Stopping antiepileptic drugs in seizure-free patients:

Exit Strategy: Balancing the Risks and Rewards of Antiseizure Medication Withdrawal

The majority of people with epilepsy achieves long-term seizure-freedom and may consider withdrawal of their anti-seizure medications (ASMs). Withdrawal of ASMs can yield substantial benefits but may be associated with potential risks. This review critically examines the existing literature on ASM withdrawal, emphasizing evidence-based recommendations, where available. Our focus encompasses deprescribing strategies for individuals who have attained seizure freedom through medical treatment, those who have undergone successful epilepsy surgery, and individuals initiated on ASMs following acute symptomatic seizures. We explore state-of-the-art prognostic models in these scenarios that could guide the decision-making process. The review underscores the importance of a collaborative shared-decision approach between patients, caregivers, and physicians. We describe the subjective and objective factors influencing these decisions and illustrate how trade-offs may be effectively managed in practice.

The differential role of magnetic resonance imaging in predicting surgical outcomes between children versus adults with temporal lobe epilepsy

OBJECTIVE

This study aims to investigate the clinical discrepancies and the different predictors of anterior temporal lobectomy (ATL) in children (<18 years at surgery) and adults (>18 years at surgery) with temporal lobe epilepsy (TLE).

MATERIALS AND METHODS

A total of 262 patients (56 children and 206 adults) with TLE who underwent ATL were included in this study. The clinical variables, including patients' characteristics, preoperative evaluations, pathology, surgical prognosis, and surgical predictors were assessed the discrepancies between TLE children versus adults using univariate and multivariate analyses. Kaplan-Meier survival analysis was used to calculate the probability of seizure freedom and AEDs withdrawal after ATL, and the difference between TLE children and adults was analyzed using the Log-Rank test.

RESULTS

There were significant differences including semiology, magnetic resonance imaging (MRI) examinations, numbers of preoperative AEDs, and pathologies between TLE children and adults (P < 0.05, Q < 0.05). The MRI-detected epileptic focus was the only independent predictor of seizure freedom (P = 0.002, Q = 0.036) in TLE children, and the concordance of MRI-detected focus with video-electroencephalography (video-EEG)-detected epileptic zone was the only variable associated with seizure freedom in TLE adults (OR = 2.686, 95% CI = 1.014-7.115, P = 0.047). The TLE children experienced a higher probability of AEDs withdrawal than adults after surgery (P = 0.005).

SIGNIFICANCE

There were remarkable differences in clinical manifestations, MRI examinations, number of preoperative AEDs, and pathologies between TLE children versus adults. TLE children had a higher possibility of AEDs withdrawal than adults after surgery. The favorable seizure outcome of ATL depended on the early complete resection of MRI-detected epileptogenic focus in TLE children, while the concordance of MRI-detected focus with EEG-detected epileptogenic zone was the only predictor of favorable seizure outcomes in TLE adults.

Risk of seizure relapse and long-term outcomes after discontinuation of antiseizure medication in children with epilepsy

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.

Psychiatric symptoms and comorbidities in patients with drug-resistant epilepsy in presurgical assessment-A prospective explorative single center study

INTRODUCTION

People with epilepsy (PWE) have a higher prevalence of psychiatric disorders. Some individuals with drug-resistant epilepsy might benefit from surgical interventions. The aim of this study was to perform an assessment of psychiatric comorbidities with a follow-up period of 12 months in patients with drug-resistant epilepsy, comparing those who underwent surgery to those who did not.

MATERIAL AND METHODS

We assessed psychiatric comorbidities at baseline, after 4 months and after 12 months. Psychiatric symptoms and diagnoses were assessed using SCID-Interview, Hamilton Rating Scale for Depression, Beck-Depression Inventory, Hamilton Anxiety Rating Scale, Prodromal-Questionnaire and the Global Assessment of Functioning Scale.

RESULTS

Twenty-five patients were included in the study, 12 underwent surgery, 11 were esteemed as being neurologically unqualified for surgery and two refused surgery. Patients in the no-surgery group were significantly older, reported more substance use, had significantly higher levels of anxiety and were more often diagnosed with a personality disorder. Age and levels of anxiety were significant predictors of being in the surgery or the no-surgery group. The described differences between surgery and no-surgery patients did not change significantly over the follow-up period.

DISCUSSION

These data point toward a higher expression of baseline psychiatric symptoms in drug-resistant PWE without surgery. Further studies are warranted to further elucidate these findings and to clarify potential psychotropic effects of epilepsy itself, drug-resistant epilepsy and of epilepsy surgery and their impact on psychopathology. Clinically, it seems highly relevant to include psychiatrists in an interdisciplinary state-of-the-art perioperative management of drug-resistant PWE.

Validation of the predictive model for seizure recurrence after withdrawal of antiepileptic drugs

PURPOSE

The purpose of this study was to validate the practicability of Lamberink's prediction model in risk assessment of antiepileptic drug (AED) withdrawal in a real, seizure-free population and to find a practical cutoff value to guide clinical withdrawal.

METHODS

A group of seizure-free patients from West China Hospital was recruited. Each patient had been seizure-free for at least two years. The seizure recurrence risk among the patients was calculated by an online AED withdrawal risk calculator. The predictive ability of Lamberink's model was assessed by analyzing discrimination and calibration with receiver operating characteristic (ROC) curves and calibration plots, respectively.

RESULTS

A total of 184 seizure-free patients received risk evaluation, all of whom were followed up for at least two years or had an earlier report of seizure relapse. Of these patients, 128 patients were followed up for at least five years or had an earlier report of relapse within five years. Sixty-two of 184 (33.7%) patients relapsed within two years, while 81 of 184 (44.0%) patients relapsed within five years after the start of AEDs' withdrawal. Cox regression analyses showed that seizure duration before remission and the age of seizure onset were independent predictors of relapse at two years. For predictors of recurrence at five years, seizure duration before remission, age at onset, and withdrawal were significant. For discrimination, ROC curve analysis showed that the area under the curve (AUC) for the seizure recurrence within two and five years was 0.605 (95% confidence interval [CI]: 0.518-0.692, p = 0.02) and 0.656 (95% CI: 0.563-0.749, p = 0.003), respectively. For calibration, it was poor in two-year prediction; the observed number was considerably lower than the predicted number. However, the calibration plot showed good calibration with the five-year prediction except for the second, fourth, and eighth deciles. With a cutoff two-year recurrence risk of 47%, the model had a sensitivity of 0.758 and a specificity of 0.410; the largest Youden index was 1.168. With a cutoff five-year recurrence risk of 77%, the model had a sensitivity of 0.358 and a specificity of 0.979; the largest Youden index was 1.337.

CONCLUSIONS

Lamberink's prediction model has a general discrimination ability. The model overestimated the actual recurrence events when predicting the two-year recurrence risk, but it showed relatively good calibration with five-year prediction. The cutoff value found in this study may be used to guide patients and clinicians towards a decision regarding the withdrawal of AEDs. The model appears to be a useful tool for predicting seizure recurrence for the five-year recurrence risk.

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.

Cost-effectiveness of surgery for drug-resistant temporal lobe epilepsy in the US

OBJECTIVE

Surgery is an effective but costly treatment for many patients with drug-resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, surgery is cost-effective compared to medical management for patients deemed surgical candidates and whether surgical evaluation is cost-effective for patients with DR-TLE in general.

METHODS

We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use second-order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both health care and societal perspectives, including direct health care costs (e.g., surgery, antiepileptic drugs) and indirect costs (e.g., lost earnings by patients and care providers.) We compare the incremental cost-effectiveness ratio to societal willingness to pay (∼$100,000 per quality-adjusted life-year [QALY]) to determine whether surgery is cost-effective.

RESULTS

Epilepsy surgery is cost-effective compared to medical management in surgically eligible patients by virtue of being cost-saving ($328,000 vs $423,000) and more effective (16.6 vs 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in patients with DR-TLE even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost-effective within 3 years, and 89% of simulations favor surgery over the lifetime horizon.

CONCLUSION

For surgically eligible patients with DR-TLE, surgery is cost-effective. For patients with DR-TLE in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. Patients with DR-TLE should be referred for surgical evaluation without hesitation on cost-effectiveness grounds.

Refining General Principles of Antiepileptic Drug Treatments for Epilepsy

Antiepileptic drugs (AEDs) are the primary treatment strategy for epilepsy. As the use of AEDs has become more widespread and diverse over the past century, it has become necessary to refine the associated prescription strategies. This prompted the Drug Committee of the Korean Epilepsy Society to perform a systemic review of both international and domestic guidelines as well as literature related to medical treatment of epilepsy, and prepared a series of reviews to provide practical guidelines for clinicians to follow. This article is the first in a series on AED treatments for epilepsy in South Korea.

Cognitive performance in distinct groups of children undergoing epilepsy surgery-a single-centre experience

Background

We aimed first to describe trends in cognitive performance over time in a large patient cohort (n = 203) from a single tertiary centre for paediatric epilepsy surgery over the period of 16 years divided in two (developing—pre-2011 vs. established—post-2011). Secondly, we tried to identify subgroups of epilepsy surgery candidates with distinctive epilepsy-related characteristics that associate with their pre- and post-surgical cognitive performance. Thirdly, we analysed variables affecting pre-surgical and post-surgical IQ/DQ and their change (post- vs. pre-surgical).

Methods

We analysed IQ/DQ data obtained using standardized neuropsychological tests before epilepsy surgery and one year post-surgically, along with details of patient’s epilepsy, epilepsy surgery and outcomes in terms of freedom from seizures. Using regression analysis, we described the trend in post-operative IQ/DQ. Cognitive outcomes and the associated epilepsy- and epilepsy surgery-related variables were compared between periods before and after 2011. Using multivariate analysis we analysed the effect of individual variables on pre- and post-operative IQ/DQ and its change.

Results

Epilepsy surgery tends to improve post-surgical IQ/DQ, most significantly in patients with lower pre-surgical IQ/DQ, and post-surgical IQ/DQ strongly correlates with pre-surgical IQ/DQ (Rho = 0.888, p < 0.001). We found no significant difference in pre-, post-surgical IQ/DQ and IQ/DQ change between the periods of pre-2011 and post-2011 (p = 0.7, p = 0.469, p = 0.796, respectively). Patients with temporal or extratemporal epilepsy differed in their pre-surgical IQ/DQ (p = 0.001) and in IQ/DQ change (p = 0.002) from those with hemispheric epilepsy, with no significant difference in post-surgical IQ/DQ (p = 0.888). Groups of patients with different underlying histopathology showed significantly different pre- and post-surgical IQ/DQ (p < 0.001 and p < 0.001 respectively) but not IQ/DQ change (p = 0.345).Variables associated with severe epilepsy showed effect on cognitive performance in multivariate model.

Discussion

Post-surgical IQ/DQ strongly correlates with pre-surgical IQ/DQ and greatest IQ/DQ gain occurs in patients with lower pre-surgical IQ/DQ scores. Cognitive performance was not affected by changes in paediatric epilepsy surgery practice. Pre- and post-operative cognitive performances, as well as patients’ potential for cognitive recovery, are highly dependent on the underlying aetiology and epileptic syndrome.

Determining when to stop antiepileptic drug treatment

PURPOSE OF REVIEW

As the number of patients diagnosed with epilepsy continues to rise and the pharmacological and device-based treatment options for epilepsy increase, determining when to stop antiepileptic drug (AED) treatment continues to be an important issue for patient management and counseling.

RECENT FINDINGS

This review focuses on outcomes following AED withdrawal in seizure-free adults with epilepsy. Practical considerations are also discussed because, despite the importance of this topic, relatively little progress has been made in the past year regarding the identification of patients whose risk for recurrent seizures after AED withdrawal is no higher than that of the general population.

SUMMARY

Although articles in the past year have updated the debates about whether and when to discontinue AEDs in seizure-free adults and have suggested potential utility for electroencephalograms as a prognostic tool for AED reduction as well as for an AED withdrawal risk calculator, decisions about AED withdrawal should still be based on the known risks and consequences of seizure recurrence and be made following well documented discussions between doctor and patient/carer.

Withdrawal of antiepileptic drugs in patients with low grade and anaplastic glioma after long-term seizure freedom: a prospective observational study

Background

When glioma patients experience long-term seizure freedom the question arises whether antiepileptic drugs (AEDs) should be continued. As no prospective studies exist on seizure recurrence in glioma patients after AED withdrawal, we evaluated the decision-making process to withdraw AEDs in glioma patients, and seizure outcome after withdrawal.

Methods

Patients with a histologically confirmed low grade or anaplastic glioma were included. Eligible patients were seizure free ≥ 1 year from the date of last antitumor treatment, or ≥ 2 years since the last seizure when seizures occurred after the end of the last antitumor treatment. Patients and neuro-oncologists made a shared decision on the preferred AED treatment (i.e. AED withdrawal or continuation). Primary outcomes were: (1) outcome of the shared decision-making process and (2) rate of seizure recurrence.

Results

Eighty-three patients fulfilled all eligibility criteria. However, in 12/83 (14%) patients, the neuro-oncologist had serious objections to AED withdrawal. Therefore, 71/83 (86%) patients were analyzed; In 46/71 (65%) patients it was decided to withdraw AED treatment. In the withdrawal group, 26% (12/46) had seizure recurrence during follow-up. Seven of these 12 patients (58%) had tumor progression, of which three within 3 months after seizure recurrence. In the AED continuation group, 8% (2/25) of patients had seizure recurrence of which one had tumor progression.

Conclusion

In 65% of patients a shared decision was made to withdraw AEDs, of which 26% had seizure recurrence. AED withdrawal should only be considered in carefully selected patients with a presumed low risk of tumor progression.

Community perceptions of epilepsy and its treatment in an onchocerciasis endemic region in Ituri, Democratic Republic of Congo

Background

A recent study in the Logo and Rethy health zones in the Ituri Province in the Democratic Republic of Congo (DRC) reported that the majority of the persons with epilepsy (PWE) had not been treated with anti-epileptic medication (AEM) or had stopped treatment. Prior to the implementation of an epilepsy treatment programme in these health zones, this study investigated the perceptions and experiences regarding epilepsy and its treatment amongst community leaders, PWE and/or their families, traditional healers and health professionals.

Methods

A total of 14 focus group discussions (FGD) and 39 semi-structured interviews (SSI) were conducted with PWE and/or their family members, community leaders, traditional healers, and health professionals in the Logo and Rethy health zones during February 2–19, 2017.

Results

In the two health zones, the clinical signs of convulsive epilepsy were recognized by community members. However, a variety of misconceptions about epilepsy were identified including the beliefs that epilepsy is a family-related condition, a contagious disease, is transmitted by insects, saliva or by touching a person of the same sex during seizures, or is caused by evil spirits and witchcraft. The role of traditional healers in spreading these beliefs was revealed. The study also reported sexual abuse on PWE, stigmatisation of PWE and loss of productivity of PWE and their families. Some PWE had been using AEM and traditional treatment but were not convinced about the efficacy of these treatment options. The lack of training of health providers about epilepsy care, financial barriers in obtaining AEM, and the shortage of AEM at primary health facilities were revealed. As remedies, the community requested access to a decentralized center for epilepsy treatment. They also proposed using churches and community health workers as communication channels for information about epilepsy.

Conclusions

Clinical signs of convulsive epilepsy were recognized by the community in the Logo and Rethy health zones but many misconceptions about epilepsy were identified. A comprehensive community-based epilepsy treatment programme with an affordable uninterrupted AEM supply needs to be established. Such a programme should address stigma, misconceptions, sexual abuse and foster the rehabilitation of PWE to alleviate poverty.

Preventing cognitive impairment in children with epilepsy

PURPOSE OF REVIEW

Cognitive impairments are common in children with epilepsy. They may already be present before the onset of epilepsy or occur - and even progress - during its course. Many variables contribute to cognitive dysfunction. Those that can be targeted to prevent (further) cognitive impairment will be highlighted in this review.

RECENT FINDINGS

Ideally, but not yet realistically, epileptogenesis is prevented to avert seizures and cognitive impairments in high-risk patients. New and targeted treatments of progressive epileptogenic disorders and precision medicine approaches in genetic epilepsies are increasingly applied. Cognitive outcome benefits from early diagnosis and treatment of epileptic encephalopathy. Ongoing seizures may cause permanent and progressive changes in brain structure and connectivity, suggesting that early seizure control optimizes eventual cognitive functioning. Frequent interictal epileptiform discharges justify treatment in children with cognitive impairments that are otherwise unexplained. Cognitive adverse effects of antiepileptic drugs should be closely monitored and balanced against potential benefits. Finally, early surgical treatment in selected candidates will improve their cognitive outcome.

SUMMARY

Although important determinants of intellectual functioning - including the child's genetic and environmental background and the epileptogenic pathology - may not be modifiable, several variables that contribute to cognitive impairment can be targeted to improve outcome. Early etiological diagnosis, personalized therapies, presurgical evaluation, and strict control of seizures - or in some patients interictal discharges - can prevent (further) cognitive impairments.

Immunotherapy by targeting of VGKC complex for seizure control and prevention of cognitive impairment in a mouse model of epilepsy

Epilepsy is a type of refractory neurologic disorder mental disease, which is associated with cognitive impairments and memory dysfunction. However, the potential mechanisms of epilepsy are not well understood. Previous evidence has identified the voltage gated potassium channel complex (VGKC) as a target in various cohorts of patients with epilepsy. In the present study, the efficacy of an antibody against VGKC (anti-VGKC) for the treatment of epilepsy in mice was investigated. A mouse model of lithium-pilocarpine temporal lobe epilepsy was established and anti-VGKC treatment was administered for 30 days. Memory impairment, anxiety, visual attention, inhibitory control and neuronal loss were measured in the mouse model of lithium-pilocarpine temporal lobe epilepsy. The results revealed that epileptic mice treated with anti-VGKC were able to learn the task and presented attention impairment, even a tendency toward impulsivity and compulsivity. It was also exhibited that anti-VGKC treatment decreased neuronal loss in structures classically associated with attentional performance in hippocampus. Mice who received Anti-VGKC treatment had inhibited motor seizures and hippocampal damage as compared with control mice. In conclusion, these results indicated that anti-VGKC treatment may present benefits for improvements of the condition of motor attention impairment and cognitive competence, which suggests that VGKC may be a potential target for the treatment of epilepsy.

Remission in epilepsy: How long is enough?

OBJECTIVE

The International League Against Epilepsy (ILAE) has proposed to expand the definition of remission to 10 years seizure-free with the last 5 years off antiepileptic drugs (AEDs). We examined if a 10-year remission is needed to predict the lowest recurrence risk.

METHODS

The population-based study cohort consisted of 148 patients with new-onset childhood epilepsy living in the catchment area of Turku University Hospital. They were prospectively followed for 44 years (median). Patients in first remission were prospectively followed for the duration of remission or possible relapse at 2 years in remission with the last year without antiepileptic drugs (AEDs), at 5 years in remission with the last 2 years without AEDs, and at 10 years with the last 5 years without AEDs. For comparison of the proportions of relapsed patients within each remission category exact Clopper Pearson 95% confidence intervals were used.

RESULTS

The magnitude of the relapse rate estimates off AEDs did not significantly improve when remission increased from 2 years (2YR) to 5 years (5YR) and further to 10 years (10YR). However, 10YR was a more sensitive measure of no relapse than 2YR. Among patients with remission on or off AEDs, the ability to predict lower relapse rate increased markedly from 2 to 5 years, and again from 5 to 10 years. The risk of relapse was virtually the same estimated after 2YR off AEDs as after 10YR on or off AEDs, except for patients with generalized epilepsy whose 2YR off AEDs was a weaker predictor than 10YR on or off AEDs.

SIGNIFICANCE

Given the modest differences in relapse rates between the 5 years seizure-free with last 2 years off medications definition and the 10 years seizure-free with last 5 years off medications, and the adverse impact of not being considered in remission, we propose that a return to the 5-year definition may be warranted.

Prognostic analysis of patients with epilepsy according to time of relapse after withdrawal of antiepileptic drugs following four seizure-free years

OBJECTIVE

We performed a retrospective, prognostic analysis of a cohort of patients with epilepsy according to time of relapse after four seizure-free years.

METHODS

Planned withdrawal of antiepileptic drugs (AEDs) and at least 3 years of follow-up after AED discontinuation were performed. The following two groups were assessed: (1) an early relapse (ER) group of patients who experienced recurrence during AED withdrawal and (2) a late relapse (LR) group of patients who experienced recurrence after completion of the AED discontinuation process. After dichotomization, the relapse rate, prognostic factors, and their impacts for each group were compared with those of a group of patients who continued to be seizure-free after AED withdrawal (SF group) using multiple logistic regression analysis. The AED intake mode was also analyzed.

RESULTS

Two hundred seventeen (64.6%) of the 336 total patients experienced relapse. One hundred thirty-nine patients (41.4%) and 78 patients (23.2%) were included in the LR and ER groups, respectively. Symptom duration >120 months showed the strongest negative prognostic impact as demonstrated by the 4.7-fold higher risk of recurrence in the ER group compared with the SF group. Additional factors with a negative prognostic impact included an age at epilepsy onset of ≤20 years and the presence of localization-related epilepsy. No reliable predictor between the SF and LR groups was revealed. After exclusion of the SF group, post hoc analysis according to age at epilepsy onset and symptom duration showed that the above-mentioned negative prognostic factors significantly affected the relapse patterns of the LR and ER groups.

SIGNIFICANCE

The results suggest that longer symptom duration, which could be associated with intrinsic reactivation of epilepsy, is the strongest negative prognostic factor for relapse. Relapse after AED withdrawal in prolonged follow-up of seizure-free patients is one aspect of the natural history of epilepsy.

The withdrawal of antiepileptic drugs in patients with low-grade and anaplastic glioma

INTRODUCTION

The withdrawal of antiepileptic drugs (AEDs) in World Health Organization (WHO) grade II-III glioma patients with epilepsy is controversial, as the presence of a symptomatic lesion is often related to an increased risk of seizure relapse. However, some glioma patients may achieve long-term seizure freedom after antitumor treatment, raising questions about the necessity to continue AEDs, particularly when patients experience serious drug side effects. Areas covered: In this review, we show the evidence in the literature from 1990-2016 for AED withdrawal in glioma patients. We put this issue into the context of risk factors for developing seizures in glioma, adverse effects of AEDs, seizure outcome after antitumor treatment, and outcome after AED withdrawal in patients with non-brain tumor related epilepsy. Expert commentary: There is currently scarce evidence of the feasibility of AED withdrawal in glioma patients. AED withdrawal could be considered in patients with grade II-III glioma with a favorable prognosis, who have achieved stable disease and long-term seizure freedom. The potential benefits of AED withdrawal need to be carefully weighed against the presumed risk of seizure recurrence in a shared decision-making process by both the clinical physician and the patient.

Antiepileptic drug therapy and recommendations for withdrawal in patients with seizures and epilepsy due to neurocysticercosis

INTRODUCTION

Neurocysticercosis (NCC) is a leading causes of secondary epilepsy worldwide. There is increasing evidence on the epileptogenic role of NCC, and the presence of edema, calcified scars, gliosis and hippocampal sclerosis support this phenomenon.

AREAS COVERED

We summarized principles of antiepileptic drug (AED) therapy as well as risk factors associated with seizure recurrence after AED withdrawal in patients with NCC. Expert commentary: First-line AED monotherapy is effective as a standard approach to control seizures in most NCC patients. Risks and benefits of AED withdrawal have not been systematically studied, and this decision must be individualized. However, a seizure-free period of at least two years seem prudent before attempting withdrawal. Risk factors for seizure recurrence after AED withdrawal include a history of status epilepticus, poor seizure control during treatment, neuroimaging evidence of perilesional gliosis, hippocampal sclerosis and calcified lesions, as well as persistence of paroxysmal activity in the EEG.