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Zhao Y, Ding H, Zhao X, Qiu X, Li B. Risk factors of recurrence after drug withdrawal in children with epilepsy. Front Neurol 2023; 14:1122827. [PMID: 37181578 PMCID: PMC10172464 DOI: 10.3389/fneur.2023.1122827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
This study aimed to evaluate the risk factors for recurrence in pediatric patients with epilepsy following normal antiseizure medication (ASM) treatment and drug withdrawal. We retrospectively analyzed 80 pediatric patients who received treatment at the Qilu Hospital of Shandong University between January 2009 and December 2019 after at least 2 years of seizure-free and normal electroencephalography (EEG) before the regular drug reduction. Patients were followed-up for at least 2 years and divided into the recurrence and nonrecurrence groups based on whether relapse occurred. Clinical information was gathered, and the risk variables for recurrence were statistically analyzed. Post 2 years of drug withdrawal, 19 patients showed relapses. The recurrence rate was 23.75%, and the mean time of recurrence was 11.09 ± 7.57 months, where 7 (36.8%) were women and 12 (63.2%) were men. In all, 41 pediatric patients were followed-up until the 3rd year, of which 2 (4.9%) patients experienced a relapse. Among the remaining 39 patients without relapse, 24 were followed-up until the 4th year, and no recurrence occurred. After being monitored for >4 years, 13 patients experienced no recurrence. The differences in the history of febrile seizures, combined use of ≥2 ASMs, and EEG abnormalities after drug withdrawal between the two groups were statistically significant (p < 0.05). Multivariate binary logistic regression analysis revealed that these factors are independent risk factors for recurrence after drug withdrawal in children with epilepsy: history of febrile seizures (OR = 4.322, 95% CI: 1.262-14.804), combined ASM use (OR = 4.783, 95% CI: 1.409-16.238), and EEG abnormalities after drug withdrawal (OR = 4.688, 95% CI: 1.154-19.050). In summary, our results suggest that the probability of seizure recurrence following drug cessation may be greatly increased by a history of febrile seizures, concomitant use of ≥2 ASMs, and EEG abnormalities after drug cessation. The majority of recurrences occurred in the first 2 years following drug discontinuation, whereas the rate of recurrence was minimal thereafter.
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Affiliation(s)
- Yongheng Zhao
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hao Ding
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyu Zhao
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaochang Qiu
- Department of Geriatrics, The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital), Jinan, China
| | - Baomin Li
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
- *Correspondence: Baomin Li,
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Yıldırım M, Bektaş Ö, Kartal AT, Yeniay Süt N, Teber S. Risk of seizure relapse and long-term outcomes after discontinuation of antiseizure medication in children with epilepsy. Epilepsy Behav 2022; 134:108779. [PMID: 35763995 DOI: 10.1016/j.yebeh.2022.108779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/21/2022] [Accepted: 05/29/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aims of this study were to evaluate the demographic and clinical characteristics of children with epilepsy who discontinued their antiseizure medication (ASM), to determine potential predictors of seizure relapse, to calculate the rate of seizure relapse, and to detect long-term seizure outcomes. METHODS A total of 269 seizure-free children with epilepsy who were decided to discontinue their ASM and were followed up for at least 18 months after ASM withdrawal were retrospectively evaluated. RESULTS The enrolled children had been followed up for a median of 46 months (range 18-126 months; IQR: 29-61) after ASM withdrawal and 90 (33.5%) of their seizures relapsed. The median time to seizure relapse was 8 months (range 0.23-117 months; IQR: 2-25). Seizure relapse occurred in 16.7% of the 90 children at 1 month, 45.6% at 6 months, 62.2% at 1 year, 74.4% at 2 years, and 94.4% at 5 years. Univariate logistic regression analyses revealed six predictors significantly related to relapse: age at first seizure, age at diagnosis of epilepsy, intellectual disability, EEG findings after ASM withdrawal, ASM tapering time, and number of seizures on ASM. In multivariate logistic regression analyses, age at first seizure, intellectual disability, and ASM tapering time were not significantly associated anymore. The other three remained independently predictive. Pharmacological control of seizures with monotherapy was restored in 93.3% of the children with seizure relapse. CONCLUSION This study evaluated potential predictors of seizure relapse, some of which have rarely been evaluated in previous studies. Adolescent age at diagnosis, abnormal EEG findings after ASM withdrawal, and high number of seizures on ASM were associated with a higher risk of seizure relapse. Abnormal MRI findings such as malformations of cortical development and hydrocephalus may be potential biomarkers for the risk of seizure relapse.
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Affiliation(s)
- Miraç Yıldırım
- Department of Pediatric Neurology, Ankara University, Faculty of Medicine, Ankara, Turkey.
| | - Ömer Bektaş
- Department of Pediatric Neurology, Ankara University, Faculty of Medicine, Ankara, Turkey.
| | - Ayşe Tuğba Kartal
- Department of Pediatric Neurology, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Nurşah Yeniay Süt
- Department of Pediatric Neurology, Ankara University, Faculty of Medicine, Ankara, Turkey.
| | - Serap Teber
- Department of Pediatric Neurology, Ankara University, Faculty of Medicine, Ankara, Turkey.
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Risk of seizure recurrence from antiepileptic drug withdrawal among seizure-free patients for more than two years. Epilepsy Behav 2020; 113:107485. [PMID: 33157416 DOI: 10.1016/j.yebeh.2020.107485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/15/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022]
Abstract
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).
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Prediction of the recurrence risk in patients with epilepsy after the withdrawal of antiepileptic drugs. Epilepsy Behav 2020; 110:107156. [PMID: 32502930 DOI: 10.1016/j.yebeh.2020.107156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 12/18/2022]
Abstract
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.
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Abstract
OBJECTIVE To study a cohort of adult patients with various forms of epilepsy to determine various clinical patterns of remission with subsequent relapse of seizures. MATERIALS AND METHODS The study included 1384 patients. Two hundred and forty-nine patients with one or more remissions in the history resulted in relapse. Patients were stratified into 6 groups by clinical features of the disease. For each group, a long-term outcome of the disease was evaluated. RESULTS AND CONCLUSIONS Return to a basic therapy after a relapse due to dose reduction or AED discontinuation does not guarantee the remission. One or more «honeymoons» in medical history are predictors of the low probability of achieving remission. Patients with focal epilepsies often have one or more long-term remissions that may not correspond with AED treatment. In these patients, the relapse often happen in the second decade of life with the following development of intractable epilepsy.
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Affiliation(s)
- A S Kotov
- Vladimirsky Moscow Regional Research and Clinical Institute, Moscow, Russia
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Yao J, Wang H, Xiao Z. Correlation between EEG during AED withdrawal and epilepsy recurrence: a meta-analysis. Neurol Sci 2019; 40:1637-1644. [PMID: 31011931 DOI: 10.1007/s10072-019-03855-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
To assess the risk of epilepsy recurrence after withdrawal from antiepileptic drugs (AEDs), researchers extensively studied recurrence-related risk factors, including electroencephalogram (EEG) during AED withdrawal. The relationship between EEG and epilepsy recurrence is controversial. We used meta-analysis to determine the correlation between EEG during AED withdrawal and epilepsy recurrence. A total of seven studies met the criteria for inclusion. The Newcastle-Ottawa Scale was used to conduct the research quality evaluation. Seven hundred three patients were included in meta-analysis. Patients with abnormal EEGs during withdrawal had a higher recurrence rate than patients with normal EEGs. Abnormal EEGs during withdrawal were a risk factor for recurrence.
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Affiliation(s)
- Juan Yao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Hao Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zheng Xiao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Ou S, Xia L, Li R, Wang L, Xia L, Zhou Q, Pan S. Long-term outcome of seizure-free patients and risk factors of relapse following antiepileptic drug withdrawal. Epilepsy Behav 2018; 88:295-300. [PMID: 30340125 DOI: 10.1016/j.yebeh.2018.09.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study aimed to investigate the long-term outcome in seizure-free patients and to explore the risk factors of seizure relapse following antiepileptic drug (AED) withdrawal. METHODS This study included 161 patients who had been seizure-free for at least 2 years. These patients were monitored over a follow-up period of at least 3 years or until seizure relapse after AED withdrawal. Patients were grouped into a seizure-free group and a relapse group. Risk factors of seizure relapse were analyzed. RESULTS During the follow-up period, 72 patients (44.7%) relapsed while 89 patients (55.3%) did not. The average time of relapse was 19.12 ± 27.17 months after the initiation of AED withdrawal, and majority of cases occurred within the first 24 months of AED withdrawal (73.6%). Univariate analysis showed that the likelihood of relapse was higher in patients with uncontrolled seizures beyond the first 6 months of AED therapy initiation, patients with a history of perinatal injury, patients with multiple seizure types, and patients who had been treated with a combination of AEDs. Multiple logistic regression analysis revealed that uncontrolled seizures beyond the first 6 months of AED treatment and a history of perinatal injury were independent risk factors of seizure relapse. CONCLUSION In the majority of cases, epilepsy relapse occurred within the first two years after the initiation of AED withdrawal. The independent risk factors of seizure relapse were uncontrolled seizures beyond the first 6 months of AED therapy and cases with a history of perinatal injury.
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Affiliation(s)
- Shuchun Ou
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Lu Xia
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Rong Li
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Li Wang
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Li Xia
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Qin Zhou
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Songqing Pan
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China.
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Lee IC, Li SY, Chen YJ. Seizure Recurrence in Children after Stopping Antiepileptic Medication: 5-Year Follow-Up. Pediatr Neonatol 2017; 58:338-343. [PMID: 28087260 DOI: 10.1016/j.pedneo.2016.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 07/06/2016] [Accepted: 08/01/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We wanted to identify in children with epilepsy the factors associated with seizure control and recurrence after a 2-year remission. METHODS We did a 5-year follow-up of epileptic children whose antiepileptic medication had been stopped. Bivariate and multivariate analyses were used to compare features of electroencephalograms (EEGs) and clinical findings. In this study, 43 patients with and 64 without a seizure recurrence (SR) were enrolled. RESULTS Clinical features strongly associated with SR in the univariate analysis included a symptomatic etiology for seizures, a history of status epilepticus, treatment duration before stopping antiepileptic drugs, and abnormal EEG findings at the time of stopping antiepileptic drugs. CONCLUSION We found that a history of status epilepticus, symptomatic partial epilepsy, treatment duration before stopping antiepileptic drugs, and an abnormal EEG when the medication was stopped are important predictors of SR. The risk factors of SR after discontinuing antiepileptic drugs have been investigated in several studies. However, a history of status epilepticus as a predictive factor is rarely mentioned.
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Affiliation(s)
- Inn-Chi Lee
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan; Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Shuan-Yow Li
- Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Genetics Laboratory and Department of Biomedical Sciences, Chung Shan Medical University, Taichung, Taiwan.
| | - Yung-Jung Chen
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
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Tang L, Xiao Z. Can electroencephalograms provide guidance for the withdrawal of antiepileptic drugs: A meta-analysis. Clin Neurophysiol 2016; 128:297-302. [PMID: 28042995 DOI: 10.1016/j.clinph.2016.11.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 11/03/2016] [Accepted: 11/19/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The discontinuation of antiepileptic drugs (AEDs) is an important treatment decision for epilepsy patients who have been seizure-free for 2years or longer. Some patients experience seizures relapse after AED withdrawal. The prognostic value of electroencephalograms (EEGs) for seizure relapse following AED withdrawal is controversial. To our knowledge, this is the first meta-analysis to address whether EEG data can be used to guide the discontinuation of AEDs. METHOD We performed a meta-analysis of cohort studies that reported original EEG data from before AED withdrawal and recurrence after AED-withdrawal. The quality of each study was assessed using the Newcastle-Ottawa Scale. RESULTS Fifteen studies including a total of 2349 participants were included in this meta-analysis. This meta-analysis of 15 studies demonstrates that an abnormal electroencephalogram was a predictor of the risk of relapse. Additionally, paroxysmal, slowing, spike and wave activities on electroencephalograms were associated with increased risk of relapse. CONCLUSION We reveal that abnormal EEG records, particularly paroxysmal abnormalities, before AED withdrawal predicted a high risk of relapse. Slowing and spike and wave activities also exhibited moderate predictive values. SIGNIFICANCE Our findings suggest that, EEGs might be an important prognostic tool for antiepileptic drug reduction.
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Affiliation(s)
- Liwei Tang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, China; Department of Neurology, The Third Hospital of MianYang, China
| | - Zheng Xiao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, China.
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Strozzi I, Nolan SJ, Sperling MR, Wingerchuk DM, Sirven J. Early versus late antiepileptic drug withdrawal for people with epilepsy in remission. Cochrane Database Syst Rev 2015; 2015:CD001902. [PMID: 25922863 PMCID: PMC7061653 DOI: 10.1002/14651858.cd001902.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Epilepsy is a chronic neurological disorder which affects millions of people around the world. Antiepileptic drugs (AED) are the main interventions used to prevent seizures and control epilepsy. Although effective in most cases, AEDs are related to long-term adverse effects, such as cognitive and behavioural alterations. Thus when epilepsy is in remission, it may be in the individual's best interest to discontinue medication. However, the optimal timing of AED discontinuation is still unknown.This is an updated version of the original Cochrane review published in Issue 3, 2001. OBJECTIVES (1) To quantify and compare risk of seizure recurrence, status epilepticus and mortality after early and late AED discontinuation in adult and pediatric epilepsy patients.(2) To assess which variables modify the risk of seizure recurrence.(3) To define a subpopulation in which early AED discontinuation is safe. SEARCH METHODS We searched the Cochrane Epilepsy Group Specialised Register (June 2014); CENTRAL (Issue 5, The Cochrane Library, May 2014); MEDLINE (1946 to June 2014); CINAHL (23 June 2014); Scopus (1823 to June 2014); ClinicalTrials.gov (23 June 2014); and WHO International Clinical Trials Registry Platform (23 June 2014). We also checked the reference lists of studies found through the electronic searches. SELECTION CRITERIA Randomised controlled trials that evaluate withdrawal of AEDs after varying periods of seizure remission in adults and children with epilepsy. Included studies compared an early AED discontinuation time (defined as a period of remission of seizures of less than two years) versus a late AED discontinuation time (defined as a period of remission of seizures of more than two years). DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed trial quality. Risk ratio (RR) with 95% confidence interval (CI) was calculated for each trial. Summary RRs and 95% CIs for dichotomous data were calculated using a fixed-effect model. A test of statistical heterogeneity was conducted for each pooled risk ratio calculation. Each included study underwent a 'Risk of bias' assessment, based on the Cochrane Handbook recommendations, and we examined the overall quality of information through the GRADE system, presented in two 'Summary of Findings' tables. MAIN RESULTS Five trials were included in this review, representing 924 randomised children with epilepsy, all under 16 years of age at randomisation, with a median follow-up of 5.6 years. No eligible trial evaluated adults or assessed mortality or status epilepticus as outcomes. The pooled risk ratio for seizure relapse after AED withdrawal was 1.34 (95% CI 1.13 to 1.59, P = 0.0007). Conforming to this estimate, the number needed to harm, that is expose an individual to a higher risk of seizure relapse because of early withdrawal of AED, is 8 (95% CI 5 to 20). Early discontinuation was associated with greater relapse rates in people with partial seizures with a pooled risk ratio of 1.51 (95% CI 0.97 to 2.35, P = 0.07). Absence type epilepsy showed a lower risk of relapse. Variables associated with higher risk of seizure relapse were abnormal EEG findings (pooled RR 1.44, 95% CI 1.13 to 1.83, P = 0.003), especially epileptiform activity (RR 2.58, 95% CI 2.03 to 3.28, P < 0.0001); epilepsy onset before 2 years or after 10 years of age; history of status epilepticus; intellectual disability (IQ < 70); and high seizure frequency before and during treatment. Gender and family history did not show any significant influence over seizure relapse. Overall, the included trials were classified as low or unclear risk of bias where methodological information was not reported and could not be provided by original study authors. AUTHORS' CONCLUSIONS There is evidence to support waiting for at least two seizure-free years before discontinuing AEDs in children, particularly if individuals have an abnormal EEG or partial seizures, or both. There is insufficient evidence to establish when to withdraw AEDs in children with generalised seizures. There is no evidence to guide the timing of withdrawal of AEDs in seizure-free adults. Further high-quality randomised controlled trials are needed, particularly recruiting adults and recruiting those with generalised seizure types, to identify the optimal timing of AED withdrawal and risk factors predictive of relapse.
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Affiliation(s)
- Isabella Strozzi
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLiverpoolUKL9 7LJ
| | - Sarah J Nolan
- The University of LiverpoolDepartment of BiostatisticsDuncan BuildingDaulby StreetLiverpoolUKL69 3GA
| | - Michael R Sperling
- Jefferson Medical CollegeDepartment of NeurologySuite 4150/ 111 S. 11th StreetThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA19107
| | - Dean M Wingerchuk
- Mayo ClinicDepartment of Neurology13400 East Shea BoulevardScottsdaleArizonaUSA85259
| | - Joseph Sirven
- Mayo ClinicDepartment of Neurology13400 East Shea BoulevardScottsdaleArizonaUSA85259
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