Withdrawal seizures: possible risk factors

ABSTRACT

Introduction

Most of the patients usually achieve seizure freedom under treatment with antiseizure medications (ASMs). Drug withdrawal in seizure-free patients is still one of the most challenging issues in the management of epilepsy. The decision-making process of whether the treatment should be discontinued must be based on the evaluation of possible long-term side effects of chronic treatment and, on the other hand, the risk of seizure relapse.

Areas covered

This review aims to describe and discuss possible predictors and risk factors for seizure relapse during and after discontinuation, according to the available literature evidence.

The most important risk factors for withdrawal failure are the etiology of the epilepsy syndrome and epilepsy-related factors, worsening or persistence of epileptiform abnormalities on EEG recordings at the time of discontinuation or during drug tapering, and brain MRI abnormalities.

Each single risk factor should be considered together with possible other concurrent predictors.

Expert opinion

The decision to withdrawal antiseizure medication in seizure-free patients should be carefully planned and based on the evaluation of predictors. A discontinuation program should include tailored discussion with patients and family members and individualized decision, the taper schedule, and plans for monitoring during and after drug tapering.

KEYWORDS:

• Antiseizure medications
• antiepileptic drugs
• withdrawal
• discontinuation
• seizure relapse
• epilepsy syndrome
• etiology
• electroencephalogram
• neuroimaging

Article highlights

• The complete remission of epilepsy is still a challenging issue.

• In patients in whom the pharmacological treatment has been successful, the decision of ASMs withdrawal should be carefully discussed, planned, and based on the evaluation of many factors.

• According to the different study designs and different populations, the risk of seizure relapse after ASMs withdrawal rages from 10% to 70% in the different series.

• The principal risk factors related to seizure relapse are etiology, epilepsy syndrome, EEG abnormalities, and neuroimaging.

• Tapering of ASMs should be carried out gradually because abrupt discontinuation can be dangerous for the patient, although, according to the available knowledge, the optimal rate of tapering of ASMs cannot be drawn.

• Controlled and prospective studies are needed in order to obtain more definite information.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.