Podcast Summary: Dr. Chapa’s OBGYN Clinical Pearls

Episode: Folic Acid Update: Women on Epilepsy Meds Do NOT Need More

Date: November 2, 2025
Host: Dr. Chapa

Episode Overview

This episode delivers a crucial update on folic acid supplementation recommendations for women of reproductive age, especially those taking anti-epileptic medications. Dr. Chapa emphasizes that the old practice of prescribing high-dose folic acid to women with epilepsy is no longer endorsed. New evidence and guidelines now recommend the standard dose—arguing that more isn't better and could, in fact, be harmful. Designed for medical students, residents, and practicing providers, this episode exemplifies Dr. Chapa's commitment to evidence-based, no-spin education.

Key Discussion Points and Insights

1. Rapid Changes in Medical Guidance

• Podcast Theme: “Everything will change. Everything has changed.” (00:47, 08:58, 27:01, 27:28)
  • The field of medicine moves rapidly; guidelines must be consistently reviewed and updated.

2. Dietary Supplements in Perinatal Care (00:47–03:40)

• Recent Green Journal publication on perinatal dietary supplements reviews micronutrients such as calcium, zinc, vitamin D, and especially folic acid.
• Reminder: Proper supplementation is critical, but more is not always better.

3. Old vs. New: Folic Acid in Women on Anti-Epileptic Drugs (03:41–06:23)

• Historical standard: Women of reproductive age taking certain antiepileptic drugs (valproate, carbamazepine, etc.) were prescribed high-dose folic acid (4–5mg/day).

• Current evidence (since 2023):

  • The blanket recommendation for high-dose folate is no longer supported.
  • International guidelines (SMFM, American Academy of Neurology, Swiss League Against Epilepsy, Germany, Australia, Switzerland) now advocate for standard dosing:
    • 0.4–0.8mg (400–800mcg) per day, same as the general population.

  “That is no longer standard. … The recommendation is the same as everybody else. 0.4, maybe up to 0.8 milligrams of folic acid.”
  —Dr. Chapa (06:23)

4. Why the Change? New Understanding of Folic Acid’s Role (09:05–14:20)

• Landmark change came from evidence showing:

  • Many anti-epileptic drug–associated neural tube defects are folate-resistant; extra folic acid doesn't reduce risk.
  • High doses might be harmful:
    • Animal and human epidemiological data suggest very high levels could impair fetal neurodevelopment, with emerging concerns about increased cancer risk.
      • Scandinavian studies observed increased childhood cancer with excessive folic acid intake.
    • Past literature (e.g., Seizure, 2015): “Are we sure [high-dose folic acid] is safe?”—raised early safety flags.

  “More is better is not always the answer.”
  —Dr. Chapa (13:41)

5. Persisting Confusion and Outdated Print Recommendations (14:20–19:20)

• Some 2025 publications (using data from 2013–2022) still promote high-dose folic acid, reflecting lag in disseminating new guidance.

  • Dr. Chapa offers grace—to those studies as they predate recent guidelines—but stresses the need for up-to-date practice.

  “There’s still stuff in print that are holding on to the old information.”
  —Dr. Chapa (16:28)

6. Direct Guidance from Recent Publications (19:20–25:00)

• Green Journal (Oct 31, 2025):

  • Prior recommendations of 1mg+ folic acid for women on valproate/carbamazepine are outdated.

  • ACOG & American Academy of Neurology: “Standard dosing of 400 micrograms [is] recommended for those with epilepsy treated with antiepileptic drugs.”

  • Swiss League Against Epilepsy & international bodies (2023):

    • Officially revised to 0.4–0.8mg daily.

  “Supplements are particularly important for women who have epilepsy as anti–seizure medications … can lead to a deficiency in folic acid. Until 2023 … high doses of 4 to 5 milligrams per day were recommended. But things started to change.”
  —(Swiss League, quoted by Dr. Chapa at 23:02)

  • Potential Harms:
    • Observational studies: Excess folic acid associated with certain malignancies and neurodevelopmental concerns.

7. Official Recommendations as of 2024–2025 (25:00–End)

• US and international consistency: SMFM, AAN, AES, and other authorities now recommend:
  • 0.4mg (400mcg) daily for women with epilepsy of reproductive age, matching the general population.
  • Exceptions:
    • Women with a previous child with a neural tube defect: 4mg (4,000mcg) daily remains indicated.
    • Multifetal gestation: 1mg (1,000mcg)
• Take-home message:
  • High-dose folic acid is not routine for women on epilepsy meds unless another indication is present.
  • Doing too much can be harmful.

Notable Quotes & Memorable Moments

• On medicine’s pace of change:

  “Medicine moves fast. Medicine moves fast. And we try to deliver that to you in the show without any spin.” (04:15, 13:41)

• On outdated practices:

  “Just because more is better is not always the answer.” (13:40)

• On patient counseling:

  “If you’re about to take your oral boards... what is the right dose for patients with a seizure disorder on anti–epileptic medications? ... The recommendation is the same as everybody else. 0.4, maybe up to 0.8 milligrams of folic acid.” (06:23–07:01)

• Summing up the implications:

  “High-dose folic acid … potentially could be linked to some adverse issues like neurodevelopmental issues and potentially some cancer based on some observational studies. So this is a big deal. Doing too much can be harmful.” (27:35)

Timestamps for Key Segments

• 00:47 – Episode theme: How guidelines evolve
• 03:40 – Classic recommendations for high-dose folic acid in epilepsy
• 06:15 – NEW guidance: Standard dosing of folic acid (0.4–0.8mg), unless other indications
• 09:05–13:41 – Reasons for guideline change, animal/human data, risks of excess
• 14:20–19:20 – Persistent “old” advice in journals, need for up-to-date knowledge
• 19:20–25:00 – Quoting Green Journal & recent SMFM/AAN/Swiss League guidelines
• 25:00–27:35 – US & international alignment, summary & take-home message

Tone and Language

Dr. Chapa’s delivery was energetic, informal, and direct, employing humor (“swab in the booty...swab into the juju”) and movie references (“Everything will change. Everything has changed.” – The Patriot) to keep the discussion lively but focused on translating data into actionable clinical pearls.

Summary Table: Folic Acid Recommendations (as of 2025)

| Patient Population | Folic Acid Dose | |---------------------------------------|-------------------------------------------------| | General reproductive age women | 0.4–0.8mg (400–800 mcg) daily | | Women on anti-epileptic medications | 0.4–0.8mg (400–800 mcg) daily | | Multifetal gestation | 1mg (1,000 mcg) daily | | Prior child with neural tube defect | 4mg (4,000 mcg) daily | | Folate-deficiency anemia | As clinically indicated |

Final Takeaways

• High-dose folic acid for women with epilepsy is outdated—the routine dose is now the same as for the general population.
• Excess supplementation in this group provides no extra benefit and may carry potential risks.
• Always check for the latest evidence and guidelines, as clinical practice continues to evolve rapidly.
• For exceptional scenarios (prior child with NTD, multifetal gestation, etc.), higher dosing remains appropriate.

For more, references from this episode (including the Green Journal, SMFM releases, and international guidelines) will be included in Dr. Chapa’s show notes.