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Anti-epileptic drugs

and osteoporosis

What else associated with epilepsy increases


What is osteoporosis?
fracture risk?
Osteoporosis occurs when the struts which make up
If you have epilepsy you are more likely to have fractures
the mesh-like structure within bones become thin
but it is likely to be due to a combination of factors
causing them to become fragile and break easily,
including the direct effects of the anti-epileptic drugs, but
often following a minor bump or fall. These broken
also the seizures themselves causing bones to break.
bones are often referred to as fragility fractures. The
Fractures (including spinal compression fractures) can
terms fracture and broken bone mean the same
be sustained during a seizure or from a fall resulting from
thing. Although fractures can occur in different parts
a seizure. Other contributory factors if you have epilepsy
of the body, the wrists, hips and spine are most
(especially if you other health conditions) include lack of
commonly affected. It is these broken bones or
exposure to sunlight which can cause lower vitamin D
fractures which can lead to the pain associated with
levels, and reduced activity levels or physical restrictions
osteoporosis. Spinal fractures can also cause loss of
which can impair bone health and consequently
height and curvature of the spine.
increase fracture risk.

What are anti-epileptic drugs?


Do all anti-epileptic drugs cause osteoporosis
Anti-epileptic drugs are used mainly to stop the seizures,
and increase fracture risk?
sometimes called fits caused by epilepsy. Epilepsy is a
Various studies have indicated a loss of bone density
very common neurological condition requiring life-long
and increased risk of fractures in people using long-term
treatment for many people of all ages.
anti-epileptic drugs. Most of the research in this area has
been in people taking the older anti-epileptic drugs such
How do anti-epileptic drugs cause osteoporosis
as phenytoin (Epanutin), phenobarbital, carbamazepine
and increase the risk of broken bones (fractures)?
(Tegretal), primidone (Mysoline) and sodium valproate
The exact mechanism by which anti-epileptic drugs (Epilim). These anti-epileptic drugs (with the exception of
affect bone strength is not entirely understood. Whilst a sodium valproate) are thought to stimulate a liver enzyme
variety of mechanisms have been proposed, it is thought which destroys vitamin D, reducing the amount of vitamin
that some anti-epileptic drugs alter the way vitamin D D in the body. These are known as enzyme inducing
is broken down and used by the body. Vitamin D helps anti-epileptic drugs. It is still unclear how sodium
the body absorb calcium which is a vital nutrient for valproate decreases bone density.
bones. Most people obtain the majority of their vitamin D
from exposure to sunlight. Severe vitamin D deficiency
can also cause osteomalacia (softening of the bones) A drug safety update from the MHRA (the UK
in adults, which is also called rickets in children. Anti- government agency that ensures medicines are
epileptic drugs are more likely to affect the strength of acceptably safe) has reviewed the evidence (April 2009)
your bones if you are taking high doses of these drugs; and found that long-term treatment with carbamazepine,
if you have taken lots of different types of anti-epileptic phenytoin and primidone, and also long-term treatment
drugs and if you have been taking them for many years. with sodium valproate, can reduce bone density which
may lead to osteoporosis and fractures in certain risk
groups. Particularly at risk are people immobilised for
Furthermore, the direct effects of anti-epileptic drugs may long periods, those not getting enough calcium in their
also increase the risk of fall-related fractures by causing food and drink and when there is insufficient exposure to
drowsiness and slowing down of the bodys protective sunlight to maintain adequate vitamin D levels.
reflexes as well as affecting balance and coordination
(this is more likely as you get older).
Currently there is only limited and conflicting research
data from the studies of other or newer non-enzyme drug treatment after the age of 50 years. You may be
inducing anti-epileptic drugs, such as gabapentin, prescribed a vitamin D supplement with or without an
lamotrigine, topiramate and levetiracetam (Keppra) osteoporosis drug treatment to ensure you are getting
regarding their effects on bone. The findings from two sufficient vitamin D. A calcium supplement may also be
recent research studies suggest that most anti-epileptic recommended if you are not getting enough calcium in
drugs are associated with an increased fracture risk. One your diet.
of these studies analysed the data from several individual
pieces of research and the other focussed on people Should my vitamin D level be checked?
aged 50 years and older taking anti-epileptic drugs. The NICE (National Institute for Health and Care
However more research is needed to evaluate the long- Excellence) guideline (2012) on the management of
term effects of these medications on bone health. epilepsy in adults and children recommends checking
vitamin D levels and undertaking any other investigations
If I am taking anti-epileptic drugs, do I need a that may be appropriate to assess bone health every
bone density scan? 2-5 years for all adults who take enzyme inducing
Bone density scans provide information about the anti-epileptic drugs. However all current UK guidance
strength of your bones and are generally indicated when suggests considering vitamin D supplementation in
the result is needed to help determine whether a drug people who are felt to be at higher risk (see above)
treatment for osteoporosis would be beneficial. Although including those taking sodium valproate or any of the
there are no definitive recommendations for people with enzyme inducing anti-epileptic drugs on a long term
epilepsy, if you have been taking anti-epileptic drugs basis. The usual dose of vitamin D is 10-20 micrograms
long term and especially if you have other risk factors (mcg) or 400-800 international units (IU), although some
(see below) it may be useful to discuss your possible risk doctors may prescribe higher doses.
of osteoporosis and fracture with your doctor. The doctor
will assess your need for a bone density scan based on What else can I do to prevent osteoporosis and
your overall risk and refer you for a scan if necessary. fractures?
Factors which can help to maintain healthy bones are
The importance of assessing fracture risk is included in a well-balanced diet with adequate calcium rich foods;
a recent (2015) National Guideline on the Management regular weight-bearing exercise but taking care to
of Osteoporosis and the prevention of fragility fractures exercise within your capabilities particularly if you have
from SIGN (Scottish Intercollegiate Guidelines Network) any balance problems or physical disability; avoiding
and recommends that people with epilepsy over the age smoking and keeping alcohol consumption within the
of 50 who are taking anti-epileptic drugs (particularly recommended limits.
the enzyme inducing type) and especially those with
additional risk factors should be considered for fracture I dont have epilepsy but I take gabapentin
risk assessment. for back pain caused by spinal compression
fractures. Is this likely to make my osteoporosis
Your bones will be less strong as you move into older worse and increase my risk for further fractures?
age, whatever your bone density result, so you are more Anti-epileptics medications such as gabapentin
likely to need scanning and assessment of fracture risk (Neurontin) can also be used to help with pain. If shape
after the age of 50 years. changes to the spine are severe as a result of vertebral
fractures, spinal nerves can get pinched or trapped
resulting in neuropathic (nerve) pain. These drugs work
As I am taking anti-epileptic drugs do I need an
by damping down the nerve signals going to your brain,
osteoporosis drug treatment to strengthen my
so pain messages arent transmitted so effectively.
bones?
The main aim of an osteoporosis drug treatment is to
reduce the risk of fractures. Treatments will usually be There is no conclusive research evidence to suggest
recommended if it is considered that your risk of fracture that either gabapentin or another commonly prescribed
is high. You risk is assessed based on a combination medication, pregabalin, have any significant effects on
of factors such as your age, personal and family history bone when used for the indication of neuropathic pain.
of fractures, lifestyle factors such as alcohol use and The above medicines will always be started in low doses
smoking as well as information about bone density -if a and increased gradually until an effective minimal dose
scan has been performed. Again, fracture risk is always is achieved to help manage your pain. Additionally when
higher in later life so you are more likely to be offered a anti-epileptic medications are prescribed for pain they
tend to be used for shorter periods compared to the
long-term use of these drugs in people with epilepsy, The National Osteoporosis Society is the
which in itself constitutes a risk factor for bone health. Its only UK-wide charity dedicated to improving
always important to weigh up risks and benefits when the prevention, diagnosis and treatment of
taking any medication, but if gabapentin is making a osteoporosis and fragility fractures. The Charity
difference and reducing your pain, then this benefit receives no Government funding and relies on
(based on current evidence) far outweighs any potential the generosity of individuals to carry out its
risk to your bone health. vital work.

For osteoporosis information and support


contact our Helpline:

0808 800 0035


@ nurses@nos.org.uk

Useful contacts To become a member or make a donation:

Epilepsy Action 01761 473 287


FREEPOST LS0995 @ join online at www.nos.org.uk
Leeds LS19 7YY
To order an information pack or other
Tel: 0808 800 5050 (Freephone helpline open
publications:
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Email: helpline@epilepsy.org.uk
01761 471 771
www.epilepsy.org.uk
@ info@nos.org.uk
Epilepsy Society or download from our website at
Chesham Lane www.nos.org.uk
Chalfont St Peter
Buckinghamshire SL9 ORJ
Tel: 01494 601400 (Helpline open 10am-4pm,
Monday to Friday)
Email: enquiries@epilepsysociety.org.uk
www.epilepsysociety.org.uk

Updated December 2015

This fact sheet is one of a range of publications produced by The National Osteoporosis Society.
If you would like more general information about osteoporosis see our booklet All about
Osteoporosis.

This information reflects current evidence and best practice but is not intended to replace
the medical advice provided by your own doctor or other health professional.