Psychiatry Article Summary

Amantadine and Modafinil as Neurostimulants Following Acute Stroke: A Retrospective Study of Intensive Care Unit Patients

Citation: Leclerc AM, Riker RR, Brown CS, May T, Nocella K, Cote J, Eldridge A, Seder DB, Gagnon DJ. Amantadine and Modafinil as Neurostimulants Following Acute Stroke: A Retrospective Study of Intensive Care Unit Patients. Neurocrit Care. 2021 Feb;34(1):102-111. doi: 10.1007/s12028-020-00986-4. PMID: 32435964; PMCID: PMC7239352.

• Neurostimulants may improve or accelerate cognitive and functional recovery after intracerebral hemorrhage, ischemic stroke, or subarachnoid hemorrhage, but few studies have described their safety and effectiveness in the intensive care unit (ICU). The objective of this study was to describe amantadine and modafinil administration practices during acute stroke care starting in the ICU and to evaluate safety and effectiveness of this practice.
• A total of 87 patients were evaluable during the 3.7-year study period, including 41 (47%) with ICH, 29 (33%) with IS, and 17 (20%) with SAH. The initial neurostimulant administered was amantadine in 71 (82%) patients, modafinil in 13 (15%), or both in 3 (3%) patients.
• Inclusion criteria: >18 y/o, admitted with an acute non- traumatic ICH, IS, or SAH, and were treated with amantadine, modafinil, or both for at least 72 h starting in an ICU.
• Exclusion criteria: if they were receiving amantadine or modafinil prior to hospitalization, were admitted with TBI, encephalopathy (including hypoxic ischemic encephalopathy after cardiac arrest), brain tumor, encephalitis, or had a history of seizures.
• Patients were considered responders if they met two of three criteria within 9 days of neurostimulant initiation: increase in Glasgow coma scale (GCS) score ≥ 3 points from pre-treatment baseline, improved wakefulness or participation documented in caregiver notes, or clinical improvement documented in physical or occupational therapy notes.
• The initial neurostimulant administered was amantadine in 71 (82%) patients, modafinil in 13 (15%), or both in 3 (3%) patients. Neurostimulants were initiated a median of 7 days post-stroke for somnolence (77%), not following commands (32%), lack of eye opening (28%), or low GCS (17%).
• The most common starting dose was 100 mg twice daily for both amantadine (86%) and modafinil (54%)
• Of the 79 patients included in the effectiveness evaluation, 42 (53%) were considered responders, including 34/62 (55%) receiving amantadine monotherapy and 8/24 (33%) receiving both amantadine and modafinil at the time they met the definition of a responder.
• No patient receiving modafinil monotherapy was considered a responder.
• The median time from initiation to response was 3 days. Responders were more frequently discharged home or to acute rehabilitation compared to non-responders. Among survivors, 63/72 (88%) were prescribed a neurostimulant at hospital discharge. The most common potential adverse drug effect was sleep disruption (16%).
• The most concerning potential adverse drug effect during amantadine therapy was seizures, though it was impossible to assess causality since seizures are not rare after the types of stroke we studied.
• This retrospective evaluation was performed in order to obtain baseline data and response estimates to help design future studies. Neurostimulant administration during acute stroke care may improve wakefulness. Future controlled studies with a neurostimulant administration protocol, prospective evaluation, and discretely defined response and safety criteria are needed to confirm these encouraging findings.