Should antiseizure medications be withdrawn after an extended period of seizure freedom in individuals with adult-onset epilepsy?

Unlike several epilepsies with onset in pediatric age, adult-onset epilepsies do not typically have a time course that is predictably self-remitting in the large majority of people. Still, about one-half of individuals with adult-onset epilepsy who have been seizure-free for an extended period (two years or longer) on antiseizure medications (ASMs) will remain in remission when their drug therapy is discontinued. Although a number of predictors of outcome have been identified (including specific adult-onset syndromes associated with a low probability of spontaneous remission), in most cases, the only way to establish whether the epilepsy has remitted in a given individual is to gradually withdraw ASMs. ASM withdrawal can be beneficial, particularly when the currently used treatment is not well tolerated, or could lead to adverse outcomes in the future (i.e., teratogenic effects should pregnancy occur in a female of childbearing potential). However, the risks associated with ASM withdrawal are significant. Relapse of seizures can have major adverse psychosocial consequences and also may carry a risk of morbidity and mortality. Most importantly, evidence suggests that in about 20% of individuals whose seizure relapsed following ASM withdrawal, re-institution of pharmacological therapy may not readily restore seizure control. Ultimately, management decisions should prioritize the preference of the well-informed person with epilepsy. Particularly, when adverse drug effects are a concern, options to be discussed should include not only withdrawal or continuation of the current treatment but also dose reduction or substitution with a different ASM.

Informations de copyright

Copyright © 2023 Elsevier Inc. All rights reserved.

Déclaration de conflit d'intérêts

Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.A.A-P. received honoraria from Cobel Daruo, Ronak, and RaymandRad, royalties from Oxford University Press (book publication), grants from the Iranian National Institute for Medical Research Development, outside the submitted work. E.P. received speaker’s or consultancy fees from Angelini, Eisai, GW Pharma, Janssen, PMI Life Sciences, Sanofi group of companies, Shackelford Pharma, SKB Life Sciences, Sun Pharma, Takeda, UCB Pharma, Xenon Pharma, and Zogenix, outside the submitted work. T.T. reports the following relations to market authorization holders of different antiseizure medications: grants from Eisai, GSK, UCB, Bial, Sanofi, Angelini Pharma, GW Pharma, Teva, Glenmark, EcuPharm, Zentiva, SF Group, and Accord; advisory board honoraria from Angelini Pharma and GW Pharma; and speaker’s honoraria from Eisai, Sanofi, Angelini Pharma, and UCB, outside the submitted work. B.M. has no competing interest to report.