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People with epilepsy (PWE) have identified driving as an important factor influencing quality of life and employment. Most countries, provinces and states have laws or guidelines regulating driving privileges following single or recurrent seizures. Driving restrictions for PWE are typically defined by the seizure-free interval (SFI), which varies by jurisdiction. The purpose of such regulations is presumed to be public safety followed by safety of the PWE. Balancing public safety with personal freedom to drive and its potential affect on quality of life may be in conflict. The efficacy of such regulations has been minimally studied.
Bonnett and colleagues reanalysed data from the Multicentre study of early Epilepsy and Single Seizures (MESS) study which was originally designed to determine the probability of seizure recurrence in the period of time 6 months beyond the first event, and the influence of seizure medications usage. Data on driving abilities and safety were not included in the MESS study.
In this reanalysis of MESS, participants not of driving age were excluded. Speculation on how their results may apply to driving regulation policy was included. The authors reported independent predictors of seizure recurrence, including an abnormal neurologic exam, epileptiform EEG abnormalities, seizure while asleep, remote symptomatic seizure and absent neuro-imaging, but none predicted recurrence with sufficient power to guide treatment decisions. Early seizure medication use (within 6 months) reportedly reduced the recurrence risk to less than 20%; a probability deemed acceptable by European Union driving guidelines. For participants not taking medication, the risk was also reported to be below 20%, but the 95% CIs exceeded the established ‘safe’ threshold (23%). The number of participants involved in crashes (because of seizure or otherwise) and other driving related data were not studied.
The authors suggest that early medication use provided short-term benefits after an initial seizure. The value of extrapolating the Bonnett-reanalysed data on seizure recurrence to help guide policy making or driving decisions is unclear. Although seizure recurrence represents an important issue accepted by driving authorities as a determinant for fitness to drive, other likely germane factors are not considered. Krauss reported that factors important for counselling PWE who have had a crash-related seizure included the SFI, presence of reliable aura and prior non-seizure related crashes (prior poor driving). The majority of Krauss's participants were driving illegally at the time of the seizure-related crash.1 Changing the SFI from 12 to 3 months had no effect on crash rates because of seizure2 and SFI length did not correlate with deaths because of seizure-related crashes.3 The lack of awareness about driving regulations may impact on driving safety, and with studies in the USA and the UK revealing a considerable knowledge gap between PWE and healthcare providers.4,–,6 The study by Bonnet and colleagues suggests the early use of seizure medication reduces recurrence risk, but the potential for untoward effects of such medications impairing the ability to drive, was not considered. Complicating the issue further is the potential for inconsistency in the application of guidelines during legal proceedings.7 Age, amount of driving, experience and physical abilities of a driver influence safe driving, with novices and older people having higher crash rates. The novice driver and aged driver are typically not specifically regulated despite posing a higher risk to the public. Almost 20 years ago, a consortium of experts representing the Epilepsy Foundation of America, American Academy of Neurology and American Epilepsy Societyprovided opinion recommending a set of regulatory parameters regarding PWE and driving.8 Progress has since been made regarding how we counsel and regulate driving for PWE, but much of our decision-making process in this area is based on opinion. Considerable knowledge gaps on this subject exist for provider and patients. The present study should be applauded for adding to our understanding of seizure recurrence risk and early medication use, which may or may not correlate with a risk of harm while driving. Specific study is needed on this subject to further understand all relevant factors which directly and clearly influence the risk of seizure-related crashes. Knowledge gained in this process should be applied to driving regulations that fairly and reasonably balance public safety with the concerns of the individual.
Competing interests None.
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