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Published online by Cambridge University Press: 06 October 2020
THERAPEUTICS
Brands
• Nuvigil
Generic?
• No
Class
• Psychostimulant
Commonly Prescribed for
(FDA approved in bold)
• Reducing excessive sleepiness in patients with narcolepsy or shift work disorder
• Reducing excessive sleepiness in patients with obstructive sleep apnea (OSA)/ hypopnea syndrome
• Attention deficit hyperactivity disorder
• Fatigue in multiple sclerosis (MS), depression, cancer, HIV, fibromyalgia, or post-stroke patients
• Bipolar depression
How the Drug Works
• Armodafinil is the R-enantiomer of modafinil (a mixture of R- and S-enantiomers). R-modafinil binds to the dopamine transporter (DAT) with 3-fold higher affinity than S-modafinil
• No binding to serotonin transporter or norepinephrine transporter
• It may act on the hypothalamus by stimulating wake-promoting areas, or inhibiting sleep-promoting areas. Increases neuronal activity selectively in the hypothalamus and activates tuberomammillary nucleus neurons that release histamine
• It also activates hypothalamic neurons that release orexin/hypocretin
How Long Until It Works
• Typically 2 hours, although maximal benefit may take days to weeks
If It Works
• Continue to use indefinitely as long as symptoms persist. Complete resolution of symptoms is unusual. Does not cause insomnia when dosed correctly
If It Doesn't Work
• Change to most effective dose or alternative agent. Re-evaluate treatment of underlying cause (e.g., OSA) of fatigue. Consider other causes of fatigue (e.g., anemia, heart disease) as appropriate. Screen for use of CNS depressants that can interfere with sleep (e.g., opioids or alcohol)
Best Augmenting Combos for Partial Response or Treatment-Resistance
• In treating OSA, armodafinil is an adjunct to standard treatments such as continuous positive airway pressure (CPAP), weight loss, and treatment of obstruction when possible
• In narcolepsy with cataplexy, TCAs or SNRIs may be of some help on cataplexy. Sleep hygiene is also important. As a last resort, sodium oxybate can be used for both narcolepsy and cataplexy
Tests
• None required
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