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From the Emory Epilepsy Program, Department of Psychiatry and Behavioral Sciences (D.J.N.), Department of Pathology (J.C.R.), Department of Neurology (P.B.P., A.K., D.K.H., M.N.), and Departments of Psychiatry and Behavioral Sciences and of Gynecology and Obstetrics (Z.N.S.), Emory University School of Medicine; and Department of Biostatistics, Rollins School of Public Health, Emory University (L.P.), Atlanta, GA.
* To whom correspondence should be addressed. E-mail: page.pennell{at}emoryhealthcare.org.
ABSTRACT
Objective: To characterize the magnitude and course of alterations in total and free lamotrigine (LTG) clearance (Cl) during pregnancy and the postpartum period, to assess the impact of therapeutic drug monitoring (TDM) on seizure frequency, to determine the ratio to individual target LTG concentration that is associated with increased seizure risk, and to evaluate maternal postpartum toxicity.
Methods: A cohort of women were enrolled before conception or during pregnancy in this prospective, observational study. Visits occurred every 1 to 3 months with review of seizure and medication diaries, examination, and blood sampling. Total and free LTG Cls were calculated. Individualized target concentrations were used for TDM. The ratio to target concentration (RTC) was compared between patients with and without increased seizures. A receiver operating characteristic curve determined the threshold RTC that best predicts increased seizure frequency.
Results: Analysis of 305 samples in 53 pregnancies demonstrated increased total and free LTG Cl in all trimesters above nonpregnant baseline (p < 0.001), with peak increases of 94% and 89% in the third trimester. Free LTG Cl was higher in white compared with black women (p < 0.05). Increased seizure frequency (n = 36 women with epilepsy) in the second trimester was associated with a lower RTC (p < 0.001), and RTC < 0.65 was a significant predictor of seizure worsening. An empiric postpartum taper reduced the likelihood of maternal LTG toxicity (p < 0.05) (n = 27). Newborn outcomes were similar to the general population (n = 52).
Conclusions: These novel data contribute to a rational treatment plan and dosing paradigm for lamotrigine use during pregnancy, parturition, and the postpartum period.
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  H. Chen, K. Yang, S. Choi, J. H. Fischer, and H. Jeong Up-Regulation of UDP-Glucuronosyltransferase (UGT) 1A4 by 17{beta}-Estradiol: A Potential Mechanism of Increased Lamotrigine Elimination in Pregnancy Drug Metab. Dispos., September 1, 2009; 37(9): 1841 - 1847. [Abstract] [Full Text] [PDF]
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 C. L. Harden, P. B. Pennell, B. S. Koppel, C. A. Hovinga, B. Gidal, K. J. Meador, J. Hopp, T. Y. Ting, W. A. Hauser, D. Thurman, et al. Practice Parameter update: Management issues for women with epilepsy--Focus on pregnancy (an evidence-based review): Vitamin K, folic acid, blood levels, and breastfeeding: Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society Neurology, July 14, 2009; 73(2): 142 - 149. [Abstract] [Full Text] [PDF]
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 T. Tomson Which Drug for the Pregnant Woman with Epilepsy? N. Engl. J. Med., April 16, 2009; 360(16): 1667 - 1669. [Full Text] [PDF]
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