Treatment of Epilepsy in Pregnancy Varies Across Geographic Settings

The differences in prescribing practices across subspecialty, clinical experience, and in developed versus developing countries suggest that refined guidelines may benefit the treatment and monitoring of epilepsy in pregnant women, according to a study published in Neurology: Clinical Practice.

The investigators of this study sought to assess different approaches to treating epilepsy in pregnant women by identifying similarities and differences in current prescribing practices using a case-based survey.

A total of 642 neurology practitioners — across subspecialties and representing a range of geographical and clinical settings — completed an anonymous electronic survey, answering 9 clinical questions regarding 2 hypothetical cases of pregnancy in women with epilepsy. Respondents from 81 countries reported demographic and practice-related questions, including number of years practicing, level of training, and the number of pregnant women treated for epilepsy in the past year. The investigators performed both descriptive and inferential analyses, using a multiple logistic regression model for the latter to test the effect of provider characteristics on the constructed binary outcome variables of interest.

Whereas most of the respondents said they would start folate supplementation in a patient of childbearing age with epilepsy, their responses to appropriate dosing varied widely. And when asked what first-line antiepileptic drugs they would prescribe, the answers also varied among respondents with different years of experience and from countries of different economic development status: respondents from countries with developed economies were more likely to recommend lamotrigine (odds ratio [OR] 1.5; P <.05) and levetiracetam (OR 1.85; P <.001) and less likely to recommend carbamazepine (OR 0.23; P <.001). Similarly, respondents from economically developed countries were 3 times more likely to monitor antiepileptic drug levels in patients (OR 3.79 for lamotrigine, OR 3.13 for levetiracetam; P <.001) and to check levels more than once a trimester (OR 3.31; P <.001).

Limitations to the study included only drawing possible respondents from the membership of the American Academy of Neurology and readers of Neurology and its spoke journals. Additionally, the cases included in the survey were intentionally concise to minimize the dropout rate and lacked detail typical of patient encounters. Two responses may have been duplicates of prior responses with separate survey login attempts. Finally, some information may have been lost due to the survey design eliciting dichotomous responses.

The researchers indicate that the respondents’ choice of first-line treatment varied by their country’s economic development status, suggesting that access to specific antiepileptic drugs may influence clinical decision-making in different geographic settings. Future studies should research appropriate dosing of folic acid supplementation and the frequency of checking patient levels of antiepileptic drugs and assess the treatment gap in epilepsy between developed versus developing countries.

Reference

George IC, Bartolini L, Ney J, Singhal D. Differences in treatment of epilepsy in pregnancy, a worldwide survey [published online April 22, 2019]. _Neurol Clin Pract. _doi:10.1212/CPJ.0000000000000642