26 October 2004
Managing epilepsy in women: new guidelines
The Royal Society of Medicine Press has published new Primary Care Guidelines for the Management of Females with Epilepsy. These guidelines were produced following a multidisciplinary consensus meeting of epilepsy experts and cover such topics as the diagnosis and treatment of epilepsy, preconception counselling and the management of epilepsy during and after pregnancy.
Weighing the risks
Over 1000 people die per year in the UK as a direct result of their seizures and 25% of all epilepsy patients are women of reproductive age. Although antiepileptic drugs (AEDs) ‘have been associated with a 2- 3 fold increase in major congenital malformations in children,’ the risk of uncontrolled seizures both mother and baby during pregnancy is ‘probably greater than the risk of continued exposure’ to the drugs.
The GP’s role
The Guidelines advise that, generally speaking, GPs should not be responsible for starting or changing AEDs. It advises that GPs need to be familiar with the issues surrounding the choice of medication in women but stress that patients ‘must be referred to a specialist within 28 days’ to prescribe and monitor treatment. The Guidelines Group give the following advice to GPs on the management of females with epilepsy who may become pregnant:
- GPs should introduce preconceptual issues to women of childbearing age soon after diagnosis and at every review, well in advance of when a woman may be planning to start a family, and these should be raised at every opportunity and documented as having been discussed
- Women with epilepsy should be reassured that if they decide to have children, their pregnancies, although medically complicated, are likely to be uneventful and they are likely to deliver healthy babies
- The choices of drug should never be presented as being either ‘perfect’ or ‘harmful’ as the ‘perfect’ drug may prove unsuitable and others may have to be tried
- GPs should advise that although sodium valproate is the antiepileptic of choice in patients with certain types of epilepsy, women taking sodium valproate during pregnancy appear to have a significantly increased risk of having a child with major malformations compared with those women taking carbamazepine or lamotrigine
- Therefore, women of childbearing potential should not be started on sodium valproate without specialist neurological advice, and should only take the drug if no other treatment can control her seizures. Changes in type of antiepileptic medication should only be made on specialist advice and there should be no abrupt changes to or withdrawal from medication
- If a woman has been seizure-free for 2-3 years, she should be offered the opportunity to discuss with a specialist the gradual withdrawal of her AED medication even though this may affect lifestyle issues
The experts
Professor Ley Sander, Institute of Neurology said, ‘These Guidelines address a very topical issue and will help GPs to optimise the treatment of women with epilepsy. It is important that a balance is struck between the risks and benefits of epilepsy treatments..’
Sally Gomersall patient representative at the National Society for Epilepsy said, ‘The GP is pivotal in ensuring female patients receive seamless care, feels supported and empowered to make informed decisions regarding her choice of AED and the different methods of contraception available to her and her partner.’
Dr Steve Simons, a GP and Medical Officer at the Meath Epilepsy Trust in Godalming said, ‘These guidelines should assist GPS in addressing some difficult issues in the management of their patients with epilepsy. Currently better care is being demanded across all clinical frameworks and these guidelines should be of particular help for GPs in setting up and maintaining regular clinical reviews for patients with epilepsy, as recommended by the new GP contract.’
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