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Withdrawal of antiepileptic medication in children--effects on cognitive function: The Multicenter Holmfrid Study
A P Aldenkamp1, W C Alpherts, G Blennow
1Department of Neuropsychology, Instituut voor Epilepsiebestrijding, Heemstede, The Netherlands.
Insights
Discontinuing antiepileptic drugs (AEDs) in seizure-free children with epilepsy showed limited impact on higher-order cognitive functions. However, psychomotor speed improved, and baseline cognitive differences between epilepsy patients and controls persisted after drug withdrawal.
Area of Science:
- Neuroscience
- Pediatric Neurology
- Clinical Psychology
Background:
- Epilepsy is a common neurological disorder in children.
- Antiepileptic drugs (AEDs) are standard treatment but may have cognitive side effects.
- Understanding the long-term cognitive impact of AEDs and the potential for recovery is crucial.
Purpose of the Study:
- To evaluate the cognitive effects of antiepileptic drug (AED) withdrawal in children with epilepsy.
- To assess changes in neuropsychological function after complete AED cessation.
- To compare cognitive performance between children with epilepsy and healthy controls post-withdrawal.
Main Methods:
- 100 children with epilepsy, seizure-free for over a year on monotherapy, were studied.
- Neuropsychological testing and EEG were conducted before and after a 3-month individualized AED withdrawal period.
- 83 children completed the study, treated with carbamazepine, valproic acid, or phenytoin; serum concentrations were monitored.
Main Results:
- Significant improvement was observed in psychomotor speed after AED withdrawal.
- No significant changes were found in higher-order cognitive functions (information processing, memory).
- Baseline cognitive differences between the epilepsy group and controls persisted post-withdrawal; absence seizure history and specific AEDs (phenytoin) were associated with poorer outcomes.
Conclusions:
- AED treatment appears to have a limited impact on higher-order cognitive functions in children with epilepsy.
- Withdrawal of AEDs may improve psychomotor speed, suggesting potential reversibility of some drug-induced effects.
- Persistent cognitive differences in epilepsy patients highlight the need for individualized assessment and management, considering seizure history and medication type.
Abstract:
We present 100 children diagnosed with epilepsy who were seizure-free for more than 1 year and still on monotherapy of antiepileptic drugs (AEDs). We matched each child with a healthy classmate and performed neuropsychological testing and EEG before and after complete withdrawal of the AEDs. The withdrawal phase lasted 3 months, but the dose decrease was individualized for each patient. Three to 4 months after complete withdrawal of the drug all patients were reassessed. Patients with seizure relapse are excluded from the study. Seventeen patients are regarded as dropout, 11 because of seizure relapse and six because of protocol violation. The remaining 83 patients were treated with carbamazepine (n = 56), valproic acid (n = 17), or phenytoin (n = 10). Serum concentrations of the AEDs were measured using peak plasma levels that were taken immediately before or after psychological testing. We used neuropsychological tests to assess psychomotor function and "central" cognitive processing such as information processing or memory function. We found significant improvement attributable to drug withdrawal on only one of the cognitive tests, namely, psychomotor speed, suggesting that the impact of AED treatment on higher-order cognitive function is rather limited. In addition, we found group differences between the epilepsy group and the control group at baseline that persisted after drug withdrawal. Subsequent analysis showed some factors that may have contributed to these group differences. First, patients with a former diagnosis of absence seizures show lower scores both at baseline and after drug withdrawal. We may assume that the seizure propensity has not disappeared completely in these patients. Some evidence is found that phenytoin may have a different cognitive profile than carbamazepine, with more impairment on tests that measure motor and mental speed. Again, this impairment persists after drug withdrawal.