High prevalence of vertebral fractures in seizure patients with normal bone density receiving chronic anti-epileptic drugs

Abstract

Summary

People with epilepsy who take certain medications are at risk for developing osteoporosis and fractures of the vertebrae that commonly go undiagnosed. By using technology available in a bone density scan, we observed at least one fracture in many subjects with bone density in the normal and osteopenic range.

Purpose/Introduction

Chronic use of antiepileptic drugs (AEDs), both enzyme-inducing (phenytoin, phenobarbital, carbamazepine, and primidone) and non-enzyme-inducing (i.e., valproate), is recognized as a cause of secondary osteoporosis. Vertebral compression fractures (VF) are the most common type of osteoporotic fractures and may confer an increased risk of future hip, wrist, and vertebral fractures. Vertebral compression fractures in the general population are frequently asymptomatic, and under-diagnosed. The purpose of this study is to describe the prevalence of VF in a cohort of male veterans with epilepsy on chronic AEDs.

Methods

The cohort for this study consisted of 146 male veterans who carried a diagnosis of epilepsy and were chronic users of AEDs known to cause osteoporosis (phenobarbital, phenytoin, carbamazepine, primidone, and valproate). Chronic AED use was defined as receiving an AED for at least 2 years. Subjects were previously seen in the osteoporosis clinic and had been evaluated by a dual-energy X-Ray absormetry (DXA) instrument including morphometric studies following a standard vertebral fracture assessment (VFA) protocol during the same DXA imaging acquisition session.

Results

The mean age was 63 years. Low bone mineral density defined as osteoporosis or osteopenia was observed in 29% and 43% respectively. We observed at least one VF in 41 % of the subjects who had normal BMD, 54% in the osteopenic range, and 75% in the osteoporotic range.

Conclusions

By performing a VFA in addition to standard bone densitometric studies, we disclosed a large prevalence of compression fractures in individuals with epilepsy chronically treated with AEDs who had BMDs in the normal and osteopenic ranges. The addition of VFA or other imaging methods to evaluate VF should be included in the evaluation of bone health in individuals with epilepsy receiving AEDs since it may modify treatment recommendations to prevent future osteoporotic fractures.

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Acknowledgements

The authors thank Linda Niesner, PharmD for proof reading and assisting with editing the final manuscript.

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Correspondence to P.M. Dussault.

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Philip M. Dussault, David McCarthy, Samuel A. Davis, Manisha Thakore-James, and Antonio A. Lazzari declare that they have no conflict of interest.

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Key points

• Vertebral compression fractures are frequently underdiagnosed and are the most common type of osteoporotic fracture and known to confer an increased risk of future hip, wrist, and vertebral fractures.

• By performing a VFA, we disclosed a large prevalence of compression fractures in male veterans with epilepsy chronically treated with AEDs.

• Detection of previously undiagnosed compression fractures may expedite a more focused treatment with the goal of improving bone health in the epileptic patient population.

• Based on these results, we recommend performing a lateral vertebral assessment in addition to bone densitometric studies when evaluating bone health in people with chronic epilepsy.

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Dussault, P., McCarthy, D., Davis, S. et al. High prevalence of vertebral fractures in seizure patients with normal bone density receiving chronic anti-epileptic drugs. Osteoporos Int (2021). https://doi.org/10.1007/s00198-021-05926-2

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Keywords

  • Epilepsy
  • Lateral vertebral assessment
  • Osteoporosis
  • Vertebral fracture assessment