Authors :
Amanda Gusovsky, PhD – Ohio State Wexner Medical Center
Presenting Author: Sarita Maturu, DO – The Ohio State University Wexner Medical Center
Chun Chieh Lin, PhD, MBA – Ohio State University
Kevin Kerber, MD, MS – Ohio State Wexner Medical Center
Seuli Brill, MD – Ohio State Wexner Medical Center
Jim Burke, MD, MS – Ohio State Wexner Medical Center
Rationale:
Optimal care for people with epilepsy of childbearing potential (PWECP) who become pregnant includes appropriately prescribing anti-seizure medications (ASMs) to minimize seizure frequency while limiting teratogenic effects (i.e., primarily from valproate followed by topiramate) and considering neuropsychological outcomes. The objective of this study was to examine ASM discontinuation and adherence among PWECP during the pre-pregnancy, pregnancy, and postpartum periods; and whether patients seen by epilepsy specialists prior to pregnancy have a difference in valproate and topiramate exposure during pregnancy.
Methods: This retrospective cohort study using Merative™ MarketScan® claims databases included female patients diagnosed with epilepsy with an ASM in the year following first epilepsy diagnosis, and with pregnancy any time after the diagnosis of epilepsy. Patients with pregnancy during the washout period (1 year pre- to 6 months post-incident diagnosis) and aged outside 13-50 years at pregnancy were excluded. ASM discontinuation was observed as percent of patients with 0 ASM fills quarterly. Quarterly ASM adherence (mean proportion of days covered (PDC)) for each medication was observed. Adjusted odds of valproate and topiramate exposure during pregnancy were examined between those treated vs. not treated by an epilepsy specialist on or before start of pregnancy.
Results: A total of 2,179 female epilepsy patients with pregnancy met study criteria. Mean age was 29 years old (SD=6). The most common ASM was levetiracetam (35%). At 1 quarter prior to start of pregnancy or 3 months prior to pregnancy (quarter -1), 14% of the cohort discontinued ASMs and ASM discontinuation consistently increased to 51% at quarter 6. At quarter -1 PDC was 62% overall, increased at the start of pregnancy followed by a decrease, and then gradually increased to 64% in quarter 6. Patients treated by an epilepsy specialist had a moderately lower proportion of: valproate and/or topiramate during pregnancy (7% vs. 12%), valproate during pregnancy (2% vs. 3%), and topiramate during pregnancy (6% vs. 9%), with significantly lower adjusted odds of valproate and/or topiramate (OR [95%CI]= 0.57 [0.38, 0.85], p=0.006) and topiramate (OR [95%CI]=0.60 [0.38, 0.93], p=0.023); and no significant difference in valproate (OR [95%CI]= 0.60 [0.26, 1.38], p=0.232)).
Conclusions: A majority of pregnant epilepsy patients discontinued ASMs during and beyond pregnancy. Among PWECP who continued to fill ASMs, adherence increased at the start of pregnancy and then decreased from the 1st quarter throughout the remainder of pregnancy. Adherence improved after pregnancy and through the end of the study period. Treatment by an epilepsy specialist was associated with decreased odds of ASM prescriptions with known teratogenic effects although absolute rates of these medications was also low amongst patients not treated by an epilepsy specialist. Factors influencing ASM discontinuation and adherence around pregnancy may inform perinatal interventions for patients with epilepsy. More research should be done to examine ASM prescribing in patient outcomes and reasons for nonadherence among PWECP and pregnancy.
Funding: N/A