Special groups

Women

Women of child bearing age provide epilepsy professionals with unique treatment dilemmas

•Epilepsy drugs and appearance

•Female hormones and seizure control

•Fertility

•Contraception

•Pregnancy

effects of drugs

effects of seizures

Commonly used AED’s

Carbamazepine Sodium Valproate Leveitracetam

Lamotrigine

Phenytoin Topiramate

Zonisamide

Clobazam

Pregabalin

Lacosamide

•Carbamazepine / Oxcarbazepine / Eslicarbazepine / Carbamazepine / Oxcarbazepine / Eslicarbazepine / Topiramate / Phenytoin / Phenobarbitone / PrimadoneTopiramate / Phenytoin / Phenobarbitone / Primadone all induce hepatic P-450

•These effect the metabolism of oestrogens and progestogens

•Leading to ineffective Oral Combined Contraceptive Pill (OCP) at normal doses

•These will also effect emergency contraception

•Lamotrigine levels are significantly reduced by the OCP

Recommendations…..

For women taking enzyme inducing medications:

Works Well Caution Not recommended

•Coil / Mirena •Barrier

•OCP (increased dose required) •Depo (time) •Emergency contraception

•Implant •Patch •Progestogen

For women NOT taking enzyme inducing medications:

Works Well Caution

•Coil / Mirena •Barrier •OCP •Implant •Patch•Emergency Contraception

•Depo (time) •Progestogen

For women taking Lamotrigine

Works Well Caution

•Coil / Mirena •Barrier •Implant •Patch•Emergency Contaception

•OCP (recommend slight increase in Lamotrigine dose) •Depo (time) •Progestogen

Pre-conceptual counselling women with epilepsy

• All women with epilepsy who are considering becoming pregnant should be offered specialist advice and information

All epilepsy medications will increase the risk of having a child with a major congenital malformation

Background2-3%

Sodium Valproate 5-9% **

Lamotrigine 3-5%

Carbamazepine3-4%

For those on polytherapy the risks increase

CSM advice, Sept 2003

Women of childbearing age should not be started on sodium valproate without specialist neurological advice

Pre-conceptual treatment choices

•Remain on current medication

•Change to alternative medication

•Withdraw medication (medication should NEVER be stopped suddenly)

•Reduce medication for 1st trimester

•5mgs Folic Acid

Broad and imprecise

Risk of passing epilepsy on…

•1% if neither parent•4% if father•8% if mother•25% if both parents

Essential Information…

•The majority have normal pregnancies

•Unchanged seizure frequencies throughout

•Will have to continue to take epilepsy medication

•Medication should not be stopped or changed during pregnancy (unless under specialist supervision)

•Will have normal vaginal deliveries

•Should be advised to breastfeed

However…

•There is an increased risk of maternal death

•The effects of seizures on a foetus are unknown

•All pregnancies should be treated as high risk and under consultant led care

The majority have normal pregnancies with normal babies

Post Natal Advice

• Child/mother safety:

feeding sleep deprivation bathing carrying safety outdoors

Catamenial Epilepsy

Direct link between seizures and menstrual cycle in about 12% of women with epilepsy

Approximately 70% of women notice increase frequency of seizures around menstruation

Clobazam 10mgs daily

Teenagers

Issues

→Compliance / denial

→Further education

→Driving

→Alcohol / recreational drugs

→Independence

→Employment

→Safety

The Elderly

Issues

→drug tolerance

→misdiagnosis

→co-morbidity

→Independence

→safety