AAN GUIDELINES Bundle

➤ Epilepsy is a common disease of the brain and accounts for approximately 1% of the global burden of all disease. In the United States alone, an estimated 70,000–200,000 adults per year will present with a first unprovoked seizure. ➤ Currently, epilepsy is not considered resolved until a patient is seizure- free for at least 10 years and off antiseizure medications (ASMs) for at least the last 5 years. Key Points Treatment Adults ➤ In adults who are seizure-free for at least 2 years, there should be a discussion between the clinician and the patient and/or caregiver, if any, about the risks and benefits of ASM withdrawal, which specifically includes and documents: 1. that there is possibly higher seizure recurrence in patients who had ASM withdrawal, and 2. that if seizures recur during or after withdrawal, there is a small chance they will no longer respond to medications (Level B). ➤ When discussing either ASM withdrawal or continuation with patients, since there is no statistically significant evidence to support either option, clinicians may consider individual patient characteristics and preferences (Level C). ➤ Counseling must include discussion that there is not strong evidence regarding the relationship between ASM withdrawal and changes in the risk of mortality and status epilepticus, and, as such, these risks have not been excluded by the evidence (Level A). ➤ Clinicians should counsel that recurrent seizures put people at risk for status epilepticus and death (Level B), although existing data do not suggest an increased risk of status epilepticus or death after ASM withdrawal. ➤ Clinicians must explore contributors to the quality of life of individual patients as part of shared decision-making regarding ASM discontinuation (Level A). ➤ Clinicians should discuss with seizure-free patients that it is unknown if EEG or imaging studies inform the decision to withdraw ASMs (Level B). ➤ Clinicians may discuss that the risk of seizure recurrence with ASM withdrawal in patients who have had epilepsy surgery and are seizure-free is uncertain due to the lack of evidence (Level C).

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