Modafinil (Provigil) & Armodafinil (Nuvigil)
Novel stimulant (dopamine reupatke inhibitor; serotonin/norepinephrine reupate inhibition)
- ADHD3
- Bipolar Depression2
- Major Depression3 (improves executive function)
- Cocaine2 and Methamphetamine3
- Sleep apnea (fatigue)1
- Shift work disorder (fatigue)1
Features
Dosing
Armodafinil (Nuvigil): 50-250 mg in am, can take PRN.
Modafinil (Provigil): 100-200 mg in am, can take PRN.
INTERACTIONS: May decrease birth control efficacy (moderate inducer at CYP3A4). May also lower levels of antipsychotics (cariprazine, lumateperone, lurasidone, quetiapine, ziprasidone, pimavanserin), citalopram, buspirone, guanfacine, benzos, z-hypnotics, tricyclics.
Management
Improves fatigue, mood, shift-work syndrome, reduces impulsivity and binge eating, treats ADHD about half as well as stimulants. Tell patient some insurers don’t cover it and we can’t authorize it since it’s not officially a psych med, but can get out-of-pocket for $35 at Harris Teetor or Costco or GoodRx.com
Armodafinil is preferred. Compared to modafinil, armodafinil has steadier serum levels throughout the day.
TOLERABILITY: anxiety, headache, insomnia (but can also help sleep by setting the sleep cycle); all improve with dose reduction.
RISKS: Caution of possible heart arrhythmias, hypertension, serious rash.
EMR Text
Depression
Modafinil use based on controlled trials in major depressive disorder, where it improved mood and cognition (Abolfazli R et al, Depress Anxiety. 2011;28(4):297-302; Vaccarino SR et al, J Clin Psychiatry. 2019;80(6):19r12767).
Modafinil’s side effects and risks reviewed with patient.
Bipolar Depression
Modafinil use based on controlled trials in bipolar depression (Nunez NA et al, Bipolar Disord. 2020;22(2):109-120).
Modafinil’s side effects and risks reviewed with patient.
ADHD
Modafinil use based on multiple controlled trials in ADHD (Wang SM et al, J Psychiatr Res. 2017;84:292-300).
Modafinil’s side effects and risks reviewed with patient.
Shift Work
Modafinil use based on FDA approval in shift work disorder.
Modafinil’s side effects and risks reviewed with patient.
Sleep Apnea
Modafinil use based on FDA approval for residual symptoms of sleep apnea.
Modafinil’s side effects and risks reviewed with patient.
Cocaine
Modafinil use based on multiple controlled trials in cocaine use disorder (Kampman KM et al, Drug Alcohol Depend. 2015;155:105-110).
Modafinil’s side effects and risks reviewed with patient.
Methamphetamine
Modafinil use based on trials in methamphetamine use disorder, where it improved memory, withdrawal symptoms, and may increase abstinence (Kalechstein AD et al, Am J Addict. 2010;19(4):340-344).
Modafinil’s side effects and risks reviewed with patient.