On Tue, 6 Jul 2004 17:46:39 -0400, Catherine Watson Genna, IBCLC
<[log in to unmask]> wrote:
>Has this mom ever been withdrawn from medication? Most neurologists
>favor a gradual withdrawl from anticonvulsants after a patient has been
>seizure free for 2 years, and certainly after 5. About 80% of seizure
>free patients are able to continue off meds without seizures. Of
>course, pregnancy is not a time to try a med withdrawal, but it
>certainly sounds like this mom might not be getting state of the art
>care. Also, phenobarb is an old drug, with many side effects.
>
>I have had clients breastfeed on many different medications, including
>phenobarb, without problems in their infants. Information on particular
>drugs is scarce.
>
> From a Medline search:
>
>
>
>
>
>Treatment of epilepsy in women of reproductive age: pharmacokinetic
>considerations.
>
>McAuley JW, Anderson GD.
>
>Clin Pharmacokinet. 2002;41(8):559-79.
>
>The Ohio State University College of Pharmacy, 500 West 12th Avenue,
>Columbus, OH 43210, USA. [log in to unmask]
>
>Although epilepsy affects men and women equally, there are many women's
>health issues in epilepsy, especially for women of childbearing age.
>These issues, which include menstrual cycle influences on seizure
>activity (catamenial epilepsy), interactions of contraceptives with
>antiepileptic drugs (AEDs), pharmacokinetic changes during pregnancy,
>teratogenicity and the safety of breastfeeding, challenge both the woman
>with epilepsy and the many healthcare providers involved in her care.
>Although the information in the literature on women's issues in epilepsy
>has grown steeply in recent years, there are many examples showing that
>much work is yet to be done. The purpose of this article is to review
>these issues and describe practical considerations for women of
>childbearing age with epilepsy. The article addresses the established or
>"first-generation" AEDs (phenobarbital, phenytoin, primidone,
>carbamazepine, ethosuximide and valproic acid) and the
>"second-generation" AEDs (felbamate, gabapentin, lamotrigine,
>levetiracetam, oxcarbazepine, tiagabine, topiramate, vigabatrin and
>zonisamide). Although a relationship between hormones and seizure
>activity is present in many women, good treatment options for catamenial
>epilepsy remain elusive. Drug interactions between enzyme-inducing AEDs
>and contraceptives are well documented. Higher dosages of oral
>contraceptives or a second contraceptive method are suggested if women
>use an enzyme-inducing AED. Planned pregnancy and counselling before
>conception is crucial. This counselling should include, but is not
>limited to, folic acid supplementation, medication adherence, the risk
>of teratogenicity and the importance of prenatal care. AED dosage
>adjustments may be necessary during pregnancy and should be based on
>clinical symptoms, not entirely on serum drug concentrations. Many
>groups have turned their attention to women's issues in epilepsy and
>have developed clinical practice guidelines. Although the future holds
>promise in this area, many questions and the need for progress remain.
>
>Publication Types:
>
> * Journal Article
> * Review
> * Review, Tutorial
>
>MeSH Terms:
>
> * Abnormalities, Drug-Induced
> * Adolescent
> * Adult
> * Animals
> * Anticonvulsants/*adverse effects/*pharmacokinetics/*therapeutic use
> * Breast Feeding
> * Clinical Trials
> * Contraceptive Agents/therapeutic use
> * Drug Interactions
> * Epilepsy/*drug therapy/metabolism/physiopathology
> * Female
> * Human
> * Pregnancy
> * Pregnancy Complications/drug therapy/metabolism/physiopathology
>
>Substances:
>
> * 0 (Anticonvulsants)
> * 0 (Contraceptive Agents)
>
>PMID: 12102641 [PubMed - indexed for MEDLINE]
>
> From PubMed
>
>------------------------------------------------------------------------
>2
>
>
>
>
>Anticonvulsant use during lactation.
>
>Hägg S, Spigset O.
>
>Drug Saf. 2000 Jun;22(6):425-40.
>
>Division of Clinical Pharmacology, Norrland University Hospital, Umeå,
>Sweden. [log in to unmask]
>
>The issue of prescribing anticonvulsant drugs during lactation is
>clinically important, but also complex. Data for some drugs are
>completely lacking and for other drugs information is only available
>from single dose or short term studies or case reports. Moreover,
>limited knowledge exists about the practical impact of the drug
>concentrations found in breast milk and there are great methodological
>problems in the assessment of possible adverse drug reactions in
>infants. Nevertheless, based on current knowledge, some recommendations
>can be suggested. Treatment with carbamazepine, valproic acid (sodium
>valproate) and phenytoin is considered compatible with breastfeeding.
>Treatment with ethosuximide or phenobarbital (phenobarbitone)/primidone
>should most probably be regarded as potentially unsafe and close
>clinical monitoring of the infant is recommended if it is decided to
>continue breastfeeding. Occasional or short term treatment with
>benzodiazepines could be considered as compatible with breastfeeding,
>although maternal diazepam treatment has caused sedation in suckling
>infants after short term use. During long term use of benzodiazepines,
>infants should be observed for signs of sedation and poor suckling. Only
>very limited clinical data are available for the new generation
>anticonvulsant drugs and no clearcut recommendations can be made until
>further data are present. If it is decided to continue breast feeding
>during treatment with these drugs, the infant should be monitored for
>possible adverse effects. In general, the drug should be given in the
>lowest effective dose, guided by maternal serum or plasma drug
>concentration monitoring. If breast feeding is avoided at times of peak
>drug levels in milk, the exposure of the infant can be reduced to some
>extent. As breast milk has considerable advantages over formula milk,
>the benefits of continuing breast feeding should always be taken into
>consideration in the risk-benefit analysis.
>
>Publication Types:
>
> * Journal Article
> * Review
> * Review, Tutorial
>
>MeSH Terms:
>
> * Anticonvulsants/*adverse effects/pharmacokinetics
> * Female
> * Human
> * Infant, Newborn
> * Lactation/*physiology
> * Milk, Human/metabolism
>
>Substances:
>
> * 0 (Anticonvulsants)
>
>PMID: 10877037 [PubMed - indexed for MEDLINE]
>
> From PubMed
>
>Hope these help.
>Catherine Watson Genna, BS, IBCLC NYC
>
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I agree completely. A quick glance tells me Tegretol and Depakote would be
preferred first generation drugs to the phenobarb, especially for breastfeeding.
Mom says she has not tried weaning from the medication because of the
pregnancy. I also misspoke: she HAS had sz in the last 2 years - it
resulted in the stillbirth of her third baby.
Thank you for the articles. Your input and effort in helping me is greatly
appreciated.
Theresa Chmiel
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