- Home>
- Specialty Care>
- Neurology>
- Summary and Comment
Immediate vs. Deferred AED Treatment for First Seizures
These data provide more information on the risks and benefits of each course, but treatment decisions must still be individualized.
In this study, researchers randomized 1443 patients presenting with new seizures (and no progressive illness) to either immediate treatment with antiepileptic drugs (AEDs) or waiting for subsequent seizures before treatment. The patients’ own physicians chose the drugs, usually low-dose carbamazepine or valproate.
During 5 years of follow-up, 43% of patients treated immediately had recurrent seizures, versus 53% with deferred treatment. At 5 years, about 75% were in remission (no seizures for at least 2 years), with no significant difference between groups. After 5 years, 60% of patients treated immediately were still taking AEDs, as were 41% of those who deferred treatment, presumably for recurrent seizures.
The study also confirmed earlier estimates of 50% recurrence within several years after a single seizure (Ann Neurol 2000; 48:140) -- but the recurrence rate was 70% if there were multiple seizures before enrollment. The authors conclude that deferring treatment of first seizures does not tend to lead to progressive illness -- i.e., it is not true that "seizures beget seizures" (J Clin Neurophysiol 1997; 14:102). Long-term seizure control was just as good in patients with deferred treatment.
Comment: The study was sufficiently powered, with patients randomized (but not blinded) to treatment plans, to answer the questions posed. Of note, patients reporting a first seizure must be questioned thoroughly about whether it is truly a first seizure. Those with multiple seizures are unlikely to remain seizure-free off medication, and they benefit more clearly from AEDs.
These data will aid counseling of patients who are considering AEDs after a first seizure, but the data can be over- or misinterpreted. True, about half of the patients taking AEDs after a first seizure probably do so unnecessarily, but it is very difficult to identify those patients beforehand; an EEG and evidence of earlier neurologic disease can help stratify the risk better (Neurology 1991; 41:965). And although there is apparently no significant danger of a worsened illness from delaying treatment, use of AEDs reduces the likelihood of seizure recurrence by 20%.
Many of the study patients expressed a preference for deferring medication. In contrast to these adolescent and young-adult patients in the U.K., many adult patients in our epilepsy center have young children, are more likely to drive, and often choose medication after a single seizure when told of the modest but significantly decreased risk for early seizure recurrence conferred by AEDs (Neurology 1993; 43:478).
— Frank W. Drislane, MD
Dr. Drislane is a Neurologist at the Comprehensive Epilepsy Center, Beth Israel Deaconess Medical Center, and Associate Professor of Neurology, Harvard Medical School, Boston.
Published in Journal Watch Neurology September 22, 2005
Citation(s):
Marson A et al. for the Medical Research Council MESS Study Group. Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: A randomised controlled trial. Lancet 2005 Jun 11; 365:2007-13.
- Medline abstract (Free)