Off to College: Safe to Stop His Antiepileptic Drug?

Charles P. Vega, MD

Disclosures

March 23, 2020

My Take on Deprescribing Antiepileptic Drugs

Records from the patient's workup 5 years earlier and the last clinic note from neurology, dated 2 years earlier, are available. At that time, the neurologist recommended continuing his treatment.

Before making any changes or recommendations, I would like input on this important medical decision from a specialist, because the evidence for when to discontinue antiepileptic drugs (AEDs) is poor overall. However, I can provide some key information with the patient and family to start them on the path toward shared decision-making.

The Cochrane Database of Systematic Reviews has examined the evidence on the timing of discontinuation of AEDs. A 2015 review included five randomized trials featuring a total of 924 children with epilepsy. All children were younger than 16 years at the time of randomization to early AED discontinuation (if < 2 years since the last seizure) or late AED discontinuation (if ≥ 2 years since the last seizure).

The median follow-up period was 5.6 years. The pooled risk ratio for seizure relapse in the early versus late discontinuation groups was 1.34, which corresponded to a number needed to harm of 8.

Early AED discontinuation was associated with a higher risk for subsequent seizures among children with partial seizures, but less so with absence seizures. Other variables associated with a higher risk for seizure recurrence included abnormal EEG findings, onset of seizures before age 2 or after age 10 years, intellectual disability, and a high frequency of seizures before discontinuation of treatment. In contrast, gender and family history did not affect recurrence. Generalized seizures, as in this case, have been associated with a higher risk for relapse in some studies, but other studies have found no difference in recurrence related to type of seizure.

Of note, no randomized trials of AED discontinuation among adults were found by reviewers, and no trial included mortality or status epilepticus as an outcome.

Recommendations regarding the discontinuation of AEDs are unhelpful. The American Academy of Neurology's latest recommendations were made in 1996, using the following criteria to determine eligibility for discontinuation of treatment:

  • No seizures for 2-5 years;

  • Only one type of epilepsy present;

  • Normal findings on EEG; and

  • Normal findings on neurologic examination.

The Italian League Against Epilepsy has provided more recent guidelines for the discontinuation of AEDs in patients of all ages. They also recommend that patients should be seizure-free for at least 2 years before discontinuation of AEDs, although a shorter seizure-free period may be acceptable among children. Although these recommendations account for relapse risk factors, they suggest that discontinuation of AEDs should only be ruled out in the presence of two or more factors, such as EEG abnormalities, partial seizures, and older age at the onset of symptoms.

Although research into the discontinuation of AEDs is limited, even fewer studies have looked at patient perspectives on treatment discontinuation. However, a just-published study found that only 44% of adults eligible for AED discontinuation were amenable to tapering off treatment. Most study participants chose to continue treatment not just out of concern for seizure recurrence, but also because they worried about their ability to work and even maintain their driver's license.

Epilepsy is frequently challenging, with implications beyond the risk for seizures. Decisions to discontinue AED reflects the complicated nature of the disease itself, and require careful consideration with advice based on evidence as well as experience. This young man deserves that chance, and I would look forward to making a thoughtful decision regarding AED discontinuation with him, his family, and his treating neurologist.

What do you think? Be sure to click on "Comments" to add your opinion on this case, and watch for the follow-up article summarizing reader views.

Charles P. Vega, MD, is a clinical professor of family medicine at UC Irvine and also serves as the UCI School of Medicine assistant dean for culture and community education. He focuses on medical education with an intent to resolve health disparities.

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