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In most cases, this helps to ruin the run. If there is a curse of obscurity and this item comes across, then I do a restart.
Mostly on whether I got high (or at least decent) shot speed when picking it up tbh because it's just gonna SUCK with low shot speed. Also items, of course, but shot speed is important to whether I'm gonna have a good time picking it up RIGHT THERE AND THEN.
just be careful what you take it with.
conversely, i never take anything that can explode in my face and i never take mom's knife. i hate that thing. i don't care if it's strong, i hate it.
also, mom's knife is not autowin against any of the super bosses, like hush or delirium, mom;s knife just is way too slow and the damage reduction just scales it down way too much.
never take a knife to a hush fight.
also, the knife and brimstone synergy is horrible. it combines the worst of both effects, making the end result weaker than either of them alone.
You won't be able to defend yourself against charging enemies very well, and the lack of knockback compounds this issue.
The best case for Ludovico is when you have very high damage through Eve's Mascara or Polyphemus, where the first tick of damage is already powerful enough to delete enemies. Or if you have a tear modifier like Technology or Brimstone that solve lots of Ludo's issues.
It's like Marked or The Wiz, decent in theory but changes how you play which can make you vulnerable.