pregnancy: What Do We Know and How Should We Treat Pregnant Women with Depression. Birth Defects Res 2017; 109:933-956. [DOI: 10.1002/bdr2.1079] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/02/2017] [Accepted: 06/06/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Asher Ornoy
- Laboratory of Teratology, Department of Medical Neurobiology; Hebrew University Hadassah Medical School; Jerusalem Israel
| | - Liza Weinstein-Fudim
- Laboratory of Teratology, Department of Medical Neurobiology; Hebrew University Hadassah Medical School; Jerusalem Israel
| | - Zivanit Ergaz
- Laboratory of Teratology, Department of Medical Neurobiology; Hebrew University Hadassah Medical School; Jerusalem Israel
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Changing antiepileptic drug use for seizures in US neonatal intensive care units from 2005 to 2014. J Perinatol 2017; 37:296-300. [PMID: 27831551 DOI: 10.1038/jp.2016.206] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 09/17/2016] [Accepted: 10/07/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Neonatal seizures are a common problem in the neonatal intensive care unit and are frequently treated with antiepileptic drugs. Limited data exist on current or changing antiepileptic drug use for seizures in the neonatal intensive care unit.We sought to describe trends of antiepileptic drug exposure in a large volume of US neonatal intensive care unit from 2005 to 2014 and we hypothesized increasing levetiracetam exposure over the 10-year study period. STUDY DESIGN Retrospective cohort study of infants from the Pediatrix Medical Group Clinical Data Warehouse, a large, multicenter, deidentified data set. Data were analyzed for trends in 2-year time periods. Our cohort included infants with a diagnosis of seizures who received an antiepileptic drug that were discharged from the neonatal intensive care unit from 1 January 2005 to 31 December 2014. RESULTS Among 778 395 infants from 341 facilities, we identified 9134 infants with a seizure diagnosis who received an antiepileptic drug. Phenobarbital was used in 98% of the cohort. From 2005-2006 to 2013-2014 phenobarbital exposure declined from 99 to 96% (P<0.001), phenytoin exposure decreased from 15 to 11% (P<0.001) and levetiracetam exposure increased 10-fold from 1.4 to 14% (P<0.001). Overall, <1% of infants were exposed to carbamazepine, lidocaine or topiramate. CONCLUSIONS Infants with seizures were overwhelmingly exposed to phenobarbital, despite a significant increase in levetiracetam exposure. The use of phenytoin declined and has been surpassed by levetiracetam as the second most widely used antiepileptic in the neonatal intensive care unit. These changes in antiepileptic drug usage patterns have occurred in the absence of novel efficacy data in neonates.
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Bromley RL, Baker GA. Fetal antiepileptic drug exposure and cognitive outcomes. Seizure 2017; 44:225-231. [DOI: 10.1016/j.seizure.2016.10.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022] Open
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Abstract
Although prenatal exposure to antiepileptic drugs (AEDs) is known to impart relatively higher risks of major congenital malformations, prospective studies have provided refined data that allow us to differentiate the risks of different types and doses of AEDs. As the number of AED prescriptions has dramatically increased in reproductive-aged women with a variety of neuropsychiatric indications, the evolving concepts learned from studies in women with epilepsy can be applied to a much larger group of pregnant women to improve child outcomes while maintaining maternal disease control. In addition to careful selection of the type of medication, the amount of fetal exposure at conception and in the first trimester probably matters across all AEDs. Some AED polytherapy regimens are not associated with a higher risk of malformations, although other outcomes have not yet been formally studied. The individual woman's drug target concentration should be established preconception and maintained during pregnancy, to prevent seizure worsening. Substantial pharmacokinetic changes occur with many of the medications during pregnancy and postpartum, and interindividual variability supports the use of therapeutic drug monitoring for most AEDs. During pregnancy, vigilance and close monitoring should also include intrauterine fetal growth, obstetric complications, and neonatal complications. Breastfeeding can provide additional neurodevelopmental benefit and should be an option for women on AEDs. Knowledge of these key principles enhances our ability to make treatment recommendations with resultant improved maternal and child outcomes. Additional prospective studies are needed to further define the risk-benefit ratio across a variety of medications, dosing strategies, and neuropsychiatric disorders.
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Affiliation(s)
- Page B Pennell
- Department of Neurology, Division of Epilepsy, Division of Women's Health, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, 02115, USA.
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Gerard EE, Meador KJ. An Update on Maternal Use of Antiepileptic Medications in Pregnancy and Neurodevelopment Outcomes. J Pediatr Genet 2016; 4:94-110. [PMID: 27617120 DOI: 10.1055/s-0035-1556741] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Antiepileptic drugs (AEDs) are prescribed commonly to women of childbearing age. In utero exposure to some AEDs can have significant cognitive and behavioral consequences for the unborn child. Recently, prospective studies of women taking AEDs during pregnancy have added significantly to our understanding of cognitive and behavioral teratogenic risks posed by fetal AED exposure. Valproate is clearly associated with impaired cognitive development as well as an increased risk of disorders such as autism and autism spectrum disorder. Exposure to carbamazepine, lamotrigine, levetiracetam, or phenytoin monotherapy is associated with more favorable cognitive and behavioral outcomes than valproate, but more data are required to clarify if these AEDs have more subtle effects on cognition and behavior. There are insufficient data on the developmental effects of other AEDs in humans. Further, the underlying mechanisms of cognitive teratogenesis are poorly understood, including the genetic factors that affect susceptibility to AEDs.
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Affiliation(s)
- Elizabeth E Gerard
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, United States
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Auvin S. Advancing pharmacologic treatment options for pharmacologic treatment options for children with epilepsy. Expert Opin Pharmacother 2016; 17:1475-82. [PMID: 27249542 DOI: 10.1080/14656566.2016.1195809] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION The pharmacological management of epilepsy is continually modified by the increase in our knowledge about the efficacy and the safety on antiepileptic drugs. AREAS COVERED This review covers the published data (2010-2015) on the pharmacological management of epilepsy in children and adolescent. We review the data from the most recent randomized controlled and open-label trials. EXPERT OPINION Even if there is an increasing number of antiepileptic drugs approved for focal seizure in children and adolescent with epilepsy, each new approval would be considered as a significant addition to the current therapeutic options. Refractory epilepsy with focal seizure should not be regarded as a single disease but as numerous various patients. Because most of evidence of efficacy is primarily from placebo-controlled trials, there is no evidence to choose a treatment based on efficacy. In case of focal seizure, we explain how possible cognitive impact, mechanisms of action, pharmacologic characteristics and side effect profile are the factors taken into an account to propose a treatment. In case of childhood absence epilepsy, there are evidences showing the ethosuximide should be the first line treatment. Finally, we stress that trials in the pediatric epilepsy syndromes are required to propose better evidence-based pharmacological management.
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Affiliation(s)
- Stéphane Auvin
- a INSERM, U1141 , Paris , France.,b Université Paris Diderot, Sorbonne Paris Cité, INSERM UMR1141 , Paris , France.,c AP-HP, Hôpital Robert Debré, Service de Neurologie Pédiatrique , Paris , France
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Bromley R. The treatment of epilepsy in pregnancy: The neurodevelopmental risks associated with exposure to antiepileptic drugs. Reprod Toxicol 2016; 64:203-10. [PMID: 27312074 DOI: 10.1016/j.reprotox.2016.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/12/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022]
Abstract
A number of antiepileptic drugs (AEDs) have been confirmed as teratogens due to their association with an increased malformation rate. The majority of research to date does not find an association between prenatal exposure to monotherapy carbamazepine, lamotrigine or phenytoin and neurodevelopmental outcome in comparison to control children and noted higher abilities in comparison to children exposed to valproate; but further work is needed before conclusions can be drawn. Data for levetiracetam was limited to one study, as was the evidence for topiramate. Sodium valproate exposure appeared to carry a dose dependent risk to the developing brain, with evidence of reduced levels of IQ, poorer verbal abilities and increased rate of autistic spectrum disorder both in comparison to control children and children exposed to other AEDs. The severity of the neurodevelopmental deficits associated with prenatal exposure to valproate highlight the critical need to consider neurodevelopmental outcomes as a central aspect of teratological research.
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Affiliation(s)
- R Bromley
- Institute of Human Development, Faculty of Medical & Human Sciences, University of Manchester, United Kingdom; Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, United Kingdom.
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Abstract
Epilepsy and antiepileptic drugs affect the menstrual cycle, aspects of contraception, reproductive health, pregnancy, and menopause through alteration of sex steroid hormone pathways. Sex steroid hormones often have an effect on seizure frequency and may alter the level of some antiepileptic drugs. Approximately one-third of women experience an increase in perimenstrual and/or periovulatory seizure frequency. Some women experience an increase in seizure frequency during pregnancy. Balancing maternal seizure control and the risk of congenital malformations associated with fetal antiepileptic drug exposure may be challenging. Some antiepileptic drugs are associated with cognitive and behavioral teratogenesis and should be avoided if possible during pregnancy.
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Affiliation(s)
- Naymeé J Vélez-Ruiz
- Division of Epilepsy, Department of Neurology, University of Miami, 1120 Northwest, 14th Street, Suite 1329, Miami, FL 33136, USA.
| | - Page B Pennell
- Division of Epilepsy, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Harvard University, 75 Francis Street, Boston, MA 02115, USA; Division of Women's Health, Brigham and Women's Hospital, Harvard Medical School, Harvard University, 75 Francis Street, Boston, MA 02115, USA
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Abstract
Many studies investigating cognitive outcomes in children of women with epilepsy report an increased risk of mental impairment. Verbal scores on neuropsychometric measures may be selectively more involved. While a variety of factors contribute to the cognitive problems of children of women with epilepsy, antiepileptic drugs (AEDs) appear to play a major role. The mechanisms by which AEDs affect neurodevelopmental outcomes remain poorly defined. Animal models suggest that AED-induced apoptosis, altered neurotransmitter environment, and impaired synaptogenesis are some of the mechanisms responsible for cognitive and behavioral teratogenesis. AEDs that are known to induce apoptosis, such as valproate, appear to affect children's neurodevelopment in a more severe fashion. Fetal valproate exposure has dose-dependent associations with reduced cognitive abilities across a range of domains, and these appear to persist at least until the age of 6. Some studies have shown neurodevelopmental deficiencies associated with the use of phenobarbital and possibly phenytoin. So far, most of the investigations available suggest that fetal exposures to lamotrigine or levetiracetam are safer with regard to cognition when compared with other AEDs. Studies on carbamazepine show contradictory results, but most information available suggests that major poor cognitive outcomes should not be attributed to this medication. Overall, children exposed to polytherapy prenatally appear to have worse cognitive and behavioral outcomes compared with children exposed to monotherapy, and with the unexposed. There is an increase risk of neurodevelopmental deficits when polytherapy involves the use of valproate versus other agents.
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Affiliation(s)
- Naymee J Velez-Ruiz
- Department of Neurology, Emory University, 1365 Clifton Rd., Clinic A, 2nd Fl., Atlanta, GA, 30322, USA,
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Tomson T, Battino D, Perucca E. Valproic acid after five decades of use in epilepsy: time to reconsider the indications of a time-honoured drug. Lancet Neurol 2015; 15:210-218. [PMID: 26655849 DOI: 10.1016/s1474-4422(15)00314-2] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/16/2015] [Accepted: 10/22/2015] [Indexed: 11/25/2022]
Abstract
Since the serendipitous discovery of its anticonvulsant properties more than 50 years ago, valproic acid has become established as an effective broad-spectrum antiepileptic drug that is particularly useful for the management of generalised epilepsies, for which treatment alternatives are few. However, during the past few years increasing evidence has accumulated that intake of valproic acid during pregnancy is associated with a significant risk of dose-dependent teratogenic effects and impaired postnatal cognitive development in children. Because of these risks, valproic acid should not be used as a first-line drug in women of childbearing potential whenever equally or more effective alternative drugs are available-as in the case of focal epilepsy. In some generalised epilepsy syndromes, such as juvenile myoclonic epilepsy, valproic acid has better documented efficacy than alternative drugs and drug selection should be a shared decision between the clinician and the informed patient based on careful risk-benefit assessment.
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Affiliation(s)
- Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Dina Battino
- Epilepsy Centre, Department of Neurophysiology and Experimental Epileptology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Neurological Institute "Carlo Besta" Foundation, Milan, Italy
| | - Emilio Perucca
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy; C Mondino National Neurological Institute, Pavia, Italy
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Affiliation(s)
- Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Verrotti A, Mencaroni E, Castagnino M, Zaccara G. Foetal safety of old and new antiepileptic drugs. Expert Opin Drug Saf 2015; 14:1563-71. [PMID: 26329145 DOI: 10.1517/14740338.2015.1084288] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Drugs teratogenicity has been studied for many years, especially teratogenic effects of antiepileptic drugs, because of the important impact that epilepsy has always had for young women, but data from literature are often conflicting. AREAS COVERED We have carried out a critical review of all human studies about the antiepileptic drugs teratogenicity. A systematic search was performed in Medline and PubMed up to May 1, 2015. The use of older antiepileptic drugs in pregnancy is associated with an increased risk of fetus malformations; in particular, Valproate can determine neural-tube-like defects; in Phenytoin and Phenobarbital-exposed pregnancies, orofacial clefts, cardiac and genitourinary malformations are the major anomalies described. Spina bifida is the only specific major congenital malformation significantly associated with exposure to Carbamazepine monotherapy Despite the small number of studies on the teratogenic effects of new antiepileptic drugs, the analysis of the literature shows that exposure of the fetus to the new antiepileptic drugs is associated with a lower risk of major congenital malformations compared to the use of older drugs. EXPERT OPINION Where possible, Valproate should be avoided in women of childbearing potential. Results about the safety of newer antiepileptic drugs require validation and further investigation.
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Affiliation(s)
- Alberto Verrotti
- a 1 University of Perugia, Department of Pediatrics , S. Andrea delle Fratte, Perugia, Italy , +39 07 55 78 44 15 ;
| | - Elisabetta Mencaroni
- a 1 University of Perugia, Department of Pediatrics , S. Andrea delle Fratte, Perugia, Italy , +39 07 55 78 44 15 ;
| | - Miriam Castagnino
- a 1 University of Perugia, Department of Pediatrics , S. Andrea delle Fratte, Perugia, Italy , +39 07 55 78 44 15 ;
| | - Gaetano Zaccara
- b 2 Unit of Neurology, Florence Health Authority, Department of Medicine , Florence, Italy
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Abstract
Over a million women with epilepsy are of childbearing age in the USA and require careful consideration of not only type of antiepileptic drug (AED) but also dosage, in the event of a planned or unplanned pregnancy. Careful selection of AEDs can lower the potential adverse effects of AEDs while maintaining seizure control for the health of not only on the patient, the mother, but also the unborn fetus. The number of treatment options has increased significantly in the last 20 years and remarkable progress has been made in characterizing the risks AEDs pose to pregnant women and fetuses. There are now robust data on teratogenesis, a growing body of data on neonatal/obstetrical outcomes and on neurodevelopmental problems associated with each AED, and some data about seizure control during pregnancy. Based on clinical evidence so far, levetiracetam and lamotrigine have emerged as the safest during pregnancy, although others may also be suitable. Despite being a common belief, not all polytherapy combinations may be detrimental, especially when avoiding valproate and topiramate. Here, we review the available clinical research, highlighting recent findings and provide thoughts for future directions in the field.
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Affiliation(s)
- P Emanuela Voinescu
- a 1 Department of Neurology, Division of Epilepsy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Page B Pennell
- a 1 Department of Neurology, Division of Epilepsy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,b 2 Division of Women's Health, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Tomson T, Marson A, Boon P, Canevini MP, Covanis A, Gaily E, Kälviäinen R, Trinka E. Valproate in the treatment of epilepsy in girls and women of childbearing potential. Epilepsia 2015; 56:1006-19. [PMID: 25851171 DOI: 10.1111/epi.13021] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 11/28/2022]
Abstract
This document provides guidance on the use of valproate in girls and women of childbearing age from a joint Task Force of the Commission on European Affairs of the International League Against Epilepsy (CEA-ILAE) and the European Academy of Neurology (EAN), following strengthened warnings from the Coordination Group for Mutual Recognition and Decentralised Procedures-Human (CMDh) of the European Medicines Agency (EMA), which highlight the risk of malformations and developmental problems in infants who are exposed to valproate in the womb. To produce these recommendations, the Task Force has considered teratogenic risks associated with use of valproate and treatment alternatives, the importance of seizure control and of patient and fetal risks with seizures, and the effectiveness of valproate and treatment alternatives in the treatment of different epilepsies. The Task Force's recommendations include the following: (1) Where possible, valproate should be avoided in women of childbearing potential. (2) The choice of treatment for girls and women of childbearing potential should be based on a shared decision between clinician and patient, and where appropriate, the patient's representatives. Discussions should include a careful risk-benefit assessment of reasonable treatment options for the patient's seizure or epilepsy type. (3) For seizure (or epilepsy) types where valproate is the most effective treatment, the risks and benefits of valproate and other treatment alternatives should be discussed. (4) Valproate should not be prescribed as a first-line treatment for focal epilepsy. (5) Valproate may be offered as a first-line treatment for epilepsy syndromes where it is the most effective treatment, including idiopathic (genetic) generalized syndromes associated with tonic-clonic seizures. (6) Valproate may be offered as a first-line treatment in situations where pregnancy is highly unlikely (e.g., significant intellectual or physical disability). (7) Women and girls taking valproate require regular follow-up for ongoing consideration of the most appropriate treatment regimen.
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Affiliation(s)
- Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anthony Marson
- Department Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom.,The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Paul Boon
- Reference Center for Refractory Epilepsy, Ghent University Hospital, Ghent, Belgium
| | - Maria Paola Canevini
- Epilepsy Center, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Athanasios Covanis
- Department of Neurology, The Children Hospital "Agia Sophia", Athens, Greece
| | - Eija Gaily
- Department of Pediatric Neurology, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Reetta Kälviäinen
- Department of Neurology, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Kuopio Epilepsy Center, Kuopio University Hospital, Kuopio, Finland
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University Salzburg, Salzburg, Austria.,Centre for Cognitive Neuroscience, Salzburg, Austria.,Department of Public Health and Health Technology Assessment, UMIT - Health & Life Sciences University, Hall in Tirol, Austria
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Cognitive outcomes of prenatal antiepileptic drug exposure. Epilepsy Res 2015; 114:89-97. [PMID: 26088891 DOI: 10.1016/j.eplepsyres.2015.04.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 04/13/2015] [Accepted: 04/23/2015] [Indexed: 01/18/2023]
Abstract
Antiepileptic drugs (AEDs) have been known to have teratogenic effects for a little over 50 years. While early reports focused on fetal malformations, there has been an increasing amount of data over the last few decades exploring the cognitive outcomes of offspring exposed to AEDs in utero. Although the challenges of confounding factors and varied methodologies have led to inconsistent results, the negative impact of some of the agents, such as valproate, have become clear. Further studies are needed to evaluate the cognitive effects of prenatal exposure to many AEDs which have not been tested, to clarify the effects of existing AEDs which have yielded mixed results, and to better understand the effects of polytherapy. Research in animal models is warranted to screen AEDs for their effects on cognition in exposed offspring and to further our understanding of the underlying mechanisms by which AEDs exert their harmful effects on the developing brain. And finally, new AEDs without these harmful effects and agents which can prevent or reverse the negative consequences imparted by AED therapy on cognition should be sought.
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