NUR 557 Module 7 Milestone Two Example

Milestone Two: Changing a Seizure Medicine Before Pregnancy, From Valproate to Levetiracetam in Juvenile Myoclonic Epilepsy

[Student Name]

Southern New Hampshire University

NUR 557: Advanced Pathophysiology and Pharmacology Across the Lifespan

Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Changing a Seizure Medicine Before Pregnancy, From Valproate to Levetiracetam in Juvenile Myoclonic Epilepsy

For most chronic conditions, a drug that controls the disease well is left alone. Pregnancy changes that calculation because a second patient, the fetus, is exposed to the medicine during the weeks when organs form. This milestone continues the course's treatment planning with a composite woman whose epilepsy is controlled by valproate. It argues that she should switch before conception, not after, from valproate to levetiracetam, because valproate's harm to the developing fetus is the largest among common antiseizure medicines and depends on dose, while levetiracetam carries a much lower risk and treats her particular form of epilepsy effectively.

The Case

The patient is a 27-year-old office manager diagnosed with juvenile myoclonic epilepsy at 16, after morning jerks of her arms and two generalized tonic-clonic seizures, both following nights of little sleep. She has taken valproate 1,000 mg daily since then and has been seizure-free for three years. She and her partner hope to conceive within the next year. She uses a combined oral contraceptive, takes no folic acid and has no other medical conditions.

How Her Seizures Arise

A seizure is a burst of abnormal, excessive and synchronized neuronal firing. In generalized epilepsies, the discharge involves networks across both hemispheres from the start, driven by an imbalance between excitatory glutamate signaling and inhibitory GABA signaling and by ion channels that regulate neuronal excitability. Juvenile myoclonic epilepsy is a genetic generalized epilepsy that typically begins in adolescence and produces brief myoclonic jerks, especially soon after waking, along with generalized tonic-clonic seizures; sleep deprivation is a classic trigger (Rosenthal & Burchum, 2021). It usually responds well to medication but tends to return if medication stops, so she will need treatment through pregnancy.

Why Valproate Works, and Why It Is the Problem

Valproate has several mechanisms: it blocks voltage-gated sodium channels, reduces T-type calcium currents and increases GABA availability. That breadth makes it highly effective across generalized epilepsies, including hers. The same drug is, however, the most harmful common antiseizure medicine for a developing fetus. In the international EURAP registry, which followed pregnancies exposed to eight antiseizure medicines, valproate carried the highest rate of major congenital malformations, and the risk rose with dose, while lamotrigine and levetiracetam carried among the lowest (Tomson et al., 2018). Valproate exposure is also associated with neural tube defects and with poorer neurodevelopmental outcomes, including lower IQ and autism spectrum disorder.

A practice guideline from the American Academy of Neurology, the American Epilepsy Society and the Society for Maternal-Fetal Medicine therefore states that clinicians must avoid valproate in people with epilepsy of childbearing potential when clinically feasible, and should choose medicines and doses that optimize both seizure control and fetal outcomes before conception, at the earliest opportunity (Pack et al., 2024).

Choosing the Replacement

The guideline names lamotrigine, levetiracetam and oxcarbazepine as options that minimize malformation risk, chosen according to the epilepsy syndrome (Pack et al., 2024). Table 1 compares them for her.

Table 1

Lower-Risk Alternatives Compared for Juvenile Myoclonic Epilepsy

Levetiracetam is the best fit. It treats both of her seizure types, does not interact with hormonal contraception and has a low malformation risk. Lamotrigine, also low risk, is less suited because sodium channel blockade can aggravate myoclonic seizures in some people with her syndrome, and its levels fall with estrogen and fall further in pregnancy, which complicates management.

The Switch Plan

The change should happen now, while she is using contraception, not after she conceives, because malformations arise in the first weeks of pregnancy and the guideline cautions against replacing an effective medicine once pregnancy is under way (Pack et al., 2024). Levetiracetam begins at a modest dose that is raised in steps over several weeks until the target is reached; once she has been on a therapeutic dose for a period without seizures, valproate is reduced gradually and stopped. Neither drug is stopped abruptly, since that could provoke a seizure. She continues her contraceptive throughout the switch and for a few months afterward, until seizure control on levetiracetam alone is confirmed. She should start folic acid now; the guideline recommends at least 0.4 mg daily for people with epilepsy of childbearing potential. Protecting sleep, her known trigger, is part of the plan.

Talking With the Patient

The plan depends on her understanding it. She has been seizure-free for three years and may be reluctant to change a medicine that works, so the conversation starts with her goal, a healthy pregnancy, and explains the difference in risk plainly: the drug that has protected her carries a much higher chance of harming a baby than the one proposed, and that risk is concentrated in the earliest weeks, often before a pregnancy is known. She should also hear the other side honestly. Any medication change carries some risk of a breakthrough seizure, which is why the switch is gradual, why she should avoid driving if any jerks return and why she should call at once if they do. Framed this way, the decision becomes hers to make with full information, which is the person-centered approach the course asks for.

Monitoring Into Pregnancy

During the switch, she is asked about morning jerks, which would signal incomplete control, and about mood, since levetiracetam can cause irritability or low mood in some people. Once she is pregnant, levetiracetam clearance increases as kidney blood flow and filtration rise, so its levels can fall; checking a baseline level before pregnancy and repeating levels during pregnancy lets the dose be adjusted before seizures recur (Rosenthal & Burchum, 2021). Minimizing convulsive seizures during pregnancy matters for both her and the fetus, and the guideline stresses it alongside minimizing drug risks (Pack et al., 2024).

Conclusion

This patient's juvenile myoclonic epilepsy is well controlled by valproate, but valproate's broad actions carry the highest fetal risk of any common antiseizure medicine, rising with dose. Levetiracetam, acting on a different target, controls her seizure types with a much lower risk and no contraceptive interaction. The switch must happen before conception, with a gradual cross-taper, continued contraception, folic acid and protected sleep, followed by level monitoring as pregnancy changes the drug's clearance. The next module turns to another pregnancy-related prescribing decision.

References

Pack, A. M., Oskoui, M., Williams Roberson, S., Donley, D. K., French, J., Gerard, E. E., Gloss, D., Miller, W. R., Munger Clary, H. M., Osmundson, S. S., McFadden, B., Parratt, K., Pennell, P. B., Saade, G., Smith, D. B., Sullivan, K., Thomas, S. V., Tomson, T., Dolan O'Brien, M., . . . Keezer, M. R. (2024). Teratogenesis, perinatal, and neurodevelopmental outcomes after in utero exposure to antiseizure medication: Practice guideline from the AAN, AES, and SMFM. Neurology, 102(11), Article e209279. https://doi.org/10.1212/WNL.0000000000209279

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician associates (2nd ed.). Elsevier.

Tomson, T., Battino, D., Bonizzoni, E., Craig, J., Lindhout, D., Perucca, E., Sabers, A., Thomas, S. V., & Vajda, F. (2018). Comparative risk of major congenital malformations with eight different antiepileptic drugs: A prospective cohort study of the EURAP registry. The Lancet Neurology, 17(6), 530-538. https://doi.org/10.1016/S1474-4422(18)30107-8