Simple Intervention Triples Folate Prescription in Women Receiving AEDs

Caroline Cassels

April 27, 2015

WASHINGTON, DC — A simple educational intervention can markedly improve the co-prescription of folic acid and antiepileptic drugs (AEDs) in women of childbearing age, potentially reducing the risk for major congenital malformations (MCMs) in their offspring, new research shows.

Investigators at the University of Cincinnati Neuroscience Institute in Ohio found that following an educational intervention delivered to residents working in a general neurology clinic resulted in a tripling of the co-prescription of folate and AEDs.

"Our study showed that simple educational efforts targeting physicians have the potential to change prescribing patterns among general neurologists, and this may improve the cognitive and physical outcomes in children born to women receiving AEDs," said lead researcher Anumeha Sharma, MD.

The findings were presented here at the American Academy of Neurology (AAN) 67th Annual Meeting.

Widely Prescribed

AEDs, particularly older agents such as valproate, are known to significantly increase the risk for MCMs, which include neural tube defects, oral cleft, congenital heart disease, gastrointestinal atresia, limb reduction, and urogenital defects.

In addition, results from the Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study have shown prenatal exposure to valproate the risk for poor cognitive outcomes, including lower IQ.

Importantly, said Dr. Sharma, AEDs not only are used to prevent epileptic seizures but are widely prescribed to treat migraine, neuropathic pain, and mood disorders.

She also noted that indirect evidence suggests that folic acid taken before pregnancy in women receiving AEDs may reduce the risk for MCMs. In 2009 the AAN released guidelines recommending the prescription of at least 0.4 mg of folate/day in women of childbearing potential who are taking AEDs. However, the investigators hypothesized that prescription of folic acid in this patient population remains low.

For the study the researchers evaluated the rate of co-prescription of AEDs and folic acid in women of childbearing potential attending a general neurology clinic before and after an educational intervention aimed at improving adherence to AAN guidelines.

The investigators screened the electronic medical records for all women aged 18 to 46 with no history of tubal ligation or hysterectomy who attended the clinic during a 3-month period and who were prescribed an AED for epilepsy, headache, pain, or mood disorders.

The researchers assessed the clinic's rate of co-prescription of AEDs and folic acid. After this assessment, the results, as well as a review of the AAN guidelines regarding folate co-prescription and plans to track the performance data in the subsequent months, were presented at a single seminar targeting general neurology attendings and residents.

During the initial 3-month survey, 54 women received a prescription for 1 or more AEDs. Dr. Sharma reported that before the intervention the rate of co-prescription of AEDS and folic acid was 20.4% (11 of 54).

General neurologists were much more likely to prescribe folic acid for the treatment of seizures (11 of 32 [34.4%]) than other neurologic disorders (0 of 22 [0%]).

The investigators also conducted a subsequent 3-month survey of all women of childbearing potential prescribed an AED in the clinic.

The results showed following the educational intervention the rate of co-prescription of folate with an AED increased from 20.4% to 64.6%.

The results underline that a relatively simple intervention can markedly improve co-prescription of folate and AEDs potentially improving cognitive and physical outcomes in children born to these women, Dr Sharma concluded.

Sustained Effect?

Commenting on the findings for Medscape Medical News, session co-chair Barbara Jobst, MD, professor of neurology at the Dartmouth-Hitchcock Epilepsy Program, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, said the findings are reassuring in that a relatively simple educational intervention can make quite a dramatic difference.

Also commenting on the findings, David Spencer, MD, director of the Comprehensive Epilepsy Center at Oregon Health and Science University in Portland, said they underline the value of clinical reminders but noted that it would be interesting to see whether the intervention had a sustained effect or whether there was a dropoff.

"One of the questions I didn't ask was whether they are considering building this into their electronic medical records so that clinicians are prompted to ask about folate co-prescription in this patient population," said Dr Spencer.

He noted, however, that pop-up messages on electronic health records can be a "double-edged sword." If they pop up on the records of all patients with an epilepsy diagnosis, they may be more likely to be dismissed. He added that a more effective strategy may be to have them display only on the electronic health records of the targeted population — in this case in women of childbearing potential.

The authors, Dr Jobst, and Dr Spencer have disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 67th Annual Meeting. Abstract S6.004. April 21, 2015.

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