Abstracts

Rationale: Driving regulations for patients with UFS vary considerably between Western countries. The regulations are reviewed and compared to consensus guidelines and data on seizure recurrence risk. Methods: Rules for non-commercial driving licenses in the USA (by state) and Western Europe were reviewed for the seizure-free period (SFP) required after a UFS and any exceptions. The literature was searched for papers on seizures and driving, and on recurrence risk following an untreated UFS. Results: International regulations for driver licensing in patients with epilepsy were last comprehensively reviewed in 1992, when considerable variation was found both between and within countries. Although the 1991 AAN/AES/EFA consensus conference suggested a 3m SFP, American states typically require longer SFP (6 or 12m) or use case-by-case decisions. Common exceptions are acute symptomatic seizures, seizures triggered by planned medication changes, nocturnal only seizures or those with a prolonged aura. Similar variability is seen in Europe, but regulations are more stringent with SFP of up to 2y and more variable exceptions. In 2005, the Second European Working Group on Epilepsy and Driving suggested a 6m SFP following a UFS. The recurrence rates for an untreated UFS were 26%, 39%, 51% and 52% at 6m, 2, 5, and 8y (n=408; MESS), 18%, 28%, 41% and 51% at 3, 6, 12 and 24m (n=193; FIRST), and 32%, 46%, 62% and 71% at 3, 6 and 12m and 3-4y (n=133; Elwes et al, 1985). Thus, a significant proportion of first recurrences occur after the range of SFP required by Western driving authorities. Nonetheless, a reduction of the driving restriction from 12 to 3m in Arizona did not lead to a higher number of seizure-related motor vehicle accidents, suggesting that a SFP of 3-6m might represent an appropriate trade-off between safeguarding the public and minimising inconvenience to the individual. At the time of AAN/AES/EFA consensus conference, relatively sparse evidence on seizure recurrence risk was available. The Second European Working Group on Epilepsy and Driving included a greater body of evidence, but predates the MESS study. It introduced risk assessment theory and the concept of an acceptable accident rate ratio, as well as making further considerations, such as patients who are banned from driving a car switching to riskier means of transport, including mopeds and bicycles. Conclusions: Western driving regulations for patients with epilepsy are highly variable both between and within countries. American and European consensus guidelines suggest SFP of 3m and 6m respectively for a UFS. In practice, regulations are more stringent, particularly in Western Europe. There is now sound evidence quantifying the recurrence risk of a UFS, but the translation of this evidence into legislation requires balancing the risk to the patient and the public against restricting an individual's freedom. It is suggested that a universal SFP of 3-6 months would not lead to a significant increase in the number of seizure-related accidents and would be less restrictive that current regulations.