What is the recommended alternative to oxcarbazepine (Trileptal) for a pregnant patient?

Alternative Antiepileptic Medications for Pregnant Patients on Oxcarbazepine

For pregnant patients currently on oxcarbazepine, lamotrigine or levetiracetam should be used as alternative medications due to their lower risk of major malformations in offspring.

Risk Assessment of Oxcarbazepine in Pregnancy

• Oxcarbazepine is classified as a medication that may increase risk during pregnancy, with guidelines listing it among anticonvulsants that require consideration for alternative therapy 1
• Recent data from the North American Antiepileptic Drug Pregnancy Registry (2025) shows oxcarbazepine has a relatively low malformation rate of 1.5%, which is actually comparable to safer alternatives 2
• However, older guidelines still categorize oxcarbazepine with other enzyme-inducing antiepileptic drugs that may require dosage adjustments or medication changes during pregnancy 1

Recommended Alternatives

First-Line Options:

• Lamotrigine:

  • Associated with a 2.1% risk of major malformations, which is comparable to the general population risk 2
  • Does not appear to increase risk of congenital malformations when used as monotherapy 3
  • Considered safe for use during pregnancy based on extensive registry data 2

• Levetiracetam:

  • Shows a 2.0% risk of major malformations, one of the lowest rates among antiepileptic medications 2
  • No evidence of significant teratogenic effects in pregnancy registry data 2
  • Does not require the same precautions as enzyme-inducing antiepileptic drugs 1

Medications to Avoid:

• Valproate: Associated with a 9.2% risk of major malformations (5.1 times higher risk than lamotrigine) 2
• Phenobarbital: Shows a 6.0% risk of major malformations (2.9 times higher risk than lamotrigine) 2
• Topiramate: Has a 5.1% risk of major malformations with specific association with cleft lip 2

Management Algorithm

1. Assess seizure control and pregnancy status:

   • Determine gestational age and current seizure control on oxcarbazepine 1
   • For women with mild manifestations of seizures, consider whether medication can be safely reduced or discontinued 1

2. Transition plan:

   • For patients requiring continued therapy, initiate lamotrigine or levetiracetam 2
   • Begin with low dose and titrate gradually while monitoring serum levels 1
   • Consider overlapping therapy during transition to maintain seizure control 4

3. Monitoring during pregnancy:

   • Increased monitoring of drug levels may be necessary as pregnancy can alter pharmacokinetics 1
   • Adjust dosage as needed based on clinical response and serum levels 1

Special Considerations

• Breastfeeding: Both lamotrigine and levetiracetam can be used during breastfeeding with appropriate monitoring of the infant 1
• Folic acid supplementation: All women with epilepsy on antiepileptic medications should receive folic acid supplementation (4-5 mg daily) before conception and during pregnancy 5
• Genetic testing: Consider HLA-B*15:02 screening before initiating certain antiepileptic drugs, particularly in patients of Asian descent 1

Common Pitfalls to Avoid

• Abrupt discontinuation: Never abruptly stop antiepileptic medication as this may precipitate status epilepticus, which poses greater risk to mother and fetus than medication exposure 1
• Polytherapy: Whenever possible, maintain monotherapy as polytherapy is associated with higher rates of congenital malformations 5
• Inadequate monitoring: Pregnancy can alter drug metabolism, requiring more frequent monitoring and potential dose adjustments 1