← Dr. Chapa’s OBGYN Clinical Pearls 
Dr. Chapa’s OBGYN Clinical Pearls
Folic Acid Update: Women on Epilepsy Meds Do NOT Need More
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- [00:00]
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Podcast Producer Michael
Everything will change. Everything has changed.
- [00:48]
Dr. Chapa
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?
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Podcast Producer Michael
Everything will change. Everything has changed.
- [09:06]
Dr. Chapa
Ah, everything will change. Everything has changed. From the Patriot 2000. Not a sponsor. So that's where we're going. We're going to tackle quickly, just quickly, famous last words, tackle this Clinical Expert series. So let me be very clear. This is not a clinical practice update. This is not a committee opinion. This is not a practice bulletin. Although those terms aren't actually applicable anymore because ACOG changed all the terms when I was still on the board. But nonetheless, it is a CES that is still a thing. Clinical Expert series Dietary Supplements in the perinatal period. And this was just released on October 31, 2025. What is the correct dose of folic acid for patients with epilepsy on anti seizure medication? The answer, which we're going to get into is the dose that's the same for everybody else. I think I've set it up enough. We will be right back. This is Dr. Chapa's OB GYN no Spin podcast. Okay. All right, so now I remember why I likely didn't cover this. I remember this, Michael. I remember why we didn't do this. Because very few people, even though there's some still around who are reproductive age, very few women are on depakote, you know, valproate or tegretol, carbamazepine. Very few folks, although I'm sure that there's some that are out there. So valproate, carbamazepine, those are very old school. Although, you know, I'm assuming maybe some are still on it. I mean, it is possible, but most of the reproductive age should be on something that is, you know, less fetal toxic, less harsh on the patient. But those are traditional, very old school valproate, carbamazepine that were linked to neural tube defects. Let me read this paragraph directly from this October 31, 2025 new release. And then I'm going to go back and let you know what they're talking about, where they got this statement from. Okay, so, and I'm not saying that folic acid is not necessary. Folic acid is very necessary in every reproductive age female who is of childbearing potential because of the need for neural tube defect prevention in general and for, just for healthy support of erythropoiesis. Right, that, that's fine. We need good, healthy food. Folate from natural sources and, or folic acid from synthetic sources, either 400 micrograms or at the higher end, 800 micrograms, but that's it. Unless you're having a multifetal gestation where it's 1000 micrograms, which is 1 milligram. Don't just take willy nilly extra doses of folic acid. There's a publication that we're going to cover also back from 2015, 2015 in the Journal Seizure that raised this question a decade ago. The title of this publication from 10 years ago was quote, high dose folic acid supplementation in women with Epilepsy. Are we sure it is safe? End quote. That was the title 10 years ago in the journal seizure. And in this publication they raised the concern that, hey, at least in some animal studies, high doses of folic acid all throughout gestation. So that's the catch. This is all throughout gestation, just to be clear, could potentially adversely affect fetal brain development. And you're like, whoa, wait a minute, we're trying to protect a child. Yeah, well, using too much just because more is better is not always the answer. So once again, this was a publication from the Journal Seizure 2015 that asked this very question, quote, high dose folic acid supplementation in women with epilepsy. Are we sure it is safe? End quote. That's what they asked 10 years ago. They said, hey, before we start recommending this to everybody, high dose folic acid, we better make sure this works because we don't have any data that this is any better for patients on these seizure medications that affect folate levels. Because here's a spoiler. That kind of folate neural tube defect deficiency and issue tends to be folate resistant anyway. Do you hear that, that's the catch. Is that the kind of neural tube defect that occurs with folate deficiency on these older antiepileptic medications, AEDs, tends to be folate resistant with a potential real harm of adverse neurological development in the child. Wow. So again, this is why our podcast tagline, either for clinical pearls or the no Spin podcast is medicine moves fast. Medicine moves fast. And we try to deliver that to you in the show without any spin. That's sociopolitical. We just give you exactly what the data is. And if it's gray, we're not telling you what to do. We want you to make your educated decision based on the data that we have presented, which has been very well vetted, by the way, very well vetted to impact patient care. So back in this 2015 publication, which I don't want to dwell on because it's not the focus, but I'm just telling you, 10 years ago, authors raised this proposal, quote, it is not suggested to advocate high dose folic acid supplementation in women with epilepsy until more information is available about its appropriateness, its safety and the optimal dosing. End quote. It is not suggested to advocate high dose folic acid supplementation in women with epilepsy. That was 10 years ago, brother. They were ahead of the curve because now there's whole international societies saying, yeah, you know what, that's potentially dangerous. And it does not seem to help. So hold on, we're going to get there because while we're laying up this foundation, we're making this case. There's still stuff in print that is confusing. Let me say that again. There's still stuff in print that are holding on to the old information. Now, before I read you this new thing from October 31, 2025, let me just give you a little idea of how people are confusing all this. And some people didn't get the memo. And again, nothing personal, but there is something coming out in December of 2025, y'. All. That's, that's next month. I'm telling you right now, it is. In the journal Maternal Fetal Neonatal Medicine. In the journal Maternal Fetal Neonatal Medicine. If you don't believe me, that's all right. That's all right. I'm going to put that reference in our show notes, okay? In the journal Maternal Fetal Neonatal Medicine, the title is a 10 year review of Periconceptual Folic Acid Supplementation in Women with Epilepsy Taking Anti Seizure Medications. End quote. This is very easy. This is just. This was an epidemiological study. This was using a hospital's computerized database just looking to see if the people who got the women who got pregnant who have a seizure disorder, were they taking the recommended higher doses of folate like they were told to. Now remember, this is a ten year review, okay? Ten year review. Now here's the idea. Even though this is a hospital's kind of database snapshot, it does mirror past epidemiological studies that have said, hey, neural tube defects are caused by anti seizure medications, well, certain anti seizure medications and therefore you need high dose folate at least three months before conception to build up your stores. Otherwise general population one month before, but on anti seizure medication three months before. That was a general thought. Now remember, this is coming out next month, December 2025. Now listen to what I'm just going to read you what's in their background. In their background and, and how this is now out of sync with the newest recommendation from smfm, aan, American Academy of Neurology and International Bodies. Okay? So again, I don't know, maybe they didn't get the message, I don't know. But this does go back 10 years. So this does predate these changes. So I'm going to give it that grace. Okay? I'm going to give it that grace. So let me read directly from this, let me read directly from this Again, coming out December 2025, international guidelines recommend that women at increased risk of a pregnancy complicated by a neural tube defect who could become pregnant should start high dose oral folic acid, open parentheses, 5 milligrams daily, at least three months before conceiving. End quote. Okay, so this is talking about those on anti seizure medications, Remember that's the name in the title. Okay? And so here in the background coming out December 2025, it says, hey, international guidelines say women at increased risk of a pregnancy complicated by neural tube defects should take 5 milligrams of folic acid starting three months before. And they took a look 10 years over a 10 year interval and the 10 years were from 2013 to 2022. So again, this did predate that. This absolutely predated the new guidance change which came out in 2023. So I get that. Again, that's the grace on there. However, once it the guidelines did change, you would figure that they would put an erratum or an addendum or an author update, letter to the editor or something going well, kind of what's in our background. I don't want that to mislead anybody because we don't do that Anymore. Okay, so again, to be fair, the data set that they use, a 10 year span predated the new guidance change. All right. And again, I'll put that reference in our show notes. All right, so where did all this change? Well, I'm sorry, before we do that, let me read you, let me read you back in October 31, 2025, and then we'll knock that out. We'll be done with this. Again, this is in the Green Journal under quote, seizure disorder treated with valprate or carbamazepine, end quote. Really, those are the ones that are more historic. But there's some women still on it. I'm sure women with seizure disorders treated with teratogenic medications such as valprate or carbamazepine are at increased risk for neural tube defects in their fetus. However, these medications have also been associated with. Here it is, guys, listen up. Folate resistant neural tube defect. Folate resistant neural tube defect, meaning extra folate ain't going to work. They go on to say, quote, although previous recommendations included a daily intake of 1mg folic acid to mitigate teratogenic effects, high dose folic acid supplements for those taking antipeleptic medications are no longer recommended by the acog. The American Academy of Neurology similarly recommends standard dosing of 400 micrograms Folic acid before pregnancy for those with epilepsy treated with antiepileptic drugs. End quote. Do you all get that? Now here they went to the 1 milligram, although some like CDC at one point did say 4 milligrams. Right. The point is the new data as of 2023, and I'm going to read to this in a minute, says additional folate is not going to help. Just take what's recommended for anybody else. The time when more is necessary likely is if your true folate deficiency and a folate deficient anemia, if you have multifetal gestation where it's 1000 micrograms, if you have a previous child with an NTD neural tube defect where it's 4000 micrograms. Okay, so this actually came out first proposed in 2023. Then it was time of, you know, it was an embargo, it was open comment and then officially I guess came out or accepted, I should say in 2024 as an update, but first proposed in 2023. I will post this link of course in our show notes. But let me read to you from the Swiss League Against Epilepsy because it very nicely summarizes this and the areas of concern.
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Dr. Chapa
Conception and during pregnancy can help protect the unborn baby from developing abnormalities. Yes, that's true. Okay, they go on to say, quote, supplements are particularly important for women who have epilepsy as anti seizure medications, previously known as anticonvulsants, can lead to a deficiency in folic acid until 2023. So, guys, y' all know that if something says until, that means it doesn't have the same implementation. Same implementation, same implication afterwards. So until 2023, high doses of 4 to 5 milligrams per day were recommended. But things started to change. Quote, Scandinavian cohort studies have discovered an increased risk of cancer in children born to mothers with epilepsy who took high dose of folic acid before or during their pregnancies. End quote. That's not my assumption. I'm not throwing stuff out. This is directly from the revision from the Swiss League Against Epilepsy that too much folate potentially is harmful. And here they're focusing on. And it's true, there is observational data. That's the catch. Observational data that too much folic acid cells don't like that. Okay? Forming cells don't like that. And there has been an increase, there's been some publications that potentially could lead to certain malignancies in the offspring in addition to the potential concerns of neurodevelopment issues that we covered like in 2015. Okay, so here it is. Based upon the most recent data. Okay, Based upon the most recent data, quote, the Epilepsy League now recommends a dose of 0.4 to 0.8 milligrams per day, following the guidelines quote, first epileptic seizure and epileptics in adulthood for Germany, Australia and Switzerland, which went into effect September 1, 2023. Now, I know what you're thinking, all right? I get that. That's great. That's good for the Swiss and their cheese. That's great for them. We're in America. What is that have to do with us? And the answer is nothing, except that SMFM and AAN also have the exact same guidance. This came out from their press release. First put in embargo in May of 2024. May of 2024. This guideline provides recommendations that are updated regarding the effects of anti seizure medications and folic acid supplementation and malformations at birth. So as they say right here, let me read you directly. This is now smfm, okay? Not the Swiss. This is SMFM and the American Academy of Neurology aan. Quote, this guideline recommends that people with epilepsy who may become pregnant, otherwise known as women, could take 0.4 milligrams of folic acid before and during pregnancy to decrease the risk of neural tube defects and. And possibly improve neurodevelopmental outcomes. Y' all get that? 0.4 milligrams. So the guidelines now recommend a much lower dose of folic acid than what was previously recommended for decades. This is a new change as of 2023, officially, I guess last year, 2024, after it was done from public comment and now mentioned again correctly on October 31, 2025. So, guys, medicine moves fast. Everything will change. What did he say? Everything will change. Everything has changed. That was the Patriot. It was a great concept of a movie. I thought it was fantastic about, you know, kind of the founding of the battle for America. That came out in 2000. That was a Mel Gibson movie, wasn't it? Is that I'm off track. All right? So anyway, I think it was a Mel Gibson movie. But that was a great quote. I remember that. And I had Michael put that in there. Everything will change. Everything has changed. I tell that to my kids all the time.
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Podcast Producer Michael
Everything will change. Everything has changed.
- [27:09]
Dr. Chapa
Oh, the drama. Oh, the drama. Everything will change. Everything has changed. Yes, because that's called life. Again, testing the science, guys, is how we do science. Never, never trust the science. The science changes. This is why we do what we do.
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Podcast Producer Michael
Everything will change. Everything has changed.
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Dr. Chapa
All right, so now that we've done all this, oh, my gosh, we're going to continue that, do we want to hear the rest of it? No, stop that. I don't want to hear the rest of it. All right. He kept that going for a little bit. All right. So anyway, yes, everything, everything will change. Everything has changed. So, officially adopted in 2024, December of 2024. So just one year ago, I just thought this was so important to put this out there, especially if you're asked about this at a time of your oral boards. So it is both by aan, SMFM and I'll even throw in the American Epilepsy Soc because all of them have the same guidance and the same wording on their website. So whether you're at aan, AES or the smfm, the new guidance on those taking anti seizure medications, which we all know historically were two, although just in general, they kind of made that a blanket statement. High dose folic acid and then we're going to wrap it up, is no longer a thing. High dose folic acid is no longer thing. 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. Podcast Family I think we've said what we're supposed to say. Just doing the updated guidance for women with epilepsy who may become pregnant and the updated recommendation for folic acid preconception and through pregnancy. Now that we've done all that, Michael, come on, let's take it home. Foreign this has been Dr. Chapa Zobe Gyn, no Spin podcast Podcast Family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast. It.