Abdul Mannan: When Antiseizure Drugs Alter DOAC Risk
Abdul Mannan, Consultant Haematologist at Betsi Cadwaladr University Health Board, shared a post on LinkedIn about a recent article by Kai Michael Schubert et al., published in JAMA Neurology, adding:
“DOAC plus epilepsy: The antiseizure medicine may alter more than seizure control.
The usual teaching is simple: avoid the obvious enzyme inducers.
This new study says the choice may be less tidy.
Schubert et al used a TriNetX target-trial emulation to compare adults taking a DOAC plus one antiseizure medicine with lamotrigine or lacosamide.
What stood out?
- Strong inducers, including carbamazepine and phenytoin: more thromboembolism (HR 1.55), but less major bleeding (HR 0.62).That pattern fits reduced DOAC exposure.
- Levetiracetam: more thromboembolism (HR 1.98) and death (HR 1.60), without less bleeding.This does not prove a drug interaction. It does mean ‘non-inducing’ is not the same as interaction-free.
- Valproate: more intracranial major bleeding (HR 3.01) and death (HR 1.49).Confounding remains a real concern.
The VKA analysis was calmer: thromboembolic estimates were close to 1.
My take? For someone needing a DOAC, antiseizure drug choice deserves a joint neurology, cardiology and haematology review.
These are observational data, with no DOAC levels, so they are not a reason for abrupt ASM changes.”
Title: Safety of Antiseizure Medications During Direct Oral Anticoagulant Therapy in Epilepsy
Authors: Kai Michael Schubert, Carolina Ferreira-Atuesta, Arunachalam Soma, Johan Zelano, David J. Seiffge, Francesco Brigo, Eugen Trinka, Nishant K. Mishra, Emilio Russo, Gregory Y. H. Lip, Gashirai K Mbizvo, Marian Galovic
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