From the Guidelines
The recommended approach for tapering antiseizure medications (AEDs) is to reduce the dose gradually over several months rather than stopping abruptly, with a suggested tapering off and stopping of antiepileptic drugs after resolution of the lesion in patients with single enhancing lesions (SELs) without risk factors for recurrent seizures who have been seizure free for 6 months. This approach is based on the guidelines provided by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH) 1.
Key Considerations
- The tapering process should be individualized based on the patient's seizure history, with longer seizure-free periods warranting consideration for withdrawal.
- Patients should be monitored closely during tapering for breakthrough seizures, which occur most commonly during the first 3-6 months of withdrawal.
- Tapering should be paused or slowed if withdrawal symptoms or seizure activity emerges.
- Risk factors for recurrent seizures include residual cystic lesions or calcifications on neuroimaging studies, breakthrough seizures, or >2 seizures 1.
Tapering Guidelines
- For patients on multiple AEDs, medications should be withdrawn one at a time, starting with the most recently added drug or the one with the most side effects.
- Common AEDs like carbamazepine, phenytoin, valproate, and lamotrigine should follow a gradual reduction pattern, typically reducing the dose by about 25% every 2-4 weeks until discontinuation.
- For benzodiazepines like clonazepam or diazepam, an even slower taper may be necessary (10-15% reduction every 2-4 weeks) to avoid withdrawal symptoms.
Important Considerations for Tapering
- Gradual tapering is essential because abrupt discontinuation can trigger withdrawal seizures or status epilepticus, even in well-controlled patients, due to neuronal hyperexcitability that develops as the brain adapts to chronic AED exposure.
- The decision to taper AEDs should be made on a case-by-case basis, taking into account the individual patient's risk factors for recurrent seizures and their overall clinical condition 1.
From the FDA Drug Label
As with all antiepileptic drugs, carbamazepine should be withdrawn gradually to minimize the potential of increased seizure frequency.
- The recommended approach for tapering antiseizure medications, such as carbamazepine, is to withdraw gradually to minimize the potential of increased seizure frequency 2.
- Gradual tapering is advised to reduce the risk of seizures and other adverse effects.
- The exact tapering schedule is not specified in the drug label, but it is recommended to adjust the dosage to the minimum effective level and attempt to reduce the dose to the minimum effective level or even to discontinue the drug at least once every 3 months throughout the treatment period 2.
From the Research
Antiseizure Medications Tapering
The decision to taper antiseizure medications (ASMs) in patients with epilepsy who are in remission is complex and should be based on an accurate estimate of seizure recurrence risk 3. Several factors can influence the risk of seizure recurrence, including the etiology of the epilepsy syndrome, epilepsy-related factors, and worsening or persistence of epileptiform abnormalities on EEG recordings 4.
Recommended Approach
There is no robust evidence available on the safest tapering regimen 3. However, some studies suggest that a slow tapering approach may be associated with a lower risk of seizure recurrence 5. The following factors should be considered when tapering ASMs:
- Duration of epilepsy 6
- Frequency of seizures before control 6
- History of previously failed tapering 6
- History of smoking/alcoholic/tobacco intake 6
- Serum AED levels 7
- Inflammatory biomarkers 7
Key Considerations
- The decision to taper ASMs should be individualized and based on the patient's specific circumstances 3.
- Patients should be closely monitored during and after tapering to minimize the risk of seizure recurrence 4.
- The tapering schedule should be tailored to the individual patient's needs and should be done gradually to minimize the risk of seizure recurrence 5.