What is the risk of soriamfetol (generic name) triggering a seizure in a patient with a seizure disorder?

Risk of Solriamfetol Triggering Seizures in Patients with Seizure Disorders

Solriamfetol should be used with caution in patients with seizure disorders as there is a potential risk of triggering seizures, though specific data on seizure exacerbation with solriamfetol is limited.

Mechanism and Risk Assessment

Solriamfetol is a dopamine and norepinephrine reuptake inhibitor approved for the treatment of excessive daytime sleepiness associated with narcolepsy and obstructive sleep apnea. As a stimulant medication, it carries theoretical concerns similar to other CNS stimulants:

• Stimulant medications can lower the seizure threshold in susceptible individuals
• The American Academy of Sleep Medicine strongly recommends solriamfetol for excessive daytime sleepiness but does not specifically address its use in patients with seizure disorders 1
• While there are no direct studies on solriamfetol's effect on seizure threshold, caution is warranted based on the known effects of similar medications

Evidence from Related Medications

The risk can be better understood by examining data from similar stimulant medications:

• Psychotropic drugs, including stimulants, can reduce seizure threshold with reported seizure incidence rates ranging from approximately 0.1% to 1.5% in patients on therapeutic doses 2
• Seizures triggered by psychotropic drugs are generally dose-dependent adverse effects 2
• Methylphenidate, another stimulant, showed a trend toward reduction rather than increase in seizure frequency in brain-injured patients with seizure disorders in one retrospective study 3

Risk Factors and Considerations

Several factors may increase the risk of seizures when using solriamfetol:

• History of epilepsy or previous seizures
• Concurrent use of other medications that lower seizure threshold
• Rapid dose titration
• Higher doses of medication
• Metabolic factors and drug-drug interactions 2, 4

Recommendations for Clinical Practice

If solriamfetol is considered necessary for a patient with a seizure disorder:

1. Start with a lower dose - Begin with 37.5mg (half the usual starting dose) and titrate slowly
2. Monitor closely - Especially during the initial treatment period and with any dose increases
3. Ensure optimal seizure control - Verify that the patient's seizure disorder is well-controlled on appropriate antiseizure medications
4. Avoid rapid dose escalation - Allow at least 7 days between dose increases (longer than the standard 3 days)
5. Consider drug interactions - Evaluate potential interactions with antiseizure medications
6. Regular follow-up - Schedule more frequent monitoring during the initial treatment period

Alternative Considerations

For patients with poorly controlled seizures or high seizure risk:

• Consider alternative treatments for excessive daytime sleepiness with potentially lower seizure risk
• Ensure optimization of the underlying seizure disorder treatment before initiating solriamfetol

Conclusion

While there is no absolute contraindication to using solriamfetol in patients with seizure disorders, the theoretical risk of seizure exacerbation necessitates careful consideration of the risk-benefit ratio, appropriate dosing strategies, and close monitoring. The decision should weigh the potential benefits of improved wakefulness against the risk of seizure exacerbation in each individual case.