Bone mineral density and fractures in institutionalised children with epilepsy and intellectual disability

Background Long-term use of antiseizure drugs is associated with a low bone mineral density (BMD) and an increased fracture risk. The literature regarding institutionalised children on chronic antiseizure drugs is limited. Therefore, the aim of this cross-sectional study is to evaluate the prevalence of low BMD and the history of fractures in institutionalised children with epilepsy and intellectual disability (ID). Methods A dual-energy X-ray absorptiometry of lumbar spine (L1-L4) and hip was performed in 24 children, residing in a long-stay care facility in the Netherlands. Additionally, serum concentrations of albumin, calcium and 25-hydroxyvitamin D were determined. Data on fractures were retrospectively extracted from the medical files. Results Ages of the children (14 male and 10 female) ranged from 5 to 17 years with a mean age of 13.0 (+/- 3.2). The criteria of the International Society for Clinical Densitometry (ISCD) were used for classification of bone mineral disorders. Eight (33.3%) children had a normal BMD (Z-score > - 2.0). Of the 16 children with a low BMD (Z-score <= - 2.0), three were diagnosed as osteoporotic, based on their fracture history. Ten children (41.7%) were reported to have at least one fracture in their medical history. Serum concentrations of albumin-corrected calcium (2.28-2.50 mmol/L) and (supplemented) vitamin D (16-137 nmol/L) were within the normal range. Conclusions This study demonstrated that 67% of institutionalised children with epilepsy and ID had low BMD and 42% had a history of at least one fracture, despite supplementation of calcium and vitamin D in accordance with the Dutch guidelines

Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures

This narrative review considers the key challenges facing healthcare professionals and policymakers responsible for providing care to populations in relation to bone health. These challenges broadly fall into four distinct themes: (1) case finding and management of individuals at high risk of fracture, (2) public awareness of osteoporosis and fragility fractures, (3) reimbursement and health system policy and (4) epidemiology of fracture in the developing world. Findings from cohort studies, randomised controlled trials, systematic reviews and meta-analyses, in addition to current clinical guidelines, position papers and national and international audits, are summarised, with the intention of providing a prioritised approach to delivery of optimal bone health for all. Systematic approaches to case-finding individuals who are at high risk of sustaining fragility fractures are described. These include strategies and models of care intended to improve case finding for individuals who have sustained fragility fractures, those undergoing treatment with medicines which have an adverse effect on bone health and people who have diseases, whereby bone loss and, consequently, fragility fractures are a common comorbidity. Approaches to deliver primary fracture prevention in a clinically effective and cost-effective manner are also explored. Public awareness of osteoporosis is low worldwide. If older people are to be more pro-active in the management of their bone health, that needs to change. Effective disease awareness campaigns have been implemented in some countries but need to be undertaken in many more. A major need exists to improve awareness of the risk that osteoporosis poses to individuals who have initiated treatment, with the intention of improving adherence in the long term. A multisector effort is also required to support patients and their clinicians to have meaningful discussions concerning the risk-benefit ratio of osteoporosis treatment. With regard to prioritisation of fragility fracture prevention in national policy, there is much to be done. In the developing world, robust epidemiological estimates of fracture incidence are required to inform policy development. As the aging of the baby boomer generation is upon us, this review provides a comprehensive analysis of how bone health can be improved worldwide for all

[Toxic epidermal necrolysis due to lamotrigine]

A 10-year-old girl developed a progressive rash and high fever more than a month after the start of lamotrigine as add-on medication for therapy-resistant epilepsy. A skin biopsy indicated toxic epidermal necrolysis (Lyell syndrome). Because her situation deteriorated and the lesions of the skin and mucosa progressed, she was transferred to a specialised centre for burn patients. Despite maximal supportive treatment, she died 3 weeks after the first skin lesions. Even with a low initial dosage of lamotrigine followed by a slow increase, a fatal toxic epidermal necrolysis is still possible. This should be kept in mind, especially in case of concurrent administration of valproic acid

Severe early onset osteopenia and osteoporosis caused by antiepileptic drugs.

Item does not contain fulltextWe describe two adult patients with epilepsy who received long-term antiepileptic drug therapy, a woman aged 39 years and a man aged 38 years, in whom severe osteopenia and osteoporosis, respectively, were diagnosed. Both had had epilepsy since childhood, both were seizure free and off medication for several years before the epilepsy started again. The female patient first sustained a complicated pelvis fracture after minor trauma. Next, both patients had infractions of several thoracic vertebrae after a generalised tonic-clonic seizure. Dual-energy X-ray absorptiometry for measurement of the bone mineral density revealed osteopenia in both. Bone biopsy was only performed in the male patient and showed moderate osteoporosis. Taking into consideration the young age for osteopenia and osteoporosis and the absence of other underlying causes, the long-term anticonvulsant therapy is the most likely cause of the development of osteopenia and osteoporosis in these patients. Reviewing recent literature data, advice from healthcare organisations and medical guidelines, the authors were surprised by the lack of protocols and preventive measures for patients with epilepsy who have been on antiepileptic drug therapy for many years. With this article we stress the urgent need to develop protocols and guidelines for preventive interventions

Dual-energy X-ray absorptiometry versus quantitative ultrasonography in diagnosing osteoporosis in patients with refractory epilepsy and chronic antiepileptic drug use

Background: The aim of this study was to assess the feasibility of calcaneal quantitative ultrasonography (QUS) as a screening method for increased risk of osteoporosis in a unique population of people with chronic epilepsy, intellectual disability (ID), and chronic use of antiepileptic drugs. Methods: A total of 205 patients from a long-stay care facility for people with epilepsy underwent dual-energy X-ray absorptiometry (DXA) and QUS of the calcaneus. T-scores for both DXA and QUS were calculated and correlated. Results: A total of 195 patients (95.1%) were successfully measured with DXA and 204 (99.5%) with QUS. High correlations were found between DXA and QUS T-scores: r = 0.666 (QUS versus T-score total femur), r = 0.631 (QUS versus T-score femur neck) and r = 0.485 (QUS versus T-score lumbar spine). All correlations were statistically significant (p = 0.01). Conclusion: QUS showed a strong correlation with DXA and proved to be a feasible measuring method in a population with ID and epilepsy. Including osteopenia in the screening process increases the sensitivity of QUS to identify those patients at risk for the development of bone diseases

Antiepileptic drugs and high prevalence of low bone mineral density in a group of inpatients with chronic epilepsy

Purpose Long-term antiepileptic drug use is associated with low bone mineral density (BMD), fractures and abnormalities in bone metabolism. We aimed at determining the prevalence of bone mineral disorders in patients with refractory epilepsy treated with antiepileptic drugs. Methods A cross-sectional survey was conducted in adult patients (n = 205) from a residential unit of a tertiary epilepsy centre. Screening for bone mineral disorders was performed with dual-energy X-ray absorptiometry (DXA) scan of spine and hip (including bone mineral density and vertebral fracture assessment) and laboratory measurements. Patient information regarding demography, epilepsy characteristics and medication use was recorded. Based on DXA T-scores, prevalence of bone mineral disorders (osteopenia and osteoporosis) was calculated. Correlations between DXA T-scores and epilepsy parameters were explored. Results Of the 205 patients, there were 10 dropouts. 80% (n = 156/195) of the patients had low BMD: 48.2% had osteopenia and 31.8% had osteoporosis. Of those having low BMD, 51.9% (n = 81/195) was between 18 and 50 years. The T-score of the femoral neck correlated significantly with total duration of epilepsy, cumulative drug load and history of fractures. Linear regression analysis showed that of the epilepsy-related parameters, only cumulative drug load significantly predicted low femoral neck T-score (P = 0.001). Conclusion In this high-risk population, we obtained a very high prevalence of 80% of low BMD. Both men and women were affected as well as patient

Bone disease during chronic antiepileptic drug therapy: general versus specific risk factors

An increasing number of studies suggest a direct effect of antiepileptic drug (AED) therapy on bone health: Patients on chronic AED therapy may have an increased risk of fractures, reduced bone mineral density, osteopenia, and osteoporosis. In an attempt to distinguish general and specific risk factors, this review examines the available empirical research. The pathophysiology is discussed and guidelines for early detection and treatment options are proposed