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FDA Drug Podcast: Valproate Anti-seizure Products Contraindicated for Migraine Prevention in Pregnant Women due to Decreased IQ Scores in Exposed Children

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Narrator: Welcome to the FDA Drug Safety Podcast from the Division of Drug Information. Today’s topic: Valproate Anti-seizure Products Contraindicated for Migraine Prevention in Pregnant Women due to Decreased IQ Scores in Exposed Children

Sonia Kim, a pharmacist in the Division, will provide you with additional information about this Communication.

Sonia Kim: On May 6, 2013 the FDA issued a Drug Safety Communication advising health care professionals and women that the anti-seizure medication valproate sodium and related products, valproic acid and divalproex sodium, are contraindicated and should not be taken by pregnant women for the prevention of migraine headaches. Based on information from a recent study, there is evidence that these medications can cause decreased IQ scores in children whose mothers took them while pregnant. Stronger warnings about use during pregnancy will be added to the drug labels, and valproate’s pregnancy category for migraine use will be changed from "D" (the potential benefit of the drug in pregnant women may be acceptable despite its potential risks) to "X" (the risk of use in pregnant women clearly outweighs any possible benefit of the drug).

With regard to valproate use in pregnant women with epilepsy or bipolar disorder, valproate products should only be prescribed if other medications are not effective in treating the condition or are otherwise unacceptable. Valproate products will remain in pregnancy category D for treating epilepsy and manic episodes associated with bipolar disorder.

With regard to women of childbearing age who are not pregnant, valproate should not be taken for any condition unless the drug is essential to the management of the woman's medical condition. All non-pregnant women of childbearing age taking valproate products should use effective birth control.

Valproate products include: valproate sodium (brand name Depacon), divalproex sodium (brand names Depakote, Depakote CP, and Depakote ER), valproic acid (brand names Depakene and Stavzor), and their generics.

This alert is based on the final results of the Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) study showing that children exposed to valproate products while their mothers were pregnant had decreased IQs at age 6 compared to children exposed to other anti-epileptic drugs. The difference in average IQ between the children who had been exposed to valproate and the children who had been exposed to other antiepileptic drugs varied between 8 and 11 points depending on the drug to which valproate was compared. 

FDA previously communicated initial findings about this risk in a June 2011 Drug Safety Communication. At that time, FDA also worked with valproate manufacturers to revise the drug labels after interim results from the NEAD study showed lower cognitive test scores at age 3 in children exposed to valproate compared to children exposed to other antiepileptic drugs.

Women who are pregnant and taking a valproate medication should not stop their medication but should talk to their health care professionals immediately. Stopping valproate treatment suddenly can cause serious and life-threatening medical problems to the woman or her baby.

It is not known whether there is a specific time period during pregnancy when valproate exposure can result in negative cognitive effects. Similarly, there is no known time during pregnancy in which exposure may be considered to have less risk for decreased IQ in children. Because the women in the NEAD study were exposed to antiepileptic drugs throughout pregnancy, whether the risk for decreased IQ was related to a particular time period during pregnancy could not be assessed.

FDA is working with manufacturers to change the drug labels for valproate products with this updated risk information. FDA continues to evaluate information about the potential risks of valproate use during pregnancy and will update the public as more information becomes available.

Pregnancy Category X means that studies in animals or humans have shown positive evidence of fetal risk, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefits.  Category D means there is a positive evidence of risk to a baby based on data from studies or other experience in humans, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.

At this time, the FDA recommends Health Care Professionals be aware of the following:

  • Valproate products should not be used in pregnant women for prevention of migraine headaches.
  • Valproate products should be used in pregnant women with epilepsy or bipolar disorder only if other treatments have failed to provide adequate symptom control or are otherwise unacceptable.
  • Inform women of childbearing age of the increased risk for decreased IQ in children exposed to valproate products in utero.
  • Valproate products should not be administered to a woman of childbearing age unless the drug is essential to the management of her medical condition. This is especially important when valproate use is considered for a condition not usually associated with permanent injury or death (e.g., migraine). 
  • Women who are planning a pregnancy should be counseled regarding the relative risks and benefits of valproate use during pregnancy, and alternative therapeutic options should be considered for these patients.
  • It is not known whether the adverse effects on IQ are related to the timing or duration of exposure to valproate during pregnancy.  Therefore, exposure to valproate at any time during pregnancy should be considered to have the potential to result in decreased IQ in children. 
  • Continue to counsel women of childbearing age taking valproate about the increased risk of other major structural and functional birth defects, particularly neural tube defects, when valproate is used during pregnancy.
  • Dietary folic acid supplementation should be routinely recommended both prior to conception and during pregnancy for patients taking valproate because studies in the general population show that folic acid supplementation prior to conception and during early pregnancy reduces the risk of neural tube defects. 
  • To collect information on the effects of in utero exposure to valproate, physicians should encourage pregnant patients taking valproate products to enroll in the North American Antiepileptic Drug Pregnancy Registry. This can be done by calling toll free 1-888-233-2334, and must be done by the patients. Information on the registry can be found at: www.aedpregnancyregistry.org
  • As always, report adverse events involving valproate products to the FDA MedWatch program at: www.fda.gov/medwatch.

Narrator: Thank you for listening. The FDA is committed to keeping healthcare professionals informed of the latest safety information.  A link to previous communications and this communication, including the complete Data Summary, can be found at www.fda.gov/DrugSafetyCommunications. If you have drug questions, you can reach us at druginfo@fda.hhs.gov.

Prescribers...be sure that your patients are filling their mail-order prescriptions at legitimate online US pharmacies by guiding them to the BeSafeRx online pharmacy map and other resources on FDA’s website.

And follow us on Twitter @FDA_Drug_Info for up to the minute important drug information.  Know the moment it happens. 

 

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