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Practice Guideline
. 2024 Jun;102(11):e209279.
doi: 10.1212/WNL.0000000000209279. Epub 2024 May 15.

Teratogenesis, Perinatal, and Neurodevelopmental Outcomes After In Utero Exposure to Antiseizure Medication: Practice Guideline From the AAN, AES, and SMFM

Affiliations
Practice Guideline

Teratogenesis, Perinatal, and Neurodevelopmental Outcomes After In Utero Exposure to Antiseizure Medication: Practice Guideline From the AAN, AES, and SMFM

Alison M Pack et al. Neurology. 2024 Jun.

Erratum in

Abstract

This practice guideline provides updated evidence-based conclusions and recommendations regarding the effects of antiseizure medications (ASMs) and folic acid supplementation on the prevalence of major congenital malformations (MCMs), adverse perinatal outcomes, and neurodevelopmental outcomes in children born to people with epilepsy of childbearing potential (PWECP). A multidisciplinary panel conducted a systematic review and developed practice recommendations following the process outlined in the 2017 edition of the American Academy of Neurology Clinical Practice Guideline Process Manual. The systematic review includes studies through August 2022. Recommendations are supported by structured rationales that integrate evidence from the systematic review, related evidence, principles of care, and inferences from evidence. The following are some of the major recommendations. When treating PWECP, clinicians should recommend ASMs and doses that optimize both seizure control and fetal outcomes should pregnancy occur, at the earliest possible opportunity preconceptionally. Clinicians must minimize the occurrence of convulsive seizures in PWECP during pregnancy to minimize potential risks to the birth parent and to the fetus. Once a PWECP is already pregnant, clinicians should exercise caution in attempting to remove or replace an ASM that is effective in controlling generalized tonic-clonic or focal-to-bilateral tonic-clonic seizures. Clinicians must consider using lamotrigine, levetiracetam, or oxcarbazepine in PWECP when appropriate based on the patient's epilepsy syndrome, likelihood of achieving seizure control, and comorbidities, to minimize the risk of MCMs. Clinicians must avoid the use of valproic acid in PWECP to minimize the risk of MCMs or neural tube defects (NTDs), if clinically feasible. Clinicians should avoid the use of valproic acid or topiramate in PWECP to minimize the risk of offspring being born small for gestational age, if clinically feasible. To reduce the risk of poor neurodevelopmental outcomes, including autism spectrum disorder and lower IQ, in children born to PWECP, clinicians must avoid the use of valproic acid in PWECP, if clinically feasible. Clinicians should prescribe at least 0.4 mg of folic acid supplementation daily preconceptionally and during pregnancy to any PWECP treated with an ASM to decrease the risk of NTDs and possibly improve neurodevelopmental outcomes in the offspring.

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Conflict of interest statement

The American Academy of Neurology (AAN) is committed to producing independent, critical, and trustworthy clinical practice guidelines (CPGs) and evidence-based documents. Significant efforts are made to minimize the potential for conflicts of interest to influence the recommendations of this evidence-based document. Management and disclosure of document developer relationships is conducted in compliance with the 2017 AAN process manual section titled, “Implementing the AAN Conflict of Interest Policy for Guidelines and Case Definitions,” which can be viewed at aan.com.

The American Academy of Neurology (AAN) is committed to producing independent, critical, and trustworthy clinical practice guidelines (CPGs) and evidence-based documents. Significant efforts are made to minimize the potential for conflicts of interest to influence the recommendations of this evidence-based document. Management and disclosure of document developer relationships is conducted in compliance with the 2017 AAN process manual section titled, “Implementing the AAN Conflict of Interest Policy for Guidelines and Case Definitions,” which can be viewed at aan.com.

A.M. Pack serves on the editorial board for the journal Epilepsy Currents, receives royalties from UpToDate, receives funding from the NIH for serving as coinvestigator and site PI for the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, and receives funding from Bayer for serving as a co-investigator on a study on women with epilepsy initiating a progestin IUD. An immediate family member of A.M. Pack has received personal compensation for serving as an employee of REGENEXBIO. M. Oskoui has received personal compensation in the range of $500–$4,999 for serving as an officer or member of the Board of Directors for the Association des Neurologues du Quebec. The institution of M. Oskoui has received research support from Biogen, Roche Genetech, Muscular Dystrophy Canada, and the Canadian Institutes of Health Research. M. Oskoui has received personal compensation in the range of $50,000–$99,999 for serving as an evidence-based medicine methodologist with the AAN. M. Oskoui has a non-compensated relationship as a Member of the Medical and Scientific Advisory Committee with Muscular Dystrophy Canada. S. Williams Roberson receives research funding from the National Institute on Aging for a study related to ICU delirium and associated cognitive decline, serves on the editorial board for Neurology Today, and has a non-compensated relationship as a Physician Advisory Board Member with Epilepsy Foundation of Middle and Western Tennessee. D.K. Donley's immediate family member has received compensation in the range of $10,000–$49,999 for serving as the vice president of Novello Physicians Organization. J. French's institution has received research support from the Epilepsy Study Consortium, the Epilepsy Foundation (funded by UCB), GW Pharmaceuticals, the One8 Foundation, FACES (Finding a Cure for Epilepsy and Seizures), the National Institute of Neurological Disorders and Stroke (NINDS), Xenon, and Cerevel. J. French has received personal compensation in the range of $100,000–$499,999 for serving as a Chief Medical and Innovation Officer with the Epilepsy Foundation. J. French has had a non-compensated relationship serving as a consultant or scientific advisory board member for Alterity Therapeutics Limited, Angelini, Arvelle Therapeutics, Autifony Therapeutics Limited, Baergic Bio, Beacon Biosignals, Biogen, Biohaven Pharmaceuticals, Bloom Science Inc., BridgeBio Pharma Inc., Bright minds Biosciences, Camp4 Therapeutics Corporation, Cerebral Therapeutics, Cerecin Inc., Cerevel, Coda Biotherapeutics, Cognizance Biomarkers, Crossject, Eisai, Eliem Therapeutics, Encoded Therapeutics, Engrail, Epalex, Epihunter, Epitel Inc., Equilibre BioPharmaceuticals, Genentech Inc., Grin Therapeutics, GW Pharmaceuticals, iQure Pharma, Janssen Pharmaceuticals, Jazz Pharmaceuticals, Knopp Biosciences, Korro Bio Inc., Leal Therapeutics, Lipocine, LivaNova, Longboard Pharmaceuticals, Lundbeck, Marinus, Mend Neuroscience, Modulight Bio, Neumirna Therapeutics, Neurelis, Neurocrine, Neuroelectrics USA Corporation, NeuroPro Therapeutics, Ono Pharmaceutical Co, Otsuka Pharmaceutical Development, Ovid Therapeutics Inc., Paladin Labs Inc., Pfizer, Praxis, PureTech LTY Inc., Rafa Laboratories Ltd., Rapport Therapeutics, Receptor, Sage Therapeutics, SK Life Science, Stoke, Supernus, Takeda, Third Rock Ventures, UCB Inc., Ventus Therapeutics, Vida Ventures Management, Xenon, and Zogenix. J. French is on the editorial board of Lancet Neurology and Neurology Today. J. French has received travel and/or meal reimbursement related to research, advisory meetings, or presentation of results at scientific meetings from the Epilepsy Study Consortium, the Epilepsy Foundation, Angelini Pharma, Biohaven Pharmaceuticals, Cerebral Therapeutics, Neurelis, Neurocrine, Praxis, Rapport, SK Life Science, Stoke, Takeda, and Xenon. E.E. Gerard has received personal compensation in the range of $500–$4,999 for serving as a consultant for Greenwich Pharmaceuticals. The institution of E.E. Gerard has received research support from NIH/NINDS, Xenon Pharmaceuticals, and Eisai, Inc. (via Stanford University). E.E. Gerard has received travel reimbursements from the American Clinical Neurophysiology Society (ACNS), various institutions for CME lectures, and from the One 8 Foundation. E.E. Gerard's institution has received compensation from the One 8 Foundation for research coordinator time. The institution of an immediate family member of E.E. Gerard has received research support from NIH and Novo Nordisk. D. Gloss has received personal compensation in the range of $500–$4,999 for serving as a Drug Utilization Review Board Member with the West Virginia Department of Health and Human Resources. W.R. Miller has received research support from Indiana University School of Nursing as part of the Ethel Clarke Fellowship for serving as a PI for Patient Preferences for Delivery of a Web-Based Epilepsy Self-Management Intervention, has received research support from Indiana University Networks Institute for serving as a co-PI (no effort) for the study Sudden Unexpected Death in Epilepsy: Identifying Risk Factors with Social Media Mining, and receives research support from the NIH/NINDS for serving as a core investigator (P30 investigator) for the development of a brain safety lab. H.M. Munger Clary's institution has received research support from the NIH, the U.S. Department of Defense, Duke Endowment, the Susanne Marcus Collins Foundation, and Eysz, Inc. H.M. Munger Clary has received personal compensation in the range of $500–$4,999 for serving as a speaker with the American Epilepsy Society (AES). H.M. Munger Clary has received personal compensation in the range of $500–$4,999 for serving as a speaker with J. Kiffin Penry Epilepsy Education Programs. H.M. Munger Clary has received personal compensation in the range of $500–$4,999 for serving as a topic editor for DynaMed. H.M. Munger Clary has had non-compensated relationships as Chair of the Psychosocial Comorbidities Committee with the American Epilepsy Society, as Co-Chair of the Integrated Mental Health Care Pathways Task Force with the International League Against Epilepsy, and as Co-Chair Elect of the Resident and Fellow Education Committee with the American Clinical Neurophysiology Society. S.S. Osmundson's institution has received research support from NIH. B. McFadden serves as Executive Director for My Epilepsy Story and is uncompensated for this role, serves as an uncompensated member of the ELC Group, serves as an uncompensated patient advisor, serves as an uncompensated Patient-Centered Outcomes Research Institute (PCORI) Ambassador, and receives travel reimbursement from PCORI for attending meetings. K. Parratt has received personal compensation in the range of $500–$4,999 for serving on a speakers bureau for Eisai and for UCB. K. Parratt receives funding from Zynerba for serving as a subinvestigator for the study Cannabidiol ZYNN2-CL-04 and ZYNN2-CL-04 for artial onset seizures, receives funding from SK Life Science for serving as a subinvestigator for the study Cenobamate YKP3089C021 for partial onset seizures, has received funding from Eisai Inc. for the study Perampanel E2007-G00-335 for partial onset seizures, has received funding from Marinus Pharmaceuticals for the study Ganaxolone 10420603 for partial onset seizures, and has received honoraria from Esai for a dinner meeting lecture. P.B. Pennell's institution has received research support from the NINDS and the Eunice Kennedy Shriver National Institute of Child Health and Human Development for observational studies of people with epilepsy of childbearing potential and their children. The institution of an immediate family member of P.B. Pennell has received research support from the U.S. Department of Defense, the Environmental Protection Agency, the NIH, and Advanced Energy Consortium. P.B. Pennell has received publishing royalties from UpToDate, a publication relating to health care. P.B. Pennell has received honoraria and/or travel reimbursements from the AES, the AAN, and various academic medical institutions for CME lectures. She has received honoraria for grant reviews from the NIH and Harvard Catalyst. She has received honoraria for serving on the scientific advisory board for BRAINS, an NIH-funded study. G. Saade has received personal compensation in the range of $500–$4,999 for serving as a Consultant for GestVision. G. Saade has received personal compensation in the range of $500–$4,999 for serving on a scientific advisory or data safety monitoring board for CooperSurgical. G. Saade has served on scientific advisory boards for Sage Therapeutics and GestVision. G. Saade has received personal compensation in the range of $5,000–$9,999 for serving as an editor, associate editor, or editorial advisory board member for Thieme Publishing. The institution of G. Saade has received research support from Sera Prognostics, and from NICHD for clinical obstetrics issues. G. Saade has received research support from the NIH for studies related to chronic hypertension and pregnancy, human placenta evaluation, and pregnancy and cardiovascular health. G. Saade has received honoraria for speaking engagements at multiple universities and has given expert testimony, prepared an affidavit, and acted as a witness for legal proceedings regarding preeclampsia. D. Smith has received personal compensation in the range of $10,000–$49,999 for serving as an evidence-based medicine methodologist for the AAN. K. Sullivan has received intellectual property interests from a discovery or technology relating to health care. S.V. Thomas is deceased; to the best of our knowledge, the relevant disclosures are as follows: S.V. Thomas served as a PI of a pregnancy registry in India that has generated clinical data pertaining to the use of antiepileptic drugs during pregnancy, received honoraria for BMJ Masterclasses on epilepsy, and received research grants from the Indian government. S.V. Thomas received personal compensation in the range of $0–$499 for serving as an editor, associate editor, or editorial advisory board member for Wiley India, and served on the editorial board of the journal Epilepsy Research. T. Tomson's institution has received personal compensation in the range of $500–$4,999 for serving on a scientific advisory or data safety monitoring board for Angelini and GW Pharmaceuticals. The institution of T. Tomson has received research support from Eisai, GSK, UCB, Bial, Sanofi, Angelini, GW Pharmaceuticals, Teva Pharma, Zentiva, Accord, Ecu Pharm, SF Group, and Glenmark (for serving as a PI in the EURAP study and the International Antiepileptic Drugs and Pregnancy Registry). T. Tomson has received personal compensation in the range of $500–$4,999 for serving as a speaker with Angelini, Sanofi, Eisai, Sun Pharma, and UCB. T. Tomson has received funding from GSK for serving as a PI for a study on sudden unexpected death in epilepsy; has received research funding from Stockholm County Council; and has received research funding from the European Union and Nordforsk. M. Dolan O'Brien was an employee of the AAN. K. Botchway-Doe is an employee of the AAN. H. Silsbee is an employee of the AAN. M.R. Keezer's institution has received research support from UCB and Eisai. M.R. Keezer serves on the editorial board for the journals Epilepsia and Neurology: Clinical Practice. M.R. Keezer has received a salary award from the Fonds de Recherche du Québec Santé and research grants from the Centre Hospitalier de l'Université de Montréal Research Centre, the Savoy Foundation, the Canadian Frailty Network, the Fonds de Recherche du Québec Santé, TD Bank, and the Canadian Institutes of Health Research. Go to Neurology.org/N for full disclosures.

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Figure. Study Selection

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