THERAPEUTICS

Brands

• Provigil, Alertec, Modiodal

Generic?

• Yes

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

• Treatment of fatigue in multiple sclerosis (MS)

• Fatigue in depression

• Attention deficit hyperactivity disorder

• Fatigue in cancer, HIV, fibromyalgia, or post-stroke patients

• Bipolar depression

How the Drug Works

• Unlike traditional stimulants which act directly via dopaminergic pathways, it may also act in the hypothalamus by stimulating wake-promoting areas, or inhibiting sleeppromoting areas

• It may also have effects on dopamine transporter pathways similar to other stimulants, hypothetically inhibiting the dopamine transporter

• 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 1–2 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 (i.e., OSA) of fatigue. Consider other causes of fatigue (i.e., anemia, heart disease) as appropriate. Screen for use of CNS depressants that can interfere with sleep, i.e., opioids or alcohol

Best Augmenting Combos for Partial Response or Treatment-Resistance

• In treating OSA, modafinil is an adjunct to standard treatments such as continuous positive airway pressure (CPAP), weight loss, and treatment of obstruction when possible

• In MS change drug regimen, i.e., antispasticity or disease-modifying agents when possible if they are significantly contributing to fatigue. Amantadine is an alternative treatment for MS-related fatigue.

• Treat coexisting medical illnesses such as HIV, depression, or chronic pain disorders with appropriate agents

Tests

• None required