What are the guidelines for driving in patients with epilepsy?

From the Guidelines

Patients with epilepsy should not drive until they have been seizure-free for at least 6 months, and even then, they should be under the guidance of a neurologist who has assessed their individual risk and medication regimen, as supported by the most recent evidence from 2024 1.

Key Considerations for Driving with Epilepsy

• The primary concern with driving and epilepsy is the risk of seizures causing sudden loss of consciousness or control, which can lead to accidents and endanger the patient and others on the road.
• The effects of antiseizure medications (ASMs) such as carbamazepine, valproate, lamotrigine, lacosamide, and levetiracetam on driving performance have been evaluated, suggesting that while these medications may impair driving under acute administration, their impact under chronic administration is less significant 1.
• However, individual responses to these medications can vary, and factors such as drug dosage, interactions, and pharmacokinetics must be considered in clinical practice 1.
• Regular follow-up with neurologists is crucial to monitor seizure control, adjust medication as necessary, and provide individualized guidance on driving safety.
• Patients must be compliant with their prescribed medication regimens and avoid factors that could trigger seizures, such as sleep deprivation and excessive alcohol consumption.
• The legal obligation to inform the driving license authority and insurance company about an epilepsy diagnosis must be emphasized to patients, as failure to do so can have serious consequences.

Medication Considerations

• The choice of ASM should be based on efficacy in controlling seizures, with consideration of potential effects on driving performance, as outlined in the tiered approach proposed by the Ministry of Health, Labour, and Welfare guideline 1.
• While minimizing the impact on driving is important, seizure control remains the paramount consideration, and there should not be a set upper limit on the dose of therapeutic agents within the tolerated range.
• The evidence suggests that under chronic administration, the five frequently prescribed ASMs (carbamazepine, valproate, lamotrigine, lacosamide, and levetiracetam) may not result in clinically meaningful driving impairment, but individual patient responses can vary, necessitating personalized guidance 1.

Clinical Practice Recommendations

• Neurologists should provide clear, individualized guidance to patients with epilepsy regarding driving, taking into account the patient's seizure history, medication regimen, and other relevant factors.
• Patients should be educated on the importance of reporting any seizure recurrence to their physician and stopping driving immediately if seizures return.
• Commercial driving licenses have stricter requirements and typically demand longer seizure-free periods, reflecting the higher risks associated with commercial driving.

From the Research

Driving Restrictions for Patients with Epilepsy

• The guidelines for driving in patients with epilepsy are a highly contentious topic, with the fundamental difficulty lying in achieving a balance between safety and practicality 2.
• The aim is to provide an overview, history, and rationale behind current laws regarding driving restriction in people with epilepsy (PWE), including seizure recurrence risk after first seizure, recurrent seizure, and anticonvulsant withdrawal 2.

Seizure Recurrence Risk

• The risk of seizure recurrence is an important factor in determining driving restrictions for patients with epilepsy.
• Studies have shown that the risk of seizure recurrence is higher in patients with a history of seizures, and that anticonvulsant therapy can reduce this risk 3, 4.

Antiepileptic Drug Therapy

• Antiepileptic drug (AED) monotherapy is the most common treatment for epilepsy, with carbamazepine and lamotrigine being recommended as first-line treatments for new onset focal seizures 3, 5.
• Levetiracetam has been shown to be a suitable alternative to carbamazepine and lamotrigine, with a superior seizure-freedom rate and comparable tolerability and retention rates 6.

Driving Restrictions

• The decision to impose driving restrictions on patients with epilepsy should be made on an individual basis, taking into account the patient's seizure history, medication regimen, and other factors 2.
• Physicians have a responsibility to advise patients with epilepsy about driving restrictions and to report patients who pose a risk to public safety 2.