Department of Neurology, University of Michigan, Ann Arbor, MI, 48109, USA.
Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, Chapel Hill, NC, 27599, USA.
BMC Neurol. 2022 Sep 1;22(1):328. doi: 10.1186/s12883-022-02852-6.
For the two-thirds of patients with epilepsy who achieve seizure remission on antiseizure medications (ASMs), patients and clinicians must weigh the pros and cons of long-term ASM treatment. However, little work has evaluated how often ASM discontinuation occurs in practice. We describe the incidence of and predictors for sustained ASM fill gaps to measure discontinuation in individuals potentially eligible for ASM withdrawal.
This was a retrospective cohort of Medicare beneficiaries. We included patients with epilepsy by requiring International Classification of Diseases codes for epilepsy/convulsions plus at least one ASM prescription each year 2014-2016, and no acute visit for epilepsy 2014-2015 (i.e., potentially eligible for ASM discontinuation). The main outcome was the first day of a gap in ASM supply (30, 90, 180, or 360 days with no pills) in 2016-2018. We displayed cumulative incidence functions and identified predictors using Cox regressions.
Among 21,819 beneficiaries, 5191 (24%) had a 30-day gap, 1753 (8%) had a 90-day gap, 803 (4%) had a 180-day gap, and 381 (2%) had a 360-day gap. Predictors increasing the chance of a 180-day gap included number of unique medications in 2015 (hazard ratio [HR] 1.03 per medication, 95% confidence interval [CI] 1.01-1.05) and epileptologist prescribing physician (≥25% of that physician's visits for epilepsy; HR 2.37, 95% CI 1.39-4.03). Predictors decreasing the chance of a 180-day gap included Medicaid dual eligibility (HR 0.75, 95% CI 0.60-0.95), number of unique ASMs in 2015 (e.g., 2 versus 1: HR 0.37, 95% CI 0.30-0.45), and greater baseline adherence (> 80% versus ≤80% of days in 2015 with ASM pill supply: HR 0.38, 95% CI 0.32-0.44).
Sustained ASM gaps were rarer than current guidelines may suggest. Future work should further explore barriers and enablers of ASM discontinuation to understand the optimal discontinuation rate.
对于三分之二在抗癫痫药物（ASM）治疗下实现癫痫发作缓解的癫痫患者，患者和临床医生必须权衡长期使用 ASM 治疗的利弊。然而，很少有研究评估在实践中 ASM 停药的频率。我们描述了持续性 ASM 用药空白的发生率和预测因素，以衡量那些可能有资格停止 ASM 治疗的个体的停药情况。
这是一项对医疗保险受益人的回顾性队列研究。我们通过要求 2014-2016 年每年有癫痫/抽搐的国际疾病分类代码和至少一种 ASM 处方，且 2014-2015 年没有癫痫急性就诊（即可能有资格停止 ASM 治疗）来确定癫痫患者。主要结局是 2016-2018 年 ASM 供应空白的第一天（30、90、180 或 360 天无药丸）。我们使用 Cox 回归分析显示累积发病率函数并确定预测因素。
在 21819 名受益人中，5191 名（24%）出现 30 天的空白，1753 名（8%）出现 90 天的空白，803 名（4%）出现 180 天的空白，381 名（2%）出现 360 天的空白。增加 180 天空白机会的预测因素包括 2015 年使用的独特药物数量（每增加一种药物的风险比 [HR]为 1.03，95%置信区间 [CI]为 1.01-1.05）和癫痫专家开具处方的医生（≥该医生 25%的癫痫就诊量；HR 2.37，95%CI 1.39-4.03）。降低 180 天空白机会的预测因素包括医疗补助双重资格（HR 0.75，95%CI 0.60-0.95）、2015 年使用的独特 ASM 数量（例如，2 种与 1 种：HR 0.37，95%CI 0.30-0.45）和更高的基线依从性（>80%与≤80%的 2015 年 ASM 药丸供应天数：HR 0.38，95%CI 0.32-0.44）。
持续性 ASM 空白比当前指南可能显示的要少见。未来的研究应进一步探讨 ASM 停药的障碍和促进因素，以了解最佳停药率。
