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Choice of seizure medication for post-stroke epilepsy may influence survival

JAMA Neurology
Reuters Health - 23/12/2021 - For patients who develop epilepsy after suffering a stroke, the choice of antiseizure medication may influence their survival, according to a Swedish registry study.

"These findings suggest that there are differences in survival between specific antiseizure medications (ASMs) and that lamotrigine and levetiracetam seem to be reasonable first-line treatment options for patients with post-stroke epilepsy," the study team writes in JAMA Neurology.

Stroke is the most commonly identified cause of new-onset epilepsy in adults. However, evidence to guide the choice of ASM in this population is lacking, and there are theoretical concerns about harmful effects of these medications on survival, Dr. David Larsson with Sahlgrenska University in Gothenburg and colleagues point out.

To explore whether mortality varies with specific ASMs in post-stroke epilepsy, they did a population-based cohort study of 2,577 patients (median age, 78; 54% men) who developed epilepsy after a stroke and were treated with a single ASM.

The results showed that patients treated with lamotrigine had a significantly lower risk of dying from cardiovascular and any cause compared with peers treated with carbamazepine.

Compared with carbamazepine, the adjusted hazard ratio for death from any cause was 0.72 (95% CI, 0.60 to 0.86) for lamotrigine, 0.96 (95% CI, 0.80 to 1.15) for levetiracetam, 1.40 (95% CI, 1.23 to 1.59) for valproic acid, 1.16 (95% CI, 0.88 to 1.51) for phenytoin and 1.16 (95% CI, 0.81 to 1.66) for oxcarbazepine.

Compared with carbamazepine, the adjusted hazard ratio for cardiovascular death was 0.76 (95% CI: 0.61 to 0.95) for lamotrigine, 0.77 (95% CI: 0.60 to 0.99) for levetiracetam, 1.40 (95% CI: 1.19 to 1.64) for valproic acid, 1.02 (95% CI: 0.71 to 1.47) for phenytoin, and 0.71 (95% CI: 0.42 to 1.18) for oxcarbazepine.

Lamotrigine had the highest three-year survival rate (0.62), followed by levetiracetam (0.55), oxcarbazepine (0.54), carbamazepine (0.53), valproic acid (0.34), and phenytoin (0.32).

In email to Reuters Health, Dr. Larsson said, "Persons with epilepsy after a stroke constitute a vulnerable group that benefit from tailored treatment. The selection of antiseizure medications depends on many factors, but on a group level, it seems reasonable to avoid drugs that may interfere with other drugs used to prevent stroke and heart disease."

"There are no official treatment guidelines in this particular patient group, but our findings support what was previously suspected. Even before this study, most clinicians would recommend modern non-enzyme-inducing drugs, such as lamotrigine or levetiracetam, as first-line treatment options," Dr. Larsson said.

The researchers caution that they lacked information about all factors influencing ASM drug selection and some confounding likely occurred. Also, the findings are based only on post-stroke epilepsy patients using a single ASM and do not pertain to patients requiring drug changes for seizure control.

The study was funded by grants from the Swedish state under the ALF agreement, and grants from the Swedish Society of Medicine, the Swedish Society of Medical Research, the Linnea and Josef Carlsson Foundation, the Goteborg Medical Society, and the Magnus Bergvall Foundation. Dr. Larsson has no relevant disclosures.

SOURCE: https://bit.ly/3m1IH2r JAMA Neurology, online December 13, 2021.

By Megan Brooks

© 2023 The Author(s). Published by Medicom Medical Publishers.
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