Choice of Seizure Medication for Post-Stroke Epilepsy May Influence Survival

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.