Written by Clark Strunk
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This multicenter RCT demonstrated that a short course of minocycline in patients with acute ischemic stroke (AIS) resulted in improved functional neurologic outcomes at 90 days.
Modulating microglia with minocycline…
This article is a multicenter, double-blinded, randomized trial in China of 1,724 patients with acute ischemic stroke (NIHSS 4-25) within 72 hours of symptom onset, comparing 4.5 days of oral minocycline to placebo. Minocycline is thought to lead to cytoprotective effects in AIS by suppressing the activation of microglia, important cells in the post-stroke neuroinflammatory cascade that contributes to worse neurological outcomes. The primary outcome was a modified Rankin Scale (mRS) of 0–1 at 90 days, which was seen in 52.6% of patients in the intervention group and 47.4% of patients in the placebo group (p = 0.0061). Furthermore, the overall distribution of favorable mRS scores favored the minocycline group, and there were no differences in safety outcomes.
How will this change my practice?
The results of this study may change my practice, although I had initial reservations about external generalizability, reproducibility, and effect size, and I was also unfamiliar with minocycline in this context. Nevertheless, taken as a whole, the results are compelling, and the physiologic rationale is sound. So, if my neurology colleagues would like to start minocycline for an AIS patient, I would have no objection. If I were to see an additional positive study in this space, that would be enough for me to give minocycline to select patients with AIS.
Source
Efficacy and safety of minocycline in patients with acute ischaemic stroke (EMPHASIS): a multicentre, double-blind, randomised controlled trial. Lancet. 2026 Feb 14;407(10529):679-688. doi: 10.1016/S0140-6736(25)01862-8. Epub 2026 Jan 30. PMID: 41628627.
Our stroke neurologists were starting Minocycline on stroke patients 10 years ago at Maimonides in Brooklyn. /Steve