What is the most important educational point to convey to a pregnant woman with generalized tonic-clonic seizures taking levetiracetam and topiramate for reimbursement purposes?

Educational Priorities for a Woman with Epilepsy Planning Pregnancy

The most important educational point to convey to this patient at every visit is appropriate folic acid supplementation.

Rationale for Folic Acid Supplementation Priority

Folic acid supplementation is critical for women with epilepsy who are planning pregnancy, particularly for this patient who is taking both levetiracetam and topiramate. This recommendation is based on several key considerations:

• Women with epilepsy taking antiseizure medications (ASMs) require higher doses of folic acid supplementation to reduce the risk of neural tube defects 1
• While levetiracetam has a relatively favorable safety profile during pregnancy, topiramate is associated with increased risk of oral clefts and fetal malformations 2
• The American Academy of Family Physicians recommends that pregnant women with epilepsy ideally be treated with lamotrigine or levetiracetam monotherapy at the lowest effective dose 1

Medication Considerations During Pregnancy

Current Medication Assessment

• Levetiracetam: Has a low teratogenic potential and is considered one of the safer options for pregnant women with epilepsy 1, 2
• Topiramate: Associated with a 2.2-fold higher risk of major malformations compared to lamotrigine and specifically linked to a higher risk of cleft lip 2
• The patient's current regimen includes both medications at substantial doses, which provides good seizure control but may present risks during pregnancy

Risk-Benefit Analysis

• Maintaining seizure control during pregnancy is critical as untreated seizures pose greater risk to mother and fetus than most medications 1
• The risk of major malformations with topiramate (5.1%) is significantly higher than with levetiracetam (2.0%) 2
• A discussion about potentially transitioning to levetiracetam monotherapy before conception should be considered, as it has better safety data for pregnancy 1, 2

Monitoring and Management During Pregnancy

• Drug levels should be monitored every 4 weeks throughout pregnancy with proactive dose adjustments as metabolism changes 1
• Therapeutic drug monitoring is essential to reduce seizure deterioration rate from 73% to 30% 1
• Ultrasound examinations should be performed around weeks 12 and 17 to monitor fetal development 1

Other Important Educational Points

While folic acid supplementation is the most important educational point for reimbursement purposes, other educational points that should be addressed include:

• Potential effects of ASMs on fetal/child development: Important but secondary to folic acid supplementation for this specific patient
• Drug interactions with contraception: Less immediate concern as she is planning pregnancy
• Risk of suicidal ideation and behavior: While important to monitor with both medications, this is less critical than folic acid supplementation for pregnancy planning

Specific Recommendations

1. Folic acid dosage: Recommend 4 mg daily, starting before conception 1
2. Medication management: Consider discussing with her neurologist about potentially transitioning to levetiracetam monotherapy if possible
3. Monitoring plan: Establish a schedule for drug level monitoring during pregnancy
4. Documentation: Clearly document the folic acid education at every visit to ensure proper reimbursement

Common Pitfalls to Avoid

• Inadequate folic acid supplementation: Standard prenatal vitamins typically contain only 0.4-0.8 mg, which is insufficient for women on ASMs 1
• Abrupt discontinuation of ASMs: Could lead to status epilepticus and should never be attempted 1
• Failure to monitor drug levels: Pregnancy alters the metabolism of many ASMs, requiring dose adjustments to maintain therapeutic levels 1

For this 25-year-old woman with well-controlled generalized tonic-clonic seizures on levetiracetam and topiramate who wants to become pregnant, appropriate folic acid supplementation education at every visit is the most important educational point for reimbursement purposes.