Narcolepsy Medications Flashcards
armodafinil (Nuvigil)
Indication: excessive daytime sleepiness associated with OSA, narcolepsy, or shift-work disorder (was declined for jet lag)
Dose: Start at 150mg QAM (or one hour before start of work shift); MAX=250mg; Schedule IV medication
Monitoring: no routine monitoring required
Mechanism: dopamine reuptake inhibitor (the r-enantiomer of modafinil)
Advantages: lasts slightly longer than modafinil
ADEs: headache; nausea; dizziness; irritability; insomnia; increased heart rate and BP; SERIOUS: SJS possible; multi-organ hypersensitivity reaction; angioedema; anaphylaxis; rare cases of mania and psychosis reported
Off-Label: ADHD; fatigue; treatment-resistant depression
modafinil (Provigil)
Indication: excessive daytime sleepiness associated with OSA, narcolepsy, or shift-work disorder
Dose: Start at 100mg QAM (or one hour before start of work shift); usual dose = 200mg; MAX = 400mg; Schedule IV medication
Monitoring: no routine monitoring required
Mechanism: dopamine reuptake inhibitor
ADEs: increased heart rate and BP; headache; nausea; jitteriness and agitation; rhinitis; diarrhea; back pain; insomnia; SERIOUS: SJS possible; multi-organ hypersensitivity reaction; angioedema; anaphylaxis; rare cases of mania and psychosis reported
Off-Label: ADHD; fatigue; treatment-resistant depression
pitolisant (Wakix)
Indication: excessive daytime sleepiness associated with narcolepsy
Dose: Start at 8.9mg QAM for one week; if needed may increase to 17.8mg; MAX=35.6mg
Monitoring: EKG
Mechanism: antagonist/inverse agonist of the histamine-3 receptor (H3 regulates wakefulness, appetite, and memory); blockage of H3 has downstream effects of increased dopamine and acetylcholine in the prefrontal cortex
Advantages: non-controlled agent with similar efficacy as modafinil
ADEs: insomnia; nausea; anxiety; QTc prolongation
Off-Label: ADHD; fatigue; treatment-resistant depression
sodium oxybate (Xyrem)
Indication: cataplexy; excessive daytime sedation in narcolepsy (7+)
Dose: Start at 2.25g at bedtime AND 4 hours later; titrate to effect by 0.75g per dose weekly; MAX=9mg/night; Schedule III – only distributed through the Xyrem REMS Program; wait for two hours after eating
Monitoring: no routine monitoring required
Mechanism: metabolized by conversion to carbon dioxide and eliminated by expiration; a sodium salt of gamma hydroxybutyrate (GHB)
ADEs: nausea; dizziness; vomiting; somnolence; enuresis; tremor; sleepwalking; SERIOUS: respiratory depression; depression; suicidality; impaired motor functioning; impaired cognitive functioning; VPA increases levels by 25%
Off-Label: fibromyalgia; chronic pain; neuropathic pain
Fun Facts: made by the same manufacturer of Xyrem (sodium oxybate)
solriamfetol (Sunosi)
Indication: excessive daytime sedation associated with narcolepsy or OSA
Dose: Start at 37.5mg QAM for sleep apnea or 75mg for narcolepsy; increase after a week; MAX=150mg/d; Schedule IV medication
Monitoring: no routine monitoring required
Mechanism: dopamine and norepinephrine reuptake inhibitor
ADEs: headache; nausea; decreased appetite; anxiety; SERIOUS: increased BP; psychosis; mania
Off-Label: ADHD; fatigue; treatment-resistant depression
Fun Facts: made by the same manufacturer of Xyrem (sodium oxybate)
tasimelteon (Hetlioz)
Indication: non-24-hour-sleep-wake disorder (seen in blind patients who have a shift in their sleep cycles by thirty minutes per day)
Dose: 20mg at bedtime (must be at the same time each night)
Monitoring: no routine monitoring required
Mechanism: melatonin receptor agonist (both MT1 and MT2 receptors)
ADEs: headache; increased LFTs; nightmares; unusual dreams; smoking lowers levels by 40%
Off-Label: insomnia; jet lag; shift-work disorder
Fun Facts: $13,000 per month; approved as an orphan drug (a drug for rare diseases that affect fewer than 200,000 people)
