Withdrawal of long-term antiepileptic treatment in children

Perhaps one of the most frequently asked questions by the parents of children whose seizures are well controlled, is if—and when—medication can be discontinued. Many reasons may prompt this question; the need to continue taking drugs when the seizures appear to have stopped, the inconvenience of having to take—or give—regular medication even if only once a day, the development of not only recognized but also potentially un-recognized side-effects (specifically on concentration, learning and behaviour) and the emotional and psychological implications of having to take medication which contributes to the real (or perceived) stigmatisation of epilepsy. In contrast, the reasons for continuing antiepileptic medication may appear to be less obvious. These include not wishing to ‘rock the boat’ in a child who is seizure-free and who appears to be functioning well both academically and socially, the largely unfounded concern that control may not be re-gained if seizures recur following drug withdrawal and the continuing debate as to whether antiepileptic drug therapy may alter the natural history of the epilepsy and prevent the development of chronic epilepsy1. The question of drug withdrawal is obviously important and although the decision to stop an anticonvulsant may ultimately depend on the personal (including emotional) feelings of the parents and the child, arguments based on medical evidence may have a role in influencing this decision. Numerous studies, including the one by Altunbasak et al.15 in this issue of Seizure have attempted to provide such evidence on which to base the decision to withdraw antiepileptic drugs in children who have been seizurefree. These studies have also tried to identify specific factors which may be associated with an increased risk of seizure relapse following drug-withdrawal. A meta-analysis of 25 drug-withdrawal studies involving 5434 adults and children showed that the overall seizure relapse rate was 25% at one year and 29% at two years following withdrawal of an anticonvulsant; in children, the relapse rate was slightly lower and in adolescents, slightly higher2. Unfortunately, although