The edition · Neurology
With a DOAC on board, the choice of antiseizure drug was linked to clot, bleed and death risk
A target-trial emulation in 9,529 adults with epilepsy found levetiracetam associated with twice the thromboembolic risk of lamotrigine or lacosamide. Also: tirofiban did not prevent deterioration in branch atheromatous stroke, how long to wait before withdrawing antiseizure drugs, and an FDA supplement action on a generic lamotrigine.
The edition in brief
A JAMA Neurology target-trial emulation, published on 1 October, followed 9,529 adults with epilepsy starting antiseizure monotherapy while on a direct oral anticoagulant. Against lamotrigine or lacosamide, levetiracetam was associated with higher thromboembolic risk (HR 1.98) and mortality (HR 1.60); strong enzyme inducers with more thromboembolism but less bleeding; and valproate with higher mortality and intracranial bleeding. It is observational, but it makes the antiseizure choice part of anticoagulation planning. The STRATEGY trial randomised 970 patients with branch atheromatous disease stroke to 24 hours of intravenous tirofiban or placebo on top of aspirin; early deterioration or new stroke occurred in 17.1% against 19.6% (HR 0.88, 95% CI 0.65 to 1.19), a neutral result. A Journal of Neurology meta-analysis of 22 studies found relapse after antiseizure drug withdrawal was more likely with under five years of seizure freedom (RR 1.49). The FDA database records a supplement action on a generic lamotrigine application; its content is not stated. The pearl covers the lamotrigine–valproate interaction.
STRATEGY: tirofiban added to aspirin did not prevent deterioration in branch atheromatous stroke
Tirofiban added to aspirin did not reduce early deterioration or new stroke in branch atheromatous disease; do not use it for this indication.
FDA records a supplement action on a generic lamotrigine application
Treat this as an administrative generic supplement; no prescribing change follows from it.
Withdrawing antiseizure drugs before five seizure-free years was linked to more relapse
When weighing antiseizure drug withdrawal, consider that relapse was more likely with under five seizure-free years in adults and under three in children.
Adding lamotrigine to valproate: halve the titration
Titrate lamotrigine more slowly, to a lower dose, in patients taking valproate.
On a DOAC, levetiracetam was linked to twice the clot risk of lamotrigine or lacosamide
In adults with epilepsy on a DOAC, consider lamotrigine or lacosamide first and avoid enzyme inducers; review the choice when anticoagulation starts.
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