Antiepileptic drug withdrawal in juvenile myoclonic epilepsy

Abstract

Juvenile myoclonic epilepsy (JME) is the most common type of epilepsy affecting adolescents, and it is hallmarked by myoclonic jerks, predominantly after awakening, aggravated by sleep deprivation and stress. 1 The majority of patients have occasional generalized tonicclonic seizures (GTCS), and about one-third have absence seizures. 2The antiepileptic drugs (AEDs) most commonly used in the treatment of JME are valproate, lamotrigine, levetiracetam, topiramate, and zonisamide. 3 Juvenile myoclonic epilepsy was initially considered a manageable type of epilepsy, with intellectual abilities within the normal range, normal neurologic examination, normal magnetic resonance imaging of the brain, and a favorable response to treatment in the majority of patients. 4,5 However, the rate of relapse upon withdrawal of AEDs was high, and the general advice was that these patients ought to continue medication throughout life. 5-7 Smaller, but more Objectives: Withdrawal of antiepileptic drugs (AEDs) has been discouraged in juvenile myoclonic epilepsy (JME). However, impulsivity as a consequence of executive dysfunction in JME may influence treatment adherence. The aim of the present study was to assess how common withdrawal of AEDs is in a large and representative JME group. Materials and methods:Patients with genetic generalized epilepsy (GGE) were identified through a retrospective search of medical records at Drammen Hospital, Norway, and invited to a clinical interview. Information related to AED withdrawal was analyzed in those classified as JME.Results: A total of 132 patients with GGE were interviewed (87 JME). Thirty-five patients with JME (40%) discontinued AEDs, of which 74% did so without consulting a doctor. The rate of self-withdrawal was significantly higher in JME than in other types of GGE. Having a parent with psychosocial difficulties was significantly overrepresented in the JME self-withdrawal group. Twelve of those who discontinued AEDs (34%) were free from generalized tonic-clonic seizures (GTCS) and without antiepileptic drugs >1 year. All but one of them withdrew AEDs without consulting a doctor. Age at first motor seizure was significantly higher in those with a favorable outcome of AED withdrawal. Conclusions: Self-withdrawal of AEDs is common in JME, especially in those with troublesome conditions at home. However, about 1/3 may remain free from GTCS without AEDs. The findings indicate a need for a stronger follow-up with appropriate information about the prognosis of the disorder. K E Y W O R D Sadherence, antiepileptic drugs, juvenile myoclonic epilepsy, withdrawal

Persistent treatment resistance in genetic generalized epilepsy: A long‐term outcome study in a tertiary epilepsy center

“…Finally, we found the relapse rate after AED withdrawal to be dramatically high, unlike in previous studies 39,40 . Such discrepancy may be partially due to our study design.…”

“…7 Finally, we found the relapse rate after AED withdrawal to be dramatically high, unlike in previous studies. 39,40 Such discrepancy may be partially due to our study design. Indeed, the exclusion of GGE patients without regular follow-up visits and with a follow-up duration <10 years may have resulted in an underrepresentation of the patients who were successfully withdrawn from antiepileptic medications.…”

Treatment and challenges with antiepileptic drugs in patients with juvenile myoclonic epilepsy

“…Sample size was based on the maximum number of participants we were able to identify and recruit, as opposed to a priori power calculations. This approach was chosen in order to obtain a highly representative sample, aiming at including all patients with JME in our region and given age group [2,17,18].…”

“…We included patients who would most likely be diagnosed with JME within the period of the medical record search, i.e., those younger than 40 years and older than 14 years. All patients diagnosed with genetic generalized epilepsy (GGE) were invited to participate, where 69% accepted, and those with a confirmed diagnosis of JME were included in the present study [2,17,18].…”

“…The choice of proper treatment in women is challenging because of restrictions in the use of valproate due to dose-dependent teratogenic effects and long-term effects on cognitive development in the offspring [11][12][13]. Another challenge is that patients with JME might have difficulties with treatment adherence as a possible consequence of executive dysfunction and impulsive decision-making [14][15][16][17][18]. The use of therapeutic drug monitoring (TDM) is considered the best way to measure adherence and is useful to individualize AED treatment and could therefore be used as a tool for improved treatment follow-up [7,19,20].…”