Narcolepsy treatment: pharmacological and behavioral strategies in adults and children

Cardiovascular Risks in People With Narcolepsy: Expert Panel Consensus Recommendations

BACKGROUND

Observational and retrospective studies suggest that people with narcolepsy may have an increased prevalence of cardiovascular and cardiometabolic comorbidities and may be at greater risk for future cardiovascular events. An expert consensus panel was formed to establish agreement on the risk of hypertension and cardiovascular/cardiometabolic disease in people with narcolepsy and to develop strategies to mitigate these risks.

METHODS AND RESULTS

Experts in sleep medicine and cardiology were selected to participate in the panel. After reviewing the relevant literature, the experts identified key elements, drafted recommendation statements, and developed discussion points to provide supporting evidence for the recommendations. The draft and final recommendations were rated on a scale from 0 (not at all agree) to 4 (very much agree). All experts had an agreement rating of 4.0 for all 14 revised recommendation statements for patients with narcolepsy. These statements comprised 3 themes: (1) recognize the risk of hypertension and cardiovascular/cardiometabolic disease, (2) reduce the risk of hypertension and cardiovascular/cardiometabolic disease, and (3) reduce sodium intake to lower the risk of hypertension and cardiovascular disease.

CONCLUSIONS

These consensus recommendations are intended to increase awareness of potential cardiovascular/cardiometabolic risks in patients with narcolepsy for all clinicians. Early monitoring for, and prevention of, cardiovascular risks in this population are of great importance, especially as narcolepsy usually develops in adolescents and young adults, who will be exposed to adverse effects of the disease for decades. Prospective systematic studies are needed to determine association and causation of narcolepsy with cardiovascular/cardiometabolic disorders.

Sleep Disorders in Childhood

OBJECTIVE

This article provides a comprehensive review of pediatric sleep disorders including the clinical features, diagnosis, and treatment of sleep-disordered breathing, insomnia, parasomnias, restless sleep disorder, restless legs syndrome, narcolepsy in childhood, and Kleine-Levin syndrome.

LATEST DEVELOPMENTS

Our understanding of pediatric sleep pathophysiology continues to evolve, and diagnostic and treatment modalities have expanded. A low-sodium oxybate formulation was approved in July 2020 in the United States to treat cataplexy and excessive daytime sleepiness in patients 7 years old and older with narcolepsy. A validated pediatric hypersomnolence survey for pediatric narcolepsy and idiopathic hypersomnia with high sensitivity, specificity, and interrater reliability is now available.

ESSENTIAL POINTS

The clinical presentation, diagnostics, and treatment of children with sleep disorders differ from those of adults. Untreated sleep disorders in childhood can lead to adverse physical and psychological consequences in adults. Correctly diagnosing and treating sleep disorders in youth can prevent a significant burden of disease in adulthood.

Secondary Narcolepsy as Worsening Sign in a Pediatric Case of Optic Pathway Glioma

Narcolepsy, a neurologic disorder that leads to excessive daytime sleepiness, may represent a rare consequence of neoplastic lesions involving the sellar/parasellar and hypothalamic regions, the anatomical areas responsible for wakefulness. Optic pathway gliomas represent the most common neoplasm of these regions and present an excellent overall survival, while long-term neurologic impairments, such as visual loss, endocrinopathies, or sleep disorders, are the principal causes of morbidity. In this case report, we describe a non-NF1 patient suffering from a very extensive optical pathway glioma, who several years after the diagnosis in a radiological condition of stable disease, presented with severe narcolepsy, a rare complication, that led to the death of the patient.

Current Understanding of Narcolepsy 1 and its Comorbidities: What Clinicians Need to Know

Narcolepsy is a chronic neurologic disorder associated with the dysregulation of the sleep–wake cycle that often leads to a decreased quality of life and results in a considerable health burden. There is often a delay to diagnosis of narcolepsy, mainly due to the lack of recognition of this disorder. One of the main factors hindering the diagnosis of narcolepsy is the association of comorbidities, which include other sleep disorders, psychiatric disorders, cardiovascular disorders, and metabolic disorders. The signs and symptoms of these comorbidities often overlap with those of narcolepsy, and some of the medications used for their treatment may obscure the symptoms of narcolepsy, leading to a delay in diagnosis. This review is targeted to clinicians unaccustomed to working with sleep disorders and aims to increase recognition and improve the management of narcolepsy.

Headache and Sleep Disturbances in the Pediatric Population

The relationship between sleep disturbances and headaches in the pediatric population is bidirectional. Common underlying molecular mechanisms of sleep and headaches have been speculated to explain the clinical connection. We will summarize various sleep disturbances and their known relationships to headache, focusing on the pediatric population. Careful recognition and assessment of sleep disturbances in patients with headache is critical and may help guide treatment. First line therapies for sleep disturbances consist of behavioral approaches, though surgical and pharmacologic strategies are utilized in particular circumstances.

Dream Activity in Narcoleptic Patients During the COVID-19 Lockdown in Italy

Some studies highlighted that patients with narcolepsy type-1 (NT1) experience high lucid dream frequency, and this phenomenon has been associated with a creative personality. Starting from the well-known “pandemic effect” on sleep and dreaming, we presented a picture of dream activity in pharmacologically treated NT1 patients during the Italian lockdown. Forty-three NT1 patients completed a web-survey during Spring 2021 and were compared with 86 matched-controls. Statistical comparisons revealed that: (a) NT1 patients showed greater sleepiness than controls; (b) controls showed higher sleep disturbances than NT1 patients, and this result disappeared when the medication effect in NT1 was controlled; (c) NT1 patients reported higher lucid dream frequency than controls. Focusing on dreaming in NT1 patients, we found that (a) nightmare frequency was correlated with female gender, longer sleep duration, higher intrasleep wakefulness; (b) dream recall, nightmare and lucid dream frequency were positively correlated with sleepiness. Comparisons between low and high NT1 lucid dreamers showed that patients more frequently experiencing lucid dreams reported a greater influence of dreaming during wakefulness, especially concerning problem-solving and creativity. Overall, our results are consistent with previous studies on pandemic dreaming carried out on healthy subjects. Moreover, we confirmed a link between lucidity and creativity in NT1 patients. Considering the small sample size and the cross-sectional design, our findings cannot provide a causal relationship between lucid dreams and the COVID-19 lockdown. Nevertheless, they represent a first contribution to address future studies on this issue, suggesting that some stable characteristics could interact with changes provoked by the pandemic.

Impact of COVID-19 pandemic lockdown on narcolepsy type 1 management

STUDY OBJECTIVES

Narcolepsy type 1 (NT1) is a chronic rare hypersomnia of central origin requiring a combination of behavioral and pharmacological treatments. During the coronavirus disease 2019 (COVID-19) pandemic, in Italy the population was forced into a lockdown. With this study, we aimed to describe the lockdown impact on NT1 symptom management, according to different patients' working schedule.

METHODS

In the period between 10 April and 15 May 2020, we performed routine follow-up visits by telephone (as recommended during the COVID-19 emergency) to 50 patients >18 years old (40% males) under stable long-term treatment. We divided patients into three groups: unchanged working schedule, forced working/studying at home, and those who lost their job ("lost occupation"). Current sleep-wake habit and symptom severity were compared with prelockdown assessment (six months before) in the three patient groups.

RESULTS

At assessment, 20, 22, and eight patients belonged to the unchanged, working/studying at home, and lost occupation groups, respectively. While in the lost occupation group, there were no significant differences compared with prepandemic assessment, the patients with unchanged schedules reported more nocturnal awakenings, and NT1 patients working/studying at home showed an extension of nocturnal sleep time, more frequent daytime napping, improvement of daytime sleepiness, and a significant increase in their body mass index. Sleep-related paralysis/hallucinations, automatic behaviors, cataplexy, and disturbed nocturnal sleep did not differ.

CONCLUSIONS

Narcolepsy type 1 patients working/studying at home intensified behavioral interventions (increased nocturnal sleep time and daytime napping) and ameliorated daytime sleepiness despite presenting with a slight, but significant, increase of weight.

Evaluating pitolisant as a narcolepsy treatment option

INTRODUCTION

Narcolepsy is a chronic sleep disorder characterized by a pentad of excessive daytime sleepiness (EDS), cataplexy, sleep paralysis, hypnagogic/hypnopompic hallucinations, and disturbed nocturnal sleep. Treatment of narcolepsy remains challenging and current therapy is strictly symptomatically based.

AREAS COVERED

The present manuscript is based on an extensive Internet and PubMed search from 1990 to 2020. It is focused on the clinical and pharmacological properties of pitolisant in the treatment of narcolepsy.

EXPERT OPINION

Currently there is no cure for narcolepsy. Although efforts have been made, current treatments do not always allow to obtain an optimal control of symptoms. Pitolisant is an antagonist/inverse agonist of the histamine H3 autoreceptor. Its mechanism of action is novel and distinctive compared to the other available therapies for narcolepsy. Clinical trials suggest that pitolisant administered at a dose of ≤36 mg/day is an effective treatment option for narcolepsy, reducing EDS and cataplexy. Pitolisant is available as oral tablets and offers a convenient once-daily regimen. Pitolisant is generally well tolerated and showed minimal abuse potential in animals and humans. Long-term studies comparing the effectiveness and tolerability of pitolisant with active drugs (e.g. modafinil, sodium oxybate) are needed.

Meditation-Relaxation (MR Therapy) for Sleep Paralysis: A Pilot Study in Patients With Narcolepsy

Sleep paralysis (SP) is a condition where a person is paralyzed upon waking or falling asleep. SP afflicts ~20% of people, and is also one of the typical symptoms in narcolepsy. During SP the sleeper may experience hallucinations. Unsurprisingly, SP is associated with great fear globally. To date, there are no published clinical trials or outcome data for treating this condition. However, few non-pharmacological interventions have been proposed, including cognitive behavioral approaches, and case studies showing clinical amelioration with auto-hypnosis and Meditation-Relaxation (MR) therapy. The latter for instance showed positive preliminary results; when applied for 8 weeks it reduced SP frequency and anxiety/worry symptoms. With this paper we aimed to evaluate, with a small-scale pilot study, the efficacy of MR therapy for SP in patients with narcolepsy. Ten patients with narcolepsy and SP were enrolled in the study. Notably, MR therapy (n = 6), applied for 8 weeks, resulted in a dramatic decrease in the number of days SP occurred (50% reduction); and the total number of SP episodes (54% reduction) in the last month of the study (demonstrated by large within-group effect sizes); unlike the control intervention (deep breathing) (n = 4). These findings are preliminary and exploratory given the small sample. Nonetheless, they represent the first proof of concept at providing empirically-guided insights into the possible efficacy of a novel treatment for frequently occurring SP. Although the study was conducted in patients with narcolepsy we cautiously suggest that the findings may generalize to individuals with isolated SP.

Can a Peer Support the Process of Self-Management in Narcolepsy? A Qualitative Narrative Analysis of a Narcoleptic Patient

INTRODUCTION

Narcolepsy type 1 (NT1) is a chronic and rare sleep disorder typically arising during adolescence and young adulthood. The main symptoms are excessive daytime sleepiness and cataplexy, a prototypical fall down elicited by huge emotions. Social relationships, school, work, and general health perception are frequently impaired in patients, who often show lower quality-of-life scores. We report which management strategies a young patient (DMG) adopted to cope with NT1 during his growth, avoiding exhibiting serious impairments to his global functioning.

METHODS

A clinical psychologist explores the history of the patient's disease and the self-acquired strategies used to cope with the symptoms. The patient's global adaptation to the disease, stress-related managing skills, and overall well-being are assessed by standardized scales [Illness Behavior Questionnaire (IBQ); Coping Orientations to Problems Experienced (COPE); and Psychological General Well-Being Index (PGWBI)]. We conducted a qualitative analysis of the patient's narration of his illness according to the procedure of the Grounded Theory. The MAXQDA software program was used to code the verbatim transcript.

RESULTS

From the qualitative analysis of the interview, three thematic cores emerged: 1) the disease history; 2) the patient's friendship with AD, a friend of his age diagnosed with NT1 since childhood; 3) the strategies used to deal with his symptoms before the diagnosis of NT1 and the related treatment. From the psychometric tests, the patient presents good coping strategies in dealing with stressful problems and events based mainly on acceptance and positive reinterpretation of the stressful situation.

CONCLUSION

This case shows that comparing peers of the same age and suffering from the same illness improve the patient's self-management ability to cope and live well with NT1.

Giving a voice to cataplectic experience: recollections from patients with narcolepsy type 1

STUDY OBJECTIVES

The objective of this study was to assess the narratives from the recalled accounts of cataplexy attacks of patients with narcolepsy type 1 (NT1).

METHODS

Twenty-two drug-naive adult patients meeting the International Classification of Sleep Disorders criteria for the diagnosis of NT1 referring to the Narcolepsy Center of the University of Bologna in the year 2017 underwent a semistructured interview focusing on their personal experiences during the cataplectic attacks. Verbatim transcripts were analyzed by thematic analysis of elementary contexts using T-LAB software.

RESULTS

The thematic analysis performed on the entire body text showed 3 clusters that explained 36.2%, 34.1%, and 29.7% of the variance, respectively: a cluster related to situations that trigger attacks of cataplexy, a cluster to bodily sensations, and another control strategies during episodes. The thematic content highlighted a tendency to disregard emotional experiences, thus affecting the ability to name, recognize, and regulate critical emotions.

CONCLUSIONS

The study showed that patients with NT1 spoke of their cataplectic attacks in terms of self-reported bodily experiences, trigger situations, and their management. Therefore, patients may have developed strategies of symptom management focused on emotion avoidance and/or inhibition.

Pitolisant: A Review in Narcolepsy with or without Cataplexy

Pitolisant (Wakix^®), an orally available, first-in-class antagonist/inverse agonist of the histamine 3 receptor, is approved in the EU (as of March 2016) for the treatment of narcolepsy with or without cataplexy in adults and in the USA (as of August 2019) for the treatment of excessive daytime sleepiness (EDS) in adults with narcolepsy. Pitolisant was demonstrated to have minimal risk of abuse in preclinical and clinical studies, and is the only anti-narcoleptic drug not scheduled as a controlled substance in the USA. The totality of evidence from pivotal and supportive phase III trials suggests that pitolisant administered at up to the recommended maximum dose of 36 mg once daily reduces EDS and cataplexy in adults with narcolepsy relative to placebo. Noninferiority of pitolisant to modafinil in the management of EDS was not demonstrated. Pitolisant was generally well tolerated in clinical trials. Consistent with its mechanism of action, the most common treatment-emergent adverse events included headache, insomnia and anxiety. With minimal abuse potential and offering the convenience of oral, once-daily administration, pitolisant extends the range of approved treatment options available to adult patients with narcolepsy with or without cataplexy.