Narcolepsy

Conventional Treatment of Narcolepsy

At present, there is no cure for narcolepsy. The focus of treatment is on treating the symptoms.

Narcolepsy is often treated by providing stimulants to counter patients' excessive daytime sleepiness. Cataplexy, hypnagogic hallucinations, and sleep paralysis are pure manifestations of REM sleep and must be treated with different medications. Most often antidepressants are used because they block REM paralysis (the source of cataplectic paralysis).

Drug therapy is often the first line of defense. However, drug therapy alone is not sufficient in most cases. Non-pharmacological strategies are used to complement drug therapy to develop an effective program to manage narcolepsy. 

Sleepiness in Narcolepsy

Jed E. Black MD., Director, Stanford University Sleep Disorders and Research Clinic recommends the following treatment strategy for sleepiness in Narcolepsy:

1. Provide nonpharmacologic treatment education and begin modafinil. Start at 100 mg/day for 3 days. Titrate to 200-400 mg/day as required to reduce sleepiness. (Occasionally, higher doses may be useful.) 

2a. If sleepiness is improved but still remains a problem, then add traditional stimulant (eg, methylphenidate, dextroamphetamine) and adjust dose as required. Or switch to traditional stimulant and add modafinil if needed. 

2b. If sleepiness is not improved after the modafilnil treatment, then switch to traditional stimulant and adjust dosage as needed. 

Dr. Black recommends the following treatment strategy for cataplexy in Narcolepsy:

1. Option 1

Begin with low dose (25 mg) of one of the following:

or venlafaxine extended- release (Effexor ER, Wyeth-Ayerst) 37.5 mg 

Titrate as needed to adequately control symptoms.

Option 2
 
Try SSRI in antidepressant dose range (may require maximum doses)

OR Give nightly divided doses (at bedtime and 3-4 hours later) of sodium oxybate (GHB) starting with 3 g total dose and titrating to 9 g as needed. (FDA approval for this medication is pending.) 

If cataplexy remains inadequately treated after any one of the options above, then he recommends a careful, combined treatment with a medication from 2 of the above classes. 

See: Medications Used in the Treatment of Narcolepsy for a discussion of the common drugs used in narcolepsy.

Nonpharmacolegic Strategies

The non-pharmaceutical strategies for narcolepsy include:

Structured nocturnal sleep

Structured daytime naps

Avoidance of irregular sleep-wake schedules

Counseling or other assistance

Structured nocturnal sleep

Maintain a structured bedtime and arising time, despite the quality or continuity of the nocturnal sleep. If you wake up during the night, and find it difficult to go back to sleep, you can take a short break and do a sedentary activity such as reading for a brief time. But you should return to bed and attempt to sleep. The time scheduled for nocturnal sleep should be 8 hours or more.

Structured daytime naps

Daytime naps provide a critical part of treatment for the daytime sleepiness associated with narcolepsy. Naps may range from 15 to 20 minutes to longer than one hour. Many find a short nap ( <30 minutes) refreshing, but others require longer naps. At least one nap, and usually two, proves very beneficial for almost all persons with narcolepsy. 

Avoidance of irregular sleep-wake schedules

If you are suffering from narcolepsy, you should maintain regular sleep-wake schedules. Most narcoleptics will find shift work or changes in work schedule extremely difficult. Daytime work is strongly recommended.

Counseling or other assistance

A recent study of more than 500 narcoleptics revealed that they suffer decrease in quality-of-life measures similar to those experienced by patients with Parkinson's disease. Most victims of narcolepsy require special considerations at work or school. They should have access to marriage or family assistance/counseling, and some require full-time disability. 

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