Stopping antiepileptic drugs in seizure-free patients

Based on the available evidence, we aim to balance risks and benefits of antiepileptic drug (AED) withdrawal in medically and surgically treated adults and children who achieved remission. We summarize risks and predictors of seizure relapse after AED withdrawal and chances of not regaining seizure freedom. Finally, we discuss how AED discontinuation can inform us on the natural course of the epileptic disorder.

In medically treated patients, the risk of recurrence after AED withdrawal is increased until 2 years after withdrawal, although long-term seizure outcomes seem to be unaffected by drug policies. Most relapses occur during the first year after withdrawal. Several predictors of postwithdrawal relapse have been identified. The risk of developing uncontrollable epilepsy following withdrawal is less than one in five. Whether AED withdrawal after epilepsy surgery contributes to seizure outcome has never been studied in a randomized controlled manner. Recent studies suggested that AED reduction merely unmasks incomplete surgical success. The risk of not regaining seizure freedom after postoperative relapse is around 30% and probably not affected by AED reduction. Timing of AED discontinuation does not influence eventual seizure outcomes.

There is no proof that AED withdrawal itself negatively affects long-term seizure outcomes in patients who became seizure-free under AED treatment or after epilepsy surgery. AED discontinuation unveils the natural history of the epilepsy in medically treated patients, and the completeness of resection of the epileptogenic network in patients who underwent epilepsy surgery.