Withdrawal of antiseizure medications – for whom, when, and how?

ABSTRACT

Introduction

Epilepsy is a chronic disorder of the brain characterized by an enduring predisposition to generate epileptic seizures. Most patients can achieve complete seizure control (seizure freedom) with antiseizure medications (ASMs). In some of them, the withdrawal of ASMs can be considered. Guidance is required to identify patients in whom drug discontinuation can be safely attempted and to inform when and how ASM withdrawal can be done.

Areas covered

In this perspective, the authors discuss the evidence on ASM withdrawal in epilepsy patients who are seizure-free and provide some suggestions on how to do it effectively in clinical practice, minimizing the risk of seizure recurrence.

Expert opinion

The decision of discontinuing ASMs in epilepsy patients should rely on an accurate estimate of seizure recurrence risk. Whenever possible, such a risk should be assessed on an individual basis. The decision should also consider the psychosocial and personal consequences of seizure relapse. No robust evidence is available on the safest tapering regimen.

KEYWORDS:

• Epilepsy
• prediction
• prognosis
• seizure freedom
• withdrawal

Article highlights

• The decision of discontinuing antiseizure medications in seizure-free epilepsy patients should rely on an accurate (and, as much as possible, individualized) estimate of seizure recurrence risk.

• The choice should consider the psychosocial and personal consequences of seizure relapse.

• The personal choice of withdrawing ASMs is independent of an exact risk threshold but relies on a balance between benefits and risks made on an individual level.

• Benzodiazepines and barbiturates should be withdrawn slowly.

• There is not enough evidence to recommend periodic EEG recordings during discontinuation in children and adults.

• Temporary driving restrictions from the commencement of withdrawal up to six months after cessation of treatment are advisable.

• In patients taking multiple medications, one drug at a time should be withdrawn.

• If seizures relapse during or after discontinuation, the last effective withdrawn drug should be reinstated, or its dose increased up to the previously effective one.

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 manuscript has not been funded.