Withdrawal of antiepileptic drugs: an individualised approach

Antiseizure medication withdrawal in seizure-free patients with PCDH19-related epilepsy: A multinational cohort survey

PURPOSE

PCDH19-related epilepsy is usually refractory to current antiseizure medications (ASM), but seizures are easier to control especially after the second decade of life. Nonetheless, there is no evidence regarding the withdrawal of ASM in this clinical scenario. We aimed to evaluate the outcomes of attempts to discontinue ASM in seizure-free patients with PCDH19-related epilepsy.

METHODS

This survey was a cross-sectional study of patients with PCDH19-related epilepsy open between June 2019 and February 2020 and implemented in collaboration with international patient advocacy groups. Caregivers or patients were asked to fill out an anonymous questionnaire of clinical data about the attempts of ASM reduction.

RESULTS

The survey received 42 unique responses with collected data of 77 attempts of ASM withdrawal. Median age at the ASM reduction was 10 years and mean duration of the previous seizure-free period was 35.8 months. Overall, 88.3 % had seizure recurrence (p < 0.001). After seizure recurrence, the medication had to be increased above the previous ASM dose in 36.5 % and come back to the previous one in 25.4 % cases. 5.2 % did not become seizure-free again. Only 2.6 % cases had their ASM totally withdrawn. Patients without seizure recurrence were significantly older and showed longer seizure-free period (p < 0.001).

CONCLUSION

This pilot study in PCDH19-related epilepsy shows that the withdrawal of ASM seems to be associated with a high risk of seizure recurrence. Despite this novel methodology is useful for rare diseases, it has some limitations and biases. Additional studies are warranted in more extensive samples.

Uncertainties from a worldwide survey on antiepileptic drug withdrawal after seizure remission

Background

We sought to determine differences in practice for discontinuation of antiepileptic drugs (AEDs) after seizure remission and stimulate the planning and conduction of withdrawal trials.

Methods

We utilized a worldwide electronic survey that included questions about AED discontinuation for 3 paradigmatic cases in remission: (1) focal epilepsy of unknown etiology, (2) temporal lobe epilepsy after surgery, and (3) juvenile myoclonic epilepsy. We analyzed 466 complete questionnaires from 53 countries, including the United States. Statistical analysis included χ² and multivariate logistic regression.

Results

Case 1: responders in practice for <10 years were less likely to taper AEDs: odds ratio (OR) (95% confidence interval [CI]) 0.52 (0.32-0.85), p = 0.02. The likelihood of stopping AEDs was higher among doctors treating children: OR (95% CI): 11.41 (2.51-40.13), p = 0.002. Doctors treating children were also more likely to stop after 2 years or less of remission: OR (95% CI): 6.91 (2.62-19.31), p = 0.002, and the same was observed for US physicians: OR (95% CI): 1.61 (1.01-2.57), p = 0.0049. Case 2: responders treating children were more likely to taper after 1 year or less of postoperative remission, with the goal of discontinuing all medications: OR (95% CI): 1.91 (1.09-3.12), p = 0.015, and so were US-based responders: OR (95% CI): 1.73 (1.21-2.41), p = 0.003. Case 3: epileptologists were less likely to withdraw the medication: OR (95% CI): 0.56 (0.39-0.82), p = 0.003, and so were those in practice for 10 or more years: OR (95% CI): 0.54 (0.31-0.95), p = 0.025.

Conclusions

We observed several differences in practice for AED withdrawal after seizure remission that highlight global uncertainty. Trials of AED discontinuation are needed to provide evidence-based guidance.