Motives and predictors of modified Atkins diet discontinuation as treatment of adults with drug-resistant epilepsy.

Objective: This study was undertaken to explore the motives and predictors of modified Atkins diet (MAD) discontinuation as a treatment of adults with drug-resistant epilepsy (DRE).

Methods: A single-center observational longitudinal study was made of a cohort of patients treated with MAD during the first 6 years at a multidisciplinary outpatient clinic dedicated to adult patients. Time to MAD discontinuation analyses were used to explore sociodemographic, clinical, and biochemical predictors of MAD persistence.

Results: Eighty patients initiated MAD (54% females, median age = 29 years, median epilepsy duration = 21 years, median baseline seizure frequency = 30/month, median antiseizure medications = 4, 68% focal epilepsy, 64% structural etiology, and 26% genetic cause). The patients used the diet for a median time of 122 days. Fifteen percent of patients were very early dropouts (before 30 days), 20% were early dropouts (30-89 days), and 17.5% were late dropouts (>365 days). The motives for dropout (n = 64) were noncompliance (34.4%), inefficacy (23.4%), side effects (23.4%), and diet tiredness (18.8%). Female sex (adjusted hazard ratio [HR] = 1.75, p = .042), focal seizures with preserved consciousness (adjusted HR = 2.69, p = .017), higher glycemic level at baseline (adjusted HR = 1.03, p = .044), and lower level of serum total proteins at baseline (adjusted HR = .55, p = .052) were associated with shorter persistence on MAD. The HR for discontinuation was also higher for patients without daily seizures (HR = 1.72, p = .038). Among patients with at least 3 months in MAD (n = 51), reduced clinical response at month 3 was associated with earlier discontinuation of MAD, as measured by lower percent seizure reduction (HR = .98, p = .004) and <50% seizure reduction (HR = 2.44, p = .027).

Significance: The dropout rate of MAD in adults with DRE is high even at dedicated centers. Females, patients with less severe epilepsies, and patients previously on carbohydrate-based diets may be more prone to earlier dropouts. These patients require closer monitoring in specialized ketogenic diet clinics to prevent MAD discontinuation before the minimum period necessary to evaluate response.