Perspective| Volume 142, 109205, May 2023

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Should antiseizure medications be withdrawn after an extended period of seizure freedom in individuals with adult-onset epilepsy?


      • Withdrawing ASMs in patients who experienced prolonged seizure freedom could bring benefits, but also carries significant risks.
      • No strong predictors of relapse following ASM discontinuation are available for most individuals with adult-onset epilepsy.
      • In some individuals whose seizures relapsed after ASM withdrawal, re-institution of ASMs may not lead to rapid restoration of seizure control.
      • Individuals with epilepsy should be informed about the potential benefits and risks of withdrawing ASMs.


      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.


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