Challenges in antiseizure medication discontinuation decisions: A qualitative study of clinicians who see patients...

Antiseizure medication (ASM) withdrawal can be considered after a period of seizure-freedom for patients with epilepsy. We interviewed clinicians who treat patients with epilepsy about challenges and existing information gaps regarding ASM withdrawal decisions.

We conducted six focus groups of 3-5 clinicians each (N = 25). We used purposive sampling to reach key informants with diversity of geography, specialty, and credentialing, focusing on epilepsy specialists who may have the greatest experience with these scenarios but also seeking non-specialist neurology input. We asked respondents to describe their greatest challenges when discussing ASM withdrawal with patients and making treatment decisions. We then performed thematic qualitative analysis.

Twenty (80 %) participants were epileptologists or clinical neurophysiologists, and three (12 %) were physician extenders. Respondents identified many challenges when discussing ASM withdrawal with patients. Estimating an individual patient's seizure risk was one of the greatest challenges, due to heterogeneity in etiologies, electroclinical syndromes, and other patient characteristics. Additional challenges included weighing the net benefit versus harm of ASM discontinuation, dealing with uncertainty even if one could accurately estimate the chance of another seizure, and questions about optimal use of EEG. Respondents also noted challenges when patient preferences are not aligned with physician recommendations and the feeling of personal responsibility should the patient have a seizure after withdrawal.

Many challenges remain in ASM discontinuation decisions after a period of seizure-freedom. Our results encourage future efforts to improve individualized seizure risk prediction and to develop prediction models into seizure risk calculators.