Survival Rate Varies With Choice Of Antiseizure Medication in Poststroke Epilepsy: JAMA

Currently, treatment recommendations for post-stroke epilepsy are based primarily on trials conducted in older adults with epilepsy of various causes. Experts have suggested lamotrigine and levetiracetam [Keppra] as valid treatment options. However, recently the US Food and Drug Administration issued a safety warning about the potential proarrhythmic properties of lamotrigine. Also, there is little evidence to guide the choice of antiseizure medication (ASM) for patients with poststroke epilepsy. Therefore, Dr David Larsson and colleagues conducted a study to investigate whether mortality varies with specific ASMs among patients with poststroke epilepsy.

In this cohort study, the researchers used individual-level data from linked registers on all adults in Sweden with acute stroke from July 1, 2005, to December 31, 2010, and subsequent onset of epilepsy before December 31, 2014. They included 2577 patients who received continuous ASM monotherapy. A total of 1,199 patients received carbamazepine, 477 received valproic acid, 354 received levetiracetam, 320 received lamotrigine, 73 received phenytoin (Dilantin), and 46 received oxcarbazepine (Trileptal). The major outcome assessed was all-cause death using Cox proportional hazards regression with carbamazepine as the reference. The researchers also assessed cardiovascular death using Fine-Gray competing risk regression models.

Key findings of the study:

♦ Upon analysis, the researchers found that the adjusted HR for all-cause mortality compared with carbamazepine was

• 0.72 for lamotrigine,
• 0.96 for levetiracetam,
• 1.40 for valproic acid,
• 1.16 for phenytoin, and
• 1.16 for oxcarbazepine.

♦ They further noted that the adjusted HR of cardiovascular death compared with carbamazepine was

• 0.76 for lamotrigine,
• 0.77 for levetiracetam,
• 1.40 for valproic acid,
• 1.02 for phenytoin, and
• 0.71 for oxcarbazepine.

The authors concluded, "This cohort study's findings suggest differences in survival between patients treated with different ASMs for poststroke epilepsy. Patients receiving lamotrigine monotherapy had significantly lower mortality compared with those receiving carbamazepine."

They further noted, "The opposite applied to patients prescribed valproic acid, who had a higher risk of cardiovascular and all-cause death. Levetiracetam was associated with a reduced risk of cardiovascular death compared with carbamazepine, but there was no significant difference in overall mortality."

For further information:

DOI:10.1001/jamaneurol.2021.4584