Narcolepsy

Narcolepsy is characterized by daytime sleepiness, cataplexy, hallucinations, and sleep paralysis. Diagnosis involves sleep tests. Treatment may include non-pharmacological measures like sleep hygiene and support groups. Medications like modafinil, armodafinil, solriamfetol, pitolisant, or stimulants can help with daytime sleepiness. Cataplexy may require drugs like venlafaxine or sodium oxybate. Patients should also be screened for depression and treated if necessary.

Narcolepsy: Overview and Diagnosis

Narcolepsy is characterized by excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Common presentations include severe daytime sleepiness, cataplexy episodes (muscle weakness triggered by emotions), sleep-related hallucinations, and paralysis after waking. Comorbid conditions like obstructive sleep apnea (OSA) and REM sleep behavior disorder are often present. Diagnosis typically involves a polysomnogram and a multiple sleep latency test. (1, 2, 3)

Management Approach to Narcolepsy

Most narcolepsy patients benefit from a combination of non-pharmacological strategies and medications, though some may find regular napping and good sleep hygiene sufficient. (4)

Non-Pharmacological Interventions

Key lifestyle modifications include maintaining consistent sleep-wake schedules, avoiding alcohol and caffeine before bedtime, and steering clear of certain sleep positions. Patients should avoid medications that can exacerbate symptoms, such as benzodiazepines and antipsychotics. Support groups can be helpful for coping and finding resources. Regular screening for depression and anxiety is recommended due to higher risks of these conditions in narcolepsy patients. (5)

Pharmacological Therapy Goals and Options

The primary aim of drug therapy is to maintain normal alertness during waking hours or to boost alertness during critical times. Options include modafinil (starting at 200 mg in the morning), armodafinil (150mg daily), solriamfetol (starting at 75 mg in the morning), pitolisant (starting at 8.9 mg daily), methylphenidate (10 mg twice daily), and dextroamphetamines (5mg twice daily). (6, 7)

Treatment for Cataplexy

For significant cataplexy, treatment involves REM sleep-suppressing drugs like antidepressants (e.g., venlafaxine 37.5-75mg) or sodium oxybate (3 g, twice per night). (8)

References

1- Black J, Reaven NL, Funk SE, McGaughey K, Ohayon M, Guilleminault C, et al. The Burden of Narcolepsy Disease (BOND) study: Health-care utilization and cost findings. Sleep Med. 2014;15(5):522-9. sleep.2014.02.001.

2-Overeem S, Reading P, Bassetti CL. Narcolepsy. Sleep Med Clin. 2012;7(2):263-81.

3- Peacock J, Benca RM. Narcolepsy: clinical features, co-morbidities & treatment. Indian J Med Res. 2010;131:338-49.

4- Ahmed I, Thorpy M. Clinical features, diagnosis and treatment of narcolepsy. Clin Chest Med. 2010;31(2):371-81.

5- Vourdas A, Shneerson JM, Gregory CA, et al. Narcolepsy and psychopathology: is there an association? Sleep Med. 2002;3(4):353–360.

6-Kondziella D, Arlien-Soborg P. Diagnostic and therapeutic challenges in narcolepsy-related psychosis. J Clin Psychiatry. 2006;67(11):1817– 1819Kondziella D, Arlien-Soborg P. Diagnostic and therapeutic challenges in narcolepsy-related psychosis. J Clin Psychiatry. 2006;67(11):1817–1819.

7-Ballon JS, Feifel D. A systematic review of modafinil: potential clinical uses and mechanisms of action. J Clin Psychiatry. 200667(4):554–566.

8-The Xyrem® International Study Group. A double-blind, placebocontrolled study demonstrates sodium oxybate is effective for the treatment of excessive daytime sleepiness in narcolepsy. J Clin Sleep Med. 2005 Oct 15;1(4):391–397.