Stay or Go: Decision-Making Surrounding Antiseizure Medication Discontinuation

Epilepsia . 2025 Jun 26. doi: 10.1111/epi.18519. Online ahead of print. Objective: This study was undertaken to investigate clinical and psychosocial factors associated with antiseizure medication (ASM) non-discontinuation in seizure-free patients with epilepsy among both neurologists and patients. Methods: In this cross-sectional study, neurologists documented their recommendations on ASM discontinuation (comprising both complete discontinuation and ≥25% dose reduction) in patients aged ≥18 years who had been seizure-free for at least 2 years. Based on these recommendations, patients made individual decisions. In both neurologists and patients, reasons for and predictors of ASM non-discontinuation were assessed considering demographic and epilepsy-related variables as well as standardized psychosocial questionnaires.Results: Among 196 patients (53.1% female, median age = 50 years, interquartile range [IQR] = 36-61; median seizure-free duration = 6 years, IQR = 4-11), neurologists recommended ASM discontinuation in 110 cases (56.1%), of which 29 patients (26.4%) agreed. Neurologists were more likely to favor ASM non-discontinuation if they had fewer years of professional experience (odds ratio [OR] = .96, 95% confidence interval [CI] = .92-.99) and if patients had shorter seizure-free durations (OR = .98, 95% CI = .98-.99). Among patients, longer seizure-free duration (OR = 1.01, 95% CI = 1.01-1.02) and a history of generalized or focal to bilateral tonic-clonic seizures (OR = 2.72, 95% CI = 1.15-6.43) were independently associated with ASM non-discontinuation. Excluding the 27 patients who favored a dose reduction, ASM non-discontinuation was still associated with a longer duration of seizure freedom (OR = 1.02, 95% CI = 1.01-1.03). Further predictors were higher anxiety scores (OR = 1.37, 95% CI = 1.05-1.78) and better ASM tolerability (OR = 1.04, 95% CI = 1.01-1.07). Significance: Neurologists and, even more so, patients are hesitant to discontinue ASM, which was accomplished in only 15% of seizure-free patients. Duration of seizure freedom has a major impact on the decision but in opposite directions comparing both groups. Understanding these differing perspectives is essential to improve shared decision-making on this complex issue in epilepsy care.