(FDA approved in bold)

• Reducing excessive sleepiness in patients with narcolepsy or shift-work related sleep disorder
  
• Reducing excessive sleepiness in patients with obstructive sleep apnea (OSA)/hypopnea syndrome
  
• Treatment of fatigue in multiple sclerosis (MS)
  
• Fatigue in depression
  
• Attention deficit hyperactivity disorder
  
• Fatigue in cancer, HIV, or post-stroke patients

• Unlike traditional stimulants which act directly via dopaminergic pathways, it may also act in the hypothalamus by stimulating wake-promoting areas, or inhibiting sleep-promoting areas
  
• It may also have effects on dopamine transporter pathways similar to other stimulants, hypothetically inhibiting the dopamine transporter
  
• Increases neuronal activity selectively in the hypothalamus and activates tuberomammillary nucleus neurons that release histamine
  
• It also activates hypothalamic neurons that release orexin/hypocretin

• Typically 1–2 hours, although maximal benefit may take days-weeks

• Continue to use indefinitely as long as symptoms persist. Complete resolution of symptoms is unusual. Does not cause insomnia when dosed correctly

• Change to most effective dose or alternative agent. Re-evaluate treatment of underlying cause (i.e., OSA) of fatigue. Consider other causes of fatigue (i.e., anemia, heart disease) as appropriate. Screen for use of CNS depressants that can interfere with sleep, i.e., opioids or alcohol

• In treating OSA, modafinil is an adjunct to standard treatments such as continuous positive airway pressure (CPAP), weight loss and treatment of obstruction when possible
  
• In MS change drug regimen, i.e., antispasticity or disease-modifying agents when possible if they are significantly contributing to fatigue. Amantadine is an alternative treatment for MS-related fatigue
  
• Treat coexisting medical illnesses such as HIV, depression, or chronic pain disorders with appropriate agents

• None required