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Evidence summaries

Early Versus Late Antiepileptic Drug Withdrawal in Pediatric Epilepsy

It appears to be reasonable to wait for at least two seizure-free years before discontinuing antiepileptic drugs (AEDs) in children, particularly if they have an abnormal EEG or partial seizures, or both. There is insufficient evidence to establish when to withdraw AEDs in children with generalised seizures. There is no evidence to guide the timing of withdrawal of AEDs in seizure-free adults. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 5 studies with a total of 924 pediatric epilepsy patients. All were under 16 years of age at randomisation, with a median follow-up of 5.6 years. Included studies compared an early versus late antiepileptic drug (AED) discontinuation.The pooled risk ratio (RR) for seizure relapse after AED withdrawal was 1.34 (95% CI 1.13 to 1.59, p=0.0007; 5 studies, n=924). The number needed to harm, that is to expose an individual to a higher risk of seizure relapse because of early withdrawal of AED, is 8 (95% CI 5 to 20; 5 trials, n=924). Early discontinuation was associated with greater relapse rates in patients with partial seizures (RR 1.51, 95% CI 0.97 to 2.35, p=0.07; 2 trials, n=180). Absence type epilepsy showed a lower risk of relapse. Variables associated with higher risk of seizure relapse were abnormal EEG findings (pooled RR 1.44, 95% CI 1.13 to 1.83, p=0.003; 2 studies, n=618), especially epileptiform activity (RR 2.58, 95% CI 2.03 to 3.28, p< 0.0001; one study, n=433); epilepsy onset before 2 years or after 10 years of age; history of status epilepticus; intellectual disability (IQ < 70); and high seizure frequency before and during treatment. Gender and family history did not show any significant influence over seizure relapse.

Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment).

    References

    • Strozzi I, Nolan SJ, Sperling MR et al. Early versus late antiepileptic drug withdrawal for people with epilepsy in remission. Cochrane Database Syst Rev 2015;2():CD001902. [PubMed]

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