Clinical Topics & News

A Patient of Child-Bearing Age


 

Nikesh Ardeshna, MD

Dr. Ardeshna is the Medical Director of Adult Epilepsy Services at Royal Oak Hospital, Beaumont Health System, in Royal Oak, Michigan.

A 20-year-old female with a history of primary generalized epilepsy presents for establishment of care, as the patient’s insurance had changed. She is currently taking levetiracetam (Keppra) 1500 mg twice daily and divalproex (Depakote) 500 mg once daily by mouth at bedtime. The patient’s last breakthrough seizure was 10 months ago, at which time divalproex was added. The patient has a history of anxiety and depression, for which she is taking escitalopram (Lexapro) 10 mg once daily. The patient also has a history of “sporadic” headaches. The patient used to be on oral contraceptives, but about 3 months ago an intrauterine device was placed.

Questions:

Given the patient’s gender and age, is this the ideal antiepileptic drug (AED) regimen for this patient?

Items to consider: The patient is a young female of child-bearing age. Divalproex has been shown to be among the least safe AEDs during pregnancy due to a higher risk for birth defects and cognitive side effects on the child.

Ideally, an AED other than divalproex should be chosen. Divalproex also has numerous other side effects.

Polytherapy and higher doses of AEDs can increase the risk of teratogenic side effects.

Levetiracetam is considered to be a relatively safe AED for pregnancy.

The goal should be to simplify the patient’s AED regimen to monotherapy and minimize the dose.

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