Early or deferred anticonvulsants: up to the patient?

The decision for immediate or deferred initiation of anti-epileptics in patients experiencing single or few seizures should be based on patient preferences, according to a new study of quality of life outcomes.Dr Ann Jacoby (University of Liverpool, UK) and colleagues comment that the decision of whether to begin antiepileptic drugs in patients experiencing single or few seizures involves an assessment of clinical and psychosocial (including "stigma") issues. The group add that to date there are few randomised studies comparing policies of immediate or deferred treatment, and none examining quality of life outcomes.To investigate further the authors randomised patients with a history of one or more unprovoked epileptic seizures, in which both the clinical and patient were uncertain whether to commence therapy, to either 'immediate' or 'deferred' treatment groups. Quality of life data was then collected using a validated questionnaire at baseline and after two years.Based on completed results from 331 patients (162 randomised to immediate, 169 to deferred treatment) Jacoby's group report that patients allocated to deferred treatment were no more likely to have impairments in general health, cognitive function, psychological well-being, or social function. However, due to local driving regulations requiring a 12 month seizure free period before reissuing a licence, the deferred treatment group were disadvantaged in this respect.Jacoby and colleagues comment "In treatment uncertain patients, there is a clear trade-off between adverse effects of seizures and adverse effects of taking antiepileptic drugs." They add, "neither policy examined in our study was associated with overall quality of life gains or losses."In a related editorial Dr Barbara Vickrey (Department of Neurology, University of California, LA) write that Jacoby et al's findings add to accumulating evidence that long-term (3-5 year) seizure control is "unaffected by whether antiepileptic drug treatment is instituted immediately or is deferred and instituted in the event of a recurrent seizure."Dr Vickrey continues, "patients' preferences for one or the other alternative approach should be the dominant driver of the decision" and calls for further investigation into potential barriers for implementation of this approach in to routine care (including; liability issues, physician knowledge and beliefs, patient expectations, economics).Reference...