The results of a prospective cohort study to investigate the effects of withdrawal of AEDs in 264 children with epilepsy after a mean seizure-free interval of 2.9 years are reported from the Montefiore/Einstein Epilepsy Management Center, Bronx, NY. Seizures recurred in 95 (36%); the mean time to recurrence was 9.5 months with a median of 4.3 months, and 90% of recurrences occurred within 25 months after study entry. The mean follow-up period was 58 months. Etiology was a significant risk factor. In the group with idiopathic epilepsy, significant risk factors for recurrence included age at onset > 12 years, family history of epilepsy, history of atypical febrile seizures (defined as seizures with fever and a history of prior afebrile seizures, or complex febrile seizures), EEG slowing, and specific syndromes such as benign rolandic epilepsy and juvenile myoclonic epilepsy. In the remote symptomatic group (includes only children with significant prior cerebral pathologies), significant predictors of seizure recurrence were age at seizure onset > 12 years, moderate to severe mental retardation, history of atypical febrile seizures, and history of absence seizures. [1]
COMMENT. The results of this extensive, prospective study agree with previous reports showing that approximately one third of children who have been seizure free for 2 or more years while on AED therapy will relapse when medication is withdrawn. In children with cerebral pathologies and remote symptomatic epilepsy, almost 50% suffered recurrences. The risk factors reported in these study groups provide a valuable guide to a decision to terminate therapy. However, the final decision should consider each child as an individual, taking into account the consequences of a seizure recurrence and the possible adverse effects of continued antiepileptic medications. For further articles on this topic, see Progress in Pediatric Neurology, PNB Pub, 1991. Holmes GL, Children’s Hospital, Boston, in an editorial [2], appears to favor a trial period of withdrawal rather than indefinite continuation of AEDs, even in children with significant risk factors. He cites Lennox and Lennox (1960) who criticized proponents of anticonvulsant continuance for life, and notes the psychological consequences and expense of long term therapy. In contrast to the concerns of Shinnar and colleagues, Holmes down plays AED side effects as a compelling reason to discontinue therapy and finds that cognitive and behavioral impairments are overstated. He takes issue with the provocative statement of our respected colleague, John Freeman, that “antiepileptic drugs are all poisons.” [3]