Antiseizure Medication Withdrawal Practice Patterns

Abstract

Background and ObjectivesTo describe neurologist practice patterns, challenges, and decision support needs pertaining to withdrawal of antiseizure medications (ASMs) in patients with well-controlled epilepsy.MethodsWe 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.ResultsWe 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.DiscussionMost 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.

Variation in seizure risk increases from antiseizure medication withdrawal among patients with well‐controlled epilepsy: A pooled analysis

“…We recently surveyed American Academy of Neurology Members who indicated that they would tolerate a median (IQR) post-discontinuation risk of 15% (IQR 9%-29%) for convulsive seizures and 24% (IQR 11%-35%) for nonconvulsive seizures in adults. 34 In our sample, only 18% had a post-discontinuation risk per the base model below 24%. Still, epilepsy is diagnosed when 10-year seizure risk rises to at least 60%.…”

“…Risk is never zero, regardless of whether the patient is treated, it is always possible that a patient may have difficulty regaining seizure control after a relapse, and all patients and clinicians will have a different level of risk tolerance. We recently surveyed American Academy of Neurology Members who indicated that they would tolerate a median (IQR) post‐discontinuation risk of 15% (IQR 9%–29%) for convulsive seizures and 24% (IQR 11%–35%) for nonconvulsive seizures in adults 34 . In our sample, only 18% had a post‐discontinuation risk per the base model below 24%.…”