Koji je najbolji lijek za epilepsiju za žene koje planiraju trudnoću ili su trudne?
Liječenje trudnica s epilepsijom mora biti strogo individualizirano jer niti jedan lijek nije dokazano siguran u smislu teratogeneze. Više detalja pročitajte u ovotjednom članku o toj temi objavljenom na medscape.com.
Which is the best antiepileptic drug for women who want to become pregnant?
Response from Andrew A. Wilner, MD
Neurohospitalist, Department of Neurology, Lawrence and Memorial Hospital, New London, Connecticut
Need for Treatment?
Approximately 500,000 women with epilepsy are of childbearing age in the United States. The need for antiepileptic drug treatment should be reassessed in all women with epilepsy who are considering pregnancy. A careful evaluation of women with “epilepsy” may identify some women who are prescribed antiepileptic drugs for ill-defined “spells” that have since gone away or women with persistent nonepileptic events, such as migraine and syncope, that were misdiagnosed as epilepsy. Still other women may have epilepsy that is sufficiently controlled (ie, they have been seizure-free for several years) to warrant a trial off medication before conception.
If it is clear that the patient needs antiepileptic drug treatment, the first priority is to select the right drug for the particular seizure type. In terms of efficacy, valproic acid and lamotrigine should be considered for women with idiopathic (primary) generalized epilepsy. The other antiepileptic drugs are appropriate for women with localization-related (partial) seizures.
Tolerability is the next consideration. Patients are unlikely to take a drug that makes them miserable. The increasing number of US Food and Drug Administration-approved antiepileptic drugs has created a plethora of options, which increases the likelihood of finding an effective and tolerable drug.
Current evidence suggests that women taking valproate in the first trimester run the highest risk for congenital malformations, an effect that is probably dose-related. Furthermore, children who are exposed to valproate prenatally had impaired fluency and originality compared with children who were exposed to carbamazepine and lamotrigine. Phenytoin and phenobarbital should also be avoided to prevent adverse cognitive outcomes.
With respect to teratogenesis, monotherapy is safer than polytherapy. Consequently, if a woman with well-controlled seizures is taking 3 drugs, consider a trial of 2 drugs. If she is taking 2 drugs, try 1. As always, the lowest effective dose should be prescribed. These interventions are best implemented before pregnancy in case seizures recur, which could be harmful to the fetus.
It is important to monitor antiepileptic drug levels at regular intervals because dosage adjustment may be required as a result of the altered pharmacokinetics of pregnancy. This is particularly true with lamotrigine, levetiracetam, and oxcarbazepine.
“New” Antiepileptic Drugs
Although the newer antiepileptic drugs may appear safer with respect to teratogenicity, this perception is influenced by a relative lack of data.
Recommendations in Brief
1.Make sure the patient really needs antiepileptic treatment
2.Choose the drug that controls the seizures and is well tolerated (but avoid valproate).
3.Use as few drugs as possible at the lowest effective dose.
4.Monitor drug levels during pregnancy.
To date, no antiepileptic drug has proven safe in pregnancy in terms of teratogenesis. Treatment must be individualized for all patients.