TAKE-HOME MESSAGE

• A systematic review of the literature published between January 1991 and March 2020 was used to update the 1996 American Academy of Neurology practice parameter that provided considerations for discontinuing antiseizure medications in affected patients.
•  

• The authors of this update developed 14 recommendations for the withdrawal of antiseizure medications in seizure-free patients.

In 1996, the American Academy of Neurology proposed a practice parameter which suggested that, after assessing the risks and benefits for both patient and society of a recurrent seizure, the discontinuation of anti-seizure medication (ASMs) may be considered if the patient was seizure-free 2 to 5 years while taking ASMs, had single-type seizures, had normal neurologic examination results with a normal IQ, and the EEG normalized while taking ASMs.

In revising these guidelines, the AAN Guideline Subcommittee reviewed published literature and updated the guidelines to emphasize the following points:

• The long-term risk of seizure recurrence is possibly higher among patients with a history of seizures who have been seizure-free over 24 to 60 months who taper ASMs when compared with patients who do not taper ASMs. 
• There were multiple prognostic factors for increased risks of seizures in adults; however, the authors encourage clinicians to discuss with seizure-free patients that fact that it is not known if EEG or imaging studies can inform the decision to withdraw ASMs. 
• Once epilepsy is masked, it is not known if the patient continues to have epilepsy or not.
• An epileptiform EEG in pediatric patients increases the risk of seizure recurrence.
• ASM withdrawal possibly does not increase the risk of status epilepticus in adults.
• In seizure-free adults, ASM weaning possibly does not change the quality of life.
• Patients should be part of the medical decision–making process, especially when there is clinical equipoise.
• None of the included studies adequately addressed the question of drug withdrawal and the risk of seizure recurrence in specific electroclinical syndromes.

These are essential guidelines that took several years to finalize. Overall, they highlight the existing gaps in knowledge, emphasize the lack of evidence to provide solid recommendations, and suggest that clinicians may consider individual patient characteristics and preferences when discussing either ASM withdrawal or continuation with patients.

Doctors Liked to Read More