Therapeutic Appendix
Chemotherapy: common Neuro-Oncologic drugs
Keywords
Neuro-oncologic chemotherapeutic drugs
| 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 weekor 40,000 units once weekly | Nausea, hypertension |
| Darbepoetin alfa (Aranesp) | Erythropoiesis stimulation | SubQ: 2.25 mcg/kg once weekly or500 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 offNeoplastic 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 |
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 (Movement Disorder)
Keywords
Chorea management, chorea medications table, chorea therapeutic appendix, tetrabenazine, deutrabenazine
| 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
Dementia medications, Donepezil, Aricept, Galantamine, Razadyne, Rivastigmine, Exelon, Memantine, Namenda, Alzheimer Disease, Vascular Dementia, Dementia with Lewy Bodies, Parkinson Disease Dementia
| 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-2D6CYP-3A4 | CYP-2D6CYP-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 impairmentadjustment | 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 |
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
Keywords
Depression, antidepressants
| 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 |
NDRIs, Norepinephrine and dopamine reuptake inhibitors; SE, side effects; SSNRIs, selective serotonin and norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors.
Epilepsy
Keywords
Anti-epileptic, seizure medications
| 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 |
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.
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
Triptans, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan
| 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/dayWafers (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/daySC: 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/dayIntranasal 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/dayWafers (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
Insomnia, benzodiazepines, sedatives, hypnotics, lunesta, ambien
Good sleep practices and cognitive behavioral approach should be considered in elderly neurological patients.
| 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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