Immediate antiepileptic drug treatment, versus placebo, defe | Figure 1

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Immediate antiepileptic drug treatment, versus placebo, deferred, or no treatment for first unprovoked seizure

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Background

Antiepileptic drug treatment following a first seizure still remains a controversial issue. In this review, we summarised evidence about the effects of immediate treatment with antiepileptic drugs compared to control (placebo [an inactive dummy treatment], deferred or no treatment) on seizure recurrence, seizure remission, side effects and mortality (death).

The evidence is current to May 2019.

Methods

Our literature search found six studies (eleven reports) that included children, adults, or both, with a first unprovoked seizure of any type (focal, generalised or unclassified). They compared antiepileptic treatment given immediately after the first seizure versus deferred (delayed) treatment, placebo or no treatment. Some of the studies did not clearly describe their methods, or how many people dropped out of the study. In five out of the six studies, the participants, clinicians and researchers involved in the studies knew which groups participants were in (immediate or delayed treatment). However, as most seizure recurrences were generalised tonic‐clonic seizures, a convulsive type of seizures that is easily recognisable, we do not think that knowing which group the participants were in influenced the results.

Results

Compared to controls, participants randomised to immediate treatment had a lower probability of seizure recurrence at one year and at five years (high‐certainty evidence), although there was no difference between immediate treatment and control in terms of five‐year remission at any time.

Immediate treatment did not contribute to the overall mortality of epilepsy after the first seizure (high‐certainty evidence), but treatment of the first seizure was associated with a significantly higher risk of adverse events. The certainty of the evidence for side effects was moderate to low with variable reporting of the outcome in the included studies; there was moderate‐certainty evidence that immediate treatment may result in more side effects than delayed treatment, but it was unclear if immediate treatment results in more side effects than placebo or no treatment.

Conclusions

In conclusion, treatment of the first unprovoked seizure seems to reduce the risk of relapse but does not affect the long‐term prognosis of epilepsy. However, treatment seems to carry a higher risk of side effects. The decision to treat a first unprovoked seizure should be individualised and based on clinical, legal, and sociocultural factors.

Read the full Cochrane Review here:

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