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Brigo F, Zelano J, Abraira L, Bentes C, Ekdahl CT, Lattanzi S, Ingvar Lossius M, Redfors P, Rouhl RPW, Russo E, Sander JW, Vogrig A, Wickström R. Proceedings of the "International Congress on Structural Epilepsy & Symptomatic Seizures" (STESS, Gothenburg, Sweden, 29-31 March 2023). Epilepsy Behav 2024; 150:109538. [PMID: 38039602 DOI: 10.1016/j.yebeh.2023.109538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy.
| | - Johan Zelano
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, Gothenburg University, Sweden; Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Sweden
| | - Laura Abraira
- Neurology Department, Epilepsy Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Epilepsy Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain; Epilepsy Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Carla Bentes
- Neurophysiological Monitoring Unit - EEG/Sleep Laboratory, Refractory Epilepsy Reference Centre (member of EpiCARE), Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Centro de Estudos Egas Moniz, Faculty of Medicine, Lisbon University, Lisbon, Portugal
| | - Christine T Ekdahl
- Division of Clinical Neurophysiology and Department of Clinical Sciences, Lund University, Sweden; Lund Epilepsy Center, Department of Clinical Sciences, Lund University, Sweden
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Morten Ingvar Lossius
- National Centre for Epilepsy, Division of Clinical Neuroscience, Oslo University Hospital, Member of the ERN EpiCARE, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Petra Redfors
- Department of Neurology, Member of the ERN EpiCARE, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rob P W Rouhl
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands; Academic Centre for Epileptology Kempenhaeghe/MUMC+ Heeze and Maastricht, The Netherlands; School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Emilio Russo
- Science of Health Department, University Magna Grecia of Catanzaro, Italy
| | - Josemir W Sander
- Department of Clinical & Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK; Centre for Epilepsy, Chalfont St Peter, Bucks., SL9 0RJ, United Kingdom; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede 2103 SW, The Netherlands; Neurology Department, West of China Hospital, Sichuan University, Chengdu 610041, China
| | - Alberto Vogrig
- Department of Medicine (DAME), University of Udine, Udine, Italy; Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Ronny Wickström
- Neuropediatric Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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Terman SW, Slinger G, Rheaume CE, Haque AS, Smith SN, van Griethuysen R, van Asch CJJ, Otte WM, Burke JF, Braun KPJ. Antiseizure Medication Withdrawal Practice Patterns: A Survey Among Members of the American Academy of Neurology and EpiCARE. Neurol Clin Pract 2023; 13:e200109. [PMID: 37063781 PMCID: PMC10101711 DOI: 10.1212/cpj.0000000000200109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/10/2022] [Indexed: 01/20/2023]
Abstract
Background and Objectives To describe neurologist practice patterns, challenges, and decision support needs pertaining to withdrawal of antiseizure medications (ASMs) in patients with well-controlled epilepsy. Methods We sent an electronic survey to (1) US and (2) European physician members of the American Academy of Neurology and (3) members of EpiCARE, a European Reference Network for rare and complex epilepsies. Analyses included frequencies and percentages, and we showed distributions through histograms and violin plots. Results We sent the survey to 4,923 individuals; 463 consented, 411 passed eligibility questions, and 287 responded to at least 1 of these questions. Most respondents indicated that they might ever consider ASM withdrawal, with respondents treating mostly children being more likely ever to consider withdrawal (e.g., medical monotherapy: children 96% vs adults 81%; p < 0.05). The most important factors when making decisions included seizure probability (83%), consequences of seizures (73%), and driving (74%). The top challenges when making decisions included unclear seizure probability (81%), inadequate guidelines (50%), and difficulty communicating probabilities (45%). Respondents would consider withdrawal after a median of 2-year seizure freedom, but also responded that they would begin withdrawal on average only when the postwithdrawal seizure relapse risk in the coming 2 years was less than 15%-30%. Wide variation existed in the use of words or numbers in respondents' counsel methods, for example, percentages vs frequencies or probability of seizure freedom vs seizure. The most highly rated point-of-care methods to inform providers of calculated risk were Kaplan-Meier curves and showing percentages only, rather than pictographs or text recommendations alone. Discussion Most surveyed neurologists would consider withdrawing ASMs in seizure-free individuals. Seizure probability was the largest factor driving decisions, yet estimating seizure probabilities was the greatest challenge. Respondents on average indicated that they may withdraw ASM after a minimum seizure-free duration of 2 years, yet also on average were willing to withdraw when seizure risk decreased below 15%-30%, which is lower than most patients' postwithdrawal risk at 2-year seizure freedom and lower than the equivalent even of a first seizure of life. These findings will inform future efforts at developing decision support tools aimed at optimizing ASM withdrawal decisions.
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Affiliation(s)
- Samuel W Terman
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - Geertruida Slinger
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - Carol E Rheaume
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - Anisa S Haque
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - Shawna N Smith
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - Renate van Griethuysen
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - Charlotte J J van Asch
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - Willem M Otte
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - James F Burke
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
| | - Kees P J Braun
- Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB)
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Terman SW, Slinger G, Koek A, Skvarce J, Springer MV, Ziobro JM, Burke JF, Otte WM, Thijs RD, Braun KPJ. Frequency of and factors associated with antiseizure medication discontinuation discussions and decisions in patients with epilepsy: A multicenter retrospective chart review. Epilepsia Open 2023. [PMID: 36693718 DOI: 10.1002/epi4.12695] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE Guidelines suggest considering antiseizure medication (ASM) discontinuation in patients with epilepsy who become seizure-free. Little is known about how discontinuation decisions are being made in practice. We measured the frequency of, and factors associated with, discussions and decisions surrounding ASM discontinuation. METHODS We performed a multicenter retrospective cohort study at the University of Michigan (UM) and two Dutch centers: Wilhelmina Children's Hospital (WCH) and Stichting Epilepsie Instellingen Nederland (SEIN). We screened all children and adults with outpatient epilepsy visits in January 2015 and included those with at least one visit during the subsequent 2 years where they were seizure-free for at least one year. We recorded whether charts documented (1) a discussion with the patient about possible ASM discontinuation and (2) any planned attempt to discontinue at least one ASM. We conducted multilevel logistic regressions to determine factors associated with each outcome. RESULTS We included 1058 visits from 463 patients. Of all patients who were seizure-free at least one year, 248/463 (53%) had documentation of any discussion and 98/463 (21%) planned to discontinue at least one ASM. Corresponding frequencies for patients who were seizure-free at least 2 years were 184/285 (65%) and 74/285 (26%). The probability of discussing or discontinuing increased with longer duration of seizure freedom. Still, even for patients who were 10 years seizure-free, our models predicated that in only 49% of visits was a discontinuation discussion documented, and in only 16% of visits was it decided to discontinue all ASMs. Provider-to-provider variation explained 18% of variation in whether patients discontinued any ASM. SIGNIFICANCE Only approximately half of patients with prolonged seizure freedom had a documented discussion about ASM discontinuation. Discontinuation was fairly rare even among low-risk patients. Future work should further explore barriers to and facilitators of counseling and discontinuation attempts.
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Affiliation(s)
- Samuel W Terman
- University of Michigan Department of Neurology, Ann Arbor, Michigan, USA
| | - Geertruida Slinger
- Department of Child Neurology, UMC Utrecht Brain Center, Wilhelmina Children's Hospital, member of ERN EpiCare, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Adriana Koek
- University of Michigan Department of Neurology, Ann Arbor, Michigan, USA
| | - Jeremy Skvarce
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Julie M Ziobro
- University of Michigan Department of Pediatrics, Ann Arbor, Michigan, USA
| | - James F Burke
- Ohio State University Department of Neurology, Columbus, Ohio, USA
| | - Willem M Otte
- Department of Child Neurology, UMC Utrecht Brain Center, Wilhelmina Children's Hospital, member of ERN EpiCare, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands.,Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.,Queen Square Institute of Neurology, University College London, London, UK
| | - Kees P J Braun
- Department of Child Neurology, UMC Utrecht Brain Center, Wilhelmina Children's Hospital, member of ERN EpiCare, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
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Terman SW, Niznik JD, Slinger G, Otte WM, Braun KPJ, Aubert CE, Kerr WT, Boyd CM, Burke JF. Incidence of and predictors for antiseizure medication gaps in Medicare beneficiaries with epilepsy: a retrospective cohort study. BMC Neurol 2022; 22:328. [PMID: 36050646 PMCID: PMC9434838 DOI: 10.1186/s12883-022-02852-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/25/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND For the two-thirds of patients with epilepsy who achieve seizure remission on antiseizure medications (ASMs), patients and clinicians must weigh the pros and cons of long-term ASM treatment. However, little work has evaluated how often ASM discontinuation occurs in practice. We describe the incidence of and predictors for sustained ASM fill gaps to measure discontinuation in individuals potentially eligible for ASM withdrawal. METHODS This was a retrospective cohort of Medicare beneficiaries. We included patients with epilepsy by requiring International Classification of Diseases codes for epilepsy/convulsions plus at least one ASM prescription each year 2014-2016, and no acute visit for epilepsy 2014-2015 (i.e., potentially eligible for ASM discontinuation). The main outcome was the first day of a gap in ASM supply (30, 90, 180, or 360 days with no pills) in 2016-2018. We displayed cumulative incidence functions and identified predictors using Cox regressions. RESULTS Among 21,819 beneficiaries, 5191 (24%) had a 30-day gap, 1753 (8%) had a 90-day gap, 803 (4%) had a 180-day gap, and 381 (2%) had a 360-day gap. Predictors increasing the chance of a 180-day gap included number of unique medications in 2015 (hazard ratio [HR] 1.03 per medication, 95% confidence interval [CI] 1.01-1.05) and epileptologist prescribing physician (≥25% of that physician's visits for epilepsy; HR 2.37, 95% CI 1.39-4.03). Predictors decreasing the chance of a 180-day gap included Medicaid dual eligibility (HR 0.75, 95% CI 0.60-0.95), number of unique ASMs in 2015 (e.g., 2 versus 1: HR 0.37, 95% CI 0.30-0.45), and greater baseline adherence (> 80% versus ≤80% of days in 2015 with ASM pill supply: HR 0.38, 95% CI 0.32-0.44). CONCLUSIONS Sustained ASM gaps were rarer than current guidelines may suggest. Future work should further explore barriers and enablers of ASM discontinuation to understand the optimal discontinuation rate.
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Affiliation(s)
- Samuel W. Terman
- grid.214458.e0000000086837370Department of Neurology, University of Michigan, Ann Arbor, MI 48109 USA
| | - Joshua D. Niznik
- grid.10698.360000000122483208Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, Chapel Hill, NC 27599 USA ,grid.10698.360000000122483208Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina At Chapel Hill, Chapel Hill, NC 27599 USA
| | - Geertruida Slinger
- grid.5477.10000000120346234Department of Child Neurology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Willem M. Otte
- grid.5477.10000000120346234Department of Child Neurology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kees P. J. Braun
- grid.5477.10000000120346234Department of Child Neurology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Carole E. Aubert
- grid.5734.50000 0001 0726 5157Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland ,grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Wesley T. Kerr
- grid.214458.e0000000086837370Department of Neurology, University of Michigan, Ann Arbor, MI 48109 USA
| | - Cynthia M. Boyd
- grid.21107.350000 0001 2171 9311Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD 21224 USA
| | - James F. Burke
- grid.261331.40000 0001 2285 7943Department of Neurology, the Ohio State University, Columbus, OH 43210 USA
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