When to discontinue antiepileptic (anti-seizure) medications after post-stroke epilepsy?

From the Guidelines

The decision to stop anti-seizure medications (ASMs) after post-stroke epilepsy should generally be considered after a seizure-free period of at least 2 years, though this varies based on individual risk factors. Begin by discussing discontinuation with a neurologist who can evaluate your specific situation. Common ASMs used for post-stroke epilepsy include levetiracetam (Keppra, 500-1500mg twice daily), lamotrigine (Lamictal, 25-200mg twice daily), and carbamazepine (Tegretol, 200-400mg twice daily) 1. When discontinuation is appropriate, medications should be tapered gradually over 2-3 months rather than stopped abruptly to minimize withdrawal seizures. For example, reduce the dose by about 25% every 2-4 weeks. Factors favoring successful discontinuation include complete seizure control on medication, a single seizure type, normal EEG, and absence of structural abnormalities on imaging. Risk factors for seizure recurrence include multiple prior seizures, abnormal EEG, severe stroke with significant brain damage, and cortical involvement. The biological rationale for waiting 2 years is that this allows time for neural reorganization and stabilization of the post-stroke brain environment, reducing epileptogenicity. About 30-40% of patients may experience seizure recurrence after discontinuation, so regular follow-up is essential during and after the tapering process.

Some key points to consider when stopping ASMs include:

• The patient's overall health and medical history
• The type and severity of the stroke
• The presence of any underlying medical conditions
• The patient's ability to tolerate potential side effects of medication withdrawal
• The need for ongoing monitoring and follow-up care. According to the 2018 guidelines for the early management of patients with acute ischemic stroke, prophylactic use of anti-seizure drugs is not recommended 1. Additionally, the Canadian stroke best practice recommendations suggest that a single, self-limiting seizure occurring at the onset or within 24 h after an ischemic stroke should not be treated with long-term anticonvulsant medications 1. The WHO guidelines for mental, neurological, and substance use disorders in low- and middle-income countries also recommend that discontinuation of antiepileptic drug treatment should be considered after 2 seizure-free years 1.

It is essential to weigh the potential benefits and risks of stopping ASMs on an individual basis, taking into account the patient's unique circumstances and medical history. Regular follow-up with a neurologist is crucial to monitor for any changes in seizure activity or other potential complications. By carefully considering these factors and following established guidelines, healthcare providers can make informed decisions about when to stop ASMs in patients with post-stroke epilepsy.

From the Research

Stopping Anti-Seizure Medications After Post-Stroke Epilepsy

There is limited research on when to stop anti-seizure medications after post-stroke epilepsy. However, some studies provide insights into the management of post-stroke seizures:

• The decision to stop anti-seizure medications should be individualized, considering the risk of seizure recurrence and the potential side effects of the medication 2.
• A study found that newer-generation antiseizure medications, such as levetiracetam and lamotrigine, may be safe and tolerable for post-stroke seizures, with lower seizure recurrence rates and fewer adverse events compared to older-generation medications 3, 4.
• The optimal duration of treatment with anti-seizure medications after post-stroke epilepsy is unclear, and further research is needed to determine the best approach 2, 5.
• Some studies suggest that the risk of seizure recurrence decreases over time, but the risk of late-onset seizures may increase, making it difficult to determine when to stop treatment 5.
• Factors such as stroke severity, cortical location, and the presence of permanent lesions may influence the risk of seizure recurrence and the decision to continue or stop treatment 5.

Considerations for Stopping Treatment

When considering stopping anti-seizure medications, the following factors should be taken into account:

• The risk of seizure recurrence, which may be higher in patients with certain risk factors, such as stroke severity and cortical location 5.
• The potential side effects of the medication, which may be more significant in older adults or those with comorbidities 2, 3.
• The patient's individual circumstances, including their overall health, quality of life, and preferences 2.
• The need for ongoing monitoring and follow-up to detect any changes in seizure activity or medication side effects 4.