October 2005 • www.clinicalneurologynews.com Sleep Disorders 13 Armodafinil Useful Adjunct to CPAP in Apnea BY BRUCE JANCIN Societies. Based on these findings as well tion of Cephalon’s Provigil (modafinil), the morning in this 12-week, double-blind Denver Bureau as data from two other phase III trials in- which has a markedly shorter half-life than multicenter trial. volving patients with shift work sleep dis- the newer enantiomer. Patients on both doses of armodafinil D ENVER — The investigational drug ar- order or narcolepsy, the drug’s manufac- Jed E. Black, M.D., reported on 392 pa- showed significantly improved daytime modafinil significantly increased daytime turer, Cephalon Inc., has filed a new drug tients with excessive daytime sleepiness as wakefulness, compared with patients on wakefulness in patients with obstructive application seeking approval to market defined by a baseline Epworth Sleepiness placebo, as measured objectively by the sleep apnea who experienced excessive armodafinil (Nuvigil) as a wakefulness- Scale score of 10 or more despite good ad- Maintenance of Wakefulness Test at sleepiness despite regular nighttime con- promoting agent in patients with any of herence to continuous positive airway weeks 4, 8, and 12. tinuous positive airway pressure therapy, three disorders: obstructive sleep ap- pressure (CPAP) therapy for obstructive Moreover, at each assessment, blinded according to the results of two phase III nea/hypopnea syndrome, narcolepsy, or sleep apnea/hypopnea syndrome. Partic- physicians rated the armodafinil-treated clinical trials presented at the annual meet- shift work sleep disorder. ipants were randomized to armodafinil at patients as showing significantly more ing of the Associated Professional Sleep Armodafinil is a single-isomer formula- 150 mg, 250 mg, or placebo once daily in clinical improvement. For example, at the final visit, physicians rated 71% of pa- tients in the 150-mg armodafinil group Slight maternal toxicity, decreased pup weights and an increased incidence Treatment emergent signs and symptoms that occurred during 8 controlled of non-ossified cervical vertebrae were seen at an oral dose of clinical trials and 4 open-label trials were recorded as adverse events by and 74% in the 250-mg group as showing 18 mg/kg/day in a study in which rats were given oral memantine beginning the clinical investigators using terminology of their own choosing. To provide pre-mating and continuing through the postpartum period. Slight maternal an overall estimate of the proportion of individuals having similar types of at least minimal clinical improvement on toxicity and decreased pup weights were also seen at this dose in a study events, the events were grouped into a smaller number of standardized in which rats were treated from day 15 of gestation through the post- categories using WHO terminology, and event frequencies were calculated the Clinical Global Impression of Change partum period. The no-effect dose for these effects was 6 mg/kg, which across all studies. (CGIC) scale compared with 37% of pa- Rx Only is 3 times the MRHD on a mg/m2 basis. All adverse events occurring in at least two patients are included, except Brief Summary of Prescribing Information. There are no adequate and well-controlled studies of memantine in pregnant for those already listed in Table 1, WHO terms too general to be informative, tients taking placebo. From a mean base- women. Memantine should be used during pregnancy only if the potential minor symptoms or events unlikely to be drug-caused, e.g., because they For complete details, please see full Prescribing Information for Namenda. benefit justifies the potential risk to the fetus. are common in the study population. Events are classified by body system line Epworth Sleepiness Scale score of INDICATIONS AND USAGE Nursing Mothers and listed using the following definitions: frequent adverse events - those Namenda (memantine hydrochloride) is indicated for the treatment of It is not known whether memantine is excreted in human breast milk. occurring in at least 1/100 patients; infrequent adverse events 15.5, the armodafinil group (both dosages moderate to severe dementia of the Alzheimer’s type. Because many drugs are excreted in human milk, caution should be - those occurring in 1/100 to 1/1000 patients. These adverse events are combined) improved by a mean of 5.5 exercised when memantine is administered to a nursing mother. not necessarily related to Namenda treatment and in most cases were CONTRAINDICATIONS Pediatric Use observed at a similar frequency in placebo-treated patients in the points, compared with 3.3 points in the Namenda (memantine hydrochloride) is contraindicated in patients with controlled studies. known hypersensitivity to memantine hydrochloride or to any excipients There are no adequate and well-controlled trials documenting the safety Body as a Whole: Frequent: syncope. Infrequent: hypothermia, allergic placebo group. The armodafinil-treated used in the formulation. and efficacy of memantine in any illness occurring in children. reaction. ADVERSE REACTIONS patients rated their global fatigue as im- PRECAUTIONS Cardiovascular System: Frequent: cardiac failure. Infrequent: angina Information for Patients and Caregivers: Caregivers should be instructed The experience described in this section derives from studies in patients with Alzheimer’s disease and vascular dementia. pectoris, bradycardia, myocardial infarction, thrombophlebitis, atrial proved by a mean of 1.2 points from a in the recommended administration (twice per day for doses above 5 mg) fibrillation, hypotension, cardiac arrest, postural hypotension, pulmonary and dose escalation (minimum interval of one week between dose increases). Adverse Events Leading to Discontinuation: In placebo-controlled trials embolism, pulmonary edema. baseline of 4.9 on the Brief Fatigue In- in which dementia patients received doses of Namenda up to 20 mg/day, Neurological Conditions Central and Peripheral Nervous System: Frequent: transient ischemic Seizures: Namenda has not been systematically evaluated in patients the likelihood of discontinuation because of an adverse event was the ventory; that was twice as great a gain as same in the Namenda group as in the placebo group. No individual attack, cerebrovascular accident, vertigo, ataxia, hypokinesia. Infrequent: with a seizure disorder. In clinical trials of Namenda, seizures occurred in paresthesia, convulsions, extrapyramidal disorder, hypertonia, tremor, 0.2% of patients treated with Namenda and 0.5% of patients treated adverse event was associated with the discontinuation of treatment in 1% in the placebo arm, said Dr. Black of Stan- or more of Namenda-treated patients and at a rate greater than placebo. aphasia, hypoesthesia, abnormal coordination, hemiplegia, hyperkinesia, with placebo. involuntary muscle contractions, stupor, cerebral hemorrhage, neuralgia, ford (Calif.) University. Genitourinary Conditions Adverse Events Reported in Controlled Trials: The reported adverse ptosis, neuropathy. events in Namenda (memantine hydrochloride) trials reflect experience Conditions that raise urine pH may decrease the urinary elimination of Gastrointestinal System: Infrequent: gastroenteritis, diverticulitis, Armodafinil had no adverse effects on memantine resulting in increased plasma levels of memantine. gained under closely monitored conditions in a highly selected patient population. In actual practice or in other clinical trials, these frequency gastrointestinal hemorrhage, melena, esophageal ulceration. nighttime sleep as assessed by polysom- Special Populations estimates may not apply, as the conditions of use, reporting behavior and Hemic and Lymphatic Disorders: Frequent: anemia. Infrequent: leukopenia. Hepatic Impairment the types of patients treated may differ. Table 1 lists treatment-emergent Metabolic and Nutritional Disorders: Frequent: increased alkaline nography, nor did it affect CPAP use, Namenda undergoes partial hepatic metabolism, with about 48% of signs and symptoms that were reported in at least 2% of patients in phosphatase, decreased weight. Infrequent: dehydration, hyponatremia, administered dose excreted in urine as unchanged drug or as the sum of which continued at an average of 7 hours placebo-controlled dementia trials and for which the rate of occurrence aggravated diabetes mellitus. parent drug and the N-glucuronide conjugate (74%). The pharmacokinetics was greater for patients treated with Namenda than for those treated with of memantine in patients with hepatic impairment have not been Psychiatric Disorders: Frequent: aggressive reaction. Infrequent: delusion, per night throughout the study. placebo. No adverse event occurred at a frequency of at least 5% and investigated, but would be expected to be only modestly affected. personality disorder, emotional lability, nervousness, sleep disorder, libido twice the placebo rate. increased, psychosis, amnesia, apathy, paranoid reaction, thinking abnormal, Results were similar in a separate phase Renal Impairment crying abnormal, appetite increased, paroniria, delirium, depersonalization, No dosage adjustment is needed in patients with mild or moderate renal Table 1: Adverse Events Reported in Controlled Clinical Trials in at Least neurosis, suicide attempt. III trial reported by Max Hirshkowitz, impairment. A dosage reduction is recommended in patients with severe 2% of Patients Receiving Namenda and at a Higher Frequency than renal impairment. Placebo-treated