Updated after 25 years, the American Academy of Neurology issued 14 recommendations for discontinuing antiepileptic drugs in epilepsy patients without seizures

Epilepsy is a common brain disorder that accounts for approximately 1% of all disease burdens worldwide
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In the United States alone, an estimated 70,000-200,000 adults experience their first unprovoked seizure each year
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Antiepileptic drugs (ASMs) are prescribed with the aim of making people with epilepsy seizure-free, and when a person with epilepsy becomes seizure-free, the first question that arises is whether and when ASM should be discontinued
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In December 2021, the American Academy of Neurology (AAN) updated its guidelines for discontinuing ASM in patients without seizures, which updated the 1996 AAN practice parameters and recommends that the risk and benefit to patients and society of recurrent seizures be assessed when assessing the risks and benefits of recurrent seizures.
After treatment, discontinuation of ASM may be considered if the patient meets the following characteristics: ➤ Seizure-free for 2-5 years (average 3.
5 years) while taking ASM; ➤ Single type of partial seizures (simple partial or complex partial or secondary Generalized tonic-clonic seizure [GTCS]) or a single type of primary generalized seizure; ➤ normal neurological examination results/normal IQ; ➤ normal EEG during ASM
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The guideline makes 14 recommendations for discontinuing ASM in epilepsy patients without seizures, including adults and children, as follows: Recommendations related to adults Recommendation 1a: For adults who have been seizure-free for at least 2 years, Clinicians and patients should discuss the risks and benefits of discontinuing ASM, including (1) the likelihood of higher seizure recurrence in patients with ASM discontinuation; (2) if seizures recur during or after discontinuation, they will no longer Less likely to react to the drug (Grade B)
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 Recommendation 1b: When discussing ASM discontinuation or continuation with patients, clinicians may consider individual patient characteristics and preferences as there is no statistically significant evidence to support either option (Level C)
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 Recommendation 1c: Consultation must include discussion, there is no strong evidence of an association between ASM discontinuation and changes in risk of mortality and status epilepticus, therefore, these risks are not ruled out by the evidence (Level A)
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 Recommendation 1d: Clinicians should be informed that recurrent seizures place patients at risk for status epilepticus and death (Level B), although available data do not suggest an increased risk of status epilepticus or death after ASM discontinuation
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 Recommendation 1e: Clinicians must explore factors affecting individual patient quality of life as part of shared decision-making on ASM discontinuation (Level A)
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 Recommendation 1f: Clinicians should discuss with seizure-free patients, it is unknown whether EEG or imaging studies will inform the decision to discontinue ASM (Grade B)
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 Recommendation 2: Clinicians may discuss that the risk of seizure recurrence after ASM discontinuation in patients who have undergone epilepsy surgery and are seizure-free is uncertain due to lack of evidence (Grade C)
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 Recommendations Relevant to Children Recommendation 3a: For children who are at least 18-24 months without seizures, the risks and benefits of ASM discontinuation should be discussed in the absence of other electroclinical syndromes, including Seizures recur during or after drug withdrawal, and they are less likely to no longer respond to the drug (Grade B)
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 Recommendation 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)
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 Recommendation 3c: Clinicians should be informed that recurrent seizures put children at risk for status epilepticus and death (Level B), although available data do not suggest an increased risk of status epilepticus or death after ASM discontinuation
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 Recommendation 3d: Clinicians should explore factors affecting individual patient quality of life as part of a shared decision to discontinue ASM (Level B)
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 Recommendation 3e: For children who are at least 18-24 months without seizures, EEG should be performed if physician, patient, and family agree to consider discontinuation of ASM (Grade B)
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 Recommendation 3f: For children who are seizure-free for at least 18-24 months, physicians, patients, and families agree that discontinuation of ASM should be considered, and if EEG does not show epileptiform activity, it should be administered no more than every 10-14 days for 25 % speed to deactivate ASM (Class B)
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 Recommendation 3g: Clinicians must consider the known natural history of specific electroclinical syndromes (level A [no evidence of low to moderate risk of bias]) when counseling children with ASM discontinuation
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 Compiled from: Gloss, D.
, et al.
, Antiseizure Medication Withdrawal in Seizure-Free Patients: Practice Advisory Update Summary.
Neurology, 2021.
97(23): p.
1072-1081.