Appendix



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 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


Unlabelled Table


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


t0010



References


Claassen D.O., Carroll B., De Boer L.M., et al. Indirect tolerability comparison of Deutetrabenazine and Tetrabenazine for Huntington disease. J Clin Mov Disord. 2017;4(3):doi:10.1186/s40734-017-0051-5.


Dean M., Sung V.W. Review of deutetrabenazine: a novel treatment for chorea associated with Huntington’s disease. Drug Des Devel Ther. 2018;12:313–319. doi:10.2147/DDDT.S138828.



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



























































































Dementia medications
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


Unlabelled Table


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






































































































































































Selected 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


Unlabelled Table


NDRIs, Norepinephrine and dopamine reuptake inhibitors; SE, side effects; SSNRIs, selective serotonin and norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors.



References


Lexicomp Online. Copyright. Lexicomp, Inc. 1978-2017 All Rights Reserved.


Schulz, P., & Arora, G. (2015). Depression. Continuum (Minneapolis Minn), 21(3), 756–771.



Epilepsy



Keywords



Anti-epileptic, seizure medications











































































































































Commonly Prescribed Antiepileptic Drugs (AEDs)
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


t0025_at0025_b


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.



References


Fisher R.S., Acevedo C., Arzimanoglou A., et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia. 2014;55(4):475–482.


Turner A.L., et al. Outside the box: medications worth considering when traditional antiepileptic drugs have failed. Seizure. 2017;50:173–185. doi:10.1016/j.seizure.2017.06.022 Epub 2017 Jun 27.



Treatment for Essential Tremor (Movement Disorder)




References


Connor, G. S., Edwards, K., Tarsy, D. (2008). Topiramate in essential tremor: findings from double-blind, placebo-controlled, crossover trials. Clin Neuropharmacol, 31(2), 97–103.


Zesiewicz, T. A., Elble, R., Louis, E.D., et al. (2011). Evidence-based guideline update: Treatment of essential tremor. Neurology, 77(19), 1752–1755.



Headache



Keywords



Triptans, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan


































Triptans for Migraine Headache Abortive Therapy
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


Unlabelled Table



Insomnia



Keywords



Insomnia, benzodiazepines, sedatives, hypnotics, lunesta, ambien


Good sleep practices and cognitive behavioral approach should be considered in elderly neurological patients.













































































Medications Used to Treat Insomnia
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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Aug 12, 2020 | Posted by in NEUROLOGY | Comments Off on Appendix
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