Non-discontinuation of antiseizure medication in seizure-free patients with epilepsy: Reasons and predictors among neurologists and patients

Abstract

Objective: This study was undertaken to investigate clinical and psychosocial factors associated with antiseizure medication (ASM) non-discontinuation in seizure-free patients with epilepsy among both neurologists and patients.

Methods: In this cross-sectional study, neurologists documented their recommendations on ASM discontinuation (comprising both complete discontinuation and ≥25% dose reduction) in patients aged ≥18 years who had been seizure-free for at least 2 years. Based on these recommendations, patients made individual decisions. In both neurologists and patients, reasons for and predictors of ASM non-discontinuation were assessed considering demographic and epilepsy-related variables as well as standardized psychosocial questionnaires.

Results: Among 196 patients (53.1% female, median age = 50 years, interquartile range [IQR] = 36-61; median seizure-free duration = 6 years, IQR = 4-11), neurologists recommended ASM discontinuation in 110 cases (56.1%), of which 29 patients (26.4%) agreed. Neurologists were more likely to favor ASM non-discontinuation if they had fewer years of professional experience (odds ratio [OR] = .96, 95% confidence interval [CI] = .92-.99) and if patients had shorter seizure-free durations (OR = .98, 95% CI = .98-.99). Among patients, longer seizure-free duration (OR = 1.01, 95% CI = 1.01-1.02) and a history of generalized or focal to bilateral tonic-clonic seizures (OR = 2.72, 95% CI = 1.15-6.43) were independently associated with ASM non-discontinuation. Excluding the 27 patients who favored a dose reduction, ASM non-discontinuation was still associated with a longer duration of seizure freedom (OR = 1.02, 95% CI = 1.01-1.03). Further predictors were higher anxiety scores (OR = 1.37, 95% CI = 1.05-1.78) and better ASM tolerability (OR = 1.04, 95% CI = 1.01-1.07).

Significance: Neurologists and, even more so, patients are hesitant to discontinue ASM, which was accomplished in only 15% of seizure-free patients. Duration of seizure freedom has a major impact on the decision but in opposite directions comparing both groups. Understanding these differing perspectives is essential to improve shared decision-making on this complex issue in epilepsy care.

Keywords: drug withdrawal; outcome; pharmacotherapy; seizure freedom; seizure recurrence risk.

FIGURE 1

Stepwise study design and participant flow. Illustration shows the two‐step study design reflecting real‐world clinical decision‐making. First, neurologists assessed whether complete discontinuation of antiseizure medication (ASM) was appropriate. If not, they evaluated whether at least a ≥25% dose reduction was feasible. If the answer was yes for one of these two options, a shared decision‐making conversation with patients followed. If both options were declined, neurologists documented predefined or free‐text reasons for ASM non‐discontinuation. The same stepwise approach was applied to patients after their consultation. In addition, all patients completed standardized questionnaires on prior seizure severity, ASM adverse effects, quality of life, depression, anxiety, personality traits, and social context and stigma.

FIGURE 2

Decision pathways of antiseizure medication (ASM) discontinuation. Pathways of study participants based on neurologists' recommendations and patients' decisions in the shared decision‐making process regarding ASM discontinuation are shown. Eleven of 76 patients for whom the neurologists recommended complete discontinuation of ASM decided to reduce the ASM dose instead. Note that <10% (n = 7) of these 76 patients consented to completely stop the ASM; this is <4% of the entire study population.

FIGURE 3

Reasons of neurologists and patients for non‐discontinuation of antiseizure medication (ASM). Multiple reasons were allowed for both groups. Neurologists provided reasons for not recommending ASM discontinuation in 86 patients, whereas 147 patients gave reasons for favoring non‐discontinuation. This figure indicates all reasons that were given by at least four respondents. For further reasons, see Table S1 for neurologists and Table S2 for patients. ^aPredefined reasons based on a study examining patients' reasons for non‐discontinuation of ASM. ^bPredefined reasons based on clinical variables independently associated with seizure recurrence after ASM discontinuation in a large meta‐analysis. ^cEven though patients were seizure‐free for a minimum of 2 years, their neurologist still felt the seizure‐free period was too short for ASM discontinuation (mean seizure‐free period was 3 years).

FIGURE 4

Duration of seizure freedom and association with antiseizure medication (ASM) non‐discontinuation and discontinuation. Violin plots show duration of seizure freedom prior to the shared decision‐making process between neurologists and patients on potential discontinuation of ASM. The black diamonds in the middle of the violins represent the median in each group. Duration of seizure freedom is significantly shorter in patients for whom neurologists opted for ASM non‐discontinuation (left side). In patients, duration of seizure freedom is significantly longer in those favoring ASM non‐discontinuation (right side).