Guidelines & Consensus 14 Recommendations for Discontinuation of Antiepileptic Drugs in Seizure-Free Epilepsy Patients (AAN Guideline Recommendations)

In December 2021, the American Academy of Neurology (AAN) updated guidelines
for discontinuing antiepileptic drugs in patients without seizures .

Seizure-free for 2-5 years while taking ASM (average 3.

Normal neurological examination results/normal IQ

Normal EEG while taking ASM

The guidelines put forward 14 recommendations for the discontinuation of ASM in epilepsy patients without seizures, which are organized as follows:

Advice for adults

Recommendation 1a

For adults who have been seizure-free for at least 2 years, clinicians and patients or caregivers should discuss the risks and benefits of ASM discontinuation, including: Patients who discontinue ASM may have a higher rate of seizure recurrence; Seizures recur after stopping the drug, and they are less likely to no longer respond to the drug (Grade B)

Proposed Statement 1b

When discussing with patients the discontinuation or continuation of ASM use , clinicians may consider the patient's individual characteristics and preferences as there is no statistically

Proposed Statement 1c

Consultation must include discussion, there is no strong evidence of an association between ASM discontinuation and changes in mortality and status epilepticus risk, and therefore, these risks are not ruled out by the evidence (level A)

Recommendation Statement 1d

Although available data do not suggest an increased risk of status epilepticus or death after ASM discontinuation, clinicians should advise that recurrent seizures place patients at risk for status epilepticus and death (Grade B)

Proposed Statement 1e

Clinicians must explore factors affecting individual patient quality of life as part of shared decision-making regarding ASM discontinuation (Level A)

Statement of recommendation 1f

Clinicians should discuss with seizure-free patients, and it is unclear whether EEG or imaging should decide to discontinue ASM (Grade B)

Proposed Statement 2

Clinicians may discuss that the risk of seizure recurrence after discontinuation of ASM in patients undergoing epilepsy surgery without seizures is uncertain due to lack of evidence (Grade C)

Advice related to children

Proposed Statement 3a

For children who are at least 18 to 24 months without seizures, in the absence of other suggestive electroclinical syndromes, the risks and benefits of ASM discontinuation should be discussed, including and documented if seizures recur during or after discontinuation, They are less likely to no longer respond to the drug (Grade B)

Proposed Statement 3b

Clinicians should discuss with children and their families that discontinuation of ASM may be considered, as discontinuation of ASM does not significantly increase the risk of seizure recurrence (Grade B)

Proposed Statement 3c

Although available data do not suggest an increased risk of status epilepticus or death after ASM discontinuation, clinicians should inform families that recurrent seizures put children at risk for status epilepticus and death (Grade B)

Recommendation statement 3d

Clinicians should explore factors affecting individual patient quality of life as part of a shared decision to discontinue ASM (Level B)

Proposed Statement 3e

For children who have not been seizure-free for at least 18 to 24 months, EEG should be performed if the physician, patient, and family agree to consider discontinuation of ASM (Grade B)

Recommendation Statement 3f

For children who are at least 18 to 24 months without seizures, ASM should be discontinued at a rate of no more than 25% every 10 to 14 days if the physician, patient, and family are unanimously considering discontinuation of ASM and EEG does not show epileptiform activity ASM (Class B)

Recommendation Statement 3g

Clinicians must consider the known natural history of a particular electroclinical syndrome [level A (no evidence of low to moderate risk of bias)] when counseling on discontinuation of ASM in children
.