Abstract
Background
The ideal objective of treating a person with epilepsy is to induce remission (free of seizures for some time) using antiepileptic drugs (AEDs) and withdraw the AEDs without causing seizure recurrence. Prolonged usage of AEDs may have long‐term adverse effects. Hence, when a person with epilepsy is in remission, it is logical to attempt to discontinue the medication. The timing of withdrawal and the mode of withdrawal arise while contemplating withdrawal of AEDs. This review examines the evidence for the rate of withdrawal of AEDs (whether rapid or slow tapering) and its effect on seizure recurrence.
This is an updated version of the Cochrane Review previously published in 2020.
Objectives
To quantify risk of seizure recurrence after rapid (tapering period of three months or less) or slow (tapering period of more than three months) discontinuation of antiepileptic drugs in adults and children with epilepsy who are in remission, and to assess which variables modify the risk of seizure recurrence.
Search methods
For the latest update, on 8 November 2021, we searched: Cochrane Register of Studies (CRS Web), MEDLINE (Ovid), and SCOPUS. There were no language restrictions. CRS Web includes randomized or quasi‐randomized, controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), CENTRAL, and the Specialized Registers of Cochrane Review Groups including Epilepsy.
Selection criteria
Randomized controlled trials that evaluated withdrawal of AEDs in a rapid or slow tapering after varying periods of seizure control in people with epilepsy.
Data collection and analysis
Two review authors independently assessed the trials for inclusion and extracted the data. The outcomes assessed included seizure freedom after one, two, or five years of AED withdrawal; time to recurrence of seizure following withdrawal; occurrence of status epilepticus; mortality; morbidity due to seizure, such as injuries, fractures, and aspiration pneumonia; and quality of life (assessed by validated scale).
Main results
There are two included studies in this review.
One study randomized 57 children with epilepsy with seizure freedom for at least two years to taper down the AED over one or six months. The study was not blinded and there were no details of randomization. Over the period of 54 months of follow‐up, 20/30 participants in the one‐month group remained seizure‐free compared to 15/27 participants in the six‐month group (no evidence of a difference). There was no information on time of seizure recurrence for each group to allow a comparison.
The other study involved 149 children. There was a non‐significant trend towards a lower risk of seizure recurrence after one year of AED withdrawal in participants allocated to slow tapering (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.58 to 1.01; P = 0.06; very low‐certainty evidence). At the end of two years, 30 participants were seizure free in the rapid‐tapering group and 29 participants in the slow‐tapering group (RR 0.87, 95% CI 0.58 to 1.29; P = 0.48; very low‐certainty evidence). At the end of five years, 10 participants were seizure free in the rapid‐tapering group and six participants in the slow‐tapering group (RR 1.40, 95% CI 0.54 to 3.65; P = 0.49; very low‐certainty evidence). There were no data for the other outcomes.
Due to the methodological heterogeneity and the difference in the duration of tapering, we did not perform a quantitative synthesis of these studies.
Currently, one Italian trial is ongoing that is investigating if a slow or a rapid withdrawal schedule of AEDs influences return of seizures (relapse) in adults with focal or generalized epilepsy who have been seizure free for at least two years (no preliminary results available).
Authors’ conclusions
In view of methodological deficiencies, and small sample size of the two included studies, we cannot draw any reliable conclusions regarding the optimal rate of tapering of AEDs. Using GRADE, we assessed the certainty of the evidence as very low for outcomes for which data were available. We judged both studies to be at an overall high risk of bias.
Further studies are needed in adults and children to investigate the optimal rate of withdrawal of AEDs and to study the effects of variables such as seizure types, aetiology, intellectual disability, electroencephalography abnormalities, presence of neurological deficits, and other comorbidities on the rate of tapering.
PICOs
Population (11)
Intervention (1)
Comparison (1)
Outcome (3)
The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses . PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome
See more on using PICO in the Cochrane Handbook.
Plain language summary
Rapid versus slow withdrawal of antiepileptic medicines
Background
Epilepsy is a disorder where recurrent seizures (fits) are caused by abnormal electrical discharges of the brain. Antiepileptic medicines are used to prevent these seizures. Regular intake of antiepileptic medicines may have long‐term side effects. When in remission (free of seizures for some time), it is logical to attempt to stop the medicines. Two important issues are how and when to stop them.
Aim of the review
This review analyzed studies for evidence regarding rapidity of withdrawal of antiepileptic medicines. We included randomized controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) evaluating the rapid or slow withdrawal (tapering down) of these medicines after varying periods of seizure control in people with epilepsy.
Results
We included only two small studies conducted in 206 children with epilepsy. The included studies found no difference in the proportion of participants remaining seizure‐free between the rapid‐ and the slow‐tapering groups at different time points. There were no data for other measures such as status epilepticus (a long seizure), death, illness relating to seizures, and quality of life. We found no completed trials investigating antiepileptic medicine withdrawal in adults.
Currently, one Italian trial is ongoing that is investigating if a slow or a rapid withdrawal schedule of antiepileptic medicine influences return of seizures (relapse) in adults with epilepsy who have been seizure free for at least two years (no preliminary results available).
Reliability of the evidence
Evidence from the two included studies was of very low reliability. Both studies were conducted in a small number of participants and there were not enough data to detect a difference between the groups. Furthermore, they included only children, hence the results cannot be generalized to adults. Therefore, no reliable evidence is currently available on the optimal rate of tapering of antiepileptic medicines.
The evidence is current to November 2021.
