Brooks Julianne D, de Medeiros Rafaella Cazé, Sun Shuo, Sankaranarayanan Madhav, Westover M Brandon, Schwamm Lee H, Newhouse Joseph P, Haneuse Sebastien, Moura Lidia M V R
Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
medRxiv. 2025 Mar 20:2025.03.18.25324227. doi: 10.1101/2025.03.18.25324227.
The lack of specific guidelines for seizure treatment after acute ischemic stroke (AIS), makes the choice of an appropriate anti-seizure medication choice a challenge for providers because each drug may have different adverse effects and outcomes.
In this retrospective matched cohort study, we analyzed a 20% sample of U.S. Medicare beneficiaries aged 65 and over hospitalized for a first acute ischemic stroke (AIS) between 2009-2021 who were discharged home. We included individuals who were enrolled in Medicare hospital, medical and prescription drug insurance for 12 months prior to hospitalization and were not taking epilepsy-specific anti-seizure medication (ESM) prior to hospitalization. We matched individuals on days from discharge to ESM initiation. Individuals who initiated ESMs other than Levetiracetam, i.e. Lamotrigine, Carbamazepine, Oxcarbazepine within 30 days of discharge (N = 229) were matched to Levetiracetam initiators (N =687). We investigated the time to seizure-like events, emergency department (ED) visits, and re-hospitalizations with a follow-up of 180 days after initiation using a semi-competing risk framework. We estimated the average treatment effect among the treated i.e. those who received other ESMs.
The matched cohort of 916 ESM initiators had a median age of 74 (IQR 69, 82) and was 57% female and 71% Non-Hispanic White. Using the semi-competing risk framework, those who received other ESM had a 37% lower hazard of seizure-like events compared to receiving LEV, given that death had not occurred, hazard ratio 0.63 (95% CI: 0.43, 0.91). Among those who initiated ESMs other than Levetiracetam, the hazard of ED visits and hospitalizations, given that death had not occurred, did not different significantly from initiating Levetiracetam; hazard ratios 1.00 (95% CI: 0.80, 1.25) and 0.98 (95% CI: 0.75, 1.28), respectively.
In a sample of Medicare beneficiaries hospitalized for acute ischemic stroke and discharged home, initiating Levetiracetam in the outpatient setting was associated with a higher risk of seizure-like events compared to other ESMs. However, no significant differences were observed in the incidence of ED visits or hospitalizations, suggesting comparable safety profiles in these broader clinical outcomes.
急性缺血性卒中（AIS）后缺乏癫痫发作治疗的具体指南，这使得医疗服务提供者在选择合适的抗癫痫药物时面临挑战，因为每种药物可能有不同的不良反应和结果。
在这项回顾性匹配队列研究中，我们分析了2009年至2021年间因首次急性缺血性卒中（AIS）住院并出院回家的65岁及以上美国医疗保险受益人的20%样本。我们纳入了在住院前12个月参加医疗保险住院、医疗和处方药保险且住院前未服用癫痫特异性抗癫痫药物（ESM）的个体。我们根据出院至开始使用ESM的天数对个体进行匹配。在出院后30天内开始使用除左乙拉西坦以外的其他ESM（即拉莫三嗪、卡马西平、奥卡西平）的个体（N = 229）与开始使用左乙拉西坦的个体（N = 687）进行匹配。我们使用半竞争风险框架调查了癫痫样事件、急诊科（ED）就诊和再次住院的时间，并在开始使用后进行了180天的随访。我们估计了接受治疗的个体（即接受其他ESM的个体）中的平均治疗效果。
916名开始使用ESM的匹配队列的中位年龄为74岁（四分位间距69, 82），女性占57%，非西班牙裔白人占71%。使用半竞争风险框架，在未发生死亡的情况下，接受其他ESM的个体发生癫痫样事件的风险比接受左乙拉西坦的个体低37%，风险比为0.63（95%置信区间：0.43, 0.91）。在开始使用除左乙拉西坦以外的其他ESM的个体中，在未发生死亡的情况下，急诊科就诊和住院的风险与开始使用左乙拉西坦的个体相比没有显著差异；风险比分别为1.00（95%置信区间：0.80, 1.25）和0.98（95%置信区间：0.75, 1.28）。
在因急性缺血性卒中住院并出院回家的医疗保险受益人的样本中，与其他ESM相比，在门诊环境中开始使用左乙拉西坦与癫痫样事件的风险较高相关。然而，在急诊科就诊或住院的发生率方面未观察到显著差异，这表明在这些更广泛的临床结果中安全性相当。
