Initiation and discontinuation of antiepileptic drugs

Given the consequences of long-term drug therapy and its lack of effect on long-term prognosis following a first seizure, the authors generally do not recommend treatment following a first unprovoked seizure in either children or adults. Following a second seizure, treatment is generally indicated in adults and needs to be considered in children. In children and adolescents who are seizure free on antiepileptic drugs for at least 2 years, at least one attempt should be made at medication withdrawal even if risk factors for recurrence are present. In adults, the risk benefit equation in this setting is less clear and decisions must be individualized after discussing the risks and benefits with the patient. The approach presented in this chapter emphasizes that both seizures and available therapies carry some risk and that optimal patient care requires careful balancing of these risks and benefits. Assessment of risk requires not only ascertaining the statistical risk of a seizure recurrence or of an adverse event but also the consequences of such an event. This risk-benefit approach is useful not only in deciding whether to initiate or discontinue antiepileptic drug therapy but also in other treatment decisions. This approach includes deciding whether or not to add a second drug, to try experimental drugs or therapies such as the ketogenic diet, or whether to consider epilepsy surgery. In all cases, the patient must balance the risks and benefits of proposed alternatives that may change as new information becomes available. Whatever the decision, it should be made jointly by the medical providers and the patient and family after careful discussion, including not only an assessment of the risks and benefits of treatment but with the understanding that individual patients and clinicians place different values on different outcomes and on the acceptability of certain risks.