Authors :
Presenting Author: Anne Van Cott, MD – VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA
Lindsay Visnovsky, PhD, MS – University of Utah School of Medicine
Megan Amuan, MPH – Informatics, Decision-Enhancement, and Analytic Sciences Center of Innovation, Salt Lake City VA Health Care System, Salt Lake City, UT
Eydie Moses-Kolko, MD – VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA
Anna Blanken, PhD – Department of Mental Health, San Francisco VA, San Francisco, CA
Kristen Mordecai, PhD – Department of Mental Health, Baltimore VA Health Care System, Baltimore, MD
Allison Cirenza, DNP, APRN, PMHNP – University of Utah School of Medicine
Shaelene Wright, DNP – Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT; Informatic
Maria Lopez, MD – VA Epilepsy Centers of Excellence, Miami Veterans Health Care System, Miami, FL; Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL
W. Curt LaFrance Jr., MD, MPH – VA Mind Brain Program, VA Providence Health Care System, Providence, RI; Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, RI
Mary Jo Pugh, PhD, RN – Salt Lake City VA and University of Utah
Rationale:
Women are the fastest-growing population of Veterans. The national VHA Epilepsy Centers of Excellence (ECoE) have identified an increasing proportion of women Veterans diagnosed with Epilepsy Monitoring Unit (EMU) confirmed psychogenic non-epileptic seizures (PNES). Anti-seizure medications (ASMs) are often prescribed for presumed epilepsy before the diagnosis of PNES is confirmed. Given the potential for ASM side effects, including teratogenicity, it is critical to know if Veterans continue ASM use after a PNES diagnosis and identify comorbidities.
Methods:
We identified those with confirmed lone PNES (excluding dual diagnosis of PNES and Epilepsy) based on inpatient video EEG-monitoring conducted in VHA EMUs and compiled in the VHA EMU database (‘12-‘22) to examine ASM prescriptions after lone PNES diagnosis in 2023. ASM prescription data was extracted from the VHA Pharmacy Benefits Management Services Database. We compared continued ASMs among males and females using chi-square tests.
Results:
140 female and 455 male Veterans had EMU-confirmed lone PNES. Time from first documented seizure and PNES diagnosis was 3 years longer for female vs. male Veterans. There was no significant differences by sex in continued ASM use at least a year post-PNES diagnosis (n=71, 50.7% vs. n=235, 51.7%; Table 2). The most frequently prescribed ASMs among female Veterans were gabapentin (23.6%), topiramate, and lamotrigine, as compared to gabapentin, lamotrigine, and valproic acid among males. Topiramate (potentially teratogenic ASM) prescriptions were nearly twice as common among females than males after diagnosis (19.3% vs. 8.8%; p= 0.001. Among women of childbearing age, 8.6% received lamotrigine (vs. 12.3% of men; p=0.29) and a similar proportion of males with PNES were using levetiracetam (6.4%) compared to female Veterans (< 10%). Both sexes had significant physical and mental health comorbidities (Table 1), notably mood disorders, PTSD and pain/headache. Conclusions:
Half of all female Veterans remained on ASMs after receiving an EMU confirmed PNES diagnosis. Most concerning, women Veterans were significantly more likely to remain on potentially teratogenic ASM such as topiramate. It is possible that ASMs are continued after the confirmed PNES diagnosis for treatment of comorbidities. The continuation of levetiracetam is concerning, as it is not indicated in other medical or psychiatric disorders, and has higher rates of adverse behavioral effects and suicidality. Future evaluations will include chart abstractions to address child-bearing potential, shifts in ASM prescribing patterns and treatment of comorbidities. This information contributes to understanding the unique profile of women Veterans with PNES and is a critical step in coordinating women’s care within the VHA by collaborative partnerships between VHA Women’s Health Programs, VA Behavioral Health, the VA Mind Brain Program, and the VHA Headache Centers of Excellence.
Funding: VA National Neurology Office