Early versus late antiepileptic drug withdrawal for people with epilepsy in remission

Seizure-relapse risk following antiseizure medication withdrawal in children with non-lesional focal epilepsy

AIMS

We investigated seizure-relapse risk following antiseizure medication (ASM) withdrawal in children with focal epilepsy (FE) who were leading to seizure remission by ASM monotherapy without drug replacement.

METHODS

Participants were treated at our hospital between 1 July 1999 and 30 June 2015. Children showing abnormalities on brain MRI and self-limited FE were excluded. All children discontinued ASMs after more than 2 years of a seizure-free state. Associations between seizure relapse within 2 years following ASM withdrawal and age at onset, seizure-free interval before ASM withdrawal, duration of tapering, presence of interictal epileptiform discharges (IEDs) on electroencephalogram (EEG), and type of ASM used were evaluated.

RESULTS

Participants comprised 128 FE children. Twelve children (9.7 %) experienced seizure relapse. Ages at both onset and ASM withdrawal were significantly higher in the relapse group than in the non-relapse group (p < 0.0001 and p = 0.0003, respectively). Seizure-free interval before ASM withdrawal was significantly shorter in the relapse (mean, 2.6 years) than in the non-relapse group (3.6 years; p < 0.0001). Duration of tapering was significantly shorter in the relapse (mean, 5.3 months) than in the non-relapse group (9.2 months; p < 0.0001). Presence of IEDs was significantly more frequent in the relapse than in the non-relapse group (p = 0.03). Seizure relapse tended to be less frequent with levetiracetam treatment than with carbamazepine, but the difference was not significant (p = 0.067).

CONCLUSIONS

Among FE children who achieve a seizure-free state on ASMs for more than 3 years, clinicians should recommend withdrawal of ASM using a slow tapering schedules lasting more than 6 months.

Economic Evaluation of HLA-B*15:02 Genotyping for Asian Australian Patients With Epilepsy

Importance

The HLA-B*15:02 allele has been associated with an increased risk of carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in specific Asian populations (including Han Chinese, Malaysian, Thai, and Vietnamese individuals). While HLA-B*15:02 genotype testing in Asian populations is recommended by several international prescribing guidelines, it is not subsidized by the Medicare Benefits Schedule in Australia.

Objective

To evaluate the cost-effectiveness of HLA-B*15:02 genotyping in Asian Australian patients with epilepsy.

Design, Setting, and Participants

A model with components of decision analysis and Markov simulation was developed to simulate clinical trajectories of adult Asian Australian patients with newly diagnosed epilepsy being considered for carbamazepine treatment. Cost-effectiveness and cost-utility analyses over a lifetime time horizon were conducted from the perspective of the Australian health care sector. The study was conducted in May 2023 and data analysis was performed from August 2023 to November 2023.

Intervention

No HLA-B*15:02 genotyping and the empirical initiation of treatment with carbamazepine vs HLA-B*15:02 genotyping and the initiation of treatment with valproate in allele carriers.

Main Outcomes and Measures

Life-years (LYs), quality-adjusted life-years (QALYs), and costs in 2023 Australian dollars (A$); incremental cost-effectiveness ratios.

Results

HLA-B*15:02 screening was associated with an additional mean cost of A$114 (95% CI, -A$83 to A$374; US$76; 95% CI, -US$55 to US$248) and a reduction in 0.0152 LYs (95% CI, 0.0045 to 0.0287 LYs) but improvement by 0.00722 QALYs (95% CI, -0.0247 to -0.01210) compared with no screening, resulting in an incremental cost-effectiveness ratio of A$15 839 per QALY gained (US$10 523 per QALY). Therefore, universal genotyping for Asian Australian individuals was cost-effective compared with current standards of practice at the A$50 000 per QALY willingness-to-pay threshold. Sensitivity analyses demonstrated that the intervention remained cost-effective across a range of costs, utilities, transition probabilities, and willingness-to-pay thresholds. At the A$50 000 per QALY willingness-to-pay threshold, universal screening was the preferred strategy in 88.60% of simulations.

Conclusions and Relevance

The results of this economic evaluation suggest that HLA-B*15:02 screening represents a cost-effective choice for Asian Australian patients with epilepsy who are being considered for treatment with carbamazepine.

Relapse After Drug Withdrawal in Patients with Epilepsy After Two Years of Seizure-Free: A Cohort Study

BACKGROUND AND STUDY AIMS

Antiepileptic drugs are the first choice of treatment for patients with epilepsy. However, the withdrawal of antiepileptic drugs after seizure-free remains a significant focus for the majority of patients with epilepsy and their families. In this study, we evaluated the risk factors associated with relapse after drug withdrawal in patients with seizure free for 2 years. We aimed to guide patients in seizure-free to assess the risk of drug withdrawal.

PATIENTS AND METHODS

Through screening, 452 patients with epilepsy were included in the study.Patients were followed up for at least 2 years or more. Analyzed their clinical data by applying the χ2-test, Kaplan-Meier survival analysis and multivariate Cox regression analysis.

RESULTS

423 patients completed follow-up, of which 304 cases recurred (71.9%).Related recurrence factors include age of onset, type of seizure, number of AEDs, seizure-free time before withdrawal, and electroencephalogram (EEG) results before drug withdrawal (P<0.05). The results of correlation analysis showed that age of onset, seizure frequency, seizure type, number of AEDs, the period from AEDs treatment to a seizure-free status, EEG results before drug withdrawal, and pre-medication course, were all significantly related to the recurrence of seizures after drug reduction and withdrawal (P<0.05). We identified a range of independent risk factors, including onset age, seizure frequency, Multiple AEDs and the period from AEDs treatment to a seizure-free status.

CONCLUSION

The overall recurrence rate of epilepsy in our patient cohort was high, and the peak recurrence period was within one-year of drug withdrawal. Patients with partial seizures, a short seizure-free time before withdrawal, severe EEG abnormalities before drug reduction, and a long course of the disease, are prone to relapse. Patients with an older age at onset and a high frequency of attack, those taking multi-drug combination therapy, and those that take a long time to gain control, should be managed carefully to AEDs withdrawal.

Limited care offered to people with epilepsy in Mwanza, Tanzania: need for intervention

Introduction

epilepsy is a very common neurological disorder which is associated with high socioeconomic burden. While up to 90% of people with epilepsy (PWE) in developing countries do not get appropriate treatment, there is limited information about care offered to PWE in Tanzania. This study aimed to describe available care offered to PWE in Mwanza.

Methods

a cross-sectional study involving health care workers (HCWs) and PWE attending five selected hospitals outpatient clinics of Mwanza region was done. HCWs completed self-administered questionnaires while PWE or caretakers were interviewed using structured questionnaires. Coded data were analyzed using SPSS.

Results

a total of 18 HCWs and 218 PWE (or their care takers) participated in this study. Health care workers rarely used investigations to confirm epilepsy diagnosis or explore its causes. 10/18 (55.6%) of HCWs reported that counseling was given to patients but counseling information was largely inadequate regarding the use of anti-epileptic drugs (AEDs). The AEDs prescriptions were dictated by drug availability and affordability to patients. Among 197 PWE, whose AEDs doses were revealed, 136 (69.0%) were under-medicated. No follow-up investigation was done to all PWE who were interviewed. There was discrepancy between hospitals and practitioners regarding withdrawal of AEDs.

Conclusion

people with epilepsy in Mwanza received limited care. Patients were not thoroughly investigated, counseled and followed-up, and had limited choice and accessibility to AEDs. Some patients particularly in district hospitals were under-medicated despite of seizure recurrence. We recommend short-course training about epilepsy management to the HCWs who diagnose and treat PWE regularly.

Risk of seizure recurrence from antiepileptic drug withdrawal among seizure-free patients for more than two years

OBJECTIVE

The aim of this study was to determine the outcome of antiepileptic drug (AED) withdrawal in patients who were seizure-free for more than two years.

METHODS

Patients with epilepsy who were seizure-free for at least two years and decided to stop AED therapy gradually were followed up every two months for seizure relapse. The inclusion criteria were as follows: (1) diagnosis of epilepsy, defined as the following conditions: ① at least two unprovoked (or reflex) seizures occurring >24 h apart; ② one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; ③ diagnosis of an epilepsy syndrome; (2) patients remained seizure-free for at least 24 consecutive months during AED therapy; and (3) patients expressed a desire to discontinue AED therapy gradually and agreed to return for regular follow-ups. The time to a seizure relapse and predictive factors were analyzed by survival methods, including sex; age at seizure onset; number of episodes; seizure-free period before AED withdrawal; duration of follow-up after AED withdrawal; AED tapering off period (taper period); results from brain magnetic resonance (MRI); electroencephalogram (EEG) after drug withdrawal; EEG before drug withdrawal; seizure type (classified as generalized, partial, or multiple types based on history); and the number of AEDs administered for long-term seizure control. A log-rank test was used for univariate analysis, and a Cox proportional hazard model was used for multivariate analysis.

RESULTS

We selected 94 patients (58 men, 36 women). The relapse ratio was 29.8%. Univariate analysis and multivariate Cox regression analysis indicated that withdrawal times and multiple AEDs, as well as the seizure-free period before withdrawal and abnormal EEG after drug withdrawal were significantly correlated with seizure recurrence and were significant independent predictive factors, with a hazard ratio of 0.839 and 3.971, 0.957, and 3.684, respectively.

SIGNIFICANCE

The relapse rate in our study was similar to commonly reported overall rates for epilepsy. Distinguishing variables, such as withdrawal times, multiple AEDs, seizure-free period before withdrawal, and abnormal EEG after drug withdrawal, need to be considered when choosing to withdraw from AEDs. Therefore, our recommendation is that after two years of seizure-free survival, patients could consider withdrawal unless they have hippocampal sclerosis (HS).

Prediction of the recurrence risk in patients with epilepsy after the withdrawal of antiepileptic drugs

Many seizure-free patients who consider withdrawing from antiepileptic drugs (AEDs) hope to discontinue treatment to avoid adverse effects. However, withdrawal has certain risks that are difficult to predict. In this study, we performed a literature review, summarized the causes of significant variability in the risk of postwithdrawal recurrent seizures, and reviewed study data on the age at onset, cause, types of seizures, epilepsy syndrome, magnetic resonance imaging (MRI) abnormalities, epilepsy surgery, and withdrawal outcomes of patients with epilepsy. Many factors are associated with recurrent seizures after AED withdrawal. For patients who are seizure-free after treatment, the role of an electroencephalogram (EEG) alone in ensuring safe withdrawal is limited. A series of prediction models for the postwithdrawal recurrence risk have incorporated various potentially important factors in a comprehensive analysis. We focused on the populations of studies investigating five risk prediction models and analyzed the predictive variables and recommended applications of each model, aiming to provide a reference for personalized withdrawal for patients with epilepsy in clinical practice.

Epilepsy treatment in adults and adolescents: Expert opinion, 2016

INTRODUCTION

There are over twenty anti-seizure medications and anti-seizure devices available commercially in the United States. The multitude of treatment options for seizures can present a challenge to clinicians, especially those who are not subspecialists in the epilepsy field. Many clinical questions are not adequately answered in double-blind randomized controlled studies. In the presence of a knowledge gap, many clinicians consult a respected colleague with acknowledged expertise in the field. Our survey was designed to provide expert opinions on the treatment of epilepsy in adults and adolescents.

METHOD

We surveyed a group of 42 physicians across the United States who are considered experts based on publication record in the field of epilepsy, or a leadership role in a National Association of Epilepsy Centers comprehensive epilepsy program. The survey consisted of 43 multiple-part patient scenario questions and was administered online using Redcap software. The experts provided their opinion on 1126 treatment options based on a modified Rand 9-point scale. The patient scenarios focused on genetically-mediated generalized epilepsy and focal epilepsy. The scenarios first focused on overall treatment strategy and then on specific pharmacotherapies. Other questions focused on treatment of specific patient populations (pregnancy, the elderly, patients with brain tumors, and post organ transplant patients), epilepsy patients with comorbidities (renal and hepatic disease, depression), and how to combine medications after failure of monotherapy. Statistical analysis of data used the expert consensus method.

RESULTS

Valproate was considered a drug of choice in all genetically-mediated generalized epilepsies, except in the population of women of child-bearing age. Ethosuximide was a drug of choice in patient with absence seizures, and levetiracetam was a drug of choice in patients with genetic generalized tonic-clonic seizures and myoclonic seizures. Lamotrigine, levetiracetam and oxcarbazepine were considered drugs of choice for initial treatment of focal seizures. Lamotrigine and levetiracetam were the drugs of choice for women of child-bearing age with either genetic generalized epilepsy or focal epilepsy. Lamotrigine and levetiracetam were the drugs of choice in the elderly population. Lamotrigine was preferred in patients with co-morbid depression. Levetiracetam was the drug of choice in treating patients with hepatic failure, or who have undergone organ transplantation. Compared to the 2005 and 2001 surveys, there was increased preference for the use of levetiracetam and lamotrigine, and decreased preference for the use of phenytoin, gabapentin, phenobarbital and carbamazepine.

DISCUSSION

The study presented here provides a "snapshot" of the clinical practices of experts in the treatment of epilepsy. The experts were very often in agreement, and reached consensus in 81% of the possible responses. However, expert opinion does not replace the medical literature; instead, it acts to supplement existing information. Using the study results is similar to requesting an expert consultation. Our findings suggest options that the clinician should consider to achieve best practice.

Pharmacological and psychosocial management of mental, neurological and substance use disorders in low- and middle-income countries: issues and current strategies

Mental, neurological, and substance use disorders (MNS) are among the largest sources of medical disability in the world, surpassing both cardiovascular disease and cancer. The picture is not different in low- and middle-income countries (LAMIC) where the relative morbidity associated with MNS is increasing, as a consequence of improvement in general health indicators and longevity. However, 80 % of individuals with MNS live in LAMIC but only close to 20 % of cases receive some sort of treatment. The main aim of this article is to provide non-specialist health workers in LAMIC with an accessible guide to the affordable essential psychotropics and psychosocial interventions which are proven to be cost effective for treating the main MNS. The MNS discussed in this article were selected on the basis of burden, following the key priority conditions selected by the Mental Health Action Programme (mhGAP) developed by the World Health Organization (WHO) (anxiety, stress-related and bodily distress disorders; depression and bipolar disorder; schizophrenia; alcohol and drug addiction; and epilepsy), with the addition of eating disorders, because of their emergent trend in middle-income countries. We review best evidence-based clinical practice in these areas, with a focus on drugs from the WHO Model List of Essential Medicines and the psychosocial interventions available in LAMIC for the management of these conditions in primary care. We do this by reviewing guidelines developed by prestigious professional associations and government agencies, clinical trials conducted in LAMIC and systematic reviews (including Cochrane reviews) identified from the main international literature databases (MEDLINE, EMBASE and PsycINFO). In summary, it can be concluded that the availability and use of the psychotropics on the WHO Model List of Essential Medicines in LAMIC, plus an array of psychosocial interventions, can represent a cost-effective way to expand treatment of most MNS. The translation of these findings into policies can be achieved by relatively low supplementary funding, and limited effort engendered by governments and policy makers in LAMIC.

Predictors for relapse after antiepileptic drug withdrawal in seizure-free patients with epilepsy

The objective of this study was to evaluate the timing of medication withdrawal and other clinical factors as potential predictors of seizure relapse after antiepileptic drug (AED) withdrawal in patients with epilepsy. A total of 99 patients who were seizure free for more than 2 years were recruited from the Neurology Clinics of Nanjing Brain Hospital between 2001 and 2009, and were followed prospectively for at least 2 years or until seizure relapse. Kaplan-Meier survival analysis was used for calculating recurrence rates. Univariate and multivariate analyses for recurrence risk factors were performed using the Cox proportional hazards model. Thirteen patients were excluded due to loss of follow-up or incomplete seizure records. Epileptiform electroencephalography (EEG) abnormality within the first year after AED withdrawal (hazard ratio [HR] = 4.810, 95% confidence interval [CI] = 2.220-10.420) was found on multivariate analysis to be a predictor of seizure recurrence. Early AED withdrawal after a seizure-free period of 2-3 years did not significantly increase the risk of recurrence (HR = 0.999, 95% CI = 0.969-1.029) as compared with delayed AED withdrawal (patients who were seizure-free for more than 3 years). AED can be withdrawn in patients who have been seizure-free for more than 2 years. As epileptiform EEG abnormality within the first year after AED withdrawal predicts seizure relapse, it is necessary to perform EEG for patients during the first year after AED withdrawal.

Role of Cochrane reviews in pediatric neurology

Evidence-based medicine in pediatric neurology is considered an important contributor to the best quality of care. We performed a literature review of all Cochrane reviews from 1996-2010 in pediatric neurology. Some reviews concluded that a certain intervention provided benefits, some concluded that certain interventions should not be performed, and some concluded that the current level of evidence was inconclusive. One hundred and twelve reviews were enrolled; only 17 exclusively involved children. In 33/112, a clear recommendation in favor of a certain intervention was given, 11/112 issued a conditionally positive recommendation, and 32/112 concluded that certain interventions should not be performed. Six concluded that no differences were evident between different therapeutic/treatment options. Thirty were inconclusive. The proportion of inconclusive reviews increased during three a priori defined time intervals. Common criticisms regarding quality of enrolled studies included heterogeneous study populations (49/112), a small number of participants (48/112), and a lack of comparability of studies (40/112). An ongoing need exists for high-quality research to reduce the proportion of inconclusive meta-analyses. Further randomized, controlled trials should involve only pediatric populations.

Treating epilepsy across its different stages

Epilepsy is a chronic condition requiring long-term treatment with drugs that have intrinsic limitations. Antiepileptic drugs (AEDs) are effective in suppressing seizures but do not alter the disease process. They have a suboptimal tolerability profile and can be teratogenic. Second-generation compounds may be better tolerated but no more effective than traditional AEDs. In this light, as drug therapy is purely symptomatic, acute symptomatic seizures (i.e. seizures occurring in close temporal relationship with acute CNS insults) may require treatment only until recovery or stabilization of the injury. Treatment of the first unprovoked seizure may be considered in patients with abnormal EEG and imaging findings and in those in whom the relapse has severe social, emotional and personal implications. In these cases and in patients with epilepsy (i.e. repeated unprovoked seizures), drugs for partial seizures supported by class I regulatory trials or pragmatic trials are oxcarbazepine in children, carbamazepine or lamotrigine in adults, and lamotrigine or gabapentin in the elderly. Pragmatic trials support use of valproate for generalized seizures, except for women of childbearing age for whom the drug should be tailored to the individual patient. The lowest maintenance dose should be chosen, based on the efficacy and tolerability of the assigned drug. If the first monotherapy fails, the safety profile of a drug is important when opting for another monotherapy or for an add-on therapy. The epilepsy syndrome and the social, psychological and emotional profile of the patient all contribute to the individualization of treatment discontinuation after long-term seizure remission.

Refractory epilepsy: one size does not fit all

A unifying definition of refractory epilepsy has been hotly debated but, to date, has not been agreed upon. Evidence from clinical trials indicates that some patients actually are not refractory, as many will partially respond to add-on treatment or will worsen when antiepileptic drugs (AEDs) are removed. There are several important issues relating to the assessment of AED response that routinely have not been addressed in the determination of treatment responsiveness, such as incorporating baseline seizure severity, including partial response rather than solely an all-or-none response, and the consideration of variability in response over time.

To stop or not to stop the AED?

Consequences of Antiepileptic Drug Withdrawal: A Randomized, Double-Blind Study (Akershus Study). Lossius MI, Hessen E, Mowinckel P, Stavem K, Erikssen J, Gulbrandsen P, Gjerstad L. Epilepsia 2008;49:455–463. OBJECTIVE: Despite side effects associated with the use of antiepileptic drugs (AEDs), withdrawal of AEDs remains controversial, even after prolonged seizure freedom. The main objective of this study was to assess the effects of AED withdrawal on cognitive functions, seizure relapse, health-related quality of life (HRQOL), and EEG results. Additionally, potential predictors for freedom from seizures after AED withdrawal were studied. METHODS: Patients, seizure-free for more than 2 years on AED monotherapy, were recruited for a controlled, prospective, randomized, double-blinded withdrawal study lasting for 12 months, or until seizure relapse. Patients were randomized to AED withdrawal (n = 79) and nonwithdrawal (n = 81) groups. The examination program included clinical neurological examinations, neuropsychological testing, EEG-recordings, cerebral MRI, and assessments of HRQOL. Follow-up data on seizure relapse were also collected beyond the 12-month study period (median 47 months). RESULTS: Seizure relapse at 12 months occurred in 15% of the withdrawal group and 7% of the nonwithdrawal group (RR 2.46; 95% CI: 0.85–7.08; p = 0.095). After withdrawal, seizure relapse rates were 27% after a median of 41 months off medication. A normal result to all 15 neuropsychological tests increased significantly from 11% to 28% postwithdrawal. We found no significant effects of withdrawal on quality of life and EEG. Predictors for remaining seizure-free after AED-withdrawal over 1 year were normal neurological examination and use of carbamazepine prior to withdrawal. CONCLUSION: Seizure-free epilepsy patients on AED monotherapy who taper their medication may improve neuropsychological performance with a relative risk of seizure relapse of 2.46, compared to those continuing therapy.

Four-year outcome after early withdrawal of antiepileptic drugs in childhood epilepsy

Four-year follow-up of children with epilepsy included in a randomized trial of early withdrawal of antiepileptic drugs showed that 51% achieved a terminal remission of at least 2 years without medication and 21% with medication; 15% had seizures during the fourth year. Early medication withdrawal is not recommended as standard practice in children with a rapid response to medication. The authors developed a model to predict outcome if withdrawal is considered.