Anticonvulsant Primary and Secondary Prophylaxis for Acute Ischemic Stroke Patients: A Decision Analysis

• Published in: Stroke (1970) 2021-09, Vol.52 (9), p.2782-2791
• Main Authors: Jones, Felipe J.S., Sanches, Paula R., Smith, Jason R., Zafar, Sahar F., Hernandez-Diaz, Sonia, Blacker, Deborah, Hsu, John, Schwamm, Lee H., Westover, Michael B., Moura, Lidia M.V.R.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Anticonvulsants - therapeutic use; Brain Ischemia - drug therapy; Cost-Benefit Analysis; Female; Humans; Ischemic Stroke - drug therapy; Ischemic Stroke - prevention & control; Life Expectancy; Male; Middle Aged; Quality-Adjusted Life Years; Secondary Prevention - methods; Stroke - drug therapy; Stroke - prevention & control
• ISSN: 0039-2499; 1524-4628
• DOI: 10.1161/STROKEAHA.120.033299

We examined the impact of 3 anticonvulsant prophylaxis strategies on quality-adjusted life-years (QALYs) among patients with an incident acute ischemic stroke. We created a decision tree to evaluate 3 strategies: (1) long-term primary prophylaxis; (2) short-term secondary prophylaxis after an early seizure with lifetime prophylaxis if persistent or late seizures (LSs) developed; and (3) long-term secondary prophylaxis if either early, late, or persistent seizures developed. The outcome was quality-adjusted life expectancy (QALY). We created 4 base cases to simulate common clinical scenarios: (1) female patient aged 40 years with a 2% or 11% lifetime risk of an LS and a 33% lifetime risk of an adverse drug reaction (ADR); (2) male patient aged 65 years with a 6% or 29% LS risk and 60% ADR risk; (3) male patient aged 50 years with an 18% or 65% LS risk and 33% ADR risk; and (4) female patient aged 80 years with a 29% or 83% LS risk and 80% ADR risk. In sensitivity analyses, we altered the parameters and assumptions. Across all 4 base cases, primary prophylaxis yielded the fewest QALYs when compared with secondary prophylaxis. For example, under scenario 1, strategies 2 and 3 resulted in 7.17 QALYs each, but strategy 1 yielded only 6.91 QALYs. Under scenario 4, strategies 2 and 3 yielded 2.85 QALYs compared with 1.40 QALYs for strategy 1. Under scenarios in which patients had higher ADR risks, strategy 2 led to the most QALYs. Short-term therapy with continued anticonvulsant prophylaxis only after postischemic stroke seizures arise dominates lifetime primary prophylaxis in all scenarios examined. Our findings reinforce the necessity of close follow-up and discontinuation of anticonvulsant seizure prophylaxis started during acute ischemic stroke hospitalization.