The edition · Neurology
Epilepsy on a DOAC: the choice of antiseizure drug was linked to clot, bleed and death risks
A target-trial emulation in 9,529 adults found levetiracetam, valproate and enzyme inducers each carried distinct risks against lamotrigine or lacosamide. Plus a neutral tirofiban trial in branch atheromatous stroke, timing of antiseizure drug withdrawal, and a generic lamotrigine supplement.
The edition in brief
In 9,529 adults with epilepsy taking a direct oral anticoagulant, a target-trial emulation using international electronic health records compared antiseizure monotherapies with lamotrigine or lacosamide. Levetiracetam was associated with more thromboembolic events (HR 1.98) and higher mortality (HR 1.60); strong enzyme inducers with more thromboembolism (HR 1.55) but less major bleeding; valproate with higher mortality (HR 1.49) and more intracranial bleeding (HR 3.01). These are observational associations, but they support favouring lamotrigine or lacosamide when choosing a new antiseizure drug for someone on a DOAC. In the STRATEGY trial of 970 Chinese patients with branch atheromatous disease stroke, adding 24 hours of intravenous tirofiban to aspirin did not reduce early neurological deterioration or new stroke (17.1% vs 19.6%; HR 0.88, 95% CI 0.65–1.19). A meta-analysis of 22 studies found relapse after antiseizure drug withdrawal was more likely with less than five years of seizure freedom (RR 1.49). The FDA recorded a supplement to a generic lamotrigine application on 15 October; no detail of the change is given. The pearl covers lamotrigine titration and its interaction with valproate.
Tirofiban added to aspirin did not prevent deterioration in branch atheromatous stroke
Do not add tirofiban to aspirin routinely for branch atheromatous disease stroke; manage it as other minor stroke under current guidance.
Stopping antiseizure drugs: relapse was likelier with under five years seizure-free
When considering antiseizure drug withdrawal in adults, weigh a seizure-free interval under five years as a marker of higher relapse risk.
FDA records a supplement to a generic lamotrigine application
No change in practice: this is a routine supplement to a generic lamotrigine licence.
Lamotrigine: slow titration, and halve it with valproate
Titrate lamotrigine slowly, use the reduced schedule with valproate, and restart titration after a treatment gap.
On a DOAC, lamotrigine or lacosamide were linked to fewer clots and deaths than other antiseizure drugs
When starting an antiseizure drug in an adult on a DOAC, consider lamotrigine or lacosamide first and avoid strong enzyme inducers.
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