Valproate can be continued in generalized genetic epilepsy when the patient and clinician agree that the benefits of remaining on valproate outweigh the risks of withdrawal or switch.
“Those whose seizures were only controlled after failing other appropriate alternatives, and for whom the risks of withdrawal are not acceptable, can continue on valproate,” he said. Women who wish to continue on valproate but are willing to accept the risks inherent in dose reduction should aim to take doses not exceeding 600 mg/day.
Before Conception
Physicians should reassess treatment and carefully consider changes for every woman considering pregnancy. Any treatment changes should be completed, and the lowest effective dose should be established, before conception. In patients with focal epilepsy who are considering pregnancy, switch or withdrawal from valproate always should be considered, said Dr. Tomson.
For those in remission on valproate, withdrawal of treatment should be considered if the likelihood of relapse is acceptable to the patient. Alternatives to valproate should be considered if withdrawal fails or is not suitable for the patient.
Continuation of valproate can be considered for those well-controlled on low doses of valproate (ie, up to 600 mg/day) and who consider the risk of withdrawal or switch unacceptable. This scenario might include patients who failed several drugs and then became seizure-free on valproate.
Valproate During Pregnancy
If patients taking valproate discover that they are pregnant, the task force generally recommends that valproate should be continued in patients who have good seizure control.
“If you want to stop the treatment in a meaningful way, you’re likely to need to do it quite rapidly and lead to substantial risk of seizure relapses,” said Dr. Tomson. “And unfortunately there are no data out there whatsoever indicating what the outcome is in pregnancies where you have stopped the valproate treatment during pregnancy. We know that there will be a risk of seizure recurrence, but we don’t know about any benefits.”
Withdrawal of valproate during pregnancy only should be initiated if the risk of doing so is acceptable to the patient. “This is usually the case only when there is agreement that treatment is not needed for acceptable seizure control, possibly when they are likely to be in remission,” said Dr. Tomson. In addition, reduction of valproate dose can be considered when prior history suggests that the dose is higher than needed for acceptable seizure control.
—Jake Remaly