The edition · Neurology
In 15,900 pregnancies on antiseizure drugs, topiramate and polytherapy were linked to the smallest babies, lamotrigine to the least effect
EURAP adds fetal growth to the malformation and neurodevelopment data that shape preconception choices. Also: dementia follows TIA far more often than stroke does, stroke incidence in young adults nearly doubled over 27 years, the AAN's evidence review for migraine prevention, cholinesterase inhibitors in Lewy body dementia with bradycardia, and a carbamazepine recall.
The edition in brief
In the EURAP registry, 15,893 babies exposed to antiseizure medication in pregnancy showed lower birthweight centiles with polytherapy than monotherapy (small for gestational age OR 1.48); among monotherapies, topiramate, phenobarbital, oxcarbazepine, carbamazepine, valproate and levetiracetam were each associated with lower centiles than lamotrigine. In Ontario, 113,081 people after a first TIA had a 34% higher long-term hazard of dementia than matched controls (HR 1.75 in the first year), converging with post-stroke risk after five years, and dementia was far more frequent than recurrent stroke. In a US population study, stroke incidence among adults aged 20-54 rose from 33.9 to 62.2 per 100,000 between 1993 and 2020, driven by ischaemic stroke, while case fatality fell. An AAN and American Headache Society review of 217 trials found high-confidence evidence for galcanezumab and erenumab in episodic migraine and for fremanezumab, galcanezumab and onabotulinumtoxinA in chronic migraine, with moderate confidence for propranolol, topiramate and valproate. A Lancet Neurology review argues cholinesterase inhibitors need not be withheld in Lewy body dementia with 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.
After a TIA, dementia was far more common than recurrent stroke, and its risk stayed raised for 20 years
Add a cognitive screen to TIA follow-up, and repeat it; dementia after TIA was more common than recurrent stroke and the risk persisted for years.
Migraine prevention: the AAN evidence review ranks CGRP antibodies, propranolol, topiramate and valproate
Choose migraine prevention from agents with moderate or high-confidence evidence — propranolol or topiramate orally, CGRP antibodies where affordable — and avoid valproate and topiramate in women who could become pregnant.
Stroke among 20-54-year-olds nearly doubled in one US region between 1993 and 2020
Look for — and treat — hypertension, diabetes, AF and substance use in young adults, in whom ischaemic stroke is becoming more common.
Lewy body dementia with bradycardia: cholinesterase inhibitors need not be withheld
In Lewy body dementia with a conduction abnormality, screen and monitor rather than simply withholding a cholinesterase inhibitor.
FDA Class II recall: one distributor's carbamazepine 200 mg tablets, for black specks
No change to carbamazepine prescribing: this is a lot-specific manufacturing recall, and the priority is uninterrupted supply.
Start the preconception conversation at the first antiseizure prescription
Choose antiseizure drugs for women of childbearing potential as if pregnancy were possible, because it often is.
Antiseizure drugs in pregnancy: polytherapy and topiramate carried the largest fetal growth penalty; lamotrigine the least
When planning pregnancy on antiseizure drugs, aim for monotherapy, prefer lamotrigine where appropriate, avoid topiramate and phenobarbital, and arrange growth monitoring for higher-risk exposures.
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