Antiseizure Medication Dose Adjustments During Pregnancy: Findings from the MONEAD Study
Key Clinical Summary
- In a large US prospective cohort, most pregnant women with epilepsy required antiseizure medication (ASM) dose increases during pregnancy and dose reductions postpartum to maintain seizure control.
- Lamotrigine and levetiracetam doses were frequently increased, often reaching nearly double conception doses by delivery.
- Findings provide real-world dosing patterns associated with favorable seizure outcomes in pregnancy.
Optimizing antiseizure medication (ASM) dosing during pregnancy remains a major clinical challenge due to physiologic pharmacokinetic changes and limited evidence-based guidance. A new analysis from the US-based Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, published in Neurology, examines how antiseizure medications were adjusted during pregnancy and early postpartum among pregnant women with epilepsy (PWWE) who maintained good seizure control.
Study Findings
MONEAD was a prospective, observational cohort study conducted from 2012 to 2016 across 20 US epilepsy centers. The analysis included 299 PWWE aged 14 to 45 years who enrolled before 20 weeks’ gestation and had favorable seizure outcomes. ASM types and doses were recorded daily, with follow-up through 6 weeks postpartum.
Overall, dose increases occurred in 246 of 363 ASMs (67.8%) during pregnancy, beginning a median of 32 days after enrollment. Dose decreases occurred postpartum in 171 of 357 ASMs (47.9%), starting a median of 3 days after delivery.
Lamotrigine showed the most pronounced changes. During pregnancy, 128 of 146 participants (87.7%) taking lamotrigine had dose increases, with a median increase of 100 mg/day, reaching a mean of 191% of the conception dose by delivery. By 6 weeks postpartum, 70.5% had dose tapers, reducing to 116% of the conception dose.
For levetiracetam, 56.0% of participants required dose increases during pregnancy, with a median increase of 500 mg/day, reaching 177% of the conception dose at delivery. Postpartum tapering occurred in 34.4%, reducing doses to 136% of conception levels by 6 weeks.
Other ASMs showed similar but less frequently observed patterns, with most participants requiring pregnancy-related increases and early postpartum reductions.
Clinical Implications
These findings offer practical insights for neurologists managing pregnant women with epilepsy. Physiologic changes during pregnancy can substantially lower ASM concentrations, increasing seizure risk if doses are not adjusted. The observed dosing patterns highlight the need for active monitoring and timely dose escalation.
Equally important, the data demonstrate that postpartum dose reductions are common and often rapid, underscoring the risk of overtreatment if pregnancy-adjusted doses are continued after delivery. The study reflects real-world management strategies from specialized US epilepsy centers and may help inform structured dose adjustment protocols.
Expert Commentary
“Previous MONEAD analyses showed no difference in seizure control between pregnant and nonpregnant women with epilepsy,” noted Page B. Pennell, MD, FAES, Department of Neurology, University of Pittsburgh School of Medicine, PA, and study coauthors. The findings demonstrate that systematic ASM dose increases during pregnancy and early postpartum tapering were common among women with epilepsy who maintained seizure control.
Conclusion
This study provides clinically relevant benchmarks to guide ASM management during pregnancy and the postpartum period. However, the authors note limitations, including limited first-trimester data, enrollment from tertiary centers, and smaller numbers for less commonly used ASMs, which may affect generalizability.
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