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Impact of long-term antiseizure medications on serum vitamin B12 and folate levels in children with epilepsy in central India
*Corresponding author: Dr Arvind Kumar Kankane, Professor and Head , Department of Neurology, Maharani Laxmi Bai Medical College, Jhansi, Uttar Pradesh, India. akankane2014@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Kankane A, Gupta S, Kankane AK. Impact of long-term antiseizure medications on serum vitamin B12 and folate levels in children with epilepsy in central India. Ann Natl Acad Med Sci (India). 2026;62:54-9. doi: 10.25259/ANAMS_144_2025
Abstract
Objectives
This study investigates the impact of long-term antiseizure medication (ASM) therapy on serum folate and vitamin B12 levels in pediatric epilepsy patients in the Bundelkhand region of Central India. Given the region’s socioeconomic challenges and the critical role of these vitamins in neurological development, the research aims to inform comprehensive treatment strategies that address both seizure control and nutritional well-being.
Material and Methods
A comparative cross-sectional study was conducted at Maharani Laxmi Bai Medical College, Jhansi, from May to December 2024. The study included 100 children aged 5-18 years with epilepsy on ASM therapy for over 1 year and 100 age- and sex-matched healthy controls. Participants were categorized into monotherapy (phenytoin-PHY, sodium valproate-SV, or levetiracetam-LEV) and polytherapy groups. Exclusion criteria encompassed factors like body mass index (BMI) below the 3rd percentile, current vitamin supplementation, systemic illnesses, and malabsorption syndromes. Serum folate and vitamin B12 levels were measured using chemiluminescent microparticle immunoassay (CMIA). Data were analyzed using SPSS version 23, employing t-tests, Chi-square tests, and logistic regression.
Results
The mean age of participants was 10.48 ± 3.89 years, with 59% being male and 63% from rural areas. Among epilepsy patients, 34 and 66 were on monotherapy and polytherapy, respectively. Vitamin deficiencies were observed in 36% of cases versus 22% of controls. Folate deficiency was present in 24% of cases and 2% of controls, while vitamin B12 deficiency was more prevalent in the polytherapy group (53%) compared to the monotherapy group (29%). Within monotherapy, deficiency rates were highest in PHY users (39%), followed by SV (29%) and LEV (17%). All patients on a triple combination of PHY, SV, and LEV exhibited deficiencies in both vitamins. Longer treatment duration and polytherapy were significantly associated with lower serum vitamin levels.
Conclusion
The study highlights a significant association between long-term ASM therapy and deficiencies in vitamin B12 and folate among pediatric epilepsy patients. PHY and SV were particularly implicated in these deficiencies. The findings align with existing literature indicating that certain ASMs can impair the absorption and metabolism of these essential vitamins, leading to potential neurological and hematological complications. The higher deficiency rates in the Bundelkhand region may also reflect broader nutritional challenges prevalent in resource-constrained settings. Long-term ASM therapy, especially polytherapy and PHY monotherapy, is associated with increased deficiencies in vitamin B12 and folate among children with epilepsy. Regular monitoring and potential supplementation of these vitamins should be considered integral to epilepsy management, particularly in regions with underlying nutritional vulnerabilities. Incorporating nutritional assessments into routine care can mitigate adverse outcomes and enhance the overall well-being of pediatric epilepsy patients.
Keywords
Antiseizure medications
Bundelkhand
Epilepsy
Folate
Vitamin B12
INTRODUCTION
Epilepsy is a chronic neurological disorder characterized by a persistent tendency to experience epileptic seizures.1 It is among the most prevalent non-communicable neurological conditions globally, affecting individuals across all age groups. Approximately 70 million people worldwide live with epilepsy, with India accounting for nearly 12 million cases, representing about one-sixth of the global burden.2 In children, epilepsy is notably significant, impacting an estimated 0.5% to 1% of the pediatric population.3 A community-based study from North India reported epilepsy prevalence rates of 6.99 per 1,000 in rural areas and 5.48 per 1,000 in urban settings.4 Notably, over 60% of epilepsy cases commence during childhood, underscoring the importance of pediatric attention in managing this condition.4 The cornerstone of epilepsy management involves the use of antiseizure medications (ASMs). Despite the advent of newer ASM, conventional ASM remains the mainstream of treatment of epilepsy due to the broad spectrum of activity and cost.5 Prolonged ASM therapy has been associated with various adverse effects, including potential deficiencies in essential vitamins such as folate and Vitamin B12.6 These vitamins are crucial for deoxyribonucleic acid (DNA) synthesis, red blood cell formation, and neurological functions.7 Deficiencies can lead to peripheral neuropathy, cognitive impairments, and elevated homocysteine levels, which are linked to atherosclerosis and other vascular complications.8,9 Emerging evidence indicates that certain ASMs, including phenytoin (PHY), carbamazepine, and phenobarbital, may adversely affect the absorption and metabolism of folate and Vitamin B12, leading to decreased serum levels over time.10 While several studies have explored these effects in adult populations,6 limited research has been conducted on pediatric patients, particularly in resource-constrained regions like Bundelkhand in Central India. Bundelkhand, spanning parts of Uttar Pradesh and Madhya Pradesh, is home to approximately 18 million people, with around 14 million residing in rural areas.11 The region faces significant developmental challenges, including economic underdevelopment, low health and education indices, and high levels of child undernutrition. Factors such as poverty, food insecurity, and limited healthcare access exacerbate the vulnerability of children to nutritional deficiencies.12 A significant prevalence of Vitamin B12 and folate deficiencies is reported among Indian children and adolescents, particularly boys.13 Given that a substantial proportion of epilepsy cases begin in childhood and considering the physiological demands of growth and development during this period, there is a critical need to evaluate the nutritional implications of chronic ASM therapy in children. This research aims to investigate the impact of long-term ASM use on serum folate and Vitamin B12 levels in pediatric epilepsy patients in the Bundelkhand region of Central India. Understanding these effects is essential for developing comprehensive treatment strategies that address both seizure control and nutritional well-being in this vulnerable population.
MATERIAL AND METHODS
This comparative cross-sectional study was conducted at the Neurology and Pediatrics outpatient departments of Maharani Laxmi Bai Medical College, Jhansi, Uttar Pradesh, the sole tertiary super-specialty hospital in the Bundelkhand region. Data collection spanned 6 months, from May to December 2024, following approval from the Institutional Ethics Committee. The study included children aged 5 to 18 years diagnosed with epilepsy and undergoing antiepileptic medication (ASM) therapy for over 1 year. Inclusion criteria required a body mass index (BMI) above the 3rd percentile for age and sex, based on the Indian Academy of Pediatrics (IAP) growth charts.14 Participants were categorized into monotherapy (receiving a single ASM: PHY, Sodium Valproate-SV, or Levetiracetam-LEV) and polytherapy (receiving two or more ASMs) groups. The polytherapy group was further divided into double or triple therapy. Informed consent was obtained from parents or legal guardians. Exclusion criteria encompassed children under 5 or over 18 years, BMI below the 3rd percentile (per IAP charts), current use of vitamin supplements or medications affecting vitamin B12 or folate levels, presence of systemic illnesses (hepatic, renal, cardiac), malabsorption syndromes, severe developmental disabilities, congenital orofacial anomalies, or concurrent chronic medication usage. The control group comprised healthy children from the same geographic area, aged 5 to 18 years, with BMI above the 3rd percentile, visiting the outpatient department for minor ailments such as upper respiratory tract infections. Controls had no history of epilepsy, ASM usage, chronic illnesses, or current vitamin supplementation. Sample size estimation was based on anticipated vitamin B12 deficiency prevalence rates of 42.3% in controls and 68% in cases, with a 5% type I error (α), 10% type II error (β), and a design effect of 1.0, yielding a minimum requirement of 57 subjects per group. To enhance statistical power and generalizability, 100 cases and 100 controls were enrolled. Data were recorded using a structured proforma capturing demographic details, epilepsy classification, duration, ASM regimen, nutritional status, and serum vitamin B12 and folate levels. After an overnight fast, 2 mL of venous blood was collected aseptically from each participant. Serum was separated via centrifugation and stored at -20°C until analysis. Vitamin B12 and folate concentrations were measured using the Architect chemiluminescent microparticle immunoassay (CMIA). Deficiency thresholds were defined as serum folate <10 nmol/L (4 ng/mL) and plasma vitamin B12 <203 pg/mL (150 pmol/L). Data were coded and entered into Microsoft Excel, then analyzed using SPSS version 23 (IBM Corporation). Quantitative variables were expressed as mean ± standard deviation, with intergroup comparisons performed using the t-test. Qualitative variables were presented as frequencies and percentages, analyzed via the Chi-square test. Logistic regression with a stepwise backward method was employed to identify risk factors for vitamin B12 and folate deficiencies. A p-value <0.05 was considered statistically significant.
RESULTS
This study analyzed 100 pediatric epilepsy patients, with a mean age of 10.48 ± 3.89 years, predominantly between 5 and 12 years old. Males constituted 59% of the cohort, and a majority hailed from rural areas (63%) and lower socioeconomic backgrounds (53%). All participants had a BMI above the 3rd percentile for their age and sex. Controls were meticulously matched to cases based on age, sex, nutritional status, and socioeconomic status to minimize confounding variables and isolate the impact of ASM exposure on serum vitamin B12 and folate levels [Table 1]. Among the cases, 34 children were on ASM monotherapy, while 66 were receiving polytherapy. Vitamin B12 deficiencies were observed in 36% of cases compared to 22% of controls. Specifically, folate deficiency was present in 24% of cases and 2% of controls. Vitamin B12 deficiency was more prevalent among the polytherapy group (53%) than the monotherapy group (29%), with an odds ratio (OR) of 2.78 (95% confidence interval [CI]: 1.18-6.57). Folate deficiency was also more common in the polytherapy group (35%) compared to the monotherapy group (16%), with an OR of 2.73 (95% CI: 1.05-7.09) [Figure 1]. Within the monotherapy subgroup, vitamin B12 deficiency rates varied: 39% in those on PHY, 29% on SV, and 17% on LEV. Notably, all patients on a triple combination of PHY, SV, and LEV exhibited deficiencies in both vitamin B12 and folate [Table 2, Figure 2]. A multiple regression analysis assessed the relationship between serum vitamin B12 and folate levels and variables such as age, socioeconomic status, treatment duration, and type of ASM therapy. The analysis revealed that longer treatment duration and polytherapy were significantly associated with lower serum levels of both vitamins, suggesting a cumulative adverse effect of multiple ASMs on nutrient absorption or metabolism. Additionally, socioeconomic status and age had modest but notable influences, indicating that nutritional and demographic factors further modulate vitamin levels. These findings underscore the multifactorial nature of vitamin B12 and folate deficiencies in pediatric epilepsy patients undergoing ASM therapy.
| S. no. | Parameters | Control (n=100) | Cases | p-value -<0.05 | |
|---|---|---|---|---|---|
| Monotherapy (n=66) | Polytherapy (n=34) | ||||
| 1 | Age (mean±SD) | 10.48 ± 3.89 | 9.06 ± 3.27 | 8.91 ± 3.17 | 0.034 |
| 2 | Age Group (years) (n (%)) | 0.0062 | |||
| 5-12 y | 63 (63.0%) | 55 (83.3%) | 28 (82.4%) | ||
| 13-17 | 37 (37.0%) | 11 (16.7%) | 6 (17.6%) | ||
| 3 | Sex (n (%)) | 0.694 | |||
| Male | 53 (53.0%) | 39 (59.1%) | 20 (58.8%) | ||
| Female | 47 (47.0%) | 27 (40.9%) | 14 (41.2%) | ||
| 4 | Weight (kg) (mean±SD) | 31.00 ± 18.63 | 24.48 ± 9.39 | 22.39 ± 7.95 | 0.003 |
| 5 | Height (cm) (mean±SD) | 132.73 ± 30.00 | 126.76 ± 16.88 | 124.29 ± 17.43 | 0.030 |
| 6 | Habitat | 0.317 | |||
| Rural | 76 | 42 | 21 | ||
| Urban | 34 | 24 | 13 | ||
| 7 | Socioeconomic status | 0.436 | |||
| Upper | 6 | 4 | |||
| Upper middle | 12 | 6 | |||
| Lower middle | 14 | 5 | |||
| Upper lower | 13 | 9 | |||
| Lower | 21 | 10 | |||
| 8 | BMI (Kg/m2) (mean±SD) | 15.35 ± 2.26 | 14.60 ± 1.87 | 14.01 ± 1.18 | 0.006 |
| 9 | BMI centile | 0.119 | |||
| 3 to 10 | 36 (36.0%) | 27 (40.9%) | 17 (50.0%) | ||
| 10 to 50 | 46 (46.0%) | 32 (48.5%) | 17 (50.0%) | ||
| 50 to 23AE | 15 (15.0%) | 7 (10.6%) | 0 (0.0%) | ||
| 23AE To 27AE | 3 (3.0%) | 0 (0.0%) | 0 (0.0%) | ||
| 10 | Vitamin B12 level | ||||
| 280.21 ± 89.47 (mean±SD) | 245.12 ± 70.98 | 204.29 ± 74.16 | <0.001 | ||
| 11 | S. folate level (mean±SD) | 23.50 ± 6.15 | 15.79 ± 5.89 | 12.03 ± 4.33 | <0.001 |
| 12 | Vitamin B12 deficiency (%) | 22 (22.0%) | 19 (28.8%) | 18 (52.9%) | 0.003 |
| 13 | Folate deficiency (%) | 2 (2.0%) | 11 (16.7%) | 12 (35.3%) | <0.001 |
p-value <0.05 was considered statistically significant. SD: Standard deviation, BMI: Body Mass Index, AE: Adult equivqlent.
- Serum (a) Vitamin B12 and (b) Folate level among controls, cases on monotherapy and polytherapy.
| Parameter | Type of management | X2 | p-value | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Control | Monotherapy | Polytherapy | |||||||||
|
SV (n=31) |
PHY (n=18) |
LEV (n=17) |
SV+ PHY (n=15) |
SV+LEV (n=12) |
LEV+PHY (n=5) |
SV+ LEV+ PHY (n=2) |
|||||
| S. Vitamin-B12 | n (%) | 22(22) | 9(29.3) | 7(38.8) | 3(17.6) | 9(60) | 5(41.7) | 2(40) | 2(100) | 28.520 | <0.001 |
| Mean (SD) | 280.21 (89.47) | 251.29 (72.45) | 212.17 (62.91) | 268.76 (67.32) | 199.27 (74.57) | 204.92 (68.07) | 248.40 (85.12) | 128.00 (43.84) | |||
| S. Folate | n (%) | 2(2) | 5(16.1) | 5(27.7) | 1(5.8) | 7(46.7) | 4(33.3) | 0(0) | 1(50) | 96.379 | <0.001 |
| Mean (SD) | 23.50 (6.15) | 15.03 (5.24) | 12.79 (4.08) | 20.36 (6.19) | 11.13 (4.73) | 13.14 (4.20) | 13.00 (1.42) | 9.65 (7.85) | |||
p-value <0.05 was considered statistically significant. SV: Sodium valproate, PHY: Phenytoin, LEV: Levetiracetam, SD: Standard deviation.
- Serum (a) Vitamin B12 and (b) Folate levels among different monotherapy and polytherapy regimn.
DISCUSSION
Vitamin B12 and folate are vital micronutrients that play an essential role in the healthy growth and development of children.15 Folate acts as a key cofactor in the synthesis of purines and thymidylate, while vitamin B12 is necessary for the conversion of methylmalonyl-CoA to succinyl-CoA. Both nutrients are important for the demethylation of homocysteine to methionine, which serves as a precursor to S-adenosylmethionine, a universal methyl group donor involved in numerous cellular processes. Deficiencies in either nutrient can hamper blood cell production, disturb chromosomal stability, disrupt DNA methylation, and reduce the synthesis of myelin and catecholamines, leading to elevated homocysteine levels. Such deficiencies are linked with a wide range of health issues, including anemia, cognitive decline, vascular diseases, osteoporosis, cancers, psychiatric disorders, spontaneous abortions, and congenital malformations.16 The present study, focusing on children aged 5 to 12 years in the Bundelkhand region of central India, examined the impact of long-term antiepileptic drug (AED) therapy on vitamin B12 and folate levels. Findings indicated a higher prevalence of epilepsy among younger children, consistent with data from Bangalore.6 Children with epilepsy exhibited poorer nutritional status compared to healthy controls, with only 7% falling within the 50th-23rd adult equivalent range versus 15% of controls, suggesting a lower BMI potentially due to the chronic effects of epilepsy on nutrition.17 Notably, even non-epileptic controls showed deficiencies in vitamin B12 and folate, pointing to a broader regional issue possibly linked to poverty, inadequate nutrition, and low literacy rates.11,12 Children undergoing long-term AED therapy, particularly those on polytherapy, demonstrated significantly higher rates of vitamin B12 and folate deficiencies.8 Among monotherapies, PHY was associated with the highest deficiency rates,16 followed by valproate, while LEV had the least impact.18,19 These observations align with other studies indicating that AEDs like valproate, carbamazepine, and PHY can reduce serum levels of these vitamins.16 The extent of deficiency appears to correlate with the type and dosage of AEDs, the nature of epilepsy, treatment duration, and individual genetic factors. Mechanistically, PHY may impair folate status through reduced absorption, decreased synthesis, and increased metabolism via hepatic enzymes. Valproate has also been shown to significantly reduce folate levels, whereas LEV monotherapy does not exhibit a significant effect.16
CONCLUSION
This study underscores the significant impact of long-term AED therapy on vitamin B12 and folate levels in children with epilepsy. Our findings indicate that prolonged use of AEDs, particularly polytherapy and PHY monotherapy, is associated with increased deficiencies in these essential vitamins. These deficiencies can lead to adverse neurological and hematological outcomes, highlighting the need for regular monitoring and potential supplementation. Given the high prevalence of epilepsy in resource-limited regions like Bundelkhand, integrating nutritional assessments into routine epilepsy care is crucial to mitigate these risks and enhance patient well-being. This is a single-center observational study; therefore, long-term longitudinal follow-up and interventional studies are necessary to validate these findings.
Authors’ contributions
AK, SG, AKK: Concept and design of the study, acquisition, analysis and interpretation of data, drafting and revising the article, final approval of the version to be published.
Ethical approval
The research/study approved by the Institutional Review Board at Maharani Laxmi Bai Medical College, Jhansi, Uttar Pradesh, number 2722/IEC/I/2022-2023, dated 14th August 2024.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
REFERENCES
- ILAE official report: A practical clinical definition of epilepsy. Epilepsia. 2014;55:475-82.
- [CrossRef] [PubMed] [Google Scholar]
- Epilepsy in India i: Epidemiology and public health. Ann Indian Acad Neurol. 2015;18:263-77.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Incidence and prevalence of childhood epilepsy: A nationwide cohort study. Pediatrics. 2017;139:e20163908.
- [CrossRef] [PubMed] [Google Scholar]
- Prevalence and treatment gap in childhood epilepsy in a north Indian city: A community-based study. J Trop Pediatr. 2014;60:118-23.
- [CrossRef] [PubMed] [Google Scholar]
- Epilepsy in children—Important facts. Indian J. Pediatr. 2021;88:991-92.
- [CrossRef] [PubMed] [Google Scholar]
- Effect of antiepileptic drugs on serum vitamin B12 and folic acid among children with epilepsy in Bangalore. Biomed Pharmacol J. 2024;17:263-9.
- [CrossRef] [Google Scholar]
- Effects of vitamin B12 and folate deficiency on brain development in children. Food Nutr Bull. 2008;29:S126-31.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Effects of antiepileptic drugs on the serum folate and vitamin B12 in various epileptic patients. Biomed Rep. 2016;5:413-6.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Homocysteine levels in epileptic children receiving antiepileptic drugs. J Child Neurol. 2007;22:1389-92.
- [CrossRef] [PubMed] [Google Scholar]
- Epilepsy: Antiepileptic drugs reduce vitamin B(12) and folate levels. Nat Rev Neurol. 2011;7:125.
- [CrossRef] [PubMed] [Google Scholar]
- https://en.wikipedia.org/wiki/Bundelkhand Wikimedia Foundation, Inc. Available from: http://en.wikipedia.org/wiki/Bundelkhand. [Last accessed 2025 May 9]
- Nutritional status of the population in bundelkhand region. Indian J Nutr Diet. 2018;55:279-85.
- [Google Scholar]
- Ministry of health and family welfare (MoHFW), government of India, UNICEF and population council 2019. comprehensive national nutrition survey (CNNS) national report. New Delhi. https://nhm.gov.in/WriteReadData/l892s/1405796031571201348.pdf [Last accessed 2025 Apr 15].
- Revised IAP growth charts for height, weight and body mass index for 5- to 18-year-old Indian children. Indian Pediatr. 2015;52:47-55.
- [CrossRef] [PubMed] [Google Scholar]
- Vitamin B-12, folic acid, and growth in 6- to 30-month-old children: A randomized controlled trial. Pediatrics. 2015;135:e918-26.
- [CrossRef] [PubMed] [Google Scholar]
- Antiepileptic drugs interact with folate and vitamin B12 serum levels. Ann Neurol. 2011;69:352-9.
- [CrossRef] [PubMed] [Google Scholar]
- Nutritional intake and its impact on patients with epilepsy: An analytical cross-sectional study. Nutr Neurosci. 2022;25:1813-22.
- [CrossRef] [PubMed] [Google Scholar]
- Vitamin B12 and folate status in patients with epilepsy under levetiracetam monotherapy. Int J Prev Med. 2019;10:32.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- The effect of antiepileptic drugs on vitamin B12 metabolism. Int J Lab Hematol. 2008;30:26-35.
- [CrossRef] [PubMed] [Google Scholar]