In this guest blog consultant neurologist Professor Tony Marson discusses a new Cochrane reviewCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. on how treatments for epilepsy in pregnancy may affect the unborn child and the dilemma facing young women making decisions about their treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes.
A new study published today in the Cochrane Library highlights current evidence about the intelligence of children born to women taking antiepileptic medication. One medication, valproate, is of particular concern as it is associated with a drop in IQ sufficient to impact on educational and employment opportunities. There was no convincing evidence that other commonly used antiepileptic drugs affect offspring’s IQ.
As a result, some young women with epilepsy face a very tough choice about which antiepileptic medication to take for their epilepsy.
Epilepsy is a common condition with a life time riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of 3-5%. About a quarter of people with epilepsy have an idiopathic generalised epilepsy, the cause of which is genetic. This type of epilepsy starts in childhood and adolescence and valproate has been proven to be significantly better than other treatments at controlling seizures. It is young women with this type of epilepsy that face the most difficult choice.
At the time of epilepsy diagnosis, the majority of young women are not planning to start a family in the short to medium term. However, whichever medication they start, they may still be taking it if and when they do decide to conceive.
Weighing up possible harms
Taking valproate in pregnancy may be linked to developmental problems
As a result, young women and their families are faced with a very difficult decision. Do they choose valproate, accepting the riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. in pregnancy and the likely need to consider changing treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. before conceiving? Or do they choose a less effective treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. and riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. delay in controlling seizures, which also carries risks? Uncontrolled seizures can result in injury, impact on education and opportunities, impair quality of life, and are associated with an increased riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of sudden death (about 0.5% per year for uncontrolled seizures).
In order to make informed decisions it is vital that young women and their families have access to dedicated and coordinated services, from which they can receive detailed counselling from trained specialists. In developed world health care settings, this will usually be undertaken by paediatric or adult neurologists and epilepsy specialist nurses. This does highlight the need for epilepsy to be diagnosed by a specialist who is able to differentiate the different types of epilepsy and who is up to date with the latest evidence. It also highlights the need for women taking antiepileptic medication to continue to have access to specialist services so that they too can be kept up to date and be encouraged to avoid unplanned pregnancy.
There are particular challenges in the developing world where there is a massive treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. gap, with a large proportion of people with epilepsy having little or no access to care. In this setting the greatest riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. to women is that their epilepsy is not controlled, but there is also a greater riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. that they might receive valproate inappropriately.
How should the regulators respond to this information? The European Union Medicines Agency (EMA) is considering recommending that women are not prescribed valproate unless other treatments have failed. Whilst this approach might protect offspring, it denies women access to an effective treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. and incurs other significant risks at a time when they are not planning to conceive. The EMA view seems one sided and to have failed to take both benefit and riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. appropriately in to account.
This dilemma is one of many faced by people with epilepsy who are often in the shadows due to continued stigmatisation, and highlights the need for access to specialist and integrated care.
Links:
Bromley R, Weston J, Adab N, Greenhalgh J, Sanniti A, McKay AJ, Tudur Smith C, Marson AG. Treatment for epilepsy in pregnancy: neurodevelopmental outcomes in the child. Cochrane Database of Systematic ReviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 2014, Issue 10. Art. No.: CD010236. DOI: 10.1002/14651858.CD010236.pub2
The Cochrane Library, Wiley Press Room [online]. 2014. Expectant mothers with epilepsy face tough choices over their medication [press release]. 30 October 2014. Available from: http://eu.wiley.com/WileyCDA/PressRelease/pressReleaseId-113502.html