The edition · Neurology
Polytherapy in pregnancy was associated with 50% more small-for-gestational-age babies in a 15,893-birth registry
EURAP adds fetal growth to the counselling list for antiseizure drugs, the AAN–AHS review grades the evidence for every migraine preventive, and serum GFAP tracked progression independent of relapses in two MS cohorts.
The edition in brief
In the EURAP registry of 15,893 pregnancies exposed to antiseizure medication, polytherapy was associated with a lower birthweight centile and about 50% higher odds of small-for-gestational-age birth (OR 1.48) than monotherapy, with risk rising with each added drug. Against lamotrigine, birthweight centile was lowest with topiramate (−11.9), then phenobarbital, oxcarbazepine, carbamazepine, valproate and levetiracetam. The AAN and American Headache Society systematic review of 217 trials graded evidence for migraine prevention: high confidence for galcanezumab and erenumab in episodic migraine, and fremanezumab, galcanezumab and onabotulinumtoxinA in chronic migraine; moderate for atogepant, eptinezumab, propranolol, topiramate and valproate; low for amitriptyline, flunarizine and several others. Head-to-head evidence was weak. In 2,329 people with MS across two cohorts, a serum GFAP z score above 1 was associated with a 36 to 45% higher hazard of progression independent of relapse activity at the next interval, and falling GFAP on fingolimod or B-cell depletion with lower risk. A Lancet Neurology review argues cholinesterase inhibitors need not be withheld in dementia with Lewy bodies and conduction abnormalities, given screening and monitoring. The FDA lists a Class II recall of one US distributor's carbamazepine 200 mg tablets for black specks.
Migraine prevention: the AAN–AHS review grades CGRP antibodies highest, with older oral drugs close behind
Start migraine prevention with propranolol or topiramate where cost matters; the evidence for them is moderate, not weak.
FDA Class II recall: carbamazepine 200 mg tablets from one US distributor, for black specks
No change to carbamazepine prescribing; if a patient's tablets look defective, replace the supply without a gap.
Serum GFAP was associated with progression independent of relapses in multiple sclerosis
Serum GFAP is a promising marker of silent MS progression, but do not change treatment on it yet.
Cholinesterase inhibitors need not be withheld in Lewy body dementia with conduction abnormalities
In Lewy body dementia with a conduction abnormality, screen and monitor rather than routinely withholding a cholinesterase inhibitor.
Check lamotrigine levels through pregnancy
Measure a lamotrigine baseline level early in pregnancy and adjust dose each trimester to hold it.
Antiseizure drugs in pregnancy: polytherapy and topiramate were associated with the poorest fetal growth
Before pregnancy, reduce to the fewest antiseizure drugs that work, favouring lamotrigine, and scan fetal growth when polytherapy continues.
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