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Antiseizure medications (antiepileptic drugs) in adults: starting, monitoring and stop**

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Abstract

Up to 10% of people living to 80 years of age have one or more seizures; and many will not require anti-seizure medication (ASMs). In 85% of patients, the diagnosis comes from the history of the index event. One-third of patients with an apparent “first seizure” have previous events, changing their diagnosis to epilepsy. Targeted investigations are important for classification and risk prediction. Patients with a low risk of seizure recurrence are not usually offered ASM treatment. High-risk patients have multiple seizures, neurological deficits, intellectual disability and/or relevant abnormal investigations; and are offered ASMs. Individual factors modulate this decision-making. Future integrated technologies offer the game-changing potential for seizure monitoring and prediction, but are not yet robust, convenient or affordable. Therapeutic drug monitoring in patients taking ASMs may confirm ASM toxicity, or when non-adherence, malabsorption, or rapid metabolism are suspected causes of breakthrough seizures. They are less useful when these factors are intermittent or irregular. Current evidence does not favour routine monitoring of serum levels, as it neither reliably predicts control, relapse, or adverse effects. The decision to discontinue ASM should follow a full discussion with the patient of risks and benefits. Along with population risk factors for seizure recurrence, the patient’s lifestyle and preferences must be considered. ASM are usually discontinued in a slow step-wise fashion, one at a time, after at least two years of remission. Seizure recurrence risk plateaus only after 2 years following ASM discontinuation, and patients need access to specialist follow-up over that period.

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Authors and Affiliations

  1. Royal Free London NHS Foundation Trust, Pond Street, London, NW32QG, UK

    Heather Angus-Leppan

  2. Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK

    Heather Angus-Leppan

  3. Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, 19010, USA

    Michael R. Sperling

  4. Refractory Epilepsy Unit, Neurology Service, Hospital Universitario y Politécnico La Fe, Avd Fernando Abril Martorell, 106, 46026, Valencia, Spain

    Vicente Villanueva

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  1. Heather Angus-Leppan
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  3. Vicente Villanueva
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Correspondence to Heather Angus-Leppan.

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Angus-Leppan, H., Sperling, M.R. & Villanueva, V. Antiseizure medications (antiepileptic drugs) in adults: starting, monitoring and stop**. J Neurol 270, 573–581 (2023). https://doi.org/10.1007/s00415-022-11378-3

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