The Journal of Scientific Psychiatry not too long ago revealed a collection of articles on the usage of valproic acid in ladies of childbearing age. All of us agree that valproic acid is a teratogen and is related to unacceptably excessive charges of main congenital malformations, together with neural tube defects, neurodevelopmental problems, and different adversarial outcomes.
The place there appears to be a divergence of opinions, nevertheless, is whether or not or not valproic acid must be used in any respect in ladies of childbearing age. A number of different international locations have put strict limitations on the usage of valproic acid in reproductive aged ladies; america has not.
Chittaranjan Andrade, MD, et al:
Use of Valproate in Women: An Audit of Prescriptions to 10,001 Psychiatry, Neurology, and Neurosurgery Outpatients
Throughout September to November 2019, researchers examined prescriptions for 10,001 consecutive outpatients seen within the Departments of Psychiatry, Neurology, and Neurosurgery on the Nationwide Institute of Psychological Well being and Neurosciences in Bangalore, India, a big, tertiary care referral heart
A big proportion of girls (647/3,837 or 16.9%) obtained a prescription for valproate (imply dose?=?898 mg/d). Girls between the ages of 15 and 45 years accounted for 71.1% of those prescriptions. Compared, 403 (10.5%) of three,837 ladies obtained a prescription for carbamazepine. Girls had been extra prone to obtain a prescription for valproate within the Departments of Neurology and Neurosurgery than within the Division of Psychiatry (29.1% vs 14.4%, respectively).
Camille Tastenhoye, MD et al:
Valproate Prescribing Practices in Individuals of Childbearing Age at a Tertiary Care Women’s Hospital
Researchers from the College of Pittsburgh reviewed a database of digital medical data from a tertiary care ladies’s hospital and recognized ladies of childbearing age (12–52 years) who obtained valproate throughout medical admission (January 1, 2019, to December 31, 2019). They recognized 15 distinctive sufferers handled with valproate.
Documented indications for valproate use included bipolar dysfunction (7/15), seizure problems (7/15), and migraine therapy (2/15). The house dosage of valproate was continued in 14 encounters. Six encounters had a documented damaging urine being pregnant take a look at. Three out of 15 sufferers had been pregnant. One affected person was prescribed high-dose folate previous to admission; nevertheless, the opposite 14 sufferers had no documented folate supplementation. There have been no documented risk-benefit discussions.
The fact is that should you deal with people of reproductive potential, you’ll discover yourselves on the entrance strains of perinatal well being care. The perfect time to pick out a psychotropic for being pregnant is properly earlier than conception, deliberate or not. Unplanned pregnancies are widespread, and girls with psychiatric problems could also be extra probably than the overall inhabitants to have unplanned pregnancies.
Tastenhoye and her co-authors argue that valproic shouldn’t be utilized in ladies of reproductive age, and that physicians would profit from further training concerning the dangers of valproate use in ladies of childbearing age.
Joseph F. Goldberg, MD
Living in a Pharmacologically Imperfect World
On this commentary, Dr. Goldberg argues that in relation to treating ladies of childbearing age, valproic acid is however one imperfect therapy choice on a listing of different imperfect choices. He notes that second era atypical antipsychotic medicines carry a danger of weight achieve, and a few could improve danger for gestational diabetes. Lithium could also be an choice, though it does carry a danger, albeit small, for cardiovascular malformations. Whereas lamotrigine doesn’t seem to hold any teratogenic danger, it is probably not as efficient in stopping recurrent mania. Moreover, it isn’t clear whether or not ladies who reply properly to valproic acid will reply equally properly to those alternate options.
Definitely, if and when a greater and safer various to valproate exists, it warrants most popular standing. Nonetheless, the chance for relapse and purposeful impairment in bipolar dysfunction stays excessive even with state-of-the-art care, making it a dangerous proposition to advise an absolute moratorium on any therapy that might assist to avert its inordinately excessive morbidity and mortality.
Thus, Dr. Goldberg would like to go away valproic acid on the desk.
Marlene Freeman, MD:
Prescribing Guideline for Valproic Acid and Women of Reproductive Potential: Forget It Exists
On this commentary, Dr. Freeman notes that valproic acid is a recognized teratogen that may trigger a spread of main fetal malformations, together with neural tube defects, earlier than most ladies are conscious they’re pregnant. She notes the well-established literature indicating that prenatal publicity to valproic acid is related to worse neurodevelopmental outcomes and up to date information that prenatal publicity to valproic acid could have transgenerational dangers, contributing to an increased risk of malformations in the children of exposed individuals. She argues that higher training of prescribers is solely not sufficient.
There isn’t a nuance to this: Valproic acid shouldn’t be prescribed to ladies of childbearing potential for psychiatric problems. Whereas some international locations have sought to control its use and disseminate the hazards of use throughout being pregnant extra prominently, there isn’t any enough threading of this needle. Not immediately, when we’ve so many different choices as temper stabilizers than we did many years in the past.
Simply overlook it exists.
Some Last Ideas
Whereas on the floor these could appear to be dramatically divergent opinions, they don’t seem to be. On the coronary heart of the dialogue is the belief that bipolar dysfunction is an usually difficult-to-treat sickness with vital morbidity. It’s commonplace for people with bipolar dysfunction to have a protracted listing of medicines they’ve tried and failed, and so they usually battle to discover a routine that maintains their stability.
Typically that routine could embrace valproic acid. Given the dangers related to valproic acid throughout being pregnant and the excessive frequency of unplanned being pregnant, valproic acid ought to by no means be a primary selection in a lady of reproductive age. Fairly, we should always think about therapy choices within the context of a being pregnant sooner or later, and our first line choices ought to embrace medicines which might be acceptable for a given scientific scenario whereas on the similar time contemplating information on reproductive security.
Ruta Nonacs, MD PhD
