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Withdrawing AEDs after epilepsy surgery: is it safe?

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IMPORTANT NOTE: You should never alter your dose of medication without the direct supervision of your neurologist.

In some people with epilepsy arising from one area of the brain, and who are resistant to drug treatment (i.e. they have failed to respond to at least two anti-epileptic drugs / AEDs), it may be appropriate to consider surgery to remove the seizure focus. Surgery can be quite successful in carefully selected individuals, but it is difficult to know when and if AEDs can be withdrawn. What is to say that the seizures won't return once medication has been discontinued?

There have been a number of studies showing the success of epilepsy surgery, the percentage of people who become seizure-free afterwards, and how many will remain free of seizures after stopping their AED(s). Approximately two thirds of patients who had successful epilepsy surgery and then stopped their medication, remained seizure-free.

Yet these studies did not directly compare the risk of seizure recurrence in those who withdrew from their medication after successful surgery, with those who didn't. This information is necessary to weigh up the benefits versus the risks of stopping AEDs after surgery.

Researchers from the University Hospital of Erlangen, Germany, have recently completed a trial of this nature. They recruited sixty patients who underwent surgery between 1997 and 2003 and were completely free of seizures. One year after their operation, the investigators had a detailed discussion with each person about the pros and potential cons of withdrawing their medication, and a decision was made as to whether or not to discontinue. In the event, 34 patients decided to stop their AED(s) and 26 elected not to. The second group served as a control for the study.

Discontinuation was carried out in small steps over one year, with annual follow-up visits. If a patient's seizures resumed, or if he/she changed their mind about the process, withdrawal was stopped. Follow-up continued for five years post-surgery.

The results showed that 26 (76.5%) of the 34 patients in the withdrawal group and 16 (61.5%) of the 26 in the control group were seizure free five years after surgery.

The group concluded that, based on this study, AED discontinuation one year after successful epilepsy surgery is not associated with a higher risk of seizure recurrence than that of controls. Many factors need to taken into consideration when deciding whether to withdraw medication, however, and this may have had an influence on the results of the 'control' group, because there was no randomisation.

Even so, these findings are encouraging as they may assist in future discussions between specialists and their patients, about whether or not to withdraw from medication after epilepsy surgery.

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