Practice Current: "When Do You Stop AEDS?"

Transcription

1 Practice Current: "When Do You Stop AEDS?" While recognizing each case is different, please choose the answer that best reflects your common practice and limit free text to strategies that are not included. Estimated Time: 2 Minutes CASE 1: Focal epilepsy of unknown etiology A right-handed 14-year-old boy presents with a 7-year history of seizures. They usually last less than 5 minutes and are described as butterflies in the stomach sensation, followed by unresponsiveness with blank stare, sometimes accompanied by chewing and lip smacking, and stiffening of both arms. He was started on oxcarbazepine at age 8 and has had several seizures despite increasing the dose until maximized at age 13. He has been seizure- and aura-free for the past 6 months. High resolution 3T MRI and PET at age 12 were normal. Recent EEG revealed rare sharp waves in the left temporal region, similar to prior EEGs. For the past 2 years, he has been bullied at school and his parents request that medication be stopped while minimizing the risk of seizure recurrence. He is otherwise healthy with normal development, takes no other medications, and has no history of febrile seizures or family history of seizures. Show/hide trigger exists. 1. Assuming the patient remains seizure- and aura-free, when would you consider tapering the oxcarbazepine? * After a total of 1 year of seizure freedom After a total of 2 years of seizure freedom After a total of 3 years of seizure freedom After a total of 3-5 years of seizure freedom I would not consider tapering the medication Other - Write In * Hidden unless: #1 Question "Assuming the patient remains seizure- and aura-free, when would you consider tapering the oxcarbazepine?" is one of the following answers ("After a total of 1 year of seizure freedom","after a total of 2 years of seizure freedom","after a total of 3 years of seizure freedom","after a total of 3-5 years of seizure freedom")

2 2. Prior to starting the AED taper, what further tests would you recommend to guide your decision? * Repeat the EEG and wait longer if not normalized Repeat a high resolution brain MRI to look for a possible structural etiology Repeat both the EEG and MRI No further tests Other - Write In * (untitled) "When do you stop AEDs in patients with genetic generalized epilepsies and in those with focal epilepsies?" While recognizing each case is different and the patient s desire of continuing or stopping medications is often the most important factor, please choose the answer that best reflects your common practice and limit free text to strategies that are not included. CASE 2: Temporal lobe epilepsy after lobectomy A right-handed 35-year-old man diagnosed with epilepsy at age 18 is initially treated with carbamazepine. Despite optimization of treatment, he continued to have 1-2 generalized tonic-clonic seizures every 6 months; levetiracetam was added with no benefit. EEGs revealed mild right temporal slowing. A recent MRI showed blurring of the gray-white junction in the right temporal pole. He underwent a right temporal lobectomy with no perioperative complications. Pathology revealed an area of focal cortical dysplasia. He has continued to take carbamazepine and levetiracetam with excellent compliance since surgery. He has been seizure-free, but continues to have mild AED-induced sedation. Postoperative EEG shows no seizure activity and MRI reveals changes related to epilepsy surgery without any definite residual lesion. He works as an accountant, operates a motor vehicle and lives alone. He enjoys bicycling and jogging. He does not have other major co-morbidities. 3. What would you recommend for this patient s medically refractory epilepsy at the 6-month follow-up after surgery? * Taper one of the two AEDs now, with the goal of lifelong monotherapy Wait for another 6 months then taper one of the two AEDs, with the goal of lifelong monotherapy Wait for a total of 2 years then taper one of the two AEDs, with the goal of lifelong monotherapy Taper one of the two AEDs now, with the goal of withdrawing all AEDs Wait for another 6 months then taper one of the two AEDs, with the goal of withdrawing all AEDs Wait for a total of 2 years then taper one of the two AEDs, with the goal of withdrawing all AEDs Other - Write In * (untitled)

3 "When do you stop AEDs in patients with genetic generalized epilepsies and in those with focal epilepsies?" While recognizing each case is different and the patient s desire of continuing or stopping medications is often the most important factor, please choose the answer that best reflects your common practice and limit free text to strategies that are not included. CASE 3: Juvenile myoclonic epilepsy An otherwise healthy 19-year-old man is diagnosed at age 18 with juvenile myoclonic epilepsy (JME) and started on valproic acid. He has had no seizure recurrence, is not experiencing side effects from the medication, and has no atypical features on EEG. 4. How many years of seizure freedom would you recommend before considering AED withdrawal in this patient? * 2 years of seizure freedom 3 years of seizure freedom 5 years of seizure freedom More than 5 years of seizure freedom I do not generally recommend AED withdrawal for patients with JME Other - Write In * Demographic Information 5. What patient population do you treat? * Adults (18 years and older) Children (0 to 18 years) Both (adults and children) 6. Are you a neurophysiologist/epileptologist? * Yes No 7. How many years have you been in practice? * 1 to to 10 Over 10

4 8. What is your primary work setting? * Academic Based Government Based Hospital Based Multispecialty Group Neurology Group Other Public or Private Hospital or Clinic Solo Practice 9. What is your current level of training? * Faculty/Board certified physician Resident/Fellow Advanced Practice Provider None (Member of public) Demographic Information Show/hide trigger exists. 10. Do you currently reside in the United States? * Yes No Hidden unless: #10 Question "Do you currently reside in the United States?" is one of the following answers ("No") 11. In what country do you reside? * Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda

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