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Leite MDL, Topocov TN, de Oliveira TL, Almeida DDS, Mota Ortiz SR, da Silva JC. Obstetric and neonatal outcomes, antiseizure medication profile, and seizure types in pregnant women in a vulnerability state from Brazil. PLoS One 2024; 19:e0291190. [PMID: 38558080 PMCID: PMC10984515 DOI: 10.1371/journal.pone.0291190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/24/2023] [Indexed: 04/04/2024] Open
Abstract
This retrospective cohort study described the obstetric and neonatal outcomes, antiseizure medication (ASM) use, and types of seizures in pregnant women with epilepsy (PWWE). Data collected from the medical records of 224 PWWE aged < 40 years with controlled or refractory seizures and 492 pregnant women without epilepsy (PWNE) control group from high-risk maternity hospitals in Alagoas between 2008 and 2021 were included in this study. The obstetric and neonatal outcomes observed in PWWE were pregnancy-related hypertension (PrH) (18.4%), oligohydramnios (10.3%), stillbirth (6.4%), vaginal bleeding (6%), preeclampsia (4.7%), and polyhydramnios (3%). There was a greater likelihood of PrH in PWWE with generalized tonic-clonic seizures (GTCS) and that of maternal intensive care unit (ICU) admissions in those with GTCS and status epilepticus, and phenytoin and lamotrigine use. PWWE with GTCS had a higher risk of stillbirth and premature delivery. PWWE with status epilepticus were treated with lamotrigine. Phenobarbital (PB) with diazepam were commonly used in GTCS and status epilepticus. Total 14% patients did not use ASM, while 50.2% used monotherapy and 35.8% used polytherapy. Total 60.9% of patients used PB and 25.2% used carbamazepine. This study described the association between the adverse obstetric and neonatal outcomes and severe seizure types in PWWE.
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Affiliation(s)
- Magnúcia de Lima Leite
- Universidade Estadual de Ciências da Saúde Alagoas (UNCISAL), Maceió, AL, Brazil
- Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | | | | | - Sandra Regina Mota Ortiz
- Universidade Municipal de São Caetano do Sul (USCS), São Paulo, SP, Brazil
- Universidade São Judas Tadeu (USJT), São Paulo, SP, Brazil
| | - José Claudio da Silva
- Faculdade de Medicina do Centro Universitário(CESMAC), Maceió, AL, Brazil
- PPGSF/RENASF/FIOCRUZ/UNCISAL, Maceió, AL, Brazil
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Vegrim HM, Dreier JW, Igland J, Gilhus NE, Alvestad S, Gissler M, Leinonen MK, Sun Y, Zoega H, Christensen J, Bjørk MH, Tomson T. Prescribing patterns for higher dose folic acid in pregnant women with epilepsy treated with antiseizure medication. Epilepsia 2024. [PMID: 38554037 DOI: 10.1111/epi.17969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/01/2024]
Abstract
OBJECTIVE This study was undertaken to characterize the use of higher doses of folic acid (≥1 mg daily) in relation to pregnancy in Denmark, Norway, and Sweden in women with epilepsy treated with antiseizure medication (ASM). METHODS In this observational study, we used data from national medical birth, patient, and prescription registers in Denmark, Norway, and Sweden to retrospectively identify pregnancies in women with epilepsy treated with ASM from 2006 to 2017. The proportion of higher dose folic acid supplementation in pregnancies among women receiving ASM for epilepsy was calculated according to country of origin, time period, and type of ASM. Logistic regression with restricted cubic splines was used to model country-specific time trends. RESULTS Among a total of 2 748 882 pregnancies, we identified 8695 (.3%) pregnancies after restricting the population to women with ASM-treated epilepsy. A prescription for higher dose folic acid was filled in 4719 (54.3%) of these pregnancies. The proportion supplemented with higher dose folic acid was highest in Sweden (74.3%) and lower in Norway (41.4%) and Denmark (34.3%). Furthermore, we observed a decreasing trend of higher dose folic acid use in Denmark and Norway from year 2012 to 2017. Among those who used higher dose folic acid, 42% did not start preconception supplementation with higher dose folic acid. SIGNIFICANCE Supplementation with higher dose folic acid occurred in approximately half of pregnancies in women with ASM-treated epilepsy, with many not starting supplementation until after becoming pregnant. Considerable variability was observed in the use of higher dose folic acid across the countries, despite similar population characteristics and health care systems. Future guidelines should be simplified with clear recommendations developed in a collaborative manner by relevant specialists including neurologists, obstetricians, pediatricians, and public health specialists to enhance real-world applicability.
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Affiliation(s)
| | - Julie Werenberg Dreier
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Economics and Business Economics, Business and Social Science, National Center for Register-Based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Jannicke Igland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Silje Alvestad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, National Center for Epilepsy, Oslo University Hospital, Oslo, Norway
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Maarit K Leinonen
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Yuelian Sun
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Helga Zoega
- School of Population Health, Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
- Center of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Jakob Christensen
- Department of Economics and Business Economics, Business and Social Science, National Center for Register-Based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Marte-Helene Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Neurophysiology, Haukeland University Hospital, Bergen, Norway
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Lee SK. Issues of Women with Epilepsy and Suitable Antiseizure Drugs. J Epilepsy Res 2023; 13:23-35. [PMID: 38223363 PMCID: PMC10783964 DOI: 10.14581/jer.23005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/12/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Seizure aggravation in women with epilepsy (WWE) tends to occur at two specific times during the menstrual cycle: the perimenstrual phase and the ovulation period. Antiseizure drugs (ASDs), especially those that induce enzymes, can accelerate the metabolism of hormones in oral contraceptives, rendering them less effective. Estrogen in contraceptive pills increases the metabolism of lamotrigine. Physiological changes during pregnancy can significantly impact the pharmacokinetics of ASDs, potentially necessitating adjustments in dosage for women with epilepsy to maintain seizure control. The use of valproate in pregnant women is associated with the highest risk of major congenital malformations among ASDs. Risks of major congenital malformations associated with lamotrigine, levetiracetam, and oxcarbazepine were within the range reported in the general population. Exposure to valproate can lead to lower IQ in offspring. Reduced folic acid levels are linked to orofacial clefts, cardiovascular malformations, and urogenital and limb anomalies in WWE. Decreased folate levels are expected with the use of enzyme-inducing ASDs. However, a high dose of folate was associated with an increased risk of cancer in children of mothers with epilepsy. Most ASDs are generally considered safe for breastfeeding and should be encouraged. However, no single ASD is considered ideal for childbearing WWE. Lamotrigine and levetiracetam are relatively more suitable options for this situation.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Berman E, Erenburg N, Beloosesky R, Eyal S, Kovo M. Placental disposition of cannabidiol: An ex vivo perfusion study. Epilepsia 2023; 64:3354-3364. [PMID: 37777821 DOI: 10.1111/epi.17778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE In the absence of safety data in humans, the use of cannabidiol (CBD) is not recommended during pregnancy. Yet >50% of pregnancies in women with epilepsy are unintended, making fetal exposure to CBD possible. As a small-molecule, highly lipid-soluble drug, CBD is likely to be distributed into the placenta and cross it. To estimate the placental distribution profile of CBD and its potential short-term placental effects, we conducted an ex vivo perfusion study in human placentas. METHODS Placentas were obtained from healthy women undergoing cesarean deliveries. Selected cotyledons were cannulated and perfused for 180 min with a CBD-containing medium (250 ng/mL, .796 μmol·L-1 ; representative of a low therapeutic concentration; n = 8). CBD concentrations were determined at 180 min in the medium and placental tissue using liquid chromatography-tandem mass spectrometry. A customized gene panel array was used to analyze the expression of selected genes in the perfused placental cotyledons as well as in placentas perfused with 1000 ng/mL CBD (3.18 μmol·L-1 ; high therapeutic concentration; n = 8) and in those exposed to the vehicle. RESULTS CBD was sequestered in the placental tissue, exhibiting significant variability across samples (median = 5342 ng/g tissue, range = 1066-9351 ng/g tissue). CBD concentrations in the fetal compartment were one fifth of those measured in the maternal compartment (median = 59 ng/mL, range = 48-72 ng/mL vs. 280 = ng/mL, range = 159-388 ng/mL, respectively; p < .01). Placental gene expression was not significantly altered by CBD. SIGNIFICANCE The placenta acts as a depot compartment for CBD, slowing down its distribution to the fetus. This phenomenon might yield flatter but prolonged fetal CBD levels in vivo. The attenuated transplacental CBD transfer does not imply that its use by pregnant women is safe for the fetus. Only pregnancy registries and neurocognitive assessments would establish the risk of being antenatally exposed to CBD.
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Affiliation(s)
- Erez Berman
- Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Natalia Erenburg
- Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Sara Eyal
- Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
- Multidisciplinary Center for Cannabinoid Research, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Molisani SE, Parikh D, DiGiovine M, Dlugos D, Fitzgerald MP, Fried L, Helbig I, Kessler SK, McDonnell PP, Melamed S, Prelack MS, Sharif U, Tefft S, Tencer J, Witzman S, Shaw K, Abend NS. A quality improvement initiative to improve folic acid supplementation counseling for adolescent females with epilepsy. Epilepsia 2023; 64:2818-2826. [PMID: 37496463 DOI: 10.1111/epi.17723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE We designed a quality improvement (QI) project to improve rates of documented folic acid supplementation counseling for adolescent females with epilepsy, consistent with a quality measure from the American Academy of Neurology and American Epilepsy Society. Our SMART aim was to increase the percentage of visits at which folic acid counseling was addressed from our baseline rate of 23% to 50% by July 1, 2020. METHODS This initiative was conducted in female patients ≥12 years old with epilepsy who were prescribed daily antiseizure medication and were seen by the 13 providers in our Neurology QI Program. Using provider interviews, we undertook a root cause analysis of low counseling rates and identified the following main factors: insufficient time during clinic visit to counsel, lack of provider knowledge, and forgetting to counsel. Countermeasures were designed to address these main root causes and were implemented through iterative plan-do-study-act (PDSA) cycles. Interventions included provider education and features within the electronic health record, which were introduced sequentially, culminating in the creation of a best practice advisory (BPA). We performed biweekly chart reviews of visits for applicable patients to establish baseline performance rate and track progress over time. We used a statistical process control p-chart to analyze the outcome measure of documented counseling. As a balancing measure, clinicians were surveyed using the Technology Adoption Model survey to assess acceptance of the BPA. RESULTS From September 2019 to August 2022, the QI team improved rates of documented folic acid counseling from 23% to 73% through several PDSA cycles. This level of performance has been sustained over time. The most successful and sustainable intervention was the BPA. Provider acceptance of the BPA was overall positive. SIGNIFICANCE We successfully used QI methodology to improve and sustain our rates of documented folic acid supplementation counseling for adolescent females with epilepsy.
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Affiliation(s)
- Sara E Molisani
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Darshana Parikh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marissa DiGiovine
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dennis Dlugos
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mark P Fitzgerald
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Epilepsy Neurogenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy and Neurodevelopmental Disorders Center, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lawrence Fried
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ingo Helbig
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Epilepsy Neurogenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy and Neurodevelopmental Disorders Center, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sudha Kilaru Kessler
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pamela Pojomovsky McDonnell
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Epilepsy Neurogenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan Melamed
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marisa S Prelack
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Uzma Sharif
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sarah Tefft
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy Neurogenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy and Neurodevelopmental Disorders Center, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jaclyn Tencer
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephanie Witzman
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathy Shaw
- Department of Pediatrics (Division of Emergency Medicine), Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Tomson T, Zelano J, Dang YL, Perucca P. The pharmacological treatment of epilepsy in adults. Epileptic Disord 2023; 25:649-669. [PMID: 37386690 DOI: 10.1002/epd2.20093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/18/2023] [Accepted: 06/24/2023] [Indexed: 07/01/2023]
Abstract
The pharmacological treatment of epilepsy entails several critical decisions that need to be based on an individual careful risk-benefit analysis. These include when to initiate treatment and with which antiseizure medication (ASM). With more than 25 ASMs on the market, physicians have opportunities to tailor the treatment to individual patients´ needs. ASM selection is primarily based on the patient's type of epilepsy and spectrum of ASM efficacy, but several other factors must be considered. These include age, sex, comorbidities, and concomitant medications to mention the most important. Individual susceptibility to adverse drug effects, ease of use, costs, and personal preferences should also be taken into account. Once an ASM has been selected, the next step is to decide on an individual target maintenance dose and a titration scheme to reach this dose. When the clinical circumstances permit, a slow titration is generally preferred since it is associated with improved tolerability. The maintenance dose is adjusted based on the clinical response aiming at the lowest effective dose. Therapeutic drug monitoring can be of value in efforts to establish the optimal dose. If the first monotherapy fails to control seizures without significant adverse effects, the next step will be to gradually switch to an alternative monotherapy, or sometimes to add another ASM. If an add-on is considered, combining ASMs with different modes of action is usually recommended. Misdiagnosis of epilepsy, non-adherence and suboptimal dosing are frequent causes of treatment failure and should be excluded before a patient is regarded as drug-resistant. Other treatment modalities, including epilepsy surgery, neuromodulation, and dietary therapies, should be considered for truly drug-resistant patients. After some years of seizure freedom, the question of ASM withdrawal often arises. Although successful in many, withdrawal is also associated with risks and the decision needs to be based on careful risk-benefit analysis.
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Affiliation(s)
- Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Johan Zelano
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Gothenburg, Sweden
| | - Yew Li Dang
- Bladin-Berkovic Comprehensive Epilepsy Program, Austin Health, Melbourne, Victoria, Australia
- Epilepsy Research Centre, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Victoria, Australia
| | - Piero Perucca
- Bladin-Berkovic Comprehensive Epilepsy Program, Austin Health, Melbourne, Victoria, Australia
- Epilepsy Research Centre, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
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Lawal OD, Meador KJ, Hume AL, Wen X. Utilization of Antiseizure Medications in Women of Childbearing Age With Epilepsy and Nonepilepsy Indications: A Retrospective Cohort Study. Neurology 2023; 101:e1083-e1096. [PMID: 37407266 PMCID: PMC10491435 DOI: 10.1212/wnl.0000000000207580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 05/10/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Antiseizure medications (ASMs) are among the most commonly prescribed teratogenic drugs in women of childbearing age. Limited data exist on utilization patterns across different indications for therapy and for the newer-generation ASMs in this population. Thus, we assessed the pattern of ASM use in women of childbearing age with epilepsy and nonepilepsy indications (pain and psychiatric disorders). METHODS We conducted a retrospective analysis of deidentified administrative data submitted to the Optum Clinformatics database. Eligible participants included women aged 12-50 years who filled ASMs between year 2011 and 2017. Participants were followed from date of index prescription filled to study end or insurance disenrollment, whichever came first. For the overall cohort and potential therapy indications, we assessed the type and frequency of ASMs filled; proportion of participants on monotherapy, polytherapy, or treatment switching; and duration of continuous use. Trends were characterized using annual percent change from study start to study end. RESULTS Our analysis included 465,131 participants who filled 603,916 distinct ASM prescriptions. At baseline, most of the participants had chronic pain (51.0%) and psychiatric disorders (32.7%), with epilepsy the least common (0.9%). The most frequently dispensed were diazepam (24.3%), lorazepam (20.1%), gabapentin (17.4%), clonazepam (12.7%), topiramate (11.3%), and lamotrigine (4.6%). Significant linear increase in trends were observed with gabapentin (annual percent change [95% CI]: 8.4 [7.3-9.4]; p < 0.001) and levetiracetam (3.4 [0.7-6.2]; p = 0.022) and decreasing trends for diazepam (-3.5 [-2.4 to 4.5]; p < 0.001) and clonazepam (-3.4 [-2.3 to 4.5]; p = 0.001). No significant change in trend was observed with valproate (-0.4 [-2.7 to 1.9]; p = 0.651), while nonlinear changes in trends were observed with lorazepam, topiramate, lamotrigine, and pregabalin. DISCUSSION Decreasing trends were observed with older ASMs in the overall cohort and across the potential indications for therapy. Conversely, increasing trends were seen with the newer ASMs. Considering the risk of teratogenicity associated with the newer medications largely unknown, counseling and education in addition to a careful consideration of the benefits vs potential risks should remain pivotal when prescribing ASMs for women of childbearing age.
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Affiliation(s)
- Oluwadolapo D Lawal
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Kimford J Meador
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Anne L Hume
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Xuerong Wen
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA.
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Ohyama N, Furugen A, Sawada R, Aoyagi R, Nishimura A, Umazume T, Narumi K, Kobayashi M. Effects of valproic acid on syncytialization in human placental trophoblast cell lines. Toxicol Appl Pharmacol 2023; 474:116611. [PMID: 37385477 DOI: 10.1016/j.taap.2023.116611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/01/2023]
Abstract
The placenta is a critical organ for fetal development and a healthy pregnancy, and has multifaceted functions (e.g., substance exchange and hormone secretion). Syncytialization of trophoblasts is important for maintaining placental functions. Epilepsy is one of the most common neurological conditions worldwide. Therefore, this study aimed to reveal the influence of antiepileptic drugs, including valproic acid (VPA), carbamazepine, lamotrigine, gabapentin, levetiracetam, topiramate, lacosamide, and clobazam, at clinically relevant concentrations on syncytialization using in vitro models of trophoblasts. To induce differentiation into syncytiotrophoblast-like cells, BeWo cells were treated with forskolin. Exposure to VPA was found to dose-dependently influence syncytialization-associated genes (ERVW-1, ERVFRD-1, GJA1, CGB, CSH, SLC1A5, and ABCC4) in differentiated BeWo cells. Herein, the biomarkers between differentiated BeWo cells and the human trophoblast stem model (TSCT) were compared. In particular, MFSD2A levels were low in BeWo cells but abundant in TSCT cells. VPA exposure affected the expression of ERVW-1, ERVFRD-1, GJA1, CSH, MFSD2A, and ABCC4 in differentiated cells (ST-TSCT). Furthermore, VPA exposure attenuated BeWo and TSCT cell fusion. Finally, the relationships between neonatal/placental parameters and the expression of syncytialization markers in human term placentas were analyzed. MFSD2A expression was positively correlated with neonatal body weight, head circumference, chest circumference, and placental weight. Our findings have important implications for better understanding the mechanisms of toxicity of antiepileptic drugs and predicting the risks to placental and fetal development.
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Affiliation(s)
- Nanami Ohyama
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan
| | - Ayako Furugen
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan.
| | - Riko Sawada
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan
| | - Ryoichi Aoyagi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan
| | | | - Takeshi Umazume
- Department of Obstetrics, Hokkaido University Hospital, Japan
| | - Katsuya Narumi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan
| | - Masaki Kobayashi
- Laboratory of Clinical Pharmaceutics & Therapeutics, Division of Pharmasciences, Faculty of Pharmaceutical Sciences, Hokkaido University, Japan.
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Weatherspoon S, Davis A, Keezer M, Zutshi D, Pack A. Dobbs Versus Jackson: Epilepsy, Reproductive Health, and Abortion. Epilepsy Curr 2023; 23:211-216. [PMID: 37662462 PMCID: PMC10470093 DOI: 10.1177/15357597231176330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
On June 24, 2022, Dobbs vs Jackson Women's Health Organization was decided by the Supreme Court effectively overturning the former precedent of Roe v. Wade. This ruling has direct consequences for the care of persons with epilepsy of childbearing potential. Now more than ever we need to provide informed and comprehensive care to our patients with epilepsy who are particularly vulnerable to the impact of this legislation on their reproductive decision-making. Important areas to understand include (1) the current state of affairs on abortion in the United States; (2) contraception options, their effectiveness, and interactions with anti-seizure medications (ASM); (3) teratogenic effects and adverse neurocognitive outcomes of ASMs; (4) folic acid supplementation; (5) the effect on perinatal and pediatric care; and (6) unique issues related to people of color.
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Affiliation(s)
| | - Anne Davis
- Planned Parenthood of Greater New York, New York, NY, USA
| | - Mark Keezer
- Stichting Epilepsie Instellingen Nederland (SEIN), Université de Montréal, Department of Neurosciences & School of Public Health, Québec, Netherlands
| | - Deepti Zutshi
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Alison Pack
- Columbia University Irving Medical Center, New York, NY, USA
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10
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I Harrison E, Kirkpatrick LA, Hochheiser HS, Sogawa Y, Kazmerski TM. A retrospective textual analysis of sexual and reproductive health counseling for adolescent and young adult people with epilepsy of gestational capacity. Epilepsy Behav 2023; 145:109321. [PMID: 37348408 DOI: 10.1016/j.yebeh.2023.109321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/20/2023] [Accepted: 06/08/2023] [Indexed: 06/24/2023]
Abstract
Rationale The American Academy of Neurology (AAN) recommends annual sexual and reproductive health (SRH) counseling for all people with epilepsy of gestational capacity (PWEGC). Child neurologists report discussing SRH concerns infrequently with adolescents. Limited research exists regarding documentation of such counseling. METHODS We retrospectively studied clinical notes using natural language processing to investigate child neurologists' documentation of SRH counseling for adolescent and young adult PWEGC. We segmented notes into sentences and evaluated for references to menstruation, sexual activity, contraception, folic acid, teratogens, and pregnancy. We developed training sets in a labeling application and used machine learning to identify additional counseling instances. We repeated this iteratively until we identified no new relevant sentences. We validated results using external reviewers; after removing sentences reviewers disagreed on (n = 13/400), we calculated Cohen's kappa values between the model and reviewers (>0.98 for all categories). We evaluated labeled texts for each patient per calendar year with descriptive statistics and logistic regression, adjusting for race/ethnicity, age, and teratogen use. RESULTS Data comprised 971 PWEGC age 13-21 years with 2277 patient-years and 3663 outpatient child neurology notes. Nearly half of patient-years lacked SRH counseling documentation (49.1%). Among all patients, 38.0% never had SRH counseling documented. Documentation was present regarding menstruation in 26.7% of patient-years, folic acid in 25.0%, contraception in 21.9%, pregnancy in 3.5%, teratogens in 3.0%, and sexual activity in 1.8%. Documentation regarding menstruation and contraception was associated with prescription of antiseizure medications that have a higher risk of teratogenic effects (OR = 1.27, p = 0.020, 95% CI = [1.04,1.54]; OR = 1.27, p = 0.027, 95% CI = [1.03,1.58]). Documentation regarding contraception, folic acid, and sexual activity was increased among older patients (OR = 1.28, p < 0.001, 95% CI = [1.21,1.35]; OR = 1.26, p < 0.001, 95% CI = [1.19,1.32]; OR = 1.26, p = 0.004, 95% CI = [1.08,1.47]). Documentation regarding sexual activity was decreased among patients identifying as White/Non-Hispanic (OR = 0.39, p = 0.007, 95% CI = [0.20,0.78]). CONCLUSION Child neurologists counsel PWEGC on SRH less frequently than recommended by the AAN based on documentation.
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Affiliation(s)
- Elizabeth I Harrison
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Laura A Kirkpatrick
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Harry S Hochheiser
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, 5607 Baum Boulevard, Pittsburgh, PA 15206, United States.
| | - Yoshimi Sogawa
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Traci M Kazmerski
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States; Center for Innovative Research on Gender Health Equity, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213, United States.
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11
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Mesraoua B, Perucca E, Tomson T, Asadi-Pooya AA. Should antiseizure medications be withdrawn after an extended period of seizure freedom in individuals with adult-onset epilepsy? Epilepsy Behav 2023; 142:109205. [PMID: 37031583 DOI: 10.1016/j.yebeh.2023.109205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/15/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
Unlike several epilepsies with onset in pediatric age, adult-onset epilepsies do not typically have a time course that is predictably self-remitting in the large majority of people. Still, about one-half of individuals with adult-onset epilepsy who have been seizure-free for an extended period (two years or longer) on antiseizure medications (ASMs) will remain in remission when their drug therapy is discontinued. Although a number of predictors of outcome have been identified (including specific adult-onset syndromes associated with a low probability of spontaneous remission), in most cases, the only way to establish whether the epilepsy has remitted in a given individual is to gradually withdraw ASMs. ASM withdrawal can be beneficial, particularly when the currently used treatment is not well tolerated, or could lead to adverse outcomes in the future (i.e., teratogenic effects should pregnancy occur in a female of childbearing potential). However, the risks associated with ASM withdrawal are significant. Relapse of seizures can have major adverse psychosocial consequences and also may carry a risk of morbidity and mortality. Most importantly, evidence suggests that in about 20% of individuals whose seizure relapsed following ASM withdrawal, re-institution of pharmacological therapy may not readily restore seizure control. Ultimately, management decisions should prioritize the preference of the well-informed person with epilepsy. Particularly, when adverse drug effects are a concern, options to be discussed should include not only withdrawal or continuation of the current treatment but also dose reduction or substitution with a different ASM.
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Affiliation(s)
- Boulenouar Mesraoua
- Neurosciences Department, Hamad Medical Corporation and Weill Cornell Medical College, Doha, Qatar.
| | - Emilio Perucca
- Department of Medicine (Austin Health), The University of Melbourne, and Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.
| | - Torbjorn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
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12
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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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Hoeltzenbein M, Slimi S, Fietz A, Stegherr R, Onken M, Beyersmann J, Dathe K, Schaefer C. Increasing use of newer antiseizure medication during pregnancy: An observational study with special focus on lacosamide. Seizure 2023. [PMID: 37003184 DOI: 10.1016/j.seizure.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Epilepsy is a common neurological disease requiring long-term therapy also during pregnancy. Most studies on pregnancy outcomes in women with epilepsy are based on antiseizure medication (ASM) in monotherapy. However, about 20-30% of epilepsy patients require polytherapy and newer ASMs are an option, when seizure control is not achieved with first line ASMs. METHODS Observational study evaluating the use of newer ASMs with marketing authorization since 2005 reported to the Embryotox Center of Clinical Teratology and Drug Safety in Pregnancy between 2004 and 2019. In addition, course and outcome of lacosamide exposed pregnancies were analysed. RESULTS Our study confirms the increasing use of newer ASMs also in pregnant women. This is especially true for lacosamide, eslicarbazepine and brivaracetam with rising numbers of exposed pregnancies soon after marketing authorization. Analysis of 55 prospectively and 10 retrospectively ascertained lacosamide exposed pregnancies does not indicate increased risks of major birth defects or spontaneous abortion. However, bradycardia observed in 3 neonates might be related to prenatal lacosamide exposure. CONCLUSION Available data do not support the assumption of lacosamide being a major teratogen. The increasing use of newer ASMs during pregnancy underscores the need for more studies to guide preconception counselling, especially for lacosamide, eslicarbazepine and brivaracetam.
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Abstract
Treatment approaches for epilepsy for both women and men are similar, however, there are special aspects that must be considered when caring for women with epilepsy. This includes how hormonal fluctuations may affect seizure frequency, contraception, and potential drug-drug interactions, and pregnancy planning to minimize and potentially mitigate any adverse neurodevelopmental outcomes and major congenital malformations. Adequate counseling for women across the lifespan can help prepare women for the future and optimize outcomes.
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Affiliation(s)
- Maggie L McNulty
- Department of Neurology, Rush University Medical Center, 1725 West Harrison Street Suite 885, Chicago, IL 60612, USA.
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15
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Avachat C, Barry JM, Lyu X, Sherwin CM, Birnbaum AK. Management of Anti-Seizure Medications during Pregnancy: Advancements in The Past Decade. Pharmaceutics 2022; 14. [PMID: 36559227 DOI: 10.3390/pharmaceutics14122733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/24/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Management of seizures often involves continuous medication use throughout a patient's life, including when a patient is pregnant. The physiological changes during pregnancy can lead to altered drug exposure to anti-seizure medications, increasing patient response variability. In addition, subtherapeutic anti-seizure medication concentrations in the mother may increase seizure frequency, raising the risk of miscarriage and preterm labor. On the other hand, drug exposure increases can lead to differences in neurodevelopmental outcomes in the developing fetus. Established pregnancy registries provide insight into the teratogenicity potential of anti-seizure medication use. In addition, some anti-seizure medications are associated with an increased risk of major congenital malformations, and their use has declined over the last decade. Although newer anti-seizure medications are thought to have more favorable pharmacokinetics in general, they are not without risk, as they may undergo significant pharmacokinetic changes when an individual becomes pregnant. With known changes in metabolism and kidney function during pregnancy, therapeutic monitoring of drug concentrations helps to determine if and when doses should be changed to maintain similar seizure control as observed pre-pregnancy. This review concentrates on the results from research in the past decade (2010-2022) regarding risks of major congenital malformations, changes in prescribing patterns, and pharmacokinetics of the anti-seizure medications that are prescribed to pregnant patients with epilepsy.
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Falcicchio G, Russo E, Fabiano A, Scalese M, Boero G, Trojano M, de Tommaso M, La Neve A. Current safety concerns about the use of antiseizure medications in pregnancy. Expert Opin Drug Saf 2022; 21:1459-1468. [PMID: 36537559 DOI: 10.1080/14740338.2022.2160443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Given the high prevalence of epilepsy in women of childbearing potential (15 million out of 50 million people worldwide), antiseizure medication (ASM) use in pregnancy is common. Identifying the safest and most effective ASM to use during pregnancy is often difficult, but also crucially important. The challenge is to balance two needs: maintaining seizure control while minimizing teratogenicity. AREAS COVERED This review looks at seizure- and treatment-related risks to mother and fetus during pregnancy, existing healthcare information programmes, strengths and pitfalls of the main pregnancy registries, known and supposed pharmacokinetic changes during gestation, the utility of therapeutic drug monitoring, and safety concerns. Articles and related content were screened on available publications after January 2000. EXPERT OPINION The use of newer ASMs during pregnancy is still limited, as shown by the paucity of data collected by different pregnancy registries. Choosing these medications can be challenging, partly due to unknown pharmacokinetic modifications in pregnancy, an aspect that serum drug monitoring might help to clarify. The safest treatment is chosen also taking into account the woman's needs, concerns and wishes, but adequate pre-pregnancy counseling is necessary to properly inform her about personal and fetal risks related both to seizures and to medications.
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Affiliation(s)
- Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University Magna Graecia, Catanzaro, Italy
| | - Antonio Fabiano
- Science of Health Department, School of Medicine, University Magna Graecia, Catanzaro, Italy
| | - Micaela Scalese
- Pharmacy Department, Azienda Sanitaria Provinciale Di Catanzaro, Catanzaro, Italy
| | - Giovanni Boero
- Complex Structure of Neurology, SS Annunziata Hospital, Taranto, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Marina de Tommaso
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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Abstract
Women's neurology is the subspecialty within neurology concerned with the distinct healthcare needs of women. In this article, we review current literature and expert management strategies regarding disease-specific neurologic concerns of women, with an emphasis on issues related to contraception, pregnancy, and lactation. Health conditions that we discuss in this article include epilepsy, headache, stroke, multiple sclerosis, and Chiari I malformation. Current findings on neurologic disease in women suggest that many women with neurologic disease can safely manage their disease during pregnancy and have healthy children, though pregnancy planning is important in many conditions to mitigate risks and effective contraceptive management is important when pregnancy prevention is desired.
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Affiliation(s)
- Laura Kirkpatrick
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Janet Waters
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Angela O'Neal
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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18
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Abstract
Sex and gender differences in epilepsy are important influencing factors in epilepsy care. In epilepsy, the hormonal differences between the sexes are important as they impact specific treatment considerations for patients at various life stages particularly during early adulthood with establishment of the menstrual cycle, pregnancy, perimenopause and menopause. Choice of antiseizure medication may have direct consequences on hormonal cycles, hormonal contraception, pregnancy and fetal risk of major congenital malformation. Conversely hormones whether intrinsic or extrinsically administered may have direct impact on antiseizure medications and seizure control. This chapter explores these important influences on the management of persons with epilepsy.
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Affiliation(s)
- Lauren Hophing
- Krembil Brain Institute, University Health Network, University of Toronto, Toronto, Canada
| | | | - Esther Bui
- Krembil Brain Institute, University Health Network, University of Toronto, Toronto, Canada.
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Alvestad S, Husebye ESN, Christensen J, Dreier JW, Sun Y, Igland J, Leinonen MK, Gissler M, Gilhus NE, Tomson T, Bjørk M. Folic Acid and Risk of Preterm Birth, Preeclampsia, and Fetal Growth Restriction Among Women With Epilepsy: A Prospective Cohort Study. Neurology 2022; 99:e605-e615. [PMID: 35577577 PMCID: PMC9442624 DOI: 10.1212/wnl.0000000000200669] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 03/16/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Women with epilepsy treated with antiseizure medication (ASM) have increased risk of pregnancy complications including preterm birth, fetal growth restriction, and preeclampsia. We aimed to investigate whether folic acid supplementation is associated with these pregnancy complications in women with epilepsy using ASM. METHODS Singleton pregnancies in the prospective Norwegian Mother and Child Cohort Study (MoBa) (1999-2008) were included. Information on maternal epilepsy, ASM, folic acid supplementation, and pregnancy outcomes was obtained from the MoBa questionnaires and the Norwegian Medical Birth Registry. The main exposure, periconceptional folic acid supplementation, was defined as intake between 4 weeks before pregnancy and 12 weeks into pregnancy, retrospectively collected by recall of the mothers in weeks 17-19. The primary outcomes were preterm birth (gestational age <37 weeks at birth), small for gestational age (SGA), and preeclampsia. RESULTS The study included 100,105 pregnancies: 99,431 without maternal epilepsy, 316 with maternal epilepsy and ASM exposure in pregnancy, and 358 with untreated maternal epilepsy. Among ASM-treated women with epilepsy, the risk of preterm birth was higher in those who did not use periconceptional folic acid (n = 64) compared with those who did (n = 245, the reference) (adjusted odds ratio [aOR] 3.3, 95% CI 1.2-9.2), while the risk of preterm birth among the reference was similar to the risk among women without epilepsy using folic acid periconceptionally (aOR 0.9, 95% CI 0.5-1.6). ASM-treated women with epilepsy starting folic acid after the first trimester had a higher risk compared with women without epilepsy with similar timing of folic acid (aOR 2.6, 95% CI 1.1-6.5), and even higher if not using folic acid (aOR 9.4, 95% CI 2.6-34.8). Folic acid was not associated with risk of preterm birth among women with epilepsy without ASM or among women without epilepsy. Folic acid was not associated with risk of preeclampsia or SGA among women with epilepsy. DISCUSSION In women with epilepsy using ASM, periconceptional folic acid was associated with a lower risk of preterm birth. This finding supports the recommendation that ASM-treated women with epilepsy of childbearing potential should use folic acid supplementation on a regular basis. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for women with epilepsy using ASM, periconceptional folic acid supplementation decreases the risk of preterm birth.
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Affiliation(s)
- Silje Alvestad
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden.
| | - Elisabeth Synnøve Nilsen Husebye
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Jakob Christensen
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Julie Werenberg Dreier
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Yuelian Sun
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Jannicke Igland
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Maarit K Leinonen
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Mika Gissler
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Nils Erik Gilhus
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Torbjörn Tomson
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
| | - Marte Bjørk
- From the Department of Clinical Medicine (S.A., E.S.N.H., J.W.D., N.E.G., M.B.), University of Bergen; National Center for Epilepsy (S.A.), Oslo; Department of Neurology (E.S.N.H., N.E.G., M.B.), Haukeland University Hospital, Bergen, Norway; Department of Neurology (J.C., Y.S.), and National Centre for Register-Based Research (J.C., J.W.D., Y.S.), Aarhus University, Denmark; Core Facility for Biostatistics and Data Analysis (J.I.), Department of Global Public Health and Primary Care, University of Bergen, Norway; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare (THL), Helsinki, Finland; Departments of Molecular Medicine and Surgery (M.G.), Clinical Neuroscience (T.T.), and Department of Neurology (T.T.), Karolinska University Hospital, Stockholm, Sweden
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Abstract
INTRODUCTION The therapeutic management of women with epilepsy (WWE) of childbearing age can be complicated by the need to balance maternal/fetal risks related to seizure occurrence during gestation with the potential teratogenic risks related to the use of anti-seizure medications (ASMs). AREAS COVERED The authors review clinical evidence on seizure-related and ASM-related risks during pregnancy. Current regulatory indications are discussed, evaluating their impact on clinical practice, and ethical implications of pharmacological decisions are debated. EXPERT OPINION If properly informed about the maternal/fetal risks carried by different pharmacological choices, WWE can become the final decision makers regarding their care in every phase of their life. Over the coming years, analysis of aggregated pregnancy registry data on the structural impact, on the fetus, of low doses of valproate and of newer ASMs, together with analysis of the main population study data on functional (cognitive and behavioral) outcomes, could lead to huge advances, making choosing an ASM a less complex process for the clinician and a less painful decision for the woman. Future objectives should include identification of the potential role of the pharmacogenomic profile of WWE in determining the risk of fetal malformations.
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Affiliation(s)
- Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Giovanni Boero
- Complex Structure of Neurology, SS Annunziata Hospital, Taranto, Italy
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Askarieh A, MacBride-Stewart S, Kirby J, Fyfe D, Hassett R, Todd J, Marshall AD, Leach JP, Heath CA. Delivery of care, seizure control and medication adherence in women with epilepsy during pregnancy. Seizure 2022; 100:24-29. [PMID: 35728343 DOI: 10.1016/j.seizure.2022.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/08/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To evaluate service access for women with epilepsy (WWE) during pregnancy; to determine seizure frequency and rates of adherence to anti-seizure medication (ASM). METHODS Between June 2019-June 2020, pregnant WWE within NHS Greater Glasgow and Clyde health-board were identified from the National Obstetric Register. A manual review of electronic patient records was undertaken to ensure diagnostic accuracy, as well as determine contact with epilepsy services and documented seizures. Medication dispensing records were obtained six months before and six months after midwifery booking and measures of ASM adherence calculated. RESULTS Between June 2019-June 2020, 4592 women were registered with a pregnancy. Eighty-five (1.9%) were identified as having active epilepsy (generalised- 40/85 (47.0%), focal- 35/85 (41.2%), unclassified- 10/85 (11.8%)). Preconceptually, 42/85 WWE (49.4%) had input from epilepsy services. Only 59/85 (69.4%) were reviewed during pregnancy (First trimester- 21/59 (35.6%), Second trimester- 25/59 (42.4%) and Third trimester- 13/59 (22.0%)). Seizure occurrence was documented in 37/85 WWE (43.5%) during the antenatal/postnatal period. 71/85 WWE (83.5%) were prescribed ASM. Poor adherence was noted in 50/85 (58.9%) and a documented seizure recorded in 26/50 (52.0%) of these women. CONCLUSION Too many WWE do not receive input from epilepsy services during pregnancy, leaving some with poor ASM adherence and continued seizures. We aim to use "near-live" obstetric and dispensing data to facilitate early identification of WWE, promoting timely access to epilepsy specialists. This will also provide an opportunity to address concerns regarding ASM safety and allow medication dose changes to be considered.
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Affiliation(s)
- Amber Askarieh
- Department of Neurology, Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Langlands Drive, Glasgow, G51 4LB, UK, United Kingdom.
| | | | - Jack Kirby
- Department of Neurology, Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Langlands Drive, Glasgow, G51 4LB, UK, United Kingdom
| | - David Fyfe
- Pharmacy Services, NHS Greater Glasgow and Clyde, United Kingdom
| | - Richard Hassett
- Pharmacy Services, NHS Greater Glasgow and Clyde, United Kingdom
| | - Jonathan Todd
- Department of Information Management, NHS Greater Glasgow and Clyde, United Kingdom
| | - Alex D Marshall
- Institute of Health and Wellbeing, University of Glasgow, United Kingdom
| | - John Paul Leach
- Department of Neurology, Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Langlands Drive, Glasgow, G51 4LB, UK, United Kingdom; School of Medicine, University of Glasgow, United Kingdom
| | - Craig A Heath
- Department of Neurology, Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Langlands Drive, Glasgow, G51 4LB, UK, United Kingdom; School of Medicine, University of Glasgow, United Kingdom
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22
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Abstract
PURPOSE OF REVIEW Issues pertaining to women with epilepsy have advanced with a better understanding of multidirectional influences among hormones, seizures, and antiseizure medications, as well as pregnancy-related concerns around fertility, seizure destabilization, and antiseizure medication-associated teratogenicity. This article highlights important developments in this field and reviews best practices in the management of women with epilepsy. RECENT FINDINGS Important external hormonal influences may impact women with epilepsy particularly in the context of gender-affirming medications, hormonal replacement therapy, and fertility therapies. Fertility for women with epilepsy is influenced by multiple variables; however, in the absence of preexisting fertility issues, epilepsy per se is not associated with significantly impaired fertility. Once women with epilepsy are pregnant, the majority have a stable course. Antiseizure medication use in pregnancy is associated with major congenital malformations 2 to 5 times that of the general population and is highest with high-dose (≥1500 mg or greater total daily) valproate. Carefully considered changes in drug choice and dose may mitigate these risks. Therapeutic drug monitoring plays an important role in pregnancy care, and under expert supervision, women with epilepsy in pregnancy have similar seizure risks as women with epilepsy who are not pregnant. As women with epilepsy age, bone health and menopause may further be impacted by seizures and antiseizure medications. SUMMARY The care of women with epilepsy is a multifaceted discipline that recognizes the life-long impact of sex and gender influences on epilepsy care.
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23
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Kirkpatrick L, Harrison E, Borrero S, Davis AR, Miller E, Sogawa Y, Stransky OM, Talabi MB, Urban A, Van Cott AC, Kazmerski TM. Preferences and experiences of women with epilepsy regarding sexual and reproductive healthcare provision. Epilepsy Behav 2022; 129:108631. [PMID: 35247834 DOI: 10.1016/j.yebeh.2022.108631] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/16/2022]
Abstract
RATIONALE Women with epilepsy (WWE) have unique disease-specific considerations regarding their sexual and reproductive health (SRH), which impact decision-making around pregnancy and contraception. Understanding their perspectives, preferences, and experiences regarding SRH care contributes to optimizing patient-centered clinical practice. METHODS We conducted individual semi-structured interviews with WWE aged 18-45 years, exploring their SRH care experiences and preferences. We audio-recorded and transcribed all interviews. Two coders used both inductive and deductive strategies to perform thematic analysis and identify key themes and representative quotes. RESULTS Twenty WWE completed interviews (median age 23 years; range 18-43 years). Key themes included: 1) SRH counseling from neurologists often did not occur, was limited in scope, or contained misinformation, especially during adolescence and early adulthood. In particular, participants felt that they received poor counseling about contraception, fertility, folic acid, and teratogenic medications, which impacted their reproductive decision-making. 2) WWE report fragmented care between their neurologist and other SRH providers. 3) WWE prefer that their neurologists initiate routine comprehensive discussions about SRH. 4) Conversations about SRH should begin in adolescence and include private confidential discussions between neurologists and WWE. 5) Successful SRH conversations between neurologists and WWE involve detailed information, reassurance, and support for the patient's reproductive goals. CONCLUSION WWE desire comprehensive, coordinated counseling and care regarding SRH and epilepsy, and often experience suboptimal SRH care. Better understanding of the SRH needs, preferences, and experiences of WWE will help inform interventions to optimize patient-centered SRH counseling and care by healthcare professionals, especially during adolescence.
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Affiliation(s)
- Laura Kirkpatrick
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Elizabeth Harrison
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Sonya Borrero
- Center for Women's Health Research and Innovation, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213, United States; Department of Medicine, University of Pittsburgh, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States.
| | - Anne R Davis
- Department of Obstetrics and Gynecology, Columbia University, 5 Columbia Circle, New York, NY 10019, United States.
| | - Elizabeth Miller
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States; Center for Women's Health Research and Innovation, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213, United States.
| | - Yoshimi Sogawa
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Olivia M Stransky
- Center for Women's Health Research and Innovation, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213, United States.
| | - Mehret Birru Talabi
- Center for Women's Health Research and Innovation, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213, United States; Department of Medicine, University of Pittsburgh, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, United States.
| | - Alexandra Urban
- Department of Neurology, University of Pittsburgh, 811 Kaufmann Medical Building, 3461 Fifth Avenue, Pittsburgh, PA 15213, United States.
| | - Anne C Van Cott
- Department of Neurology, University of Pittsburgh, 811 Kaufmann Medical Building, 3461 Fifth Avenue, Pittsburgh, PA 15213, United States; Department of Neurology, Veterans Affairs Pittsburgh Healthcare System, 4100 Allequippa Street, Pittsburgh, PA 15240, United States.
| | - Traci M Kazmerski
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States; Center for Women's Health Research and Innovation, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213, United States.
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24
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Gosset A, Denuelle M, Valton L, Sommet A, Bénévent J, Tremollières F. Interactions between antiseizure medications and contraception: A study about the knowledge of patients and their specialist physicians. Epilepsy Behav 2022; 129:108627. [PMID: 35240507 DOI: 10.1016/j.yebeh.2022.108627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/07/2022] [Accepted: 02/12/2022] [Indexed: 11/03/2022]
Abstract
Planning pregnancy is very important for women with epilepsy (WWE), because of the potential teratogenic effects and neurodevelopmental disorders of different antiseizure medications (ASMs). Nevertheless, contraception in WWE can be challenging due to the existence of drug interactions between ASMs and hormonal contraception. The aim of this study was to assess women's knowledge of potential interactions between their ASMs and contraceptive options. The second objective was to assess neurologist's knowledge of the potential interactions between ASMs and contraceptive methods. An anonymous online survey was proposed to reproductive-age WWE during consultation with their neurologist. Another online survey was proposed to neurologists. These surveys were performed through a French regional medical network. A total of 79 patients agreed to respond to the survey. Forty-nine women used lamotrigine alone or in combination, 15 used an enzyme-inducing ASM alone or in combination, 13 used non-enzyme-inducing ASM and 2 used both lamotrigine and an enzyme-inducing ASM. Half of the WWE had mistaken beliefs about interactions between their ASM and contraception. Among them, 35% of the women treated with an enzyme-inducing ASM were unaware of a potential decreased efficacy of hormonal contraception. Moreover, 51% of the women who were taking lamotrigine did not know that combined hormonal contraception might decrease the efficacy of their ASM. On the other hand, 64.5% of WWE without an enzyme-inducing ASM wrongly thought that their ASM can decrease their hormonal contraceptive efficacy. A total of 20 neurologists answered the online survey. It revealed specific gaps concerning interactions between ASM and contraceptives; in fact, 35% of answers concerning the identification of specific enzyme-inducing ASMs were wrong. This study therefore highlights the need for educational efforts for both WWE and their physicians regarding drug interactions between ASMs and hormonal contraceptives.
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Affiliation(s)
- Anna Gosset
- Centre de Ménopause et Maladies osseuses et métaboliques, CHU-Toulouse, 330 avenue de Grande Bretagne, TSA, 70034 31059 Toulouse, France.
| | - Marie Denuelle
- Explorations Neurophysiologiques, Département de Neurologie, CHU-Toulouse, & Centre de Recherche Cerveau et Cognition, (CerCo), UMR 5549, CNRS, Université de Toulouse, 330 avenue de Grande Bretagne, TSA, 70034 31059 Toulouse, France
| | - Luc Valton
- Explorations Neurophysiologiques, Département de Neurologie, CHU-Toulouse, & Centre de Recherche Cerveau et Cognition, (CerCo), UMR 5549, CNRS, Université de Toulouse, 330 avenue de Grande Bretagne, TSA, 70034 31059 Toulouse, France
| | - Agnès Sommet
- Service de Pharmacologie Médicale et Clinique, Équipe CERPOP - SPHERE INSERM, Université Paul-Sabatier, Faculté de Médecine, 37 allées Jules Guesde, 31000 Toulouse, France
| | - Justine Bénévent
- Service de Pharmacologie Médicale et Clinique, Équipe CERPOP - SPHERE INSERM, Université Paul-Sabatier, Faculté de Médecine, 37 allées Jules Guesde, 31000 Toulouse, France
| | - Florence Tremollières
- Centre de Ménopause et Maladies osseuses et métaboliques, CHU-Toulouse, 330 avenue de Grande Bretagne, TSA, 70034 31059 Toulouse, France
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Kirkpatrick L, Van Cott AC, Kazmerski TM, Bravender T. Contraception and Reproductive Health Care for Adolescent and Young Adult Women with Epilepsy. J Pediatr 2022; 241:229-36. [PMID: 34728232 DOI: 10.1016/j.jpeds.2021.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/16/2021] [Accepted: 10/27/2021] [Indexed: 11/21/2022]
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Abstract
PURPOSE OF REVIEW Seizure disorders are the most frequent major neurologic complication in pregnancy, affecting 0.3% to 0.8% of all gestations. Women of childbearing age with epilepsy require special care related to pregnancy. This article provides up-to-date information to guide practitioners in the management of epilepsy in pregnancy. RECENT FINDINGS Ongoing multicenter pregnancy registries and studies continue to provide important information on issues related to pregnancy in women with epilepsy. Valproate poses a special risk for malformations and cognitive/behavioral impairments. A few antiseizure medications pose low risks (eg, lamotrigine, levetiracetam), but the risks for many antiseizure medications remain uncertain. Although pregnancy rates differ, a prospective study found no difference in fertility rates between women with epilepsy who were attempting to get pregnant and healthy controls. During pregnancy, folic acid supplementation is important, and a dose greater than 400 mcg/d during early pregnancy (ie, first 12 weeks) is associated with better neurodevelopmental outcome in children of women with epilepsy. Breastfeeding is not harmful and should be encouraged in women with epilepsy even when they are on antiseizure medication treatment. SUMMARY Women with epilepsy should be counseled early and regularly about reproductive health. Practitioners should discuss the risks of various obstetric complications; potential anatomic teratogenicity and neurodevelopmental dysfunction related to fetal antiseizure medication exposure; and a plan of care during pregnancy, delivery, and postpartum. Women with epilepsy should also be reassured that the majority of pregnancies are uneventful.
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Affiliation(s)
- Yi Li
- Clinical Assistant Professor of Neurology and Neurological Sciences, Stanford University, Palo Alto, California
| | - Kimford J. Meador
- Stanford, University School of Medicine, Stanford Neuroscience Health, Center, 213 Quarry Rd, MC 5979, Palo Alto, CA 94304
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Kirkpatrick L, Liu H, Bhatnagar S, Bravender T, Harrison E, Kazmerski TM, Sogawa Y, Syed T, Shope TR. A Survey of Healthcare Providers About Reproductive Healthcare for Adolescent Women With Epilepsy. J Pediatr Adolesc Gynecol 2022; 35:39-47.e1. [PMID: 34547472 DOI: 10.1016/j.jpag.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/18/2021] [Accepted: 09/12/2021] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To evaluate knowledge, attitudes, and practices about sexual and reproductive health (SRH) for adolescent and young adult (AYA) women with epilepsy among general pediatricians, adolescent medicine specialists, and pediatric gynecologists. DESIGN Survey comprising previously validated and novel items that underwent content validity testing and was distributed through specialty listservs. Categorical variables analyzed with χ2 or Fisher exact tests, and continuous variables with Kruskal-Wallis tests. SETTING Online. PARTICIPANTS Physicians and Advanced practice providers. INTERVENTIONS Online survey. MAIN OUTCOME MEASURE(S) Questions testing SRH knowledge, assessing confidence in SRH counseling practices and frequency of intended SRH counseling, and identifying barriers and facilitators to SRH provision for AYA women with epilepsy. RESULTS Of 329 participants, 57% were general pediatricians, 27% were adolescent medicine specialists, and 16% were pediatric gynecologists. On 15 items assessing knowledge, general pediatricians scored significantly lower than respondents in the other specialties (P < .01). Among 11 items about confidence in SRH skills, general pediatricians were significantly less confident than respondents in the other specialties (P < .01). General pediatricians reported that they would perform annual counseling less often on 7 SRH counseling topics compared with respondents in the other specialties (P < .01). In all, 54% of the respondents reported that barriers to SRH provision include limited time during visits and lack of epilepsy knowledge. Respondents identified facilitators including guidelines/algorithms for managing SRH (83%), provider education (61%), and electronic health record alerts (60%). CONCLUSION Responses suggest suboptimal knowledge, confidence, and care provision regarding SRH for AYA women with epilepsy, particularly among general pediatricians. Identified barriers and facilitators may serve as targets for interventions to improve SRH provision.
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Gaudio M, Konstantara E, Joy M, van Vlymen J, de Lusignan S. Valproate prescription to women of childbearing age in English primary care: repeated cross-sectional analyses and retrospective cohort study. BMC Pregnancy Childbirth 2022; 22:73. [PMID: 35086478 DOI: 10.1186/s12884-021-04351-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 12/18/2021] [Indexed: 11/30/2022] Open
Abstract
Background Valproate is a teratogenic drug that should be avoided during the preconception period and pregnancy. The aim was to explore general practitioners’ (GPs) prescription patterns over time, describe trends, and explore inter-practice variation within primary care. Methods We identified women of childbearing age (12–46 years old) in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) sentinel network. We performed repeated cross-sectional analyses from 2004 to 2018 to determine rates of prescription and a retrospective cohort estimated the prevalence of use of valproate during pregnancy. Results In 2004, 0.31% (95% Confidence Interval (95%CI):0.18 to 0.44%) women were prescribed valproate, decreasing to 0.16% (95%CI:0.07 to 0.24%) by 2018. Among women with epilepsy, the rate fell from 15.2% (95%CI:14.4 to 16.0%) to 8.8% (95% CI:8.2 to 9.7%) over the same period. In 2018, almost two thirds (62.2%) of women who were prescribed valproate had epilepsy only, whereas bipolar disorder and migraine accounted for 15.8% and 7.4% respectively. Contraceptive prescriptions did not increase over time, and only in 2018 was there greater odds of being prescribed contraception (OR 1.41, 95%CI:1.08 to 1.45). Just under a fifth (19.7%) of women were prescribed valproate during their pregnancy; two out of three of these pregnancies were preceded by folic acid prescription (5 mg). While some practices reduced their rate of valproate prescription, others did not. Conclusions Regulatory guidelines have changed GPs' prescription patterns in women of childbearing potential for valproate but not for contraception. Further research is needed to identify the barriers of GPs and women of childbearing potential to undertaking contraception. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04351-x.
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Anderson S, Mauskopf J, Talbird SE, White A, Srinivasan M. Antiseizure medications and oral contraceptives: Impact of enzyme inducers on pregnancy outcomes and costs. Epilepsy Behav 2021; 125:108368. [PMID: 34775242 PMCID: PMC8683747 DOI: 10.1016/j.yebeh.2021.108368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/30/2021] [Accepted: 09/25/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To show the impact of drug-drug interactions (DDIs) associated with co-administration of enzyme-inducing (EI) antiseizure medications and oral contraceptives (OCs) on the annual number of unintended pregnancies, their outcomes, and their associated costs in the United States (US). METHODS A Microsoft Excel pregnancy-outcomes model was developed to determine the impact of DDIs in women who take an OC as well as an EI antiseizure medication known to lower the effectiveness of the OC in preventing pregnancy. The model compared the number of unintended pregnancies, the expected pregnancy outcomes, and associated costs in women taking an OC and an EI medication with a matched cohort of women who took an OC and an enzyme-neutral (EN) antiseizure medication that is known not to interact with OCs. The model perspectives were patients and third-party payers in the US. Unintended pregnancy rates, pregnancy outcomes, and cost inputs for the model were taken from published studies. RESULTS The results of the analysis showed an estimated increase in the annual number of unintended pregnancies in the US of 503 (a change from 1151 to 1654), an increase of 44.7%, for the estimated 71,922 women currently taking an OC plus an EI medication in the US when compared with a matched cohort taking an OC plus an EN medication. This resulted in an estimated annual healthcare cost increase of $3 million, which is an increase of 5.5% in the annual costs for contraception and pregnancy care. A scenario analysis showed that the annual number of unintended pregnancies could be lower (575 vs 1654) for a matched cohort of women taking EI medications and using a copper intrauterine device, a highly effective and nonhormonal form of contraception, rather than an OC. CONCLUSIONS Physicians treating women of reproductive age for epilepsy who wish to avoid pregnancy should consider the potential for DDIs that might result in unintended pregnancies. Thus, physicians should alert women using EI medications for epilepsy control to the increased potential for unintended pregnancies if they use OCs for contraception.
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Affiliation(s)
- Seri Anderson
- RTI Health Solutions, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA.
| | - Josephine Mauskopf
- RTI Health Solutions, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA.
| | - Sandra E. Talbird
- RTI Health Solutions, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA
| | - Annesha White
- University of North Texas System College of Pharmacy, 3500 Camp Bowie Blvd, IREB Office 211, Fort Worth, TX 76107, USA.
| | - Meenakshi Srinivasan
- University of North Texas System College of Pharmacy, 3500 Camp Bowie Blvd, IREB Office 211, Fort Worth, TX 76107, USA.
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30
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Müffelmann B, Hagemann A, Knaak N, Bien CG. [Women with epilepsy before and during pregnancy: a case series of outpatient counseling in a tertiary epilepsy center]. Nervenarzt 2021; 93:566-574. [PMID: 34608536 DOI: 10.1007/s00115-021-01198-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Data of large pregnancy registries have improved the recommendations for women with epilepsy before pregnancy. Monotherapy containing antiepileptic drugs with a low malformation rate (lamotrigine or levetiracetam) is recommended as well as preconceptional folic acid supplementation, while valproic acid should be avoided. The practicability of these recommendations remains controversial. METHODS Retrospective case series of 160 women with epilepsy over a period of 5 years who were advised in our outpatient department before and during pregnancy. RESULTS Only 18.9% of women presented with valproic acid. Even without valproic acid, complications or emergency admissions rarely occurred under specialist supervision. In our case series, lamotrigine proved to be less effective and less controllable than other drugs during pregnancy. Levetiracetam also has a low malformation rate, but showed a better effect on seizure outcome during pregnancy than lamotrigine. Only 12% of women who wanted to have children took folic acid. CONCLUSION This case series comes from a tertiary center; the referred women were mainly accompanied by neurologists with special expertise in epileptology. In this group valproate could be avoided in most cases. Lamotrigine is probably less effective due to the drop in blood levels during pregnancy. Levetiracetam seems to be a good alternative, working well against focal and generalized seizures. Folic acid may be taken later than recommended.
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Affiliation(s)
- Birgitt Müffelmann
- Krankenhaus Mara, Epilepsie-Zentrum Bethel, Universitätsklinik für Epileptologie, Maraweg 17-21, 33617, Bielefeld, Deutschland.
| | - Anne Hagemann
- Epilepsie-Zentrum Bethel, Gesellschaft für Epilepsieforschung, Bielefeld, Deutschland
| | - Niklas Knaak
- Campus Kiel, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Christian G Bien
- Krankenhaus Mara, Epilepsie-Zentrum Bethel, Universitätsklinik für Epileptologie, Maraweg 17-21, 33617, Bielefeld, Deutschland
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Marxer CA, Rüegg S, Rauch MS, Panchaud A, Meier CR, Spoendlin J. A review of the evidence on the risk of congenital malformations and neurodevelopmental disorders in association with antiseizure medications during pregnancy. Expert Opin Drug Saf 2021; 20:1487-1499. [PMID: 34128743 DOI: 10.1080/14740338.2021.1943355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The majority of women with epilepsy require treatment with antiseizure medications (ASM) throughout pregnancy. However, in utero exposure to several ASM has been associated with an increased risk of congenital malformations and/or neurodevelopmental disorders (CM/NDD) in the child, but observational evidence is methodologically heterogeneous.Areas covered: We critically evaluate current evidence on the risk of CM/NDD in children of women with epilepsy after in utero exposure to different ASM. We highlight characteristics of different data sources and discuss their benefits and drawbacks. This review includes evidence published before December 2020.Expert opinion: Given the lack of randomized controlled trials, evidence on in utero safety of ASM originates from methodologically heterogeneous post-marketing observational studies based on registries, prospective cohorts, and large electronic health databases. It has been clearly demonstrated that valproate is associated with a high risk of CM/NDD, whereas lamotrigine and levetiracetam are relatively safe. However, evidence is less explicit for other ASM. Reported risks vary depending on the size and origin of the underlying study population, the definition of exposure and outcomes, and other aspects of the study design. Increased collaboration between data sources to increase sample size is desirable.
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Affiliation(s)
- Carole A Marxer
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marlene S Rauch
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute for Pharmaceutical Sciences of Western Switzerland, Switzerland
| | - Christoph R Meier
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.,Boston Collaborative Drug Surveillance Program, Lexington, MA, United States
| | - Julia Spoendlin
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
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Kirkpatrick L, Harrison E, Khalil S, Miller E, Patterson C, Sogawa Y, Van Cott AC, Kazmerski TM. A survey of child neurologists about reproductive healthcare for adolescent women with epilepsy. Epilepsy Behav 2021; 120:108001. [PMID: 33964536 DOI: 10.1016/j.yebeh.2021.108001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate child neurologists' knowledge, attitudes, and practices regarding sexual and reproductive health (SRH) care for adolescent and young adult women with epilepsy (WWE). METHODS Child neurologists (including attending physicians, residents, fellows, and advanced practitioners) completed an online survey distributed through subspecialty listservs. We analyzed results using descriptive statistics, chi-square, and logistic regression. RESULTS Two hundred eight child neurologists completed the survey. Most believed that child neurologists should counsel young WWE on: teratogenesis (99%, n = 206/207), contraception-antiseizure medication interactions (96%, n = 194/202), pregnancy (95%, n = 198/206), contraception (89%, n = 184/206) and folic acid supplementation (70%, n = 144/205). Fewer respondents felt confident with such counseling (teratogenesis: 90%, n = 188/208, drug interactions: 65%, n = 133/208, pregnancy 75%, n = 156/208, contraception: 47-64%, n = 96-134/208, p < 0.05). Ninety-five percent (n = 172/181) reported ever discussing SRH with typically developing young WWE, compared to 78% (n = 141/181) for young WWE with mild intellectual disability (p < 0.01). One third (n = 56/170) who ever discussed SRH did not do so routinely. Respondents correctly answered 87% ± 5% of knowledge questions about SRH for WWE, 80% ± 4% of questions about teratogenic antiseizure medications, and 61% ± 7% of questions about contraception-antiseizure drug interactions. The greatest barrier to SRH care was time constraints (80%, n = 149/186). The majority (64%, n = 119/186) identified solutions including longer appointment times and co-managing SRH care with other specialties. CONCLUSIONS Findings reveal gaps in SRH care by child neurologists for adolescent and young adult WWE, especially those with mild intellectual disability. Provider-identified barriers and solutions may serve as targets to improve SRH care for this population.
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Affiliation(s)
- Laura Kirkpatrick
- UPMC Children's Hospital of Pittsburgh, Division of Child Neurology, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Elizabeth Harrison
- UPMC Children's Hospital of Pittsburgh, Division of Child Neurology, 4401 Penn Avenue, Pittsburgh, PA 15224, United States
| | - Suad Khalil
- Michigan State University College of Human Medicine, Department of Neurology, 965 Fee Road A110, East Lansing, MI 48824, United States
| | - Elizabeth Miller
- UPMC Children's Hospital of Pittsburgh, Division of Adolescent and Young Adult Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, United States
| | - Christina Patterson
- UPMC Children's Hospital of Pittsburgh, Division of Child Neurology, 4401 Penn Avenue, Pittsburgh, PA 15224, United States
| | - Yoshimi Sogawa
- UPMC Children's Hospital of Pittsburgh, Division of Child Neurology, 4401 Penn Avenue, Pittsburgh, PA 15224, United States
| | - Anne C Van Cott
- UPMC Presbyterian Hospital, Department of Neurology, 200 Lothrop Street, Pittsburgh, PA 15213, United States; Veterans Affairs Pittsburgh Healthcare System, Department of Neurology, 4100 Allequippa Street, Pittsburgh, PA 15240, United States
| | - Traci M Kazmerski
- UPMC Children's Hospital of Pittsburgh, Division of Adolescent and Young Adult Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, United States; Center for Women's Health Research and Innovation, University of Pittsburgh, 4200 Fifth Avenue, Pittsburgh, PA 15260, United States
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Tripathi M, Parihar J. Shared Decision-Making in the Management of Women with Epilepsy. Neurol India 2021; 69:435-436. [PMID: 33904469 DOI: 10.4103/0028-3886.314547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Manjari Tripathi
- Professor, Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Jasmine Parihar
- Assistant Professor, Neurology, Lady Hardinge Medical College, New Delhi, India
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Ajinkya S, Fox J, Lekoubou A. Contemporary trends in antiepileptic drug treatment among women of childbearing age with epilepsy in the United States: 2004-2015. J Neurol Sci 2021; 427:117500. [PMID: 34087566 DOI: 10.1016/j.jns.2021.117500] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/18/2021] [Accepted: 05/15/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Certain antiepileptic drugs are associated with an increased risk for major congenital malformations (MCM). However, little is known regarding recent patterns of antiepileptic drug (ASM) prescriptions to women of childbearing age with epilepsy (WCE) in the United States. METHODS Data from the Medical Expenditure Panel Survey was analyzed between the years 2004-2015 to determine trends in national antiepileptic drug prescriptions for WCE. Analysis of associations between demographic covariates and prescription of ASMs with MCM rate > 5% (topiramate, valproate, or phenobarbital) was performed with logistic regression. RESULTS There was a weighted total of 395,292 WCE. 29.1% (23.2%-35.8%) of WCE were prescribed an AED with MCM rate > 5%. The odds of a LEV prescription significantly increased in the 2010-2012 (OR 2.91, 95% CI 1.09-7.79) and 2013-2015 (OR 5.06, 95% CI 2.02-12.67) intervals compared to 2004-2006. Conversely, the odds of PB prescriptions significantly decreased in 2010-2012 (OR 0.13, 95% CI 0.02-0.83) and 2013-2015 (OR 0.13, 95% CI 0.02-0.93) compared to 2004-2006. WCE between the ages of 25-34 (OR = 2.67, 95% CI = 1.32-5.41) and 35-44 years (OR = 2.59, 95% CI = 1.23-5.45), had lower odds of being prescribed ASMs with MCM rate > 5% compared to those between the ages of 15-24 years. SIGNIFICANCE Between 2004 and 2015, the prescriptions of ASMs given to WCE has changed. Regardless, nearly one third were prescribed potentially teratogenic medications despite available and affordable safer alternatives. Identifying factors associated with the prescription of teratogenic drugs to WCE is critical so that it may be further limited in the future.
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Affiliation(s)
- Shaun Ajinkya
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Jonah Fox
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alain Lekoubou
- Department of Neurology, Penn State University Hershey Medical Center, Hershey, PA, USA
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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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Abstract
There are complex interactions between hormones, epilepsy, and antiepileptic drugs (AEDs). While there is ample evidence that hormones influence epilepsy, it is also apparent that epileptic activity influences hormones in both women and men. In addition, AEDs may disturb endocrine function. The clinical importance of these interactions is primarily related to the effects on reproductive hormones, which is the focus of this article. Reproductive endocrine dysfunction is common among women and men with epilepsy. Menstrual disorders, polycystic ovaries, and infertility have been described among women with epilepsy, while reduced potency and sperm abnormalities have been found in men. Sexual problems and endocrine changes have been frequently described in both sexes. Epilepsy and AEDs can target a number of substrates to impact hormone levels. These include the limbic system, hypothalamus, pituitary, peripheral endocrine glands, liver, and adipose tissue. AEDs may also alter the synthesis of steroids and binding proteins, as well as hormone metabolism, and produce direct gonadal effects.
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Affiliation(s)
- Erik Taubøll
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
| | | | - Andrew G Herzog
- Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, MA, United States; Faculty of Medicine, Harvard Medical School, Boston, MA, United States
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Abstract
A plethora of hormonal and physical changes occur as adolescents grow into adulthood. These changes pose additional challenges for youth with epilepsy. Providers, parents, and patients must be well educated about the hormonal influences, both intrinsic and pharmaceutical, on seizures and antiepileptics (AEDs). In addition, they must be made aware of safe/effective contraception, the importance of pregnancy planning, and potential menstrual and sexual health disturbances related to epilepsy and AEDS. Reproductive and sexual health should be an integral component of transition education and planning for all youth, but is especially important for the youth with epilepsy. While many clinicians will collaborate with adolescent gynecologists or pediatricians, it is important for all child neurologists to be aware of these issues.
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Affiliation(s)
- Maria Stefanidou
- Department of Neurology, Boston University School of Medicine, Boston, MA.
| | - Georgia Montouris
- Department of Neurology, Boston University School of Medicine, Boston, MA
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Guido-Estrada N, Sattar S. Pharmacological Considerations When Transitioning the Care of Epilepsy Patients from Pediatric to Adult Epilepsy Centers. Journal of Pediatric Epilepsy 2020. [DOI: 10.1055/s-0040-1716865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThere is scarce evidence in review of the available literature to support a clear and superior model for the transition of care for epilepsy patients from pediatric to adult centers. Anecdotally, there is a common perception that families are reluctant to make this change and that the successful transition of care for epilepsy can be a challenge for patients, families, and physicians. As part of the effort to prepare the patient and family for the adult model of care, several treatment issues should be addressed. In this article, we discuss the specific challenges for physicians in transition of care for epilepsy patients from a pharmacological standpoint, which include differences in metabolism and pharmacodynamics that can impact tolerability or efficacy of antiepileptic medications, lifestyle changes affecting medication compliance and seizure control, acquired adult health conditions necessitating new medications that may result in adverse drug interactions, and adult neurologists' potential lack of familiarity with certain medications typically used in the pediatric epilepsy population. We offer this as a guide to avoid one of the many possible pitfalls when epilepsy patients transition to adult care.
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Affiliation(s)
- Natalie Guido-Estrada
- Division of Child Neurology, University of California San Diego and Rady Children’s Hospital, San Diego, California, United States
| | - Shifteh Sattar
- Division of Child Neurology, University of California San Diego and Rady Children’s Hospital, San Diego, California, United States
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Abstract
Epilepsy is one of the most common neurologic disorders seen in children, with the highest incidence in the first year of life. Diagnostic accuracy can be challenging because many seizure mimics must be considered. Electroencephalography and neuroimaging can be critical in determining etiology and syndrome. Genetic testing is a high-yield endeavor, particularly in early-life epilepsies. Up to one-fourth of children with epilepsy will develop drug-resistant seizures. Comorbidities are very common in children with epilepsy, including intellectual disability in 25% and learning disability and attention-deficit/hyperactivity disorder in a significant minority. These comorbidities must be recognized and addressed as part of the child's overall care.
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Affiliation(s)
- Anthony Fine
- Division of Epilepsy and Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Elaine C Wirrell
- Division of Epilepsy and Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN
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Abstract
In the United States, there are over one million women with epilepsy (WWE) in their childbearing years. Pregnancy can be challenging for this population. A number of international registries have documented that children born to these women are at increased risk for major congenital malformations (MCM), lower intelligence quotient scores and neurodevelopmental disorders, when the mother is managed on antiseizure medications (ASMs). To prevent poor neonatal outcomes for this population, safe and thoughtful management strategies are necessary. We propose to divide these management strategies into five principles. These include (I) choosing suitable ASMs for the patient's seizure type, (II) choosing an ASM with the least teratogenic and cognitive side effects, (III) dosing at the lowest possible effective dosage, (IV) selecting the best ASM regimen as promptly as possible, even before a woman has her first menses, and (V) supplementing these patients with folic acid in order to try to enhance cognition and reduce neural tube defects.
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Affiliation(s)
- Rebecca Spiegel
- Department of Neurology, Stony Brook Medicine, Stony Brook, NY, United States
| | - Heidy Merius
- Department of Neurology, Stony Brook Medicine, Stony Brook, NY, United States
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Zhang YY, Song CG, Wang X, Jiang YL, Zhao JJ, Yuan F, Yang XA, Yang F, Jiang W. Clinical characteristics and fetal outcomes in women with epilepsy with planned and unplanned pregnancy: A retrospective study. Seizure 2020; 79:97-102. [PMID: 32460217 DOI: 10.1016/j.seizure.2020.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/02/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To compare the antiepileptic drug (AED) treatment patterns, seizure control, and folic acid supplementation between planned and unplanned pregnancy in women with epilepsy (WWE) and to investigate the effects of planned pregnancy on fetal outcomes. METHODS A prospectively collected database including WWE with pregnancy from Feb 2010 to Dec 2018 was retrospectively analyzed. Planned pregnancy was defined as WWE being regularly supervised by epileptologists from the time of intended pregnancy until delivery. Clinical characteristics and fetal outcomes were compared between the planned and unplanned pregnancy groups. Logistic regression was used to identify modifiable factors associated with adverse fetal outcomes. RESULTS A total of 188 planned pregnancies and 289 unplanned pregnancies were enrolled in our study. Among planned pregnancies, 66.0 % took AED monotherapy, and 32.4 % received polytherapy. Among unplanned pregnancies, 58.1 % didn't take AEDs, 28.0 % took monotherapy, and 12.8 % received polytherapy. The planned pregnancies had less generalized tonic-clonic seizures (P = 0.002) and higher proportion of being seizure-free (41.0 % vs. 22.8 %; P <0.001). All planned pregnancies took folic acid while 39.8 % of unplanned pregnancies never took it (P <0.001). The planned pregnancies had less rates of induced abortions (2.7 % vs. 13.5 %; P <0.001), preterm births (3.3 % vs. 20.4 %; P <0.001), and major congenital malformations (1.6 % vs. 7.5 %; P = 0.016). Pregnancy planning was independently associated with adverse fetal outcomes (adjusted OR, 0.14; 95 % CI, 0.08-0.27; P <0.001). CONCLUSION Planned pregnancy in WWE contributes to more optimized AED pattern, better seizure control, more appropriate folic acid supplementation, and less adverse fetal outcomes.
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Affiliation(s)
- Yao-Yao Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Chang-Geng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yong-Li Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jing-Jing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xi-Ai Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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Kirkpatrick L, Collins A, Sogawa Y, Birru Talabi M, Harrison E, Kazmerski TM. Sexual and reproductive healthcare for adolescent and young adult women with epilepsy: A qualitative study of pediatric neurologists and epileptologists. Epilepsy Behav 2020; 104:106911. [PMID: 31986439 DOI: 10.1016/j.yebeh.2020.106911] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of this study was to explore the attitudes and practices of pediatric neurologists and epileptologists regarding sexual and reproductive healthcare for adolescent and young adult women with epilepsy (WWE). BACKGROUND Adolescent and young adult WWE have unique sexual and reproductive healthcare needs, including counseling on teratogenesis, folic acid, and interactions between contraception and antiseizure medications. There are no prior studies regarding sexual and reproductive healthcare practices of pediatric neurologists or epileptologists. DESIGN/METHODS Individual semi-structured interviews were conducted with pediatric neurologists and epileptologists regarding their attitudes, practices, and experiences with sexual and reproductive healthcare for adolescent and young adult WWE. Interviews were audio-recorded and transcribed verbatim. Qualitative analysis was conducted using a thematic analysis approach. RESULTS Six child neurologists and 10 epileptologists (44% male) participated. Major themes included the following: (1) Sexual and reproductive healthcare is important for adolescent WWE, and neurologists have a key role in providing this care. (2) Sexual and reproductive healthcare should be comanaged with a primary care provider or women's health provider although neurologists have significant concerns regarding comanagement. (3) There is wide variability in sexual and reproductive healthcare practice among pediatric neurologists and epileptologists. Important subthemes included parent education and differences in sexual and reproductive healthcare practices for women with intellectual disabilities. (4) Many systemic and interpersonal barriers exist to delivering sexual and reproductive healthcare to adolescent and young adult WWE. Important barriers included limited time; provider, patient, or family discomfort; and lack of necessary knowledge or expertise. (5) Providers desire standardization of sexual and reproductive healthcare for adolescent WWE along with patient and provider education. CONCLUSION This is the first study to assess attitudes and practices of pediatric neurologists and epileptologists regarding sexual and reproductive healthcare for adolescent and young adult WWE. Our findings suggest that there is a need for development of improved systems for sexual and reproductive healthcare delivery and comanagement for adolescent and young adult WWE. Providers identified many barriers and facilitators that might serve as the basis for interventions to improve care.
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Jones JE, Asato MR, Brown MG, Doss JL, Felton EA, Kearney JA, Talos D, Dacks PA, Whittemore V, Poduri A. Epilepsy Benchmarks Area IV: Limit or Prevent Adverse Consequence of Seizures and Their Treatment Across the Life Span. Epilepsy Curr 2020; 20:31S-39S. [PMID: 31973592 PMCID: PMC7031803 DOI: 10.1177/1535759719895277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Epilepsy represents a complex spectrum disorder, with patients sharing seizures as a common symptom and manifesting a broad array of additional clinical phenotypes. To understand this disorder and treat individuals who live with epilepsy, it is important not only to identify pathogenic mechanisms underlying epilepsy but also to understand their relationships with other health-related factors. Benchmarks Area IV focuses on the impact of seizures and their treatment on quality of life, development, cognitive function, and other aspects and comorbidities that often affect individuals with epilepsy. Included in this review is a discussion on sudden unexpected death in epilepsy and other causes of mortality, a major area of research focus with still many unanswered questions. We also draw attention to special populations, such as individuals with nonepileptic seizures and pregnant women and their offspring. In this study, we review the progress made in these areas since the 2016 review of the Benchmarks Area IV and discuss challenges and opportunities for future study.
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Affiliation(s)
- Jana E Jones
- University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
| | - Miya R Asato
- Division of Child Neurology, UPMC Children's Hospital of Pittsburgh, PA, USA
| | - Mesha-Gay Brown
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Elizabeth A Felton
- University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
| | | | - Delia Talos
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Vicky Whittemore
- Division of Neuroscience, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MA, USA.,Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Annapurna Poduri
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
During puberty, with activation of the hypothalamic pituitary axis that has been quiescent since the neonatal period, linear growth accelerates, secondary sexual characteristics develop, and adult fertility potential and bone mass are achieved, together with psychosocial and emotional maturation.Disordered pubertal onset and progress, either early or late, presents frequently for endocrine care. Where a disorder is found, due either to a central hypothalamic pituitary cause or to primary gonadal failure, pharmacotherapeutic interventions are required to alter the trajectory of disturbed pubertal onset or progress and for maintenance of adolescent and adult sex hormone status. This paper describes pharmacologic interventions used for pubertal disorders but is not intended to address the diagnostic cascade in detail.
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Affiliation(s)
- Margaret Zacharin
- Department of Endocrinology, Royal Children's Hospital, Parkville, VIC, Australia.
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Brussé IA, Kluivers ACM, Zambrano MD, Shetler K, Miller EC. Neuro-obstetrics: A multidisciplinary approach to care of women with neurologic disease. Handb Clin Neurol 2020; 171:143-160. [PMID: 32736747 DOI: 10.1016/b978-0-444-64239-4.00007-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The term "neuro-obstetrics" refers to a multidisciplinary approach to the care of pregnant women with neurologic comorbidities, both preconceptionally and throughout pregnancy. General preconception care should be offered to all women, including women with neurologic disease. Women with neurologic comorbidities should also be offered specialist preconception care by an obstetrician who consults with a neurologist, anesthesiologist, and if indicated clinical geneticist and/or other specialists. In women with neurologic comorbidities, neurologic sequelae may influence the course of the pregnancy and delivery. Also, pregnancy may influence the severity of the neurologic condition, depending on the type of disease. Physiologic adaptations during pregnancy and altered pharmacokinetics may cause altered blood serum levels of drugs, leading to decreased or increased drug effects. When administering drugs to a woman who wishes to conceive, it is important to consider possible teratogenic effects and possible secretion in breast milk. Tailoring medication regimens should be considered, preferably preconceptionally. In this chapter, we review general principles of neuro-obstetric care, as well as some specific considerations for neurologists, obstetricians, and anesthesiologists caring for pregnant women with common neurologic conditions.
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Affiliation(s)
- Ingrid A Brussé
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Anna C M Kluivers
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maria D Zambrano
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Kara Shetler
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States
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Abstract
PURPOSE OF REVIEW This article provides the latest information to guide practitioners in counseling and treating women with epilepsy. RECENT FINDINGS There is an increasing body of literature on the multidirectional effects of sex hormones on seizure frequency and severity and of seizures altering areas of the brain involved in neuroendocrine function. Ongoing pregnancy outcome data from pregnancy registries and meta-analysis of observational studies have provided key information on the safety of using antiseizure medications during pregnancy and the risk to the fetus. SUMMARY In treating and counseling women with epilepsy from puberty to menopause, it is important to understand the complex interactions of sex hormones, seizures, and antiseizure medications on reproductive health and pregnancy outcomes.
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Herzog AG, Mandle HB, MacEachern DB. Association of Unintended Pregnancy With Spontaneous Fetal Loss in Women With Epilepsy: Findings of the Epilepsy Birth Control Registry. JAMA Neurol 2019; 76:50-55. [PMID: 30326007 DOI: 10.1001/jamaneurol.2018.3089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance If unintended pregnancy is common among women with epilepsy and is associated with increased risk of spontaneous fetal loss (SFL), it is important to develop guidelines for safe and effective contraception for this community. Objective To assess whether planned pregnancy is a determinant of SFL in women with epilepsy. Design, Setting, and Participants The Epilepsy Birth Control Registry conducted this web-based, retrospective survey between 2010 and 2014. It gathered demographic, epilepsy, antiepileptic drug (AED), contraceptive, and reproductive data from 1144 women with epilepsy in the community between ages 18 and 47 years. Data were analyzed between March 2018 and May 2018. Main Outcomes and Measures The primary outcome was the risk ratio (RR) with 95% confidence intervals for SFL in unplanned vs planned pregnancies. The secondary outcome was the identification of some potentially modifiable variables (maternal age, pregnancy spacing, and AED category) of SFL vs live birth using binary logistic regression. Results The participants were proportionally younger (mean [SD] age, 28.5 [6.8] years), and 39.8% had household incomes of $25 000 or less. Minority women represented only 8.7% of the participants. There were 530 of 794 unplanned pregnancies (66.8%) and 264 of 794 planned pregnancies (33.2%). The risk for SFL in 653 unaborted pregnancies in women with epilepsy was greater for unplanned (n = 137 of 391; 35.0%) than planned (n = 43 of 262; 16.4%) pregnancies (RR, 2.14; 95% CI, 1.59-2.90; P < .001). Regression analysis found that the risk for SFL was greater when planning was entered alone (odds ratio [OR], 2.75; 95% CI, 1.87-4.05; P < .001) and more so when adjusted for maternal age, interpregnancy interval, and AED category (OR, 3.57; 95% CI, 1.54-8.78; P = .003). Interpregnancy interval (OR, 2.878; 95% CI, 1.8094-4.5801; P = .008) and maternal age (OR, 0.957; 95% CI, 0.928-0.986 for each year from 18 to 47 years; P = .02), but not AED category, were also associated. The risk was greater when interpregnancy interval was less than 1 year (n = 56 of 122; 45.9%) vs greater than 1 year (n = 56 of 246; 22.8%) (RR, 2.02; 95% CI, 1.49-2.72; P < .001). Relative to the younger than 18 years cohort (n = 15 of 29; 51.7%), the risks were lower for the intermediate older cohort aged 18 to 27 years (n = 118 of 400; 29.5%; RR, 0.57; 95% CI, 0.39-0.84; P < .004) and the cohort aged 28 to 37 years (n = 44 of 212; 20.8%; RR, 0.40; 95% CI, 0.26-0.62; P < .001) but not significantly different for the small number of participants in the aged 38 to 47 years cohort (n = 3 of 12; 25.0%). No individual AED category's SFL frequency differed significantly from the no AED category. Conclusions and relevance The Epilepsy Birth Control Registry retrospective survey finding that unplanned pregnancy in women with epilepsy may double the risk for SFL warrants prospective investigation with outcome verification.
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Affiliation(s)
- Andrew G Herzog
- Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Hannah B Mandle
- Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Devon B MacEachern
- Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Bjørk M, Riedel B, Spigset O, Veiby G, Kolstad E, Daltveit AK, Gilhus NE. Association of Folic Acid Supplementation During Pregnancy With the Risk of Autistic Traits in Children Exposed to Antiepileptic Drugs In Utero. JAMA Neurol 2019; 75:160-168. [PMID: 29279889 DOI: 10.1001/jamaneurol.2017.3897] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Strategies to prevent autism in children exposed to antiepileptic drugs (AEDs) during pregnancy are important. Objective To explore whether folic acid supplementation and folate status in pregnancy are associated with reduced risk of autistic traits owing to in utero AED exposure. Design, Setting, and Participants The population-based, prospective Norwegian Mother and Child Cohort Study approached Norwegian-speaking women attending routine ultrasonographic examinations from June 1999 through December 31, 2008 (163 844 of 277 702 women refused). No exclusion criteria were applied beyond language. Questionnaires during and after pregnancy, analysis of blood samples, and linkage to the Medical Birth Registry of Norway were performed. Children aged 18 to 36 months of women with available information on use of AEDs and of folic acid supplementation (n = 104 946) were included in the analysis from March 1, 2016, through June 13, 2017. Exposures Maternal folic acid supplementation 4 weeks before to 12 weeks after conception. Plasma folate concentration was analyzed at gestational weeks 17 to 19. Main Outcomes and Measures Autistic traits were evaluated using the Modified Checklist for Autism in Toddlers and Social Communication Questionnaire. Odds ratios (ORs) for autistic traits in children by maternal use vs nonuse of folic acid supplements were adjusted for maternal health and socioeconomic factors. Folate concentrations and folic acid doses were associated with the degree of autistic traits. Results The overall mean (SD) age of the 104 946 mothers of participating children was 29.8 (4.6) years, with complete information available for analysis in 103 868. Mean (SD) age of women with epilepsy who received AED treatment was 29.4 (4.9); women with epilepsy who did not receive AED treatment, 29.1 (4.9); and without epilepsy, 29.8 (4.6) years. In the 335 children exposed to AEDs, the risk for autistic traits was significantly higher at 18 months of age (adjusted OR [AOR], 5.9; 95% CI, 2.2-15.8) and 36 months of age (AOR, 7.9; 95% CI, 2.5-24.9) when their mothers had not used folic acid supplements compared with children of mothers who had used supplements. Among women without epilepsy, the corresponding risks were lower at 18 months of age (AOR, 1.3; 95% CI, 1.2-1.4) and 36 months of age (AOR, 1.7; 95% CI, 1.5-1.9); among the 389 children of women with untreated epilepsy, the corresponding risks were not significant at 18 months of age (AOR, 1.0; 95% CI, 0.4-3.0) and 36 months of age (AOR, 2.5; 95% CI, 0.4-16.6). Degree of autistic traits was inversely associated with maternal plasma folate concentrations (β = -0.3; P = .03) and folic acid doses (β = -0.5; P < .001). Concentrations of AEDs were not associated with the degree of autistic traits. Conclusions and Relevance Risk of autistic traits in children exposed to AEDs in utero may be mitigated by periconceptional folic acid supplementation and folate status. Fertile women using AEDs should take folic acid supplements continuously.
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Affiliation(s)
- Marte Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Bettina Riedel
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Laboratory of Clinical Biochemistry, Section of Clinical Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Gyri Veiby
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Eivind Kolstad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Anne Kjersti Daltveit
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Division of Epidemiology, Norwegian Institute of Public Health, Bergen, Norway
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Affiliation(s)
- Kimford J Meador
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
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Noe K. Mission: Control. How Can We Increase Highly Effective Contraception Use in Women With Epilepsy? Epilepsy Curr 2019; 19:297-298. [PMID: 31409154 PMCID: PMC6864570 DOI: 10.1177/1535759719869014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Prevalence of Highly Effective Contraception Use by Women With Epilepsy Herzog AG, Mandle HB, MacEachern DB. Neurology. 2019; pii: 10.1212/WNL.0000000000007581. doi:10.1212/WNL.0000000000007581. [Epub ahead of print]. PMID: 31101739. Objective: To determine (1) the proportion of women with epilepsy (WWE) at risk of unintended pregnancy who use highly effective contraception, (2) demographic predictors, and (3) folic acid (FA) use. Methods: These cross-sectional data come from 311 US WWE, 18 to 47 years, who participated in the Epilepsy Birth Control Registry (EBCR) web-based survey in 2017. They provided demographic, epilepsy, antiepileptic drug (AED), contraceptive, and FA data. We report frequencies of highly effective contraception use and use logistic regression to determine demographic predictors. We report the proportion who take FA. Results: A total of 186 (59.8%) of the 311 WWE were at risk of unintended pregnancy. A total of 131 (70.4%) used a highly effective contraceptive category; 55 (29.6%) did not. An additional 13 (7.0%) used a combination of generally effective hormonal contraception with an enzyme-inducing AED, which poses increased risk of unintended pregnancy. Overall, 68 (36.6%) of the 186 WWE at risk did not use highly effective contraception. Increasing income (P = .004) and having insurance (P = .048) were predictors of highly effective contraception. A total of 50.0% took FA supplement. There was no significant difference in relation to the use or lack of use of highly effective contraception. Conclusion: A total of 36.6% of WWE in the EBCR did not use highly effective contraception and 50.0% did not take FA in 2017 despite the important negative consequences of unintended pregnancy on pregnancy outcomes. There is a need for more readily available information and counseling on safe and effective contraception and FA use for this community.
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