How do you approach the use of newer anti-seizure medications for epilepsy patients on DOACs?

Levetiracetam and valproic acid:

• A nested case-control study published in 2021 (Gronich et al., PMID 34287842) in patients with afib identified an increased risk of stroke/systemic embolism with levetiracetam and valproic acid. This was followed by a few retrospective studies published in 2022 and 2023 that also identified a potential interaction with these agents. A more recent pharmacovigilance study using the FDA Adverse Event Reporting System found a higher association of reported thromboembolic events with both levetiracetam and valproic acid when combined with DOACs.
  • Many of these studies classify levetiracetam and valproic acid as "enzyme-inducing" ASMs. Levetiracetam is not known to alter CYP enzymes or P-gp (though some animal d...