Should Vitamin D supplementation be given for children on Antiepileptic drugs
[edit] Q: Should Vitamin D supplementation be given for children on Antiepileptic drugs ?
The effect of antiepileptic drugs on bone density has been well documented.
Sheth et al 2008 in a cross-sectional evaluation compared 82 ambulatory children aged 6 to 18 years (12.4 ± 3.3 years) with epilepsy for <1 year (n = 18), 1 to 5 years (n = 37), and 6 or more years (n = 27) and 32 controls aged 12.8 ± 2.6 years . This study reported significant bone mineral density (BMD) deficit (measured using dual-energy x-ray (DXA) technology ) in children with epilepsy during the initial 1 to 5 years of treatment which progressively worsens thereafter.
Fuleihan G et al 2008 obtained BMD and detailed clinical information from 137 adults mean age of 31 years, on therapy for a mean of 11.7 years, and 88 children mean age of 13 years, on therapy for an average of 4.7 years and showed low Vit D levels in epileptic patients. They concluded that antiepileptic drug therapy is associated with low bone density at clinically relevant skeletal sites with age, therapy duration, polypharmacy and the use of enzyme-inducing drugs as possible risk factors.
The only published clinical trials of vitamin D supplementation among children on antiseizure drugs is from Mikati et al 2006 where they conducted two parallel, randomized, controlled trials in 72 adults (18 to 54 years old) and 78 children and adolescents (10 to 18 years) on long-term AED therapy . The participants received either low-dose vitamin D 400 IU/day or high-dose vitamin D 4,000 IU/day (adults) and 2,000 IU/day (children/adolescents) . The trial results showed significant and comparable increases in BMD measured using dual-energy x-ray absorptiometry in children with both treatment groups. In adults the 4,000 IU/day dose was found to be more effective than 400 IU/day dose.
Mikati et al 2009 [1] on the basis of the above evidence (Level II) proposes:
- Measurement of BMD at the start of treatment and periodically on an individualized basis at follow-up.
- Monitoring of vitamin D (25-OHD) levels to help adjust the vitamin D dosing on an individualized basis.
- Enforcement of adequate calcium intake and vitamin D supplementation at each clinic visit.
- Vitamin D replacement at doses of 400–2,000 IU/day as prophylaxis at the start of therapy.
- Higher doses may be recommended in patients with low baseline vitamin D levels, 2,000 IU/day in children, and 4,000 IU/day in adults and doses of 5,000–15,000 IU/day in patients with osteomalacia.
The American Academy of Pediatrics (AAP)[2] have recommended that all children receive 200 IU of vitamin D supplements as infants and continue through adolescence, but do not recommend vitamin D doses specifically for children on antiseizure drugs.
The International Society for Clinical Densitometry (ISCD) [3] has not specified epilepsy in its recent position development statement as an indication for BMD measurements in children
The ISCD guidelines also state that the diagnosis of osteoporosis should not be made based upon densitometric criteria alone, and that therapeutic interventions should not be based upon a single DXA measurement and recommend that prior to treatment, when technically feasible, all children have spine and total body less head bone mineral content and bone mineral density (BMD) measurements.
Additional questions need to be answered before large scale prevention programs are instituted including [4]
- If screening for BMD loss is begun within the first 6 to 18 months of epilepsy treatment, what is the appropriate screening method and at what intervals should DXA scan screening be done?
- Do Children with epilepsy who also have impairment of mobility and reduced weight-bearing (e.g., children with cerebral palsy, spina bifida) who are at a higher risk for BMD loss require different screening and prevention strategies?
- For those at increased risk of osteopenia or with early BMD loss, does early treatment restore normal BMD, and which treatment regimen is best for each age group?
- How should epilepsy-associated osteopenia research and prevention priorities in developing countries interface with other nutrition and supplement programs already occurring in those countries?
[edit] References
- Mikati MA, Ataya N, and El-Hajj Fuleihan G. Re: Epilepsy-associated bone mineral density loss should be prevented. Neurology 2009 Mar 10; 72(10) 943; author reply 943-4. doi:10.1212/01.wnl.0000346324.60732.5e pmid:19273833.
- Gartner LM and Greer FR. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics 2003 Apr; 111(4 Pt 1) 908-10. pmid:12671133.
- Official Positions and Official Pediatric Positions of the International Society for Clinical Densitometry. Available at: at http://www.ISCD.org.
- Trevathan E. Epilepsy-associated bone mineral density loss should be prevented. Neurology 2008 Jan 15; 70(3) 166-7. doi:10.1212/01.wnl.0000299751.87703.c5 pmid:18195262.
