Top 5 Modafinil Clinical Pearls

Modafinil (Provigil) is a stimulant type of medication that is most often utilized in narcolepsy. In my geriatric practice, I do see occasional off-label use to help stimulate energy in patients who are experiencing fatigue. I’ll outline my top 5 modafinil clinical pearls.

Modafinil Clinical Pearls

Polypharmacy is a problem in my geriatric patient population. Modafinil can be a band-aid for a patient who is on numerous sedative medications. This is something I hate seeing. If a patient is reporting significant fatigue, make sure that the medication regimen is reviewed for drugs that can cause sedation. I’ve seen numerous cases where patients were taking first-generation antihistamines, sleepers, benzodiazepines, or other sedating medications when modafinil was added to help manage “fatigue”. Reducing or discontinuing sedative medications should be the first action.

Cardiovascular concerns are an issue with this medication. Use modafinil cautiously in patients who have preexisting cardiac conditions. The stimulant action can increase the risk of tachycardia and hypertension. At a minimum, vital signs should be monitored closely.

While modafinil is generally considered to have a lower potential for abuse compared to traditional stimulants like amphetamines, it is still a Schedule IV controlled substance due to its potential for misuse, particularly for cognitive enhancement and wakefulness in non-medical settings.

Psychiatric changes are possible with modafinil. Insomnia and anxiety are two of the most common adverse effects of modafinil. In patients with bipolar disorder, this medication can induce mania so ideally this medication should be avoided in this patient population.

Modafinil can interact with medications metabolized by the cytochrome P450 system, particularly CYP3A4 (e.g., oral contraceptives, some anticonvulsants, and warfarin). Women using hormonal contraception should use an alternative method due to reduced efficacy while taking modafinil. Modafinil is a mild-moderate CYP3A4 enzyme inducer so it can impact numerous medications. Increasing the risk for seizure and unintended pregnancy are two real risks since this medication will likely reduce the efficacy of these agents.

If you are looking for more modafinil clinical pearls, be sure to check out this podcast episode.

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