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letter
. 2015 Oct;5(5):368–369. doi: 10.1212/01.CPJ.0000472924.45066.59

First seizure management

I can see clearly now?

Allan Krumholz 1, Shlomo Shinnar 1, Jacqueline A French 1, Gary S Gronseth 1, Samuel Wiebe 1
PMCID: PMC5762017  PMID: 29443159

We appreciate Drs. Cole and Cascino's thoughtful comments and provocative insights1 regarding our recently published first seizure management guideline.2 We concur that even the American Academy of Neurology's (AAN's) rigorous guideline process has limitations, but caution not to make the perfect the enemy of the good.

Practice guidelines are meant to systematically summarize the best evidence relevant to specific clinical questions. Sometimes guidelines can make recommendations that favor one treatment approach over another.3,4 Practice guidelines are not meant to replace clinical judgment. Rather, guidelines highlight when good judgment is needed because of limitations in the evidence. This guideline and its earlier companion5 review the evidence on reducing short- and long-term seizure recurrence risk, but this may be different from the consequences inherent in a recurrent seizure. This is why the guideline emphasizes the clinician's role in helping patients individually weigh those risks and values.1 That is the practice of medicine, and guidelines are not supposed to replace it but rather to inform good clinical decision making.3,4 AAN guidelines are highly regarded and used by neurologists,3 and growing access to them on modern digital media make them more available to all medical providers and to patients. This is also good.

References

  • 1.Cole AJ, Cascino GD. First seizure management: I can see clearly now? Neurol Clin Pract. 2015;5:278–280. doi: 10.1212/CPJ.0000000000000151. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Krumholz A, Wiebe S, Gronseth GS. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84:1705–1713. doi: 10.1212/WNL.0000000000001487. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Gronseth G, French J. Practice parameters and technology assessments: what they are, what they are not, and why we should care. Neurology. 2008;71:1639–1643. doi: 10.1212/01.wnl.0000336535.27773.c0. [DOI] [PubMed] [Google Scholar]
  • 4.Ben-Menachem E, French JA. Guidelines—are they useful? Epilepsia. 2006;47:62–64. doi: 10.1111/j.1528-1167.2006.00663.x. [DOI] [PubMed] [Google Scholar]
  • 5.Krumholz A, Wiebe S, Gronseth G. Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence- based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007;69:1996–2007. doi: 10.1212/01.wnl.0000285084.93652.43. [DOI] [PubMed] [Google Scholar]
Neurol Clin Pract. 2015 Oct;5(5):368–369.

This letter is copublished in Neurology® and Neurology® Clinical Practice.

Disclosures: A. Krumholz serves on the editorial board for Clinical EEG and Neuroscience and has received royalties from UpToDate. S. Shinnar has served on scientific advisory boards for Acorda, Questcor, and Upsher-Smith; has received royalties for Febrile Seizures and honoraria from Questcor, UCB, and Upsher-Smith; has received research funding from the National Institute of Neurological Disorders and Stroke and the Citizens United for Research in Epilepsy Foundation; and has given expert testimony. J.A. French has served as a consultant for Acorda, Biotie, Eisai Medical Research, GlaxoSmithKline, Impax, Johnson & Johnson, LCGH, Marinus, Novartis, Pfizer, Sunovion, SK Life Science, Supernus Pharmaceuticals, UCB, Upsher-Smith, and Vertex; has received grants from Eisai Medical Research, Epilepsy Research Foundation, Epilepsy Study Consortium, Epilepsy Therapy Project, Lundbeck, Pfizer, and UCB; and is president of the Epilepsy Study Consortium. All consulting is done on behalf of the Consortium, and fees are paid to the Consortium. New York University receives salary support from the Consortium. G.S. Gronseth reports no disclosures. S. Wiebe has received research funding from the Alberta Heritage Medical Research Foundation, the Canadian Institutes for Health Research, the M.S.I. Foundation of Alberta, and the Hotchkiss Brain Institute of the University of Calgary.

Neurol Clin Pract. 2015 Oct;5(5):368–369.

Authors Respond:

Andrew J. Cole, MD, Gregory D. Cascino, MD: We appreciate Dr. Krumholz and his team's hard work on the guidelines2 and their thoughtful response to our commentary.1 While the perfect may be the enemy of the good, the good is not perfect. Nonetheless, guidelines take on the mantle of standard of care and are sometimes used by payers, lawyers, quality and safety officers, auditors, and administrators to bludgeon thoughtful physicians who come to alternative conclusions. Our point is that guidelines are frequently useful but were not brought down from the mountain on stone tablets; thus, blind acceptance should not be substituted for considered judgment in specific clinical situations.

Massachusetts General Hospital and Harvard Medical School (AJC), Boston; Mayo Clinic (GDC), Rochester, MN.

Disclosures: A.J. Cole serves on scientific advisory boards for BrainVital Corporation, Precisis AG, and Sage Therapeutics; serves as an associate editor for Annals of Clinical and Translational Neurology; receives publishing royalties from UpToDate; serves as a consultant to Sage Therapeutics, Clarus Ventures, and Precisis AG; receives research support from Neuropace and Sunovion; and has received stock/stock options from Precisis AG and Sage Pharmaceuticals. G.D. Cascino serves as an associate editor for Neurology; receives research support from the NIH; and receives royalties for Mayo Foundation- Mayo Clinic Ventures-High frequency nerve stimulation to treat lower back pain (Nevro, 2013).

Articles from Neurology: Clinical Practice are provided here courtesy of American Academy of Neurology

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