Narcolepsy

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Treatment

There is no cure for narcolepsy, so excessive daytime sleepiness, sudden sleep onset, and cataplexy are treated symptomatically. Therapies for narcolepsy involve the practice of getting sufficient sleep each night, proper sleep hygiene practices, and drug therapy. Proper sleep hygiene, including a consistent sleep schedule and the avoidance of shift work and alcohol, is especially important for people who have narcolepsy.

Patients with narcolepsy often feel refreshed after a short nap; therefore, taking short scheduled naps can benefit patients combatting excessive daytime sleepiness. For example, a 15-minute nap after lunch and another at 5:30 p.m. may help diminish the intensity of daytime sleepiness and provide temporary alertness.

Drug Therapy
Stimulants are the mainstay of drug therapy for excessive daytime sleepiness and sleep attacks in narcolepsy patients. These drugs include methylphenidate (Ritalin®), modafinil, dextroamphetamine, and pemoline. Other medications, such as certain antidepressants and drugs that are still being tested in the United States, are also used to treat the predominant symptoms of narcolepsy.

Note: In October of 2005, the Food and Drug Administration (FDA) withdrew approval for magnesium pemoline (Cylert®), a drug that had been used rarely as a treatment for narcolepsy. This medication carries a high risk for liver failure. Generic versions have remained on the market to allow physicians to find alternative treatments for their patients.

Stimulant dosages are determined on a case-by-case basis. These medications generally are taken in the morning and at noon. Major side effects of stimulants include irritability, anxiety, quickened heart rate, high blood pressure (hypertension), substance abuse, and disturbances of nocturnal sleep. Methylphenidate and dextroamphetamine are known to cause hypertension. Headache, usually related to dose size, is a common side effect of modafinil. This side effect occurs in up to 5% of patients. Pemoline poses a very low but noticeable risk for liver complication. These stimulants do not affect the occurrence of narcolepsy's auxiliary symptoms and they usually are not used to treat them.

Methylphenidate and dextroamphetamine carry a risk for addiction. A newer modafinil drug (called Provigil®) does not act as a stimulant and does not produce side effects like anxiety and irritability. The therapeutic effects of Provigil have been observed in maintenance of wakefulness test research, where patients have tripled their wakefulness.

Treatment of Auxiliary Symptoms
Pharmacological control of narcolepsy's auxiliary symptoms—cataplexy, hypnogogic and hypnopompic hallucinations, and sleep paralysis—may involve antidepressants and selective serotonin reuptake inhibitors (SSRIs).

Tricyclic antidepressants (e.g., imipramine, chlorimimipramine) are the most widely prescribed medications for the three subsymptoms of narcolepsy. In some cases, these medications improve symptoms within 2 days. Antidepressant side effects include dry mouth, blurred vision, and sweating.

Selective serotonin reuptake inhibitors, such as fluoxetine (Prozac®) may be used to treat cataplexy and may also reduce the frequency of sleep attacks in some cases. Cataplexy is often much worse in sleep-deprived patients with poor sleep hygiene; therefore, establishing good sleep practices may be the most important aspect of controlling cataplexy.

Sodium oxybate (Xyrem®) is an oral central nervous system depressant approved by the U.S. Food and Drug Administration (FDA) to treat excessive daytime sleepiness and cataplexy in people with narcolepsy. This medication carries a black box warning and should only be used as directed. Sodium oxybate abuse can cause severe, life-threatening side effects, including difficulty breathing, confusion, and loss of consciousness.

Recent Developments in Treatment and a Possible Cure
The study of narcolepsy in other animals has illuminated continuities between human narcolepsy and the condition found in dogs and mice. This information is being used to help discover the cause for the condition and develop additional treatments. Many of these studies have focused on the biochemical dissimilarities that exist between humans and other animals, which may lead to new treatments.

Currently, researchers are studying a gene that may be responsible for narcolepsy. Comparison between the human and dog gene maps has led to the discovery of a mutual deficiency in a substance called hypocretin. Hypocretin is a chemical in the brain that, when absent, corresponds to narcolepsy. Narcoleptic dogs are being injected with this chemical in an attempt to affect the symptoms of narcolepsy and cataplexy. At this point, researchers expect that a version of this substance will be used to treat human narcolepsy in the future. Treatment with hypocretin may effectively treat symptoms of narcolepsy, as well as the underlying deficiency that may cause the condition, perhaps providing a cure.

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