Transcript
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Podcast Producer Michael (0:40)
Everything will change. Everything has changed.
Dr. Chapa (0:47)
Oh, those famous words from the movie The Patriot in 2000. Everything will change. Everything has changed. So true. So true. Remember, that's actually the tagline of our show, Medicine moves fast. Medicine moves fast. And that's what we're going to talk about here because something just came out ahead of print in the green journal that's Obstetrics and Gynecology titled Dietary Supplements in the Perinatal Period. Now, this addresses micronutrients like calcium, zinc, vitamin D and of course folic acid in the periconception interval. And it's a good read. I mean, it's good reminders that if somebody's calcium deficient, then supplementation with additional calcium potentially and those that are calcium deficient may help prevent against preeclampsia in that population. Talks about iron supplementation and something that we've covered here, which is daily versus every other day iron supplementation because of its effect on on hepcidin. And while the data is a little unclear, there is a clear advantage to taking iron every other day, which is less GI distress, less constipation, with the net yield being about the same as daily supplementation and or slightly better because of the effect on hpcitin. We've covered all of that. None of that is new. However, when I was reviewing this again, this came out just on October 31, 2025. That's Halloween. There was something in here that I'm like, that's right. I remember this changed. And I was going to cover this back then as an episode, but I asked our producer, hey, did we ever do that? Or we didn't. And the answer was no, because we forgot about it. But it's a great time to review folate or folic acid, which is what's the recommended type for folic acid supplementation. Oh, by the way, we have a whole other episode on folate versus folate, folic acid versus methylfolate. Go back and listen to that. Look for that in the archive. Folate versus Folic acid versus methylfolate. And the truth is there's nothing wrong with synthetic form of the natural folate. So taking folic acid, even in patients with MTHFR mutation, there's going to be enough conversion where folic acid is going to do the job. So go back and listen to that because we have a whole episode on, on the social media controversy of why do we recommend a synthetic version of a natural thing? And the answer is, if we all ate the natural thing, we wouldn't need a synthetic version because we should get folate from our diet. That is the best way to do it. But for those who don't, and very few of us actually have a good healthy diet, I'm just speaking in generalities and I'm speaking for myself at the same time too. Folic acid seems to be just fine. So we've got that whole other topic on that because what is recommended for supplementation in the perinatal interval and during pregnancy is folic acid. Okay, Nothing wrong with folate, nothing wrong with methylfolate. But to say that they are intuitively better than folic acid is just not evidence based. You can go back and listen to that. By the way. That's not what we're talking about. Well, we're not covering that, but it was a good reminder. I just wanted to put that out there. What I am going to talk about is the amount of folic acid that traditionally was recommended for patients with seizure disorders. Historically with certain anti epileptic medications. I understand we've got new medications now. I know that, like lamotrigine, that is less neurotoxic and I get that. But historically, because certain antiepileptic medications depleted the body of folate stores. And of course that link with neural tube defects. That is true, that is real. But historically we offered those patients, we recommended those patients actually until 2023, high dose of folate or folic acid. And that was traditionally, that was about 4 milligrams or 5 milligrams. All right. That was the traditional recommendation that we gave patients who could become pregnant and who are on certain antiepileptic medications use this higher dose of 4 to 5 milligrams per day because that protects the child. All right. Just wanted to make sure that you're aware that that is no longer true. Okay, so. And this is nothing new. This actually went out in 2023. And I cannot believe, cannot believe that we didn't cover it. I had it on my list. I know because I remember putting it on there. But Michael, my producer, said, bro, you did not do that. I remember you talking about it and then you got distracted. Surprise. And then I didn't do it. However, it works out great because this new publication from the Green Journal addresses that in a little paragraph. And I thought, aha, now it's the time to do it. So while this is stated in a new release from October 31, 2025, and, and I'm gonna read that directly, it is not new. It is actually about two years old. Because the buzz of this started in 2023 when SMFM and the American Academy of Neurology and the Swiss League Against Epilepsy all jumped on board along with international published guidance, like the guidance from Germany, Australia and Switzerland who actually adopted this September of 2023. They're like, man, taking too much acid. Not only does it not help patients with seizure disorder, potentially, here it is, guys, I'm gonna get into it. Potentially could be harmful. What? I'm telling you the truth. I'm telling you the truth. So this is why, you know, the whole statement of hey, take more folic acid, it can't hurt, is not right. You've gotta know the recommended amount. So for multifetal gestation, it is still 1000 micrograms. In other words, 1 milligram of folic acid, that is recommended. That hasn't changed. That's the old tradition. 1000 micrograms of folic acid. Or if they have a child with a prior neural tube defect, that is still the max of 4,000 micrograms, 4 milligrams and that's it. But for those on certain antiepileptic medications, and we used to do that card blanc, it doesn't matter if you have epilepsy. I don't care what medication you're taking. Even if it's lamictal, even if it's one of the newer ones, just take high dose folic acid, 4-5mg. Let me say it again, that is no longer standard. So if you're about to take your oral boards, because we're recording this on November 2, is that what today is? Today's November 2, 2025. This is two days from when that e publication was just out. And you're asked on the oral boards for abog, what is it? Great. What is the right dose for patients with a prior who have a seizure disorder on anti epileptic medications, your answer is, well, let me just clarify. Do they also have a child with a previous neural tube defect? Because that wins. That's 4,000 micrograms of folic acid. That is forever going to be the deal. It's like having a previous child affected with gbs, early onset sepsis. They're forever going to be called a carrier. You don't have to screen, you don't have to swab them. You don't need to swab in their booty. They don't need a swab into the juju. Just call them a carrier. Okay. Same thing with the previous child with neural tube defect. Just give them 4 milligrams of folic acid. Just give them 4 milligrams. But if they don't, then the recommendation is the same as everybody else. 0.4, maybe up to 0.8 milligrams of folic acid. In other words, 400 to 800 micrograms of folic acid. Why? Because as of 2023, both SMFM, the American Academy of Neurology and International Guidance say that too much folate may actually be harmful. And you know why that is?