ORCID

Abstract

Valproate is the most effective medication for generalised epilepsies, and several specific epilepsy syndromes. For some people, it will be the only medication to establish seizure remission, and withdrawing it carries risks of seizure recurrence and Sudden Unexpected Death in Epilepsy (SUDEP). It is also of proven efficacy for bipolar disorder and migraine prevention.Guidelines based on observational and epidemiological studies stress that maternal valproate related teratogenicity and neurodevelopmental effects are significantly higher than for other antiseizure medications (ASMs). It should, therefore, only be used if other medications are ineffective and after balancing the teratogenicity risk. Regulatory restrictions have changed prescribing practices and reduced valproate use. The number of other medications that must be trialled in the different conditions for which valproate has effectiveness and the consequences of the lack of efficacy of those drugs leading to significant harm including death remains unexplored. Risk minimisation measures (RMMs) for valproate, chiefly Pregnancy Prevention practices (PPP), consider foetal risk and not risk to people living with epilepsy. In the United Kingdom (UK), limitations relating to valproate use in all people < 55 years commenced in January 2024. While the evidence in child-bearing women is not disputed, the data in males are based on animal models, case reports, and one commissioned, unpublished, non-peer reviewed report unavailable to the UK public, stakeholder charities or professionals. Evidence suggests that 30–40% of people switching from valproate have breakthrough seizures. Thus, an estimated 21,000–28000 people in the UK will imminently be exposed to the potential hazards of breakthrough seizures, including death. There is little government investment in monitoring the effects of these changes to valproate prescribing on patient health and quality of life. This review summarises the history of valproate regulation, evidence underpinning it and argues how the latest regulations in the UK do not align with the country’s medical regulatory bodies ethical principles nor with the Montgomery principles of informed patient choice and autonomy. It dissects how such regulations infringe Common Law principles, nor give due regard for patient outcomes beyond reproduction. The paper looks to provide recommendations to redress these concernswhile appreciating the core need for such governance to emerge in the first place.

Publication Date

2024-06-19

Publication Title

Journal of Neurology

Volume

271

Issue

8

ISSN

0340-5354

Acceptance Date

2024-05-09

Deposit Date

2024-06-24

Funding

HAL gave evidence at MHRA meetings on valproate, at the Cumberlege hearings in 2019, and Sanofi Women and Epilepsy Education Board 2018. She has also received honoraria for non-pharmaceutical educational talks, as well as NIHR, Royal Free Charity, ncode funding, and Eisai and UCB investigator-initiated research grants. LW has Honoraria for work outside this project from Veriton Pharma. PNC is an unpaid member of the Council, Quality Committee and Epilepsy Advisory Group of the Association of British Neurologists, and a member of the Guidelines and Assessment Committee of the American Epilepsy Society. RS has received institutional and research support from LivaNova, UCB, Eisai, Veriton Pharma, Bial, Angelini, UnEEG and Jazz/GW pharma outside the submitted work. He holds grants from Innovate, NIHR AI, SBRI, ESPRC, ESRC and other funding bodies all outside this work. RA and DH have no Disclosures. The views of all authors are there own.

Keywords

Antiepileptic drugs, Antiseizure medications, Congenital malformations, Medicines and Healthcare products Regulatory Agency, Neurodevelopmental abnormalities, Valproate

First Page

5671

Last Page

5686

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