Withdrawal of antiepileptic treatment — benefits, risks, expediency and safety

May 21, 2020
732
Specialities :
Resume

Most patients with epilepsy (60–70%), of both childhood and adulthood, can achieve remission of seizures through drug therapy. The subject of discussion for many years is the question of how expedient and safe it can be to stop treatment in a seizure-free patient, under what conditions and in what time frame can be withdrawned anti-epileptic drugs, how quickly doses of drugs should be reduced, what are the risks and benefits of treatment discontinuation, what risk factors exist for relapse of epileptic seizures. An analysis of the available information sources was carried out in order to study the world expertise on this issue. Currently, there is no generally accepted timeline for withdrawal of antiepileptic drugs, as well as clear recommendations for the rate of dose reduction for most anticonvulsants. The article presents the latest literature data on the world expertise of discontinuing antiepileptic therapy in patients of different age groups, with different types of seizures and etiology of epilepsy, describes the main risk factors of treatment withdrawal, options for reducing the dose of antiepileptic drugs, the value of electroencephalography in the process of treatment withdrawal. Own approaches to the discontinuation of antiepileptic therapy are presented.

References:

  • Rohacheva T.A. (2019) Lechenye эpylepsyy. Ynnovatsyonnыe tekhnolohy. MYA, Moskva, 376 s.
  • Armijo J.A., Adín J. (2000) Pharmacological basis for withdrawal of antiepileptic drugs. Rev. Neurol., 30(4): 336–350.
  • Arts W.F., Geerts A.T., Brouwer O.F. et al. (2019) Childhood epilepsy with a small number of seizures may be left untreated: an international prospective study. Epileptic Disord., 21(2): 141–153. doi: 10.1684/epd.2019.1040.
  • Ayuga Loro F., Gisbert Tijeras E., Brigo F. (2020) Rapid versus slow withdrawal of antiepileptic drugs. Cochrane Database Syst. Rev., 1: CD005003. doi: 10.1002/14651858.CD005003.pub3.
  • Bartolini L. (2016) Practice Current: When do you stop antiepileptic drugs in patients with genetic generalized epilepsies and in those with focal epilepsies? Neurol. Clin. Pract., 6: 530–537. doi: 10.1212/CPJ.0000000000000326.
  • Bartolini L., Majidi S., Koubeissi M.Z. (2018) Uncertainties from a worldwide survey on antiepileptic drug withdrawal after seizure remission. Neurol. Clin. Pract., 2: 108–115. doi: 10.1212/CPJ.0000000000000441.
  • Beghi E., Giussani G., Grosso S. et al. (2013) Withdrawal of antiepileptic drugs: guidelines of the Italian League Against Epilepsy. Epilepsia, 54(Suppl. 7): 2–12. doi: 10.1111/epi.12305.
  • Beghi E., Giussani G., Sander J.W. (2015) The natural history and prognosis of epilepsy. Epileptic Disord., 17(3): 243–253. doi: 10.1684/epd.2015.0751.
  • Benzodiazepine withdrawal Protocol (2012) UK Council for Information on Tranquillisers, Antidepressants and Painkillers (http://www.citap.org.uk/Benzodiazepine-Protocol.pdf).
  • Braun K.P., Schmidt D. (2014) Stopping antiepileptic drugs in seizure-free patients. Curr. Opin. Neurol., 27(2): 219–226. doi: 10.1097/WCO.0000000000000075.
  • Brorson L.O., Eriksson M., Blomberg K., Stenninger E. (2019) Fifty years’ follow-up of childhood epilepsy: Medical outcome, morbidity, and medication. Epilepsia, 60(3): 381–392. doi: 10.1111/epi.14643.
  • Camfield C., Camfield P. (2005) Management guidelines for children with idiopathic generalized epilepsy. Epilepsia, 46(Suppl. 9): 112–116.
  • Camfield P., Camfield C. (2008) When is it safe to discontinue AED treatment? Epilepsia, 49 (Suppl. 9): 25–28. doi: 10.1111/j.1528-1167.2008.01923.x.
  • Chen Z., Brodie M.J., Liew D., Kwan P. (2018) Treatment Outcomes in Patients With Newly Diagnosed Epilepsy Treated With Established and New Antiepileptic Drugs: A 30-Year Longitudinal Cohort Study. JAMA Neurol., 75: 279–286.
  • Cvetkovska E., Babunovska M., Kuzmanovski I. et al. (2020) Patients’ attitude toward AED withdrawal: A survey among individuals who had been seizure-free for over 2 years. Epilepsy Behav., 104(Pt A): 106881. doi: 10.1016/j.yebeh.2019.106881.
  • Fisher R.S., Acevedo C., Arzimanoglou A. et al. (2014) ILAE official report: a practical clinical definition of epilepsy. Epilepsia, 55(4): 475–482. doi:10.1111/epi.12550.
  • Foged M.T., Stefánsdóttir A., Brændgaard M. et al. (2019) Why are antiepileptic drugs continued after successful epilepsy surgery in adults? Epilepsy Behav., 100(Pt A): 106452. doi: 10.1016/j.yebeh.2019.106452.
  • Gebremariam A., Mengesha W., Enqusilassie F. (1999) Discontinuing anti-epileptic medication(s) in epileptic children: 18 versus 24 months. Ann. Trop. Paediatr., 19(1): 93–99.
  • Geerts A., Brouwer O., Stroink H. et al. (2012) Onset of intractability and its course over time: the Dutch study of epilepsy in childhood. Epilepsia, 53(4): 741–751. doi: 10.1111/j.1528-1167.2012.03429.x.
  • Hartl E., Seethaler M., Lauseker M. et al. (2019) Impact of withdrawal of antiepileptic medication on the duration of focal onset seizures. Seizure, 67: 40–44. doi: 10.1016/j.seizure.2019.03.005.
  • He R.Q., Zeng Q.Y., Zhu P. et al. (2016) Risk of seizure relapse after antiepileptic drug withdrawal in adult patients with focal epilepsy. Epilepsy Behav., 64(Pt A): 233–238. doi: 10.1016/j.yebeh.2016.08.006.
  • Karalok Z.S., Guven A., Öztürk Z., Gurkas E. (2020) Risk factors for recurrence after drug withdrawal in childhood epilepsy. Brain Dev., 42(1): 35–40. doi: 10.1016/j.braindev.2019.08.012.
  • Lamberink H.J., Otte W.M., Geerts A.T. et al. (2017) Individualised prediction model of seizure recurrence and long-term outcomes after withdrawal of antiepileptic drugs in seizure-free patients: a systematic review and individual participant data meta-analysis. Lancet Neurol., 16(7): 523–531. doi: 10.1016/S1474-4422(17)30114-X.
  • Lossius M.I., Alfstad K.A., Aaberg K.M., Nakken K.O. (2017) Discontinuation of antiepileptic drugs in seizure-free patients — when and how? Tidsskr Nor Laegeforen, 137(6): 451–454. doi: 10.4045/tidsskr.16.0957.
  • Lossius M.I., Hessen E., Mowinckel P. et al. (2008) Consequences of antiepileptic drug withdrawal: a randomized, double-blind study (Akershus Study). Epilepsia, 49(3): 455–463.
  • Park S., Lee D.H., Kim S.W., Roh Y.H. (2017) Prognostic analysis of patients with epilepsy according to time of relapse after withdrawal of antiepileptic drugs following four seizure-free years. Epilepsia, 58(1): 60–67. doi: 10.1111/epi.13624.
  • Pavlović M., Jović N., Pekmezović T. (2011) Antiepileptic drugs withdrawal in patients with idiopathic generalized epilepsy. Seizure, 20(7): 520–525. doi: 10.1016/j.seizure.2011.03.007.
  • Pavlović M., Jović N., Pekmezović T. (2012) Withdrawal of antiepileptic drugs in young patients with cryptogenic focal epilepsies. Seizure, 21(6): 431–436. doi: 10.1016/j.seizure.2012.04.008.
  • Ranganathan L.N., Ramaratnam S. (2006) Rapid versus slow withdrawal of antiepileptic drugs. Cochrane Database Syst. Rev., 2: CD005003.
  • Rubboli G., Sabers A., Uldall P., Malmgren K. (2017) Management of Antiepileptic Treatment After Epilepsy Surgery — Practices and Problems. Curr. Pharm. Des., 23(37): 5749–5759. doi: 10.2174/1381612823666170823111712.
  • Sander J.W.A.S., Sillanpää M. (1997) Natural history prognosis. In: J. Engels, T.A. Pedley (Eds). Epilepsy. A comprehensive textbook, vol. I/III. Raven Press, New York, p. 69–86.
  • Schmidt D., Sillanpää M. (2017) Stopping epilepsy treatment in seizure remission: Good or bad or both? Seizure, 44: 157–161. doi: 10.1016/j.seizure.2016.09.003.
  • Seneviratne U., Boston R.C., Cook M., D’Souza W. (2017) EEG correlates of seizure freedom in genetic generalized epilepsies. Neurol. Clin. Pract., 7(1): 35–44. doi: 10.1212/CPJ.0000000000000323.
  • Serra J.G., Montenegro M.A., Guerreiro M.M. (2005) Antiepileptic drug withdrawal in childhood: does the duration of tapering off matter for seizure recurrence? J. Child. Neurol., 20(7): 624–626.
  • Sethi N.K. (2018) Reader Response: Uncertainties from a worldwide survey on antiepileptic drug withdrawal after seizure remission. Neurology. Clinical practice, 8(4): 277. doi:10.1212/CPJ.0000000000000499.
  • Specchio L.M., Beghi E. (2004) Should antiepileptic drugs be withdrawn in seizure-free patients? CNS Drugs, 18(4): 201–212.
  • Strozzi I., Nolan S.J., Sperling M.R. et al. (2015) Early versus late antiepileptic drug withdrawal for people with epilepsy in remission. Cochrane Database Syst. Rev., CD001902. doi: 10.1002/14651858.CD001902.pub2.
  • Syvertsen M., Fløgstad I., Enger U. et al. (2019) Antiepileptic drug withdrawal in juvenile myoclonic epilepsy. Acta Neurol. Scand., 139(2): 192–198. doi: 10.1111/ane.13042.
  • Su L., Di Q., Yu N., Zhang Y. (2013) Predictors for relapse after antiepileptic drug withdrawal in seizure-free patients with epilepsy. J. Clin. Neurosci., 20(6): 790–794. doi: 10.1016/j.jocn.2012.07.010.
  • Tang L., Xiao Z. (2017) Can Electroencephalograms Provide Guidance for the Withdrawal of Antiepileptic Drugs: A Meta-Analysis. Clin. Neurophysiol., 128: 297–302. doi: 10.1016/j.clinph.2016.11.024.
  • Tennison M., Greenwood R., Lewis D., Thorn M. (1994) Discontinuing antiepileptic drugs in children with epilepsy. A comparison of a six-week and a nine-month taper period. N. Engl. J. Med., 330(20): 1407–1410.
  • Vorderwülbecke B.J., Kirschbaum A., Merkle H. et al. (2019) Discontinuing antiepileptic drugs in long-standing idiopathic generalised epilepsy. J. Neurol., 266(10): 2554–2559. doi: 10.1007/s00415-019-09457-z.
  • Wang X., He R., Zheng R. et al. (2019) Relative Seizure Relapse Risks Associated with Antiepileptic Drug Withdrawal After Different Seizure-Free Periods in Adults with Focal Epilepsy: A Prospective, Controlled Follow-Up Study. CNS Drugs, 33(11): 1121–1132. doi: 10.1007/s40263-019-00679-3.
  • Wang J., Huang P., Song Z. (2019) Comparison of the relapse rates in seizure-free patients in whom antiepileptic therapy was discontinued and those in whom the therapy was continued: A meta-analysis. Epilepsy Behav., 101(Pt A): 106577. doi: 10.1016/j.yebeh.2019.106577.
  • Xinghua T., Lin L., Qinyi F. et al. (2020) The clinical value of long — term electroencephalogram (EEG) in seizure — free populations: implications from a cross-sectional study. BMC Neurol., 20(1): 88. doi:10.1186/s12883-019-1521-1.
  • Yao J., Wang H., Xiao Z. (2019) Correlation between EEG during AED withdrawal and epilepsy recurrence: a meta-analysis. Neurol Sci., 40(8): 1637–1644. doi: 10.1007/s10072-019-03855-x.
  • Younus I., Reddy D.S. (2018) A resurging boom in new drugs for epilepsy and brain disorders. Expert Rev. Clin. Pharmacol., 11(1): 27–45. doi: 10.1080/17512433.2018.1386553.