Antiseizure medications (antiepileptic drugs) in adults: starting, monitoring and stopping

Up to 10% of people living to 80 years of age have one or more seizures; and many will not require anti-seizure medication (ASMs). In 85% of patients, the diagnosis comes from the history of the index event. One-third of patients with an apparent first seizure have previous events, changing their diagnosis to epilepsy. Targeted investigations are important for classification and risk prediction. Patients with a low risk of seizure recurrence are not usually offered ASM treatment. High-risk patients have multiple seizures, neurological deficits, intellectual disability and/or relevant abnormal investigations; and are offered ASMs. Individual factors modulate this decision-making. Future integrated technologies offer the game-changing potential for seizure monitoring and prediction, but are not yet robust, convenient or affordable. Therapeutic drug monitoring in patients taking ASMs may confirm ASM toxicity, or when non-adherence, malabsorption, or rapid metabolism are suspected causes of breakthrough seizures. They are less useful when these factors are intermittent or irregular. Current evidence does not favour routine monitoring of serum levels, as it neither reliably predicts control, relapse, or adverse effects. The decision to discontinue ASM should follow a full discussion with the patient of risks and benefits. Along with population risk factors for seizure recurrence, the patient's lifestyle and preferences must be considered. ASM are usually discontinued in a slow step-wise fashion, one at a time, after at least two years of remission. Seizure recurrence risk plateaus only after 2 years following ASM discontinuation, and patients need access to specialist follow-up over that period.

Automated summary

Up to 10% of people over the age of 80 experience seizures, and many do not require anti-seizure medication. The diagnosis is often made based on the patient's medical history. Targeted investigations are important for classification and risk prediction. Patients with a low risk of seizure recurrence do not usually need medication, while high-risk patients with multiple seizures and other symptoms are offered medication. Future technologies may offer better seizure monitoring and prediction, but they are not yet reliable or convenient. Therapeutic drug monitoring can be useful in confirming medication toxicity or identifying causes of breakthrough seizures. Current evidence does not support routine monitoring of medication levels. The decision to discontinue medication should be made after a discussion with the patient, considering their individual risks and preferences. Medication is usually discontinued gradually after at least two years of remission, and patients need specialist follow-up during this time.