Treatment of Epilepsy to Optimize Bone Health

Abstract

When treating a person with epilepsy, one must consider many factors in addition to the obvious need to treat the seizures. Both epilepsy itself and treatment with antiepileptic drugs (AEDs) subject one to numerous potential secondary long-term health concerns. Poor bone health is one of these concerns. Studies suggest that persons with epilepsy treated with AEDs have an increased risk of fracture, low bone mineral density (BMD), and abnormalities in bone metabolism. Multiple factors likely contribute to the increased risk. Falls during generalized tonic-clonic seizures, secondary effects of AEDs on balance, inactivity, low BMD, reduced calcium intake, reduced active vitamin D metabolites, and a genetic predisposition to low BMD may all contribute. Studies suggest a differential influence of AEDs. Phenytoin, phenobarbital, and primidone are most consistently associated with a negative impact on bone. Carbamazepine and valproate may also result in bone abnormalities, but data are mixed. Current studies suggest that lamotrigine has limited (if any) effect, but again, data are inconsistent. Other AEDs have received limited study. Screening for poor bone health includes serologic testing of vitamin D metabolites (notably 25-hydroxyvitamin D) as well as BMD testing using dual energy x-ray absorptiometry. Optimizing intake of calcium and vitamin D is important for all persons with epilepsy treated with AEDs. Although many treatments for low BMD are available, these agents have not been studied in persons with epilepsy treated with AEDs. Overall, physicians treating persons with epilepsy must consider the potential effect of having epilepsy and its main treatment, AED therapy, on bone health. For patients in whom bone health is a particular concern (eg, those with diagnosed bone disease or with significant risk factors for bone disease, including glucocorticosteroid use), it is best to avoid AEDs known to negatively affect bone. In addition, practitioners should work with other treating physicians to optimize bone health in these patients.

Contraception for Women with Epilepsy

“…Effects on bone may be compounded when women are taking AEDs known to negatively impact bone. Enzyme-inducing AEDs and valproate are associated with decreased bone mineral density and increased markers of bone turnover [ 53 ]. Sustained increased bone turnover results in bone loss.…”

“…Dual energy X-ray absorptiometry (DXA) scans are recommended for those at signifi cant risk for bone loss. At risk persons include perimenopausal women, persons with prolonged AED use, particularly enzyme inducing AEDs and valproate, and those with other risk factors such as concomitant steroid use [ 53 ]. Since BMD loss with DMPA may be recovered, DMPA use alone is not considered a reason monitor BMD.…”

“…Intravenous sedation does not increase the risk of seizures, indeed, benzodiazepines are anticonvulsants. The Essure (Bayer Healthcare Pharmaceuticals, Wayne, NJ, USA) coils and Filshie Clips are not likely to impact MRI safety and are not likely to interfere with MR image quality [ 53 ]. The Essure product label states that a maximum temperature change of +1.7 C occurred during 15 min of 3 T pelvic MRI, and that MR image quality may be compromised only when the structure being imaged is close to the device; brain images should not be impacted [ 54 ].…”

Osteoporoza prouzrokovana lekovima

“…Podaci o drugim antiepilepticima za sada ne postoje, verovatno zbog malog broja pacijenata koji ih koriste, ali je sklonost ka osteoporozi veća kod pacijenata sa politerpijom nego monoterapijom [37].…”

Review of Fractures and Low Bone Mass in Children with Cerebral Palsy

“…Multidisciplinary feeding team approach 43 Early use of Ryles tube, surgical correction of gastro-esophageal reflux or gastrostomy Abnormal vitamin D metabolism: Low vitamin D status 5 Use of AEDs 5,9,17,21 Ensure adequate vitamin D intake Vitamin D treatment for rickets or osteomalacia 5 Use of AEDs with the lowest impact on bone metabolism 44 Vitamin D and calcium supplementation in children receiving AEDs 45…”