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Antiseizure Medications and Bone Health

P. Gaete,V. Cuéllar-Rodríguez,C. O. Mendivil

Published 2025 in Neurological Therapeutics

ABSTRACT

Epilepsy frequently requires treatment with antiseizure medications (ASM). With the progressive rise in life expectancy in this population, patients are more exposed to potential undesirable effects, some of them on bone tissue. Here, we review current knowledge concerning the impact of ASM on bone biology. Cytochrome P450 inductors decrease serum concentrations of active vitamin D, increasing parathyroid hormone (PTH) secretion and hence bone resorption. Valproic acid also reduces active vitamin D, but in addition activates osteoclasts and impairs osteoblastic function through different pathways. Although the mechanism remains unclear, topiramate is associated with reductions in bone mineral density and increased PTH. Levetiracetam has a very favorable bone profile. Lacosamide and lamotrigine have a preferable bone effect compared to other sodium channel blockers. These ASM with a lower impact on bone biology should be prioritized whenever possible. Every person with epilepsy receiving high-risk ASM should undergo fracture risk assessment. Drugs used to treat epilepsy are known as antiseizure medications (ASM). Several ASMs potentially increase the risk of fractures, some of them by modifying the metabolism of sex hormones and vitamin D (phenytoin, carbamazepine, oxcarbazepine, eslicarbazepine, and phenobarbital), and others by their direct effects on bone biology (valproic acid and topiramate). Conversely, levetiracetam, lacosamide and lamotrigine have a more favorable bone profile. These ASM should be prioritized whenever possible. All patients receiving high-risk ASM should undergo fracture risk assessment.

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