Are doses of lamotrigine or levetiracetam adjusted during pregnancy?

Abstract

SummarySubtherapeutic levels of lamotrigine and levetiracetam are more likely to occur during pregnancy owing to the effect of pregnancy on their pharmacokinetics. This can lead to suboptimal control of epilepsy, and guidelines recommend proactive dose adjustment in the second and third trimesters alongside therapeutic drug monitoring (TDM). This retrospective cohort study using administrative databases aimed to investigate whether prescribers adjust the dose of lamotrigine or levetiracetam during and after pregnancy and whether TDM is used to manage dose adjustment. In 460 individual pregnancies, 232 women (61.4%) had their lamotrigine dose increased in the second and third trimesters and 44 women (53.7%) had their levetiracetam dose increased. Only 57 women (12.4%) had any TDM. The dose was not always decreased postpartum, and 157 women (56.9% of those who had escalated doses during pregnancy) had dose reduced following birth. Between 2012 and 2015, 29 women had an epilepsy‐coded hospital discharge during pregnancy and were more likely to have had their dose of lamotrigine or levetiracetam increased. Overall, doses of lamotrigine and levetiracetam were not increased during pregnancy in 40% of the study population, dose changes were not often guided by TDM, and doses were not always reduced postpartum.

Dose Monitoring of Lamotrigine Monotherapy in Pregnancy: Are Pregnant Women with Epilepsy Currently Optimally Managed? A Systematic Review

“…There were 6 prospective studies (4 observational studies, 12,23,28,29 1 observational survey, 10 and 1 doubleblind randomized trial), 30 4 retrospective studies, [31][32][33][34] and 1 study combining both prospective and retrospective aspects (Table 1). 35 The sample size varied across the studies, ranging from 12 to 1251 participants.…”

“…35 The sample size varied across the studies, ranging from 12 to 1251 participants. Among these studies, 5 exclusively focused on patients receiving lamotrigine monotherapy, 10,12,23,31,35 2 involved patients on different antiepileptic drugs, including lamotrigine monotherapy, 28,33 and 4 included a combination of patients on either lamotrigine monotherapy or combination therapy. 29,30,32,34 From these studies, only lamotrigine-specific data were extracted, if available.…”

Levetiracetam, lamotrigine and carbamazepine: which monotherapy during pregnancy?

“…Only one patient on LTG had to increase the drug dosage due to reduced blood levels. Hence, our data suggest that in clinical practice, therapeutic adjustments during gestation are only rarely necessary and that the monitoring of drug serum levels is not always required [ 32 ], while clinical outcome may efficiently drive ASMs changes. Indeed, it is still unclear whether the blood reduction of LEV and LTG levels has implications in terms of seizure recurrence risk or increased seizure frequency [ 28 , 30 , 32 – 34 ].…”

Psychopharmacologic Considerations for Transgender and Gender Diverse People

“…This is often done for patients who become pregnant while taking lamotrigine. 7 For patients who are already taking estrogen when starting lamotrigine, monitoring serum estradiol and lamotrigine levels may reassure TGD patients hesitant to start a medication that could interfere with GAH effectiveness and thus bolster lamotrigine adherence. We recommend rechecking serum levels of both medications after adjusting the dose of either one.…”

“…For patients who reach an effective lamotrigine dose before initiating estrogen, we recommend aiming to maintain that serum lamotrigine level after starting estrogen. This is often done for patients who become pregnant while taking lamotrigine . For patients who are already taking estrogen when starting lamotrigine, monitoring serum estradiol and lamotrigine levels may reassure TGD patients hesitant to start a medication that could interfere with GAH effectiveness and thus bolster lamotrigine adherence.…”