(ar moe DAF i nil)
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Nuvigil: 50 mg, 150 mg, 200 mg, 250 mg
Generic: 50 mg, 150 mg, 200 mg, 250 mg
Brand Names: U.S.
- Central Nervous System Stimulant
The exact mechanism of action of armodafinil is unknown. It is the R-enantiomer of modafinil. Armodafinil binds to the dopamine transporter and inhibits dopamine reuptake, which may result in increased extracellular dopamine levels in the brain. However, it does not appear to be a dopamine receptor agonist and also does not appear to bind to or inhibit the most common receptors or enzymes that are relevant for sleep/wake regulation.
Vd: 42 L
Hepatic, multiple pathways, including amine hydrolysis and CYP3A4/5; metabolites include R-modafinil acid and modafinil sulfone
Urine (based on modafinil: 80% predominantly as metabolites; <10% as unchanged drug)
Time to Peak
2 hours (fasted)
~60% (based on modafinil; primarily albumin)
Special Populations: Renal Function Impairment
Severe chronic renal failure (CrCl ≤20 mL/minute) did not influence the pharmacokinetics of modafinil, but increased exposure to modafinil acid ninefold.
Special Populations: Hepatic Function Impairment
In patients with severe hepatic impairment, clearance of modafinil was decreased by ~60% and the steady-state concentration was doubled.
Special Populations: Elderly
Systemic exposure of armodafinil was ~15% higher and clearance was ~12% lower in patients greater than 65 years of age.
Use: Labeled Indications
Narcolepsy: To improve wakefulness in patients with excessive sleepiness associated with narcolepsy.
Obstructive sleep apnea: To improve wakefulness in patients with excessive sleepiness associated with obstructive sleep apnea (OSA).
Limitations of use: In OSA, armodafinil is indicated to treat excessive sleepiness and not as treatment for the underlying obstruction. If continuous positive airway pressure (CPAP) is the treatment of choice for a patient, a maximal effort to treat with CPAP for an adequate period of time should be made prior to initiating armodafinil for excessive sleepiness.
Shift-work disorder: To improve wakefulness in patients with excessive sleepiness associated with shift-work disorder.
Hypersensitivity to armodafinil, modafinil, or any component of the formulation.
Narcolepsy: Oral: 150 to 250 mg once daily in the morning
Obstructive sleep apnea (OSA): Oral: 150 to 250 mg once daily in the morning; doses >150 mg have not been shown to have an increased benefit.
Shift-work disorder: Oral: 150 mg given once daily ~1 hour prior to work shift
Refer to adult dosing. Consider lower initial dosage.
Dosing: Renal Impairment
There are no dosage adjustments provided in the manufacturer's labeling.
Dosing: Hepatic Impairment
Mild to moderate hepatic impairment: No dosage adjustment necessary.
Severe hepatic impairment: The manufacturer recommends a reduced dose due to decreased clearance and increased steady-state concentration of modafinil in this patient population.
May be administered without regard to food.
Store at 20°C to 25°C (68°F to 77°F).
Acebrophylline: May enhance the stimulatory effect of CNS Stimulants. Avoid combination
Alcohol (Ethyl): May diminish the therapeutic effect of Armodafinil. Avoid combination
ARIPiprazole: Armodafinil may decrease the serum concentration of ARIPiprazole. Monitor therapy
AtoMOXetine: May enhance the hypertensive effect of Sympathomimetics. AtoMOXetine may enhance the tachycardic effect of Sympathomimetics. Monitor therapy
Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Cannabinoid-Containing Products: May enhance the tachycardic effect of Sympathomimetics. Exceptions: Cannabidiol. Monitor therapy
Cilostazol: CYP2C19 Inhibitors may increase the serum concentration of Cilostazol. Management: Consider reducing the cilostazol dose to 50 mg twice daily in patients who are also receiving inhibitors of CYP2C19. Consider therapy modification
CloZAPine: CYP3A4 Inducers (Weak) may decrease the serum concentration of CloZAPine. Monitor therapy
Cocaine: May enhance the hypertensive effect of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Consider therapy modification
CycloSPORINE (Systemic): Armodafinil may decrease the serum concentration of CycloSPORINE (Systemic). Monitor therapy
CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification
Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification
Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Doxofylline: Sympathomimetics may enhance the adverse/toxic effect of Doxofylline. Monitor therapy
Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Consider therapy modification
Estrogen Derivatives (Contraceptive): Armodafinil may decrease the serum concentration of Estrogen Derivatives (Contraceptive). Management: The manufacturer recommends that patients use nonhormonal contraceptives, in addition to or in place of hormonal contraceptives, during and for one month following treatment with armodafinil. Consider therapy modification
Guanethidine: May enhance the arrhythmogenic effect of Sympathomimetics. Guanethidine may enhance the hypertensive effect of Sympathomimetics. Monitor therapy
HYDROcodone: CYP3A4 Inducers (Weak) may decrease the serum concentration of HYDROcodone. Monitor therapy
Iobenguane I 123: Sympathomimetics may diminish the therapeutic effect of Iobenguane I 123. Avoid combination
Linezolid: May enhance the hypertensive effect of Sympathomimetics. Management: Reduce initial doses of sympathomimetic agents, and closely monitor for enhanced pressor response, in patients receiving linezolid. Specific dose adjustment recommendations are not presently available. Consider therapy modification
Mitotane: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Consider therapy modification
NiMODipine: CYP3A4 Inducers (Weak) may decrease the serum concentration of NiMODipine. Monitor therapy
Pitolisant: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Combined use of pitolisant with a CYP3A4 substrate that has a narrow therapeutic index should be avoided. Other CYP3A4 substrates should be monitored more closely when used with pitolisant. Consider therapy modification
Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
St John's Wort: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification
Sympathomimetics: May enhance the adverse/toxic effect of other Sympathomimetics. Monitor therapy
Tedizolid: May enhance the hypertensive effect of Sympathomimetics. Tedizolid may enhance the tachycardic effect of Sympathomimetics. Monitor therapy
Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
>10%: Central nervous system: Headache (14% to 23%; dose related)
1% to 10%:
Cardiovascular: Palpitations (2%), increased heart rate (1%)
Central nervous system: Insomnia (4% to 6%; dose related), dizziness (5%), anxiety (4%), depression (1% to 3%; dose related), fatigue (2%), agitation (1%), depressed mood (1%), lack of concentration (1%), migraine (1%), nervousness (1%), pain (1%), paresthesia (1%)
Dermatologic: Skin rash (1% to 4%; dose related), contact dermatitis (1%), diaphoresis (1%)
Endocrine & metabolic: Increased gamma-glutamyl transferase (1%), increased thirst (1%)
Gastrointestinal: Nausea (6% to 9%; dose related), xerostomia (2% to 7%; dose related), diarrhea (4%), dyspepsia (2%), upper abdominal pain (2%), anorexia (1%), constipation (1%), decreased appetite (1%), loose stools (1%), vomiting (1%)
Hypersensitivity: Seasonal allergy (1%)
Neuromuscular & skeletal: Tremor (1%)
Renal: Polyuria (1%)
Respiratory: Dyspnea (1%), flu-like symptoms (1%)
Miscellaneous: Fever (1%)
<1%, postmarketing, and/or case reports: Anaphylaxis, angioedema, DRESS syndrome, hypersensitivity reaction (including bronchospasm, dysphagia), hypouricemia, increased liver enzymes, increased serum alkaline phosphatase, irritability, multi-organ hypersensitivity, oral mucosa changes (including blistering, sores, ulceration), pancytopenia, skin changes (including blistering, sores, ulceration), Stevens-Johnson syndrome, suicidal ideation, systolic hypertension, toxic epidermal necrolysis
Concerns related to adverse effects:
• CNS effects: May impair the ability to engage in potentially hazardous activities; patients must be cautioned about performing tasks which require mental alertness (eg, operating machinery, driving).
• Dermatologic effects (severe): Serious and life-threatening rashes including Stevens-Johnson syndrome and toxic epidermal necrolysis have been reported. In modafinil clinical trials, rashes were more likely to occur in children; serious, postmarketing reactions have occurred with modafinil and armodafinil in adults and children. Most cases have been reported within the first 8 weeks of initiating therapy; however, rare cases have occurred after prolonged therapy. No risk factors have been identified to predict occurrence or severity of these reactions. Patients should be advised to discontinue use at first sign of rash, skin or mouth sores or blistering or ulceration (unless the rash is clearly not drug-related).
• Hypersensitivity reactions: Rare cases of drug reaction with eosinophilia and system symptoms (DRESS), also known as multiorgan hypersensitivity, and cases of angioedema and anaphylactoid reactions have been reported. Signs and symptoms of DRESS are diverse. Patients typically present with fever and rash associated with other organ system involvement. Patients should be advised to discontinue therapy and promptly report any signs or symptoms related to these adverse effects.
• Cardiovascular disease: Use is not recommended in patients with a history of left ventricular hypertrophy or patients with mitral valve prolapse who have developed mitral valve prolapse syndrome with previous CNS stimulant use. Patients with these conditions may also experience chest pain, palpitations, dyspnea, and transient ischemic T-wave changes on ECG. Due to limited experience use caution in patients with history of myocardial infarction (MI) or angina. Increased blood pressure monitoring may be required, and new or additional antihypertensive therapy may be needed.
• Hepatic impairment: Use with caution in patients with hepatic impairment; dosage reduction is recommended with severe dysfunction.
• Psychiatric disorders: Use caution in patients with a history of psychosis, depression, or mania. Armodafinil has been shown to worsen the symptoms of these diseases (eg, mania, hallucinations, suicidal thoughts). Discontinue therapy if psychiatric symptoms develop.
• Sleep disorders: Appropriate use: For use following complete evaluation of sleepiness and in conjunction with other standard treatments (eg, CPAP). The degree of sleepiness should be reassessed frequently; some patients may not return to a normal level of wakefulness. Patients with excessive sleepiness should be advised to avoid driving or any other potentially dangerous activity. Use >12 weeks has not been studied; patient should be reevaluated to determine effectiveness if use exceeds 12 weeks.
• Tourette syndrome/tics: Use with caution in patients with Tourette syndrome and other tic disorders. Stimulants may exacerbate tics (motor and phonic) and Tourette syndrome; however, evidence demonstrating increased tics is limited. Evaluate for tics and Tourette syndrome prior to therapy initiation (AACAP [Murphy 2013]; Pliszka 2007).
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Elderly: Use reduced doses in elderly patients; concentrations of armodafinil are significantly higher in patients >65 years of age.
• Abuse potential: Use with caution in patients with a history of drug abuse; potential for drug dependency exists.
Signs of hypersensitivity, rash, psychiatric symptoms, levels of sleepiness, blood pressure, and drug abuse
Intrauterine growth restriction and spontaneous abortion have been reported in association with armodafinil. Efficacy of steroidal contraceptives may be decreased; alternate means of contraception should be considered during therapy and for 1 month after armodafinil is discontinued.
A pregnancy registry has been established for patients exposed to armodafinil; healthcare providers are encouraged to register pregnant patients or pregnant women may register themselves by calling 1-866-404-4106.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience anxiety, diarrhea, insomnia, back pain, dizziness, nausea, or dry mouth. Have patient report immediately to prescriber signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice), signs of depression (suicidal ideation, anxiety, emotional instability, or confusion), signs of kidney problems (urinary retention, hematuria, change in amount of urine passed, or weight gain), signs of a severe pulmonary disorder (lung or breathing problems like difficulty breathing, shortness of breath, or a cough that is new or worse), swollen glands, hallucinations, difficulty swallowing, angina, tachycardia, confusion, severe headache, abnormal heartbeat, chills, pharyngitis, shortness of breath, swelling of arms or legs, bruising, bleeding, severe loss of strength and energy, muscle pain, joint pain, or signs of Stevens-Johnson syndrome/toxic epidermal necrolysis (red, swollen, blistered, or peeling skin [with or without fever]; red or irritated eyes; or sores in mouth, throat, nose, or eyes) (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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- Drug class: CNS stimulants
Other brands: Nuvigil