Quality care in epilepsy: Women’s counseling and its association with folic acid prescription or recommendation

       This study focused on women of child-bearing age who are being treated for epilepsy with antiepileptic drugs (AEDs). Taking folic acid during the pre-conceptual period has been found to decrease the risk for congenital malformations in babies born to women with epilepsy who take AEDs. The purpose of this study was to determine if annual counseling about contraception and pregnancy in a treatment setting for women with epilepsy is associated with increased recommendations or prescriptions for folic acid.

        This was a retrospective cohort study that collected the data by abstracting medical records from the subjects. 77 women of childbearing age were included in this study who had two or more visits for epilepsy at a neurology clinic. The assessment included a review of documentation from the first three visits for epilepsy within a 24-month follow-up window. The women in this study were placed into 2 groups based on the type of counseling they received about pregnancy and contraception in relation to their epilepsy treatment: one group received something called DFCW (N=28) while the other group did not receive DFCW (N=49). DFCW was defined as the health care provider perfectly adhering to annual counseling about the impact of epilepsy treatment on contraception or pregnancy during their sessions with the patients. A recommendation from the provider that the patient take over-the-counter (OTC) folic acid or a prescription for folic acid was independently abstracted from the chart at each visit.

       The group of subjects who received DFCW and the group who did not receive DFCW had no significant differences in respect to age, disease duration, baseline history of drug-resistant epilepsy (DRE), presence of concurrent psychiatric disease, epileptologist involvement, number of AEDs prescribed, types of seizures experienced, and etiology. The results were that 71.4% of subjects (20 women) in the DFCW group and 85.7% of subjects (42 women) in the non-DFCW group were NOT recommended or prescribed folic acid by their health care provider. These results show that providers are missing a big area of counseling for their female patients with epilepsy who are of child-bearing age. Even though many of the providers counsel their female epilepsy patients about how epilepsy treatment may affect contraception and pregnancy, they often times do not mention or actively recommend their patients to take folic acid if they are thinking about trying to conceive.

     I think the results of this study are interesting and very eye-opening. It is concerning to me that many health care providers are not mentioning the benefits of taking folic acid to their female epilepsy patients of child-bearing age because previous studies have proved that folic acid can prevent congenital malformations in babies born to women with epilepsy who took AEDs during their pregnancies. I am wondering if this finding about folic acid is relatively new in the treatment of women with epilepsy and that many providers, especially those who have been practicing for many years, are simply not aware of this finding. Whatever the reason is, I hope this study has been reviewed in the world of epilepsy treatment and that more providers start recommending the use of folic acid in their female epilepsy patients of child-bearing age in order to prevent more congenital malfunctions from the use of AEDs during pregnancy from occurring.

My question posed to colleagues: How can pharmacists play a role in making female epilepsy patients of child-bearing age taking antiepileptic drugs aware of the fact that taking folic acid could decrease the risk for their children having congenital malfunctions?

Moura, LMVR, Mendez, DY, De Jesus, J, et al. Quality care in epilepsy: Women’s counseling and its association with folic acid prescription or recommendation. Epilepsy Behav. 2015;44:151-154.  

Pharmacist Role in Counseling on Preconception Health

As accessible health care providers, pharmacists have a unique opportunity to improve preconception health in women which can lead to overall improved pregnancy outcomes. If women are thinking about conceiving a baby, it is important that they are counseled on prenatal supplementation and vaccinations. The information that a pharmacist can provide can help the woman make informed decisions about their lifestyle.

Screening for immunizations for measles, mumps, rubella, varicella, human papillomavirus, hepatitis A, and hepatitis B should all be recommended for women thinking about conceiving since they may have harmful effects on the developing fetus after conception. Not all vaccinations are off limits however. Inactivated influenza virus and tetanus, diphtheria, and pertussis vaccinations are recommended) even if the woman is pregnant (regardless of trimester) and should not pose a risk to the fetus. Moreover, contraction of influenza may cause problems for the baby. Influenza contraction in the first trimester gives rise to higher incidence of schizophrenia in the child. Contraction of the virus in the second and third trimesters poses more risk for the mother as breathing is impaired and the fetus is applying pressure on the mother’s diaphragm and lungs.

Counseling the woman on supplementation of folic acid may also lead to improved pregnancy outcomes as this B vitamin has been shown to improve optimal birth outcomes and neural tube development. Deficiency of this vitamin may result in spina bifida, a condition in which the spine does not close properly which can result in paralysis or mental retardation. It can also result in anencephaly or the case in which the brain does not form altogether. Since these events occur in the developing fetus within the first 28 days, it is important that the woman supplements this ahead of time.

Pharmacists have a role in helping educate people about medication day to day. However this role may be all the more important when discussing good preconception habits with women. This is a situation that there is a good chance that they have not been in before and since the development of the fetus is so fragile, it is important to make sure that they are getting all of the information correct in order to improve the likelihood of optimal birth outcomes.

Reference

El-Ibiary S, Raney E, Moos M. The pharmacist’s role in preconception health. J Am Pharm Assoc. 2014; 54(5): 288-303

J Am Pharm Assoc. 2014; 54(5): 288-303