Managing epilepsy in women of childbearing age

Prenatal exposure to benzodiazepines and Z-drugs in humans and risk of adverse neurodevelopmental outcomes in offspring: A systematic review

When used during pregnancy, benzodiazepines (BZDs) and related z-drugs could pass readily through the placenta and the foetal blood-brain barrier, where they can bind to γ-amino butyric acid (GABA) receptors in the developing foetal brain. Yet, data on long-term safety of prenatal BZD and z-drug use and its impact on offspring neurodevelopment are inconclusive. In this systematic review, we qualitatively synthetize the existing evidence on maternal exposure to various BZDs and z-drugs during pregnancy and offspring cognitive, emotional, behavioural, and motor skills developmental outcomes. Nineteen studies were included. We used harvest plots to visualize the directions of reported associations. Despite several associations between distinct types of BZDs and z-drugs and an increased risk of outcomes within different neurodevelopmental domains were observed, a remarkable scarcity of overall research on the topic and considerable discrepancies in methodology, particularly towards controlling for confounding by indication, precluded drawing conclusions with a reasonable degree of certainty. We outline various research strategies to mitigate methodological limitations and provide directions for future empirical studies on the topic.

Assessment and effect of a gap between new-onset epilepsy diagnosis and treatment in the US

Objective

To estimate the treatment gap between a new epilepsy diagnosis and antiepileptic drug (AED) initiation in the United States.

Methods

Retrospective claims-based cohort study using Truven Health MarketScan databases (commercial and supplemental Medicare, calendar years 2010–2015; Medicaid, 2010–2014) and a validation study using PharMetrics Plus Database linked to LRx claims database (2009–2014). Persons met epilepsy diagnostic criteria, had an index date (first epilepsy diagnosis) with a preceding 2-year baseline (1 year for persons aged 1 to <2 years; none for persons <1 year), and continuous medical and pharmacy enrollment without epilepsy/seizure diagnosis or AED prescription during baseline. Outcomes included percentage of untreated persons (no AED prescription) up to 3 years' follow-up and comparative outcomes (incidence rate ratio: untreated persons/treated persons), including medical events and health care resource utilization.

Results

In the primary study, 59,970 persons met selection (or inclusion) criteria; 36.7% of persons with newly diagnosed epilepsy remained untreated up to 3 years after diagnosis. In the validation study (N = 30,890), 31.8% of persons remained untreated up to 3 years after diagnosis. Lack of AED treatment was associated with an adjusted incidence rate ratio (95% confidence interval) of 1.2 (1.2–1.3) for medical events, 2.3 (2.2–2.3) for hospitalizations, and 2.8 (2.7–2.9) for emergency department visits.

Conclusions

One-third of newly diagnosed persons remain untreated up to 3 years after epilepsy diagnosis. The increased risk of medical events and health care utilization highlights the consequences of delayed treatment after epilepsy diagnosis, which might be preventable.

Collaboration of Care for Women with Epilepsy in their Reproductive Years

Over half a million women of childbearing age have epilepsy, many of which will require family planning care at some point in their reproductive years. Matters relating to contraception, pregnancy, fertility, and sexual functioning are all impacted to varying degrees by the use of antiepileptic drugs (AEDs) to treat epilepsy and require active management by a woman's neurologist. It is important that a woman's obstetrician/gynecologist (OBGYN) and internist are aware of the way in which their care may be related to her epilepsy care and how this can be successfully comanaged with her neurologist. This includes the impact AED therapies have on pregnancy, such as risk of teratogenicity, changes to AED clearance rates during pregnancy and postpartum, and risk of seizure worsening while pregnant; interactions of hormonal contraceptives and AEDs; side effects of AED treatment on hormonal systems and sexual functioning; and matters of fertility and infertility treatments. The current editorial discusses these relationships between AED choice, dose, and family planning matters for women with epilepsy in their childbearing years to support the collaboration of care between her neurologist, OBGYN, and internist.

Drug-resistant focal epilepsy in women of childbearing age: Reproduction and the effect of epilepsy surgery

OBJECTIVE

Women with epilepsy (WWE) have lower birth rates than expected. The reasons for this are multifactorial and involve a complex interaction between reproductive endocrine and psychosocial factors. The effect of epilepsy surgery on reproduction in women with drug-resistant focal epilepsy has not previously been studied.

METHODS

Adult women of childbearing age (18-45years old) with drug-resistant focal epilepsy who had undergone a focal cortical resection between 1997 and 2008 at the Mayo Clinic in Rochester, MN were included in the study. Patients who had a history of hysterectomy or tubal ligation or who were menopausal at the time of surgery were excluded. Data on prior pregnancies and births, epilepsy history, surgical treatment, hormonal dysfunction, and socioeconomic status were obtained using a retrospective chart review. Associations between various clinical and demographic variables with changes in pregnancies and births from pre- to postsurgery were assessed using Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. All tests were 2-sided, and p-values less than 0.05 were considered statistically significant. All analyses were performed using SAS software version 9.2 (SAS INC, Cary NC).

RESULTS

One hundred and thirteen women (average age: 30.5years) were included in the study. Average length of follow-up was 5.7years (SD-3.90). Sixty-four patients (57.5%) were nulliparous at the time of surgery. Sixty-one patients (54%) had never been married. Average number of pregnancies per patient prior to surgery was 0.93, and average number of births prior to surgery was 0.73. After surgery, a total of 17 women had a total of 35 pregnancies and 25 births. The average number of pregnancies and births after surgery was 1.27 and 0.96, respectively. Infertility was reported in one patient postoperatively. Patients who were younger at the time of surgery experienced a greater change in the number of pregnancies and births after surgery (p=0.0036 and 0.0060, respectively). Patients who received fewer antiepileptic drug medication trials by the time of surgery also had a greater change in the number of births after surgery (p=0.0362). Seizure onset localization and lateralization, presurgical seizure frequency, age at seizure onset, duration of epilepsy, and postoperative seizure outcome were not statistically significant factors.

CONCLUSION

The present retrospective observational study provides additional evidence for the importance of early surgical treatment in women with drug-resistant focal epilepsy. Patients who had received fewer medications prior to surgery were more likely to experience an increase in births following surgery. The significance of these findings requires further investigation but may support a role for earlier surgical intervention in the management of drug-resistant focal epilepsy.

The Impact of Gonadal Hormones on the Expression of Human Neurological Disorders

The effects of gonadal steroids on neurological well-being and disease constitute a rich and rapidly expanding area of basic and clinical neuroscience. Gonadal hormones exert potent effects on monoaminergic, cholinergic and peptidergic pathways as well as neurosteroidogenesis which, in turn, impact normal brain organization and function. A spectrum of human neurological conditions are influenced by hormonal fluctuations associated with the menstrual cycle, pregnancy, the menopause and use of oral contraceptives. An appreciation of these relationships may facilitate the development of specific hormonal and anti-hormonal therapies for neurological disorders as disparate as catamenial epilepsy and acute intermittent porphyria.

Gender issues in antiepileptogenic treatments

Disease modification of epilepsy refers to the alleviation of epileptogenesis or comorbidities after genetic or acquired epileptogenic brain insults. There are currently 30 proof-of-concept experimental pharmacologic studies that have demonstrated some beneficial disease-modifying effects. None of these studies, however, has yet passed from the laboratory to the clinic. The International League Against Epilepsy and American Epilepsy Society working groups on antiepileptogenic (AEG) therapies recently released recommendations for conducting preclinical AEG studies, taking into account many of the critiques raised by previous study designs. One of the issues relates to the lack of analysis of AEG efficacy in both sexes. A review of the literature reveals that most of the preclinical studies have been performed using male rodents, whereas clinical study cohorts include both males and females. Therefore, it is important to determine whether sex differences should be taken into account to a greater extent than they have been historically at different phases of experimental studies. Here we address the following questions based on analysis of available experimental AEG studies: (a) whether sex differences should be considered when searching for novel AEG targets, (b) how sex differences can affect the preclinical AEG study designs and analysis of outcome measures, and (c) what factors should be considered when examining the effect of sex on outcome of clinical AEG trials or the clinical use of AEGs.

A mixed-methods exploration of the contraceptive experiences of female teens with epilepsy

PURPOSE

We explored the contraceptive experiences of female teens with epilepsy, including their knowledge and perceptions of interactions between antiepileptic drugs and hormonal contraception and contraceptive decision-making processes.

METHOD

From November 2012 to May 2013, we conducted one online survey (n=114) and 12 online focus group discussions (n=26) with female teens with epilepsy about their contraceptive experiences and unmet needs. Survey data were analyzed using descriptive statistics and focus group transcripts were analyzed thematically using modified grounded theory methods.

RESULTS

Both survey and focus group participants reported believing that interactions between epilepsy medications and hormonal contraceptives could lead to reductions in contraceptive efficacy and seizure control. However, their knowledge about these types of medication interactions was often incomplete. Many study participants viewed contraceptive decision making as a difficult process, and some participants reported avoiding hormonal contraceptives because of potential interactions with antiepileptic drugs. Study participants reported relying on health care providers and parents for contraceptive decision-making support. Focus group participants also reported they wanted health care providers to provide more in-depth and comprehensive counseling about contraception, and that they desired peer support with contraceptive decisions.

CONCLUSION

The ability to make informed contraceptive decisions is important for teens with epilepsy as interactions between anti-epileptic drugs and hormonal contraceptives can impact seizure occurrence and lead to an increased risk of unplanned pregnancy. Guidance for providers offering contraceptive care to this population is needed, as well as a contraceptive support tool that empowers teens with epilepsy to advocate for desired health care.

Antiepileptic drugs and breastfeeding

INTRODUCTION

This review provides a synopsis for clinicians on the use of antiepileptic drugs (AEDs) in the breastfeeding mother.

METHODS

For each AED, we collected all retrievable data from Hale's "Medications and Mother Milk" (2012), from the LactMed database (2013) of the National Library of Medicine, and from a MedLine Search of relevant studies in the past 10 years.

RESULTS

Older AEDs, such as carbamazepine, valproic acid, phenytoin, phenobarbital, primidone are considered to have a good level of safety during lactation, due to the long term clinical experience and the consequent amount of available data from the scientific literature. On the contrary, fewer data are available on the use of new AEDs. Therefore, gabapentin, lamotrigine, oxcarbazepine, vigabatrin, tiagabine, pregabalin, leviracetam and topiramate are compatible with breastfeeding with a less documented safety profile. Ethosuximide, zonisamide and the continue use of clonazepam and diazepam are contraindicated during breastfeeding.

CONCLUSIONS

Although the current available advice on the use of AEDs during breastfeeding, given by different accredited sources, present some contradictions, most AEDs can be considered safe according to our review.

Old and new antiepileptic drugs during pregnancy and lactation--report of a case

We describe a case of a woman with epilepsy treated with primidone/phenobarbital (so-called "old" antiepileptic drug) and levetiracetam (so-called "new" antiepileptic drug) who was discouraged from breastfeeding, resulting in clinically significant withdrawal seizures in her newborn. As a consequence, even when two or more antiepileptic drugs are needed for the treatment of women with epilepsy, breastfeeding should be recommended, mothers should be informed about the possibility of drug effects on the neonate, and infants of mothers treated with primidone/phenobarbital should be closely monitored for possible signs of sedation.

Treatment initiation in epilepsy: an expert consensus in Spain

OBJECTIVE

The goals of this study were to explore the diverse criteria surrounding indications for antiepileptic therapy and to establish a consensus on drug selection for initial monotherapy in adult patients with epilepsy.

METHODS

The study was performed using the modified Delphi method, which aims to achieve professional consensus by means of a series of questionnaires. Three different groups of items were evaluated: the beginning of antiepileptic treatment, the drug selected for initial monotherapy with respect to the type of epilepsy, and the drug selected for initial monotherapy with respect to comorbidity.

RESULTS

Sixty experts completed two rounds of a questionnaire. In the first round, consensus was reached on 135 of the 194 questions analyzed. After the second round, consensus was reached on 148 items. The main findings of the survey revealed a consensus on beginning treatment after the first seizure when the EEG showed abnormalities such as generalized spike-wave discharges, when MRI demonstrated an epileptogenic brain lesion, and in elderly patients. Regarding to the antiepileptic drug selected for initial monotherapy with respect to type of epilepsy, levetiracetam and lamotrigine were recommended for generalized tonic-clonic seizures regardless of sex or age; levetiracetam was recommended for myoclonic epilepsy regardless of sex; valproic acid, ethosuximide, levetiracetam, and lamotrigine were chosen for absence epilepsy; and carbamazepine, levetiracetam, lamotrigine, and oxcarbazepine were recommended for partial epilepsy regardless of age or sex. Finally, in the evaluation of drug selection with respect to comorbidity, first-generation drugs were less recommended than second-generation drugs, which were clearly preferable. The drugs on which there was a greater consensus were levetiracetam, lamotrigine, valproic acid, and topiramate.

CONCLUSIONS

There is a tendency to begin treatment after the first seizure, depending on the results of additional testing. In general, first-generation drugs are less recommended for different types of epilepsy, especially in the presence of a comorbid condition. However, the authors are conveying perceptions and opinions, the effect of which on treatment outcomes has not been evaluated.

Efficacy, safety, and potential of extended-release lamotrigine in the treatment of epileptic patients

Epilepsy is a frequent, chronic disease demanding long-term medication with antiepileptic drugs (AEDs). When slow release formulations of AEDs are used the chance of compliance and control of seizures is increased. Lamotrigine (LTG) is a broad spectrum antiepileptic drug (AED), effective against both generalized and partial seizures. Its immediate-release formulation (LTG-IR) requires twice-daily dosing. In contrast, an extended-release formulation (LTG-XR) may be given once daily, providing a flatter dose-concentration curve with apparently lower maximum serum levels. Simplified dosing positively affects compliance and LTG-XR has a similar profile of efficacy and tolerability to LTG-IR. Rashes, including Stevens-Johnson syndrome, are the most serious adverse effect impacting 0.8% of pediatric patients. Thus, LTG-XR should be discontinued upon the appearance of rash.