Neuro-oncologic chemotherapeutic drugs EGFR, Epidermal growth factor receptor; G-CSF, granulocyte-colony stimulating factor; PCV, procarbazine, CeeNU, vincristine; PDGFR, platelet-derived growth factor receptor; VEGF, vascular endothelial growth factor. Chorea management, chorea medications table, chorea therapeutic appendix, tetrabenazine, deutrabenazine Dementia medications, Donepezil, Aricept, Galantamine, Razadyne, Rivastigmine, Exelon, Memantine, Namenda, Alzheimer Disease, Vascular Dementia, Dementia with Lewy Bodies, Parkinson Disease Dementia AD, Alzheimer dementia; PDD, Parkinson disease dementia; DLB, Lewy body dementia; VasD, vascular dementia. ** Patch can be used with severe forms of AD and PDD. Depression, antidepressants NDRIs, Norepinephrine and dopamine reuptake inhibitors; SE, side effects; SSNRIs, selective serotonin and norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors. Anti-epileptic, seizure medications Side effects in bold indicate black box warning. D, Diarrhea; HI, homicidal ideations; N, nausea; SI, suicidal ideations; SJS, Stevens-Johnson syndrome; SLE, systemic lupus erythematosus; TEN, toxic epidermal necrolysis; V, vomiting. a Indications represent older terminology as indicated by FDA labeling prior to new terminology b Common side effects to almost all AEDs: mental status: dizziness, drowsiness, sleepiness; cerebellar/coordination: unsteadiness, blurred vision, ataxia, tremor, nystagmus; cognitive: impaired memory, fatigue. Triptans, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan Insomnia, benzodiazepines, sedatives, hypnotics, lunesta, ambien Good sleep practices and cognitive behavioral approach should be considered in elderly neurological patients.
Therapeutic Appendix
Chemotherapy: common Neuro-Oncologic drugs
Keywords
Agent
Mechanism
Dosage
Major side effects
Carboplatin
DNA alkylation
IV: 400 to 500mg/m2 every 4 weeks
Myelosuppression, nausea, hypersensitivity reactions
Carmustine (BiCNU)
DNA and RNA alkylation
IV: 80 mg/m2/day for 3 days every 8 wk for 6 cycles
Myelosuppression, nausea, pain at injection site, hypotension
Carmustine wafer (Gliadel)
Wafer implanted intracranially into the resection cavity
Implantation: 8 wafers
(7.7 mg each and total dose 61.6 mg)
Seizures, cerebral edema, depression
Cisplatin
DNA alkylation
IV: 100 mg/m2 every 3 wk
Renal toxicity, ototoxicity, hypersensitivity reactions, severe nausea
Erlotinib (Tarceva)
EGFR kinase inhibitor
Oral: 150 mg once daily
Skin rash, fatigue, diarrhea
Gefitinib (Iressa)
EGFR kinase inhibitor
Oral: 250 mg once daily
Skin reactions, diarrhea
Hydroxyurea (Droxia; Hydrea)
Antimetabolite: inhibits ribonucleoside diphosphate reductase
Oral:15 mg/kg/day
Eczema, transient myelosuppression
Imatinib (Gleevec)
c-kit and PDGFR kinase inhibitor
Oral: 400 mg twice daily
Edema, fatigue, skin rash,
nausea, diarrhea
Irinotecan (Camptosar)
Topoisomerase I inhibitor
IV: 125 mg/m2 once every 2 wk
Cholinergic syndrome, alopecia, myelosuppression, diarrhea
Lomustine (CeeNU)
DNA and RNA alkylation
Oral: PCV regimen 75 to 130 mg/m2 once every 6 wk
Myelosuppression, nausea, stomatitis, pulmonary fibrosis
Methotrexate
Antimetabolite: inhibits dihydrofolate reductase
IV: 8000 mg/m2 every 14 days
Arterial thrombosis, myelosuppression, hepatotoxicity
Procarbazine (Matulane)
DNA alkylation and depolymerization
Oral: 60 mg/m2 (6 cycles) or 75 mg/m2 (4 cycles) days 8 to 21 every 6 wk in PCV regimen
Nausea, myelosuppression, edema
13-cis-Retinoic acid (Absorica)
Inhibits cell proliferation
Oral: 160 mg/m2/day days 1 through 14 every 28 days for 6 cycles
Hypertriglyceridemia, back pain, conjunctivitis
Tamoxifen (Soltamox)
Competitively binds to estrogen receptors on tumors and decreases DNA synthesis
Oral: 20 to 40 mg daily (males and females)
Flushing, rash, hypertension
Temozolomide (Temodar)
DNA methylation
Concomitant: Oral, IV: 75 mg/m2/day for 42 days with focal radiotherapy; Maintenance: 150 mg/m2/day for 5 days of a 28-day cycle
Fatigue, peripheral edema, alopecia, myelosuppression
Vincristine (Vincasar PFS)
Inhibits RNA synthesis
IV: PCV regimen 1.4 mg/m2/dose on days 8 and 29 of a 6-wk cycle for a total of 6 cycles
Alopecia, peripheral neuropathy, constipation
Everolimus (Afinitor)
Reduces protein synthesis, cell proliferation and angiogenesis
Oral: 4.5 mg/m2 daily
Pneumonitis, stomatitis, metabolic toxicity
Bevacizumab (Avastin)
Inhibits VEGF
IV: 10 mg/kg every 2 wk
Hypertension, fatigue, infections, hemorrhage
OTHERS
Erythropoietin alpha (Epogen; Procrit)
Erythropoiesis stimulation
SubQ: 150 units/kg 3 times a week
or 40,000 units once weekly
Nausea, hypertension
Darbepoetin alfa (Aranesp)
Erythropoiesis stimulation
SubQ: 2.25 mcg/kg once weekly or
500 mcg once every 3 weeks
Hypertension, dyspnea, peripheral edema
Filgrastim (GRANIX; Neupogen)
G-CSF stimulation
SubQ, IV: 5 mcg/kg/day
Nausea, thrombocytopenia, fatigue
Pegfilgrastim (Neulasta)
G-CSF stimulation
SubQ: 6 mg once per chemotherapy cycle
Ostealgia, limb pain
Dexamethasone (Decadron)
Suppression of neutrophil migration and production of inflammatory mediators; reversal of increased capillary permeability
Cerebral edema: IV: 10 mg stat, then 4 mg IM/IV every 6 hours until response is maximized, then switch to oral regimen and gradually taper off
Neoplastic epidural spinal cord compression: IV: 10 to 96 mg bolus; followed by 4 to 24 mg four times daily for 3 days and then taper over 10 days
Adrenal insufficiency, myopathy
Chorea (Movement Disorder)
Keywords
Medication
Dosage
Action
Side Effects
Clozapine (Clozaril)
12.5–25 mg qh, increase by 12.5-25 mg q 3 d max 150 mg
D1 and D2 blocker, blocks serotonin type 2 (5 HT2), alpha-adrenergic, H1, and cholinergic receptors
Sedation, diarrhea, weight gain, hypotension, dose-related seizures, agranulocytosis
Haloperidol (Haldol)
Begin 0.5–1 mg and increase by 0.5 mg qw in tid dosing max 10 mg
Blocks D1 and D2 receptors in the brain
Tardive dyskinesia, acute dystonia, akathisia, swallowing, gait difficulties, parkinsonism
Perphenazine
Begin 4 mg qd, increase by 4 mg/wk tid max 24 mg
Blocks postsynaptic mesolimbic dopaminergic receptors
Tardive dyskinesia, acute dystonia, akathisia, swallowing, gait difficulties, parkinsonism
Quetiapine (Seroquel)
25 mg qh, increase by 25 mg q 3–5 d bid max 400 mg
Proposed D2 and 5-HT2 antagonist
Parkinsonism, depression, drowsiness, hypotension
Reserpine
Begin 0.1 mg, increase by 0.1 mg q 5–7 d tid or qid max 3 mg
Depletes norepinephrine and dopamine
Parkinsonism, depression, drowsiness, hypotension
Risperidone (Risperdal)
0.5 mg qh, increase by 0.5 mg q 3–5 d max 6 mg
Mixed D2 and 5-HT2 antagonist
Parkinsonism, depression, drowsiness, hypotension
Tetrabenazine
Begin 12.5 mg, increase q 5–7 d tid or qid max 200 mg
Presynaptic dopamine depleter, binds to central VMAT2
Parkinsonism, depression, drowsiness, hypotension
Deutetrabenazine
Begin 6 mg, increase 6 mg q 7 d bid max 96 mg
Presynaptic dopamine depleter, binds to central VMAT2
Same profile as Tetrabenazine, but milder
Dementia: Primary Medications
Keywords
Medication
Donepezil (Aricept)
Galantamine (Razadyne)
Rivastigmine (Exelon)
Memantine (Namenda)
Indication
AD (Mild to Severe); PDD, DLB (Off-Label)
AD (Mild-moderate); AD (Severe; off-label); PDD, DLB (Off-label)
AD (Mild-moderate)**
PDD** (Mild-moderate);
DLB (Off-label);
AD (Moderate to severe); VasD (mild-moderate; off label); PDD/DLB (off label)
Mechanism of action
AChE-I
AChE-I
AChE-I
NMDA-R antagonist
Absorption affected by food
No
Yes; take with meals
Yes; take with meals
No
Time to peak
3 hr
(Extended release 23 mg tab 8 hr)
1 hr (2.5 hr with food)
ER 5 hr
1 hr for tablets; Patch 8–16 hr
3–7 hr (ER 9–12 hr)
Serum t1/2
70 hr
7 hr
1.5 hr (Patch 3 hr)
60–80 hr
Metabolism
CYP-2D6
CYP-3A4
CYP-2D6
CYP-3A4
Nonhepatic
Nonhepatic
Dose: Initial
5 mg QD
(ER 8 mg/day)
4mg BID
(ER 8 mg QD)
1.5 mg BID
(Patch 4.6 mg /24 hr)
2.5 mg BID or 5 mg QD
(ER 7 mg QD)
Titration required
Yes
Yes
Yes
Yes
First effective dose:
5 mg (severe AD: 10 mg)
8 mg BID
(ER 16 mg QD)
3 mg BID; 4.6 mg/24 hr patch
10 mg BID
Dose: Maximum
10 mg qd
(23 mg QD)
12 mg BID
(ER 24 mg QD)
6 mg BID
(Patch 13.3 mg/24 hr)
10 mg BID
(ER 28 mg QD)
Renal impairment
adjustment
N/A
CrCl 9-59 Max dose 16 mg QD; CrCl < 9 Not recommended
None; use with caution CrCl < 50
For CrCl 15–29: max 5 mg BID (ER 14 mg QD)
Hepatic impairment
N/A
ChildPugh 7–9: Max 16 mg daily; ChildPugh 10–15: Not recommended
Max dose 4.6 mg/24 hr (applies to patch only)
N/A
Common side effects
Nausea, vomiting, diarrhea, insomnia, muscle cramps
Nausea, vomiting, diarrhea
Nausea, vomiting, diarrhea, weight loss
Dizziness, agitation, headache
Depression
Keywords
Generic name
Brand name
Dosage range (mg/d)
Anticholinergic effect
Sedative effect
Comments/side effects
Tricyclics/heterocyclics
Amitriptyline (3)
Elavil
25–300
High
High
SE: Orthostatic hypotension, sedation, weight gain, sexual dysfunction, QT prolongation, arrhythmia, decreased seizure threshold, overdose lethal
Desipramine (2)
Norpramin
25–200
Low
Low
Doxepin (3)
Sinequan
25–150
Moderate
Moderate
Imipramine (3)
Tofranil
25–300
Moderate
Moderate
Nortriptyline (2)
Aventyl, Pamelor
20–150
Low
Low
SSRIs
Fluoxetine
Prozac
20–60
Very low
Very low
Lexapro is effective in GAD
Sertraline
Zoloft
25–250
Very low
Very low
SE: Dry mouth, nausea, nervousness insomnia, sexual dysfunction, headache, QT prolongation (especially citalopram)
Paroxetine
Paxil
20–40
Low
Low
Paroxetine and Fluoxetine CYP2D6 inhibitors
Citalopram
Celexa
20–40
Very low
Very low
Escitalopram
Lexapro
10–20
Very low
Very low
SSNRIs
Duloxetine
Cymbalta
20–60
Very low
Very low
SE: Nausea and anorexia, weight loss, nervousness, headache, insomnia, fatigue, dry mouth, constipation, sexual dysfunction, tachycardia, hyperlipidemia, diaphoresis, hypertension
Venlafaxine
Effexor
37.5–225
Very low
Low
This class is effective in treating neuropathic pain.
Desvenlafaxine
Khedezla
50
Very low
Very low
Levomilnacipran
Fetzima
20–120
Very low
Very low
Reuptake inhibitors and receptor antagonists
Trazodone
Desyrel
50–600
Very low
High
SE: Dry mouth, nausea, dizziness
Nefazodone
Sermonette
200-600
Low
Moderate
Mirtazapine
Remeron
15–45
Low
High (activating effect with higher doses)
Mirtazapine helpful with appetite stimulation, improved sleep, and no sexual SE.
NDRIs
Bupropion
Wellbutrin
200–300
Very low
Very low
SE: Agitation, nausea, headache, anorexia, insomnia, hypertension, decreased seizure threshold. No sexual SE.
5-HT reuptake inhibitor and selective/partial 5-HTR agonist
Vilazodone
Viibryd
10–40
Very low
Very low
SE: Diarrhea, nausea, vomiting, insomnia, bleeding, suicidal ideation
Vortioxetine
Trintellix
10–20
Very low
Very low
SE: Constipation, nausea, vomiting, hyponatremia, suicidal thoughts
Epilepsy
Keywords
AED
Best treated epilepsy typea
Dosage
Renal/hepatic pharmacokinetics
Adverse effects (common side effects)b
Carbamazepine
Partial, generalized
400 mg mg qd, increase by 200 mg mg/day at 1 wk intervals. Max 1200 mg/day
Induces CYP3A4 & CYP1A2. Primarily renal excretion.
Hyponatremia, rash, N/V, SJS, aplastic anemia, agranulocytosis
Clobazam
Lennox-Gastaut Syndrome
> 30 Kg: 5 mg BID, 10 mg BID (day 7), 20 mg BID (day 14) < 30 Kg: start at 2.5 mg BID with goal of 10 mg BID
CYP3A4 > CYP2C19 & CYP2B6. Primarily renal excretion.
Constipation, SJS, toxic epidermal necrolysis
Ethosuximide
Generalized (absence)
500 mg, increase by 250 mg/day at 1 wk intervals. Caution with > 1.5 g/d
Induces CYP3A4 > CYP2E1. Partial renal excretion.
Anorexia, SLE-like symptoms, GI: pain, N/V/D. Skin: SJS, hirsutism, gingival hyperplasia, headache, mood changes
Eslicarbazepine
Partial
400 mg qd, increase by 400-600 mg increments to max 1600 mg/d
Induces CYP3A4 > CYP2C19.
Primarily renal excretion.
N/V, diplopia, eosinophilia, transaminitis, suicidal thoughts, angioedema
Ezogabine
Partial
100 mg TID, increase by 50 mg TID at 1 wk intervals. Maint: 200-400 mg TID
No major CYP450 effects.
Primarily renal excretion.
Prolonged QT interval, skin discoloration, weight gain, diplopia, retinal disorder
Gabapentin
Partial
300 mg TID. Maint: 300-600 mg TID. Max 2400 mg/day
Very slight CYP2A6 inhibition.
Primarily renal excretion.
SJS, hypoglycemia, eosinophilia, mood changes, angioedema
Felbamate
Partial w/wo generalization
1200 mg/day (TID or QID); increase by 600 mg Q2wk. Max: 3600 mg/day
Substrate for CYP3A4 and CYP2E1. Inhibits CYP2C19.
Primarily renal excretion.
Aplastic anemia, hepatic failure, SI
Lacosamide
Partial
100 mg BID; increase by 50 mg BID. Max: 200 mg BID
Substrate for CYP3A4, CYP2C9, CYP2C19. Primarily renal excretion.
Cardiac: atrial fibrillation/flutter, 1° AV block, prolonged PR interval; diplopia; SI; eosinophilia
Lamotrigine
Partial, Lennox-Gastaut, tonic-clonic
1st 2 wk: 25 mg Q48h. 2nd 2 wk: 25 mg Q24Hh. Increase by 25–50 mg/day Q1–2 wk to maint of 100-400 mg/day
If adding to valproate then maintenance 100-200 mg/d. Primarily renal excretion.
Ophthalmic: blurred vision, diplopia. Dysmenorrhea. Rhinitis. Derm: SJS, TEN. Liver failure. Neuromalignant syndrome.
Levetiracetam
Myoclonic associated with JME, focal, tonic-clonic
500 mg BID. Increase by 1 g/day Q2wk to Max: 3 g/day
No significant CYP activity. Primarily renal excretion.
V, decreased bone mineral density, abnormal behavior, irritability, SHS, TEN, pancytopenia, liver failure, SI
Oxcarbazepine
Partial
300 mg BID. Increase by up to 600 mg/day weekly. Max: 1200 mg/day or ER 2400 mg/day
Keto analogue of carbamazepine. Little effect on CYP450. Primarily renal excretion.
Weight gain, N/V. Derm: erythema multiforme, SJS, TEN, agranulocytosis, pancytopenia, hypersensitivity reaction, SI, angioedema
Perampanel
Partial, tonic-clonic
2 mg QHS. Increase by 2 mg/day Qwk. Maint: 8-12 mg QHS
Substrate of CYP3A4/5, CYP1A2, CYP2B6. Inhibitor of CYP2C8, CYP3A4, UGT1A9, UGT2B7. Inducer of CYP2B6, CYP3A4/5, UGT1A1, UGT1A4. Mixed excretion fecal > renal.
Various psychiatric symptoms including SI & HI; fatigue
Phenobarbital
Focal and generalized seizures
50–100 mg BID or TID
CYP450 Inducer. Mostly non-renal excretion.
Megaloblastic anemia, liver damage, hallucinations, somnolence, depression, erythroderma
Phenytoin
Generalized tonic-clonic, complex partial
100 mg TID. Maint: 300-400 mg/day. Max: 600 mg/day
CYP450 Inducer. Primarily excreted in bile. Renal excretion following GI reabsorption.
Constipation, N/V, numerous dermatological and hematological symptoms, hepatotoxicity, SI
Pregabalin
Partial
75 mg BID or 50 mg TID. Max: 300 mg/day
Negligible CYP activity. Primarily renal excretion.
Peripheral edema, weight gain, constipation, xerostomia, visual disturbances, jaundice, elevated creatinine kinase, SI, angioedema
Rufinamide
Lennox-Gastaut
200–400 mg BID. Increase by 400–800 mg/day Q48H. Max: 1600 mg BID
No significant CYP activity. Primarily renal excretion.
Shortened QT interval, N/V, visual disturbances, leukopenia, SJS, SI
Tiagabine
Partial
4 mg/day. Increase by 4–8 mg Qwk in BID or QID dosing. Max: 56 mg/day
Substrate of CYP3A and possibly CYP1A2, 2D6, 2C19. Mixed excretion fecal > renal.
Pruritis, N, poor concentration, pharyngitis, SJS, SI
Topiramate
Lennox-Gastaut, partial, tonic-clonic
25–50 mg/day. Increase by 25–50 mg/day Qwk. Maint: 200 mg BID
Inducer of CYP3A4. Inhibitor of CYP2C19. Primarily renal excretion.
Flushing, weight loss, poor concentration, psychiatric disturbances including SI, SJS, TEN, hyperammonemia, hypohidrosis, metabolic acidosis, nephrolithiasis
Valproate
Absence, complex partial
15 mg/kg/day Increase 5-10 mg/kg/day Q1wk Max: 60 mg/kg/day
Inhibitor of CYP2C9 and possibly CYP3A4. Nearly 50% renal excretion.
N, hyperammonemia, pancreatitis, myelodysplastic syndrome, thrombocytopenia, teratogenesis, hepatotoxicity
Vigabatrin
Complex partial
500 mg BID. Increase by 500 mg/day Qwk. Max: 3 g/day
No significant CYP activity. Primarily renal excretion.
Weight gain, arthralgia, visual field/acuity defects, nystagmus, aggression, dysmenorrhea, liver failure, SI
Zonisamide
Partial
100 mg/day Increase by 100 mg/day Q2wk No benefit above 400 mg/day
No significant CYP activity. Primarily renal excretion.
Rash with sulfa-allergy, pruritis, weight loss, psychiatric disturbances, schizophrenia or disorder, agranulocytosis, SJS, TEN
Treatment for Essential Tremor (Movement Disorder)
Medication/Procedure
Dosages
Action
Side effects
FIRST LINE
Propanalol
60–320 mg/day BID dosing (short acting) or QD for LA
Non-Selective Beta-Adrenergic antagonist for limb and head tremor
Hypotension, bradycardia
Primidone
250 mg–750 mg/day QHS dosing (administer higher doses as BID)
GABA-A agonist for limb tremor
Sedation, Ataxia, Nystagmus
SECOND LINE
Gabapentin
1200–3600 mg/day TID dosing
Decreases release of Calcium dependent neurotransmitters from nerve terminals, used for limb tremor
Drowsiness, Ataxia
Topiramate
150–300 mg/day BID dosing
Inhibits kainate/AMPA and sodium receptors; enhances GABA-A receptors, weak carbonic anhydrase inhibitor. It is used for limb tremor
Paresthesia, abnormal taste, word finding difficulties, and acute angle closure glaucoma
SECOND LINE, NON-MEDICAL
Thalamic deep brain stimulation
Surgical option for limb tremor refractory to medical treatment
Direct brain action through electrical modulation
Surgery related complications, stroke, infection, failure/recurrence
THIRD LINE, NON-MEDICAL
Thalamotomy
Unilateral lesion as surgical option for medically refractory essential tremor of the limb
Direct brain action through lesion
Surgery related complications, stroke, infection, failure/recurrence
Headache
Keywords
Drug
Dose/route
Other considerations
Almotriptan (Axert)
6.25–12.5 mg PO, may repeat after 2 hr; max 25 mg/day
Side effects: Warm/hot sensation, tingling, chest pain/tightness, hyper/hypotension, burning, feeling of heaviness and tightness, flushing, drowsiness, malaise/fatigue, and anxiety.
Eletriptan (Relpax)
20–40 mg PO, may repeat after 2 hr; max 80 mg/day
Frovatriptan (Frova)
2.5 mg, may repeat after 2 hr; max 7.5 mg/day
Naratriptan (Amerge)
1–2.5 mg PO, may repeat after 4 hr; max 5 mg/day
Rizatriptan (Maxalt)
Tablets: 5–10 mg PO, may repeat after 2 hr; max 20 mg/day
Wafers (orally disintegrating tablets): 5–10 mg PO, may repeat after 2 hr; max 20 mg/day
Sumatriptan (Imitrex)
Oral: 25–100 mg PO, may repeat after 2 hr; max 200 mg/day
SC: 1–6 mg, may repeat after 1 hr; max 12 mg/day
Intranasal spray: 5–20 mg in 1 nostril, may repeat after 2 hr; max 40 mg/day
Intranasal powder: 22 mg (11 mg in each nostril), may repeat after 2 hr; max 44 mg/day.
Precaution: All triptans should be avoided in patients with familial hemiplegic migraine, basilar migraine, ischemic stroke, ischemic heart disease, Prinzmetal angina, uncontrolled hypertension, and pregnancy. MAO inhibitors are contraindicated with triptans. Triptans should not be used within 24 hr of the use of ergotamine preparations or different other than naratriptan, Eletriptan, and Frovatriptan.
Zolmitriptan (Zomig)
Tablets: 1.25–2.5 mg PO, may repeat after 2 hr; max 10 mg/day
Wafers (orally disintegrating tablets): 2.5 mg PO, may repeat after 2 hr; max 10 mg/day Intranasal: 5 mg in 1 nostril, may repeat after 2 hr; max 10 mg/day
Insomnia
Keywords
Drug
Dosage range
Benefits
Side effects
First-line Pharmacotherapy (FDA Approved)
Eszopiclone (Lunesta)a,b
1–3 mg
Short half-life provides lower risk of morning hangover effect
Rash, xerostomia, dizziness, nausea and vomiting, confusion, headache, hallucinations, nervousness, dysmenorrhea, reduced libido
Zaleplon (Sonata)a,b
5–10 mg (5 mg dose is largely ineffective and not routinely used)
Ultra-short half-life. Used for sleep initiation and prn for night-time awakenings (3–4 hr before rising)
Headache, drowsiness, nausea, and rash
Temazepam (Restoril)a,b
15–30 mg
Intermediate half-life carries a low-moderate risk of hangover effect
Headache, fatigue, nervousness, lethargy, dizziness, anxiety, and confusion
Triazolam (Halcion)a,b
0.125–0.5
Zolpidem (Ambien)a,b
10 mg (12.5 extended release)
Short half-life
Nausea, vomiting, abdominal pain, caution with depressed patients
Ramelteon (Rozerem)b
8 mg
Less risk of abuse
Daytime sedation
Doxepin (Sinequan, Silenor)b
3–6 mg
Sleep maintenance
Hypertension, behavioral side effect
Suvorexant (Belsomra)b
10–20 mg
Daytime sedation
Second-line Pharmacotherapy
Amitriptyline (Elavil)
10–50 mg
Longer half-life carries risk of hangover effect and cognitive impairment
Weight gain, bloating symptom, asthenia, constipation, xerostomia, dizziness, fatigue, headache, blurred vision
Trazodone (Desyrel)
25–100 mg
Shorter half-life lowers risk of hangover effect
Sweating, weight change, worsening depression, suicidal ideation
Variable Evidence
L-Tryptophan
500 mg–2 g
May be preferred by patient wanting a “natural medicine”
Unknown
Melatonin
1–5 mg
Valerian root
400–900 mg 
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