The edition · Neurology
Factor XIa inhibition cuts recurrent stroke by a quarter without a bleeding penalty, and lamotrigine levels fall by two-thirds by 32 weeks
A meta-analysis of three randomised trials puts numbers on factor XIa inhibitors added to antiplatelet therapy after noncardioembolic stroke; a 947-woman cohort quantifies how far antiseizure drug concentrations fall in pregnancy, drug by drug; carbamazepine tablets are recalled for manufacturing deviations; and atogepant beats topiramate head to head on both tolerability and efficacy.
The edition in brief
Three randomised trials totalling 14,239 participants, dominated by one phase 3 trial of 12,327, were pooled to assess factor XIa inhibitors added to standard antiplatelet therapy after acute noncardioembolic ischaemic stroke or transient ischaemic attack. Any stroke fell by a quarter (RR 0.75, 95% CI 0.66-0.84), ischaemic stroke likewise (RR 0.74, 0.66-0.84) and composite cardiovascular events by 17% (RR 0.83, 0.75-0.92), with no increase in major bleeding (RR 1.12, 0.87-1.44), haemorrhagic stroke, intracranial haemorrhage or death. A prospective Chinese cohort of 947 women with epilepsy contributing 1,638 samples quantified gestational falls in concentration-to-dose ratio: lamotrigine 28.8%, 54.3% and 63.2% by trimester with a nadir of 65.8% at 32 weeks; levetiracetam 26.2%, 40.1% and 31.0% with a nadir of 35.5% at 24 weeks; the oxcarbazepine metabolite 23.1%, 32.6% and 44.3%. A meta-analysis of eight studies found higher anticholinergic burden in Parkinson's disease significantly associated with fracture (OR 1.53, 1.28-1.84) and emergency department visits (OR 1.25, 1.15-1.36), while associations with dementia and cognitive decline were not significant overall. The FDA has posted an ongoing Class II recall of 200 mg carbamazepine tablets for manufacturing deviations. The edition closes on TEMPLE, in which atogepant 60 mg daily was discontinued for adverse events by 12% against topiramate's 30%, with a 50% responder rate of 64% against 39%.
Factor XIa inhibitors cut recurrent stroke by a quarter with no measurable bleeding cost
A genuinely new antithrombotic option for secondary stroke prevention is emerging, but nothing changes in clinic until an agent is licensed and available.
Lamotrigine concentrations fall by two-thirds by 32 weeks of pregnancy — and the fall differs by drug
Monitor antiseizure drug concentrations against the woman's own preconception baseline, and follow lamotrigine to term rather than stopping at the second trimester.
Anticholinergic burden in Parkinson's disease: the fracture and emergency-visit signals are the solid ones
Review and reduce anticholinergic burden in Parkinson's disease for the fracture risk, which is where the evidence is solid, not only for the cognitive risk, which is not.
Class II recall of 200 mg carbamazepine tablets for manufacturing deviations
If a patient reports discoloured carbamazepine tablets, replace the supply — but do not let them interrupt treatment while that happens.
Take a preconception antiseizure drug level in every woman of childbearing age who might become pregnant
File a preconception trough level for every woman of childbearing potential on an antiseizure drug; pregnancy levels cannot be interpreted without it.
Atogepant beat topiramate head to head — 12% stopped for adverse events against 30%, and it worked better too
Expect about a third of patients to stop topiramate for side effects, and have the next step decided in advance — atogepant now has head-to-head evidence on both tolerability and efficacy.
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