Should any medications be held in a patient with fever, alcohol use disorder, nicotine use disorder, and seizure disorder, taking Valproate and Lemborexant?

Management of Medications in a Patient with Fever and Seizure Disorder

In a patient with fever (100°F), alcohol use disorder, nicotine use disorder, and seizure disorder on valproate and lemborexant, no medication needs to be held at this time, but close monitoring is required as the fever may be investigated for underlying causes.

Evaluation of Current Medications

Valproate (250 mg twice daily)

• Valproate is a first-line antiepileptic drug for seizure disorders and should be continued during fever to maintain seizure control 1
• Abrupt discontinuation of antiepileptic drugs can precipitate status epilepticus with potential life-threatening consequences 2
• Fever itself can lower seizure threshold, making maintenance of therapeutic antiepileptic medication levels particularly important 1
• The current low-grade fever (100°F) does not warrant discontinuation of valproate therapy 1

Lemborexant (10 mg at bedtime)

• Lemborexant is a sleep medication (orexin receptor antagonist) used for insomnia
• There is no evidence suggesting that lemborexant needs to be discontinued during mild febrile illness 1
• No significant drug interactions between lemborexant and valproate have been documented that would necessitate discontinuation during fever 1

Special Considerations

Alcohol Use Disorder and Valproate

• Valproate has shown efficacy in managing alcohol withdrawal symptoms and may be beneficial in patients with comorbid alcohol use disorder and seizure disorder 3
• Continuing valproate is particularly important in this patient population as alcohol withdrawal can trigger seizures 1
• Discontinuing valproate could potentially worsen both seizure control and alcohol withdrawal symptoms 3

Fever Management

• The current fever is mild (100°F) and does not necessarily indicate serious infection requiring medication changes 1
• Investigation for the cause of fever is warranted, particularly in a patient with seizure disorder 1
• If the fever is found to be due to infection requiring antibiotics, caution should be exercised with certain antibiotics:
  • Carbapenem antibiotics (ertapenem, imipenem, meropenem) can significantly reduce serum valproate levels and should be avoided if possible 2, 4
  • If carbapenems are necessary, increased monitoring of valproate levels and seizure activity is essential 2

Seizure Risk Factors

• This patient has multiple risk factors for seizures:
  • Pre-existing seizure disorder 1
  • Alcohol use disorder (potential for withdrawal seizures) 1
  • Fever (can lower seizure threshold) 1
• Maintaining adequate antiepileptic medication is critical to prevent breakthrough seizures 5

Monitoring Recommendations

• Monitor temperature trends and investigate underlying cause of fever 1
• Assess for signs of infection that might require specific treatment 1
• Watch for signs of valproate toxicity (confusion, somnolence, tremor) which could be exacerbated during illness 2
• Ensure adequate hydration, as dehydration during febrile illness can affect drug levels 2
• If fever persists or worsens, reassess medication management but prioritize seizure control 1

Conclusion

For this patient with mild fever, seizure disorder, and substance use disorders, the benefits of continuing both valproate and lemborexant outweigh the risks of discontinuation. Close monitoring for seizure control, medication side effects, and the underlying cause of fever is recommended.