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February 2023; 13 (1) Research Article

Antiseizure Medication Withdrawal Practice Patterns

A Survey Among Members of the American Academy of Neurology and EpiCARE

Samuel W. Terman, Geertruida Slinger, Carol E. Rheaume, Anisa S. Haque, Shawna N. Smith, Renate van Griethuysen, Charlotte J.J. van Asch, Willem M. Otte, James F. Burke, View ORCID ProfileKees P.J. Braun
First published January 17, 2023, DOI: https://doi.org/10.1212/CPJ.0000000000200109
Samuel W. Terman
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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Geertruida Slinger
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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Carol E. Rheaume
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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Anisa S. Haque
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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Shawna N. Smith
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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Renate van Griethuysen
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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Charlotte J.J. van Asch
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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Willem M. Otte
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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James F. Burke
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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Kees P.J. Braun
Department of Neurology (SWT), University of Michigan, Ann Arbor; Department of Child Neurology (GS, WMO, KB), UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands; American Academy of Neurology (CER), Minneapolis, MN; University of Michigan Medical School (ASH); Department of Health Management and Policy (SNS), School of Public Health, University of Michigan, Ann Arbor; Department of Clinical Neurophysiology and Sleep Centre SEIN Zwolle (RvG, CJJvA), the Netherlands; Department of Neurology (JFB), the Ohio State University, Columbus; and Member of the European Reference Network EpiCARE (KPJB).
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  • ORCID record for Kees P.J. Braun
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Citation
Antiseizure Medication Withdrawal Practice Patterns
A Survey Among Members of the American Academy of Neurology and EpiCARE
Samuel W. Terman, Geertruida Slinger, Carol E. Rheaume, Anisa S. Haque, Shawna N. Smith, Renate van Griethuysen, Charlotte J.J. van Asch, Willem M. Otte, James F. Burke, Kees P.J. Braun
Neurol Clin Pract Feb 2023, 13 (1) e200109; DOI: 10.1212/CPJ.0000000000200109

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Abstract

Background and Objectives To describe neurologist practice patterns, challenges, and decision support needs pertaining to withdrawal of antiseizure medications (ASMs) in patients with well-controlled epilepsy.

Methods We sent an electronic survey to (1) US and (2) European physician members of the American Academy of Neurology and (3) members of EpiCARE, a European Reference Network for rare and complex epilepsies. Analyses included frequencies and percentages, and we showed distributions through histograms and violin plots.

Results We sent the survey to 4,923 individuals; 463 consented, 411 passed eligibility questions, and 287 responded to at least 1 of these questions. Most respondents indicated that they might ever consider ASM withdrawal, with respondents treating mostly children being more likely ever to consider withdrawal (e.g., medical monotherapy: children 96% vs adults 81%; p < 0.05). The most important factors when making decisions included seizure probability (83%), consequences of seizures (73%), and driving (74%). The top challenges when making decisions included unclear seizure probability (81%), inadequate guidelines (50%), and difficulty communicating probabilities (45%). Respondents would consider withdrawal after a median of 2-year seizure freedom, but also responded that they would begin withdrawal on average only when the postwithdrawal seizure relapse risk in the coming 2 years was less than 15%–30%. Wide variation existed in the use of words or numbers in respondents' counsel methods, for example, percentages vs frequencies or probability of seizure freedom vs seizure. The most highly rated point-of-care methods to inform providers of calculated risk were Kaplan-Meier curves and showing percentages only, rather than pictographs or text recommendations alone.

Discussion Most surveyed neurologists would consider withdrawing ASMs in seizure-free individuals. Seizure probability was the largest factor driving decisions, yet estimating seizure probabilities was the greatest challenge. Respondents on average indicated that they may withdraw ASM after a minimum seizure-free duration of 2 years, yet also on average were willing to withdraw when seizure risk decreased below 15%–30%, which is lower than most patients' postwithdrawal risk at 2-year seizure freedom and lower than the equivalent even of a first seizure of life. These findings will inform future efforts at developing decision support tools aimed at optimizing ASM withdrawal decisions.

Footnotes

  • Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

  • Submitted and externally peer reviewed. The handling editor was Editor Luca Bartolini, MD.

  • Received June 13, 2022.
  • Accepted October 10, 2022.
  • © 2023 American Academy of Neurology
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