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Ouyang H, Zhou Z, Dai X, Zhang J. Circadian rhythm of daytime sleepiness in pediatric narcolepsy: A pilot study. Brain Behav 2023; 13:e3109. [PMID: 37287413 PMCID: PMC10454348 DOI: 10.1002/brb3.3109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 05/03/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Excessive daytime sleepiness (EDS) has been far back reported as the most disabling symptom in the pediatric narcoleptic patients. However, there is a lack of studies to examine the circadian rhythms of EDS in pediatric narcoleptic population. Therefore, we aim to investigate the circadian rhythm of EDS in pediatric narcolepsy patients. METHODS We identified 50 pediatric narcoleptic patients (36 males and 14 females, mean age 13.68 ± 2.75 years). Data were collected through interviews and the relevant questionnaires (children depression inventory [CDI] and the pediatric quality of life inventory [PedsQL]). RESULT The frequencies of sleep attacks during different intervals of the day differed significantly, with higher frequency in the morning (p < .001). The times of sleep attacks in the morning and in the afternoon were significantly associated with the degree of impairment on class and the severity of worry about sleepiness, with spearman correlation coefficient ranging from .289 to .496 (p < .05). The total scores of PedsQL and CDI differed significantly among morning sleepiness dominant, afternoon sleepiness dominant, and evening sleepiness dominant groups (p = .042, p = .040). The severity scores of the narcoleptic patients' sleepiness had two peaks, one of which occurred at 16:00, and the other peaks occurred at about 11:00. CONCLUSION These results suggest that changes based on the circadian rhythm of sleepiness of the pediatric narcoleptic patients should be made in the treatment strategy. In addition, regulating the secretion of melatonin could serve as a promising treatment to relieve sleepiness in the future.
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Affiliation(s)
- Hui Ouyang
- Department of Clinical NeurologyPeople's Hospital of Peking UniversityBeijingChina
| | - Zechen Zhou
- Department of Peking UniversityHealth Science CenterBeijingChina
| | - Xiaotong Dai
- Department of Peking UniversityHealth Science CenterBeijingChina
| | - Jun Zhang
- Department of Clinical NeurologyPeople's Hospital of Peking UniversityBeijingChina
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2
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Pintwala SK, Fraigne JJ, Belsham DD, Peever JH. Immortal orexin cell transplants restore motor-arousal synchrony during cataplexy. Curr Biol 2023; 33:1550-1564.e5. [PMID: 37044089 DOI: 10.1016/j.cub.2023.03.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/11/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023]
Abstract
Waking behaviors such as sitting or standing require suitable levels of muscle tone. But it is unclear how arousal and motor circuits communicate with one another so that appropriate motor tone occurs during wakefulness. Cataplexy is a peculiar condition in which muscle tone is involuntarily lost during normal periods of wakefulness. Cataplexy therefore provides a unique opportunity for identifying the signaling mechanisms that synchronize motor and arousal behaviors. Cataplexy occurs when hypothalamic orexin neurons are lost in narcolepsy; however, it is unclear if motor-arousal decoupling in cataplexy is directly or indirectly caused by orexin cell loss. Here, we used genomic, proteomic, chemogenetic, electrophysiological, and behavioral assays to determine if grafting orexin cells into the brain of cataplectic (i.e., orexin-/-) mice restores normal motor-arousal behaviors by preventing cataplexy. First, we engineered immortalized orexin cells and found that they not only produce and release orexin but also exhibit a gene profile that mimics native orexin neurons. Second, we show that engineered orexin cells thrive and integrate into host tissue when transplanted into the brain of mice. Next, we found that grafting only 200-300 orexin cells into the dorsal raphe nucleus-a region densely innervated by native orexin neurons-reduces cataplexy. Last, we show that real-time chemogenetic activation of orexin cells restores motor-arousal synchrony by preventing cataplexy. We suggest that orexin signaling is critical for arousal-motor synchrony during wakefulness and that the dorsal raphe plays a pivotal role in coupling arousal and motor behaviors.
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Affiliation(s)
- Sara K Pintwala
- Department of Cell and Systems Biology, University of Toronto, Toronto, ON M5S 3G5, Canada
| | - Jimmy J Fraigne
- Department of Cell and Systems Biology, University of Toronto, Toronto, ON M5S 3G5, Canada
| | - Denise D Belsham
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - John H Peever
- Department of Cell and Systems Biology, University of Toronto, Toronto, ON M5S 3G5, Canada; Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada.
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3
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Clinical characteristics of a large cohort of patients with narcolepsy candidate for pitolisant: a cross-sectional study from the Italian PASS Wakix® Cohort. Neurol Sci 2022; 43:5563-5574. [PMID: 35750949 PMCID: PMC9385823 DOI: 10.1007/s10072-022-06210-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/11/2022] [Indexed: 12/29/2022]
Abstract
Introduction Narcolepsy is a chronic and rare hypersomnia of central origin characterized by excessive daytime sleepiness and a complex array of symptoms as well as by several medical comorbidities. With growing pharmacological options, polytherapy may increase the possibility of a patient-centered management of narcolepsy symptoms. The aims of our study are to describe a large cohort of Italian patients with narcolepsy who were candidates for pitolisant treatment and to compare patients’ subgroups based on current drug prescription (drug-naïve patients in whom pitolisant was the first-choice treatment, switching to pitolisant from other monotherapy treatments, and adding on in polytherapy). Methods We conducted a cross-sectional survey based on Italian data from the inclusion visits of the Post Authorization Safety Study of pitolisant, a 5-year observational, multicenter, international study. Results One hundred ninety-one patients were enrolled (76.4% with narcolepsy type 1 and 23.6% with narcolepsy type 2). Most patients (63.4%) presented at least one comorbidity, mainly cardiovascular and psychiatric. Pitolisant was prescribed as an add-on treatment in 120/191 patients (62.8%), as switch from other therapies in 42/191 (22.0%), and as a first-line treatment in 29/191 (15.2%). Drug-naive patients presented more severe sleepiness, lower functional status, and a higher incidence of depressive symptoms. Conclusion Our study presents the picture of a large cohort of Italian patients with narcolepsy who were prescribed with pitolisant, suggesting that polytherapy is highly frequent to tailor a patient-centered approach.
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Latorre D, Federica S, Bassetti CLA, Kallweit U. Narcolepsy: a model interaction between immune system, nervous system, and sleep-wake regulation. Semin Immunopathol 2022; 44:611-623. [PMID: 35445831 PMCID: PMC9519713 DOI: 10.1007/s00281-022-00933-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/22/2022] [Indexed: 12/21/2022]
Abstract
Narcolepsy is a rare chronic neurological disorder characterized by an irresistible excessive daytime sleepiness and cataplexy. The disease is considered to be the result of the selective disruption of neuronal cells in the lateral hypothalamus expressing the neuropeptide hypocretin, which controls the sleep-wake cycle. Diagnosis and management of narcolepsy represent still a substantial medical challenge due to the large heterogeneity in the clinical manifestation of the disease as well as to the lack of understanding of the underlying pathophysiological mechanisms. However, significant advances have been made in the last years, thus opening new perspective in the field. This review describes the current knowledge of clinical presentation and pathology of narcolepsy as well as the existing diagnostic criteria and therapeutic intervention for the disease management. Recent evidence on the potential immune-mediated mechanisms that may underpin the disease establishment and progression are also highlighted.
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Affiliation(s)
| | - Sallusto Federica
- Institute of Microbiology, ETH Zurich, Zurich, Switzerland.,Center of Medical Immunology, Institute for Research in Biomedicine, Università della Svizzera italiana, Bellinzona, Switzerland
| | | | - Ulf Kallweit
- Clinical Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Witten, Germany.,Center for Biomedical Education and Research (ZBAF), University Witten/Herdecke, Witten, Germany
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5
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Schifano F, Catalani V, Sharif S, Napoletano F, Corkery JM, Arillotta D, Fergus S, Vento A, Guirguis A. Benefits and Harms of 'Smart Drugs' (Nootropics) in Healthy Individuals. Drugs 2022; 82:633-647. [PMID: 35366192 DOI: 10.1007/s40265-022-01701-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/14/2022]
Abstract
'Smart drugs' (also known as 'nootropics' and 'cognitive enhancers' [CEs]) are being used by healthy subjects (i.e. students and workers) typically to improve memory, attention, learning, executive functions and vigilance, hence the reference to a 'pharmaceutical cognitive doping behaviour'. While the efficacy of known CEs in individuals with memory or learning deficits is well known, their effect on non-impaired brains is still to be fully assessed. This paper aims to provide an overview on the prevalence of use; putative neuroenhancement benefits and possible harms relating to the intake of the most popular CEs (e.g. amphetamine-type stimulants, methylphenidate, donepezil, selegiline, modafinil, piracetam, benzodiazepine inverse agonists, and unifiram analogues) in healthy individuals. CEs are generally perceived by the users as effective, with related enthusiastic anecdotal reports; however, their efficacy in healthy individuals is uncertain and any reported improvement temporary. Conversely, since most CEs are stimulants, the related modulation of central noradrenaline, glutamate, and dopamine levels may lead to cardiovascular, neurological and psychopathological complications. Furthermore, use of CEs can be associated with paradoxical short- and long-term cognitive decline; decreased potential for plastic learning; and addictive behaviour. Finally, the non-medical use of any potent psychotropic raises serious ethical and legal issues, with nootropics having the potential to become a major public health concern. Further studies investigating CE-associated social, psychological, and biological outcomes are urgently needed to allow firm conclusions to be drawn on the appropriateness of CE use in healthy individuals.
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Affiliation(s)
- Fabrizio Schifano
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, UK.
| | - Valeria Catalani
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, UK
| | - Safia Sharif
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, UK
| | - Flavia Napoletano
- East London Foundation Trust (ELFT), Newham Early Intervention Service, London, UK
| | - John Martin Corkery
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, UK
| | - Davide Arillotta
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, UK
| | - Suzanne Fergus
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, UK
| | - Alessandro Vento
- Department of Mental Health, ASL Roma 2, Rome, Italy
- Addictions' Observatory (ODDPSS), Rome, Italy
- Department of Psychology, Guglielmo Marconi University, Rome, Italy
| | - Amira Guirguis
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, UK
- Swansea University Medical School, Institute of Life Sciences 2, Swansea University, Singleton Park, Swansea, UK
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Kallweit U, Nilius G, Trümper D, Vogelmann T, Schubert T. Prevalence, incidence, and health care utilization of patients with narcolepsy: a population-representative study. J Clin Sleep Med 2022; 18:1531-1537. [PMID: 35088707 DOI: 10.5664/jcsm.9910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Previous estimated prevalence of narcolepsy in Europe was 47 patients per 100,000 persons, with a yearly incidence of 0.64-1.37 per 100,000. However, analyses of representative datasets from large cohorts are limited. This study aimed to estimate the population-based diagnostic prevalence and incidence of narcolepsy in Germany, and to describe these patients and their health care resource utilization. METHODS This study used the InGef research database, an anonymized representative dataset of 4 million persons covered by statutory health insurance in Germany. Patients with confirmed narcolepsy diagnoses in 2018 were included. Mid-p exact tests were used to calculate 95%-confidence intervals. Patients with narcolepsy diagnoses and narcolepsy-targeting therapy in 2014-2018 were included to describe health care resource utilization in the year prior to diagnosis. RESULTS In 2018 diagnostic prevalence was estimated as 17.88 (95%-CI 16.45-19.40), and 12-month incidence as 0.79 (0.52-1.15) per 100,000 persons. 46% patients were in psycho-behavioral therapeutic treatment and 61% of employees had sick-leave days. One in three patients was hospitalized for any cause. 28% received antibiotics. CONCLUSIONS Diagnostic prevalence was lower, but incidence was consistent with previous reports, though previous estimates may diverge in terms of age/gender-distributions. Patients showed a substantial utilization of health care resources, including sick leave and hospitalization. Almost half the patients underwent psycho-behavioral treatment in the year prior to diagnosis, which might indicate high burden of psychiatric symptoms. The increased use of antibiotics could indicate more frequent infections than in the general population.
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Affiliation(s)
- Ulf Kallweit
- Universität Witten/Herdecke, Klin. Schlaf- und Neuroimmunologie, Institut für Immunologie, Witten, Germany
| | - Georg Nilius
- Universität Witten/Herdecke, Klin. Schlaf- und Neuroimmunologie, Institut für Immunologie, Witten, Germany.,KEM
- Evang. Kliniken Essen-Mitte gGmbH, Pneumologie, Essen, Germany
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7
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Meskill GJ, Kallweit U, Zarycranski D, Caussé C, Finance O, Ligneau X, Davis CW. Pitolisant for the treatment of cataplexy in adults with narcolepsy. Expert Opin Orphan Drugs 2022. [DOI: 10.1080/21678707.2021.2022472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Gerard J. Meskill
- Tricoastal Narcolepsy and Sleep Disorders Center, Sugar Land, Texas, USA
| | - Ulf Kallweit
- Center for Narcolepsy, Hypersomnias and Daytime Sleepiness, Universität Witten/Herdecke, Witten, Germany
| | | | | | | | | | - Craig W. Davis
- Harmony Biosciences, Plymouth Meeting, Pennsylvania, USA
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8
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Current Understanding of Narcolepsy 1 and its Comorbidities: What Clinicians Need to Know. Adv Ther 2022; 39:221-243. [PMID: 34894325 PMCID: PMC8799537 DOI: 10.1007/s12325-021-01992-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/09/2021] [Indexed: 11/29/2022]
Abstract
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.
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Watson NF, Davis CW, Zarycranski D, Vaughn B, Dayno JM, Dauvilliers Y, Schwartz JC. Time to Onset of Response to Pitolisant for the Treatment of Excessive Daytime Sleepiness and Cataplexy in Patients With Narcolepsy: An Analysis of Randomized, Placebo-Controlled Trials. CNS Drugs 2021; 35:1303-1315. [PMID: 34822113 PMCID: PMC8642365 DOI: 10.1007/s40263-021-00866-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pitolisant is approved in the USA and Europe for the treatment of excessive daytime sleepiness or cataplexy in adults with narcolepsy. OBJECTIVE Analyses evaluated the time to onset of clinical response during treatment with pitolisant. METHODS Data were obtained from two randomized, double-blind, 7-week or 8-week, placebo-controlled studies (HARMONY 1, HARMONY CTP). Study medication was individually titrated to a maximum dose of pitolisant 35.6 mg/day and then remained stable. Efficacy assessments included the Epworth Sleepiness Scale and weekly rate of cataplexy (calculated from patient diaries). Onset of clinical response was defined as the first timepoint at which there was statistical separation between pitolisant and placebo. RESULTS The analysis included 61 patients in HARMONY 1 (pitolisant, n = 31; placebo, n = 30) and 105 patients in HARMONY CTP (pitolisant, n = 54; placebo, n = 51). Onset of clinical response began at week 2 (HARMONY 1) or week 3 (HARMONY CTP) for the mean change in Epworth Sleepiness Scale score, and week 2 (HARMONY CTP) or week 5 (HARMONY 1) for the mean change in weekly rate of cataplexy, with further improvements observed in pitolisant-treated patients through the end of treatment. The percentage of treatment responders was significantly greater with pitolisant vs placebo beginning at week 3 for excessive daytime sleepiness (defined as an Epworth Sleepiness Scale score reduction ≥ 3) and week 2 for cataplexy (defined as a ≥ 50% reduction in weekly rate of cataplexy [HARMONY CTP]). CONCLUSIONS Onset of clinical response for excessive daytime sleepiness and/or cataplexy was generally observed within the first 2-3 weeks of pitolisant treatment in patients with narcolepsy. CLINICALTRIALS. GOV IDENTIFIER NCT01067222 (February 2010), NCT01800045 (February 2013).
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Affiliation(s)
- Nathaniel F Watson
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA.
| | | | | | | | | | - Yves Dauvilliers
- National Reference Center for Narcolepsy, Montpellier, France
- Gui-de-Chauliac Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
- Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, Montpellier, France
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Liang Y, Shi W, Xiang A, Hu D, Wang L, Zhang L. The NAergic locus coeruleus-ventrolateral preoptic area neural circuit mediates rapid arousal from sleep. Curr Biol 2021; 31:3729-3742.e5. [PMID: 34270948 DOI: 10.1016/j.cub.2021.06.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/26/2021] [Accepted: 06/10/2021] [Indexed: 01/04/2023]
Abstract
The locus coeruleus (LC), which is located in the brain stem, plays an important role in promoting arousal. However, the neural circuitry underlying this function remains unclear. Using cortical electroencephalography combined with optrode recording, we found that LC noradrenergic (LCNA) neurons exhibit high activity during wakefulness, while suppressing the activity of these neurons causes a reduction in wakefulness. Viral tracing showed that LCNA neurons directly project to the ventrolateral preoptic area (VLPO) and that optogenetic activation of the noradrenergic (NAergic) LC-VLPO (NAergicLC-VLPO) neural circuit promotes arousal. Optrode recordings in the VLPO revealed two functionally distinct neuronal populations that were stimulated in response to the optogenetic activation of LCNA neurons. Consistently, we identified two types of VLPO neurons that exhibited different responses to NAergic projections from the LC mediated by discrete adrenergic receptors. Together, our results demonstrate that the NAergicLC-VLPO neural circuit is a critical pathway for controlling wakefulness and that a synergistic effect is produced by inhibition of sleep-active neurons in the VLPO through α2 receptors and activation of wake-active neurons in the VLPO through α1 and β receptors.
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Affiliation(s)
- Yue Liang
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei 230000, China; The First Rehabilitation Hospital of Shanghai, Tongji University School of Medicine, Shanghai 200090, China
| | - Wu Shi
- The First Rehabilitation Hospital of Shanghai, Tongji University School of Medicine, Shanghai 200090, China
| | - Anfeng Xiang
- The First Rehabilitation Hospital of Shanghai, Tongji University School of Medicine, Shanghai 200090, China; Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration of Ministry of Education, Orthopaedic Department of Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, 200065 Shanghai, P. R. China
| | - Dandan Hu
- The First Rehabilitation Hospital of Shanghai, Tongji University School of Medicine, Shanghai 200090, China; Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration of Ministry of Education, Orthopaedic Department of Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, 200065 Shanghai, P. R. China
| | - Liecheng Wang
- Department of Pharmacology, School of Basic Medical Sciences, Anhui Medical University, Hefei 230000, China.
| | - Ling Zhang
- The First Rehabilitation Hospital of Shanghai, Tongji University School of Medicine, Shanghai 200090, China; Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration of Ministry of Education, Orthopaedic Department of Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, 200065 Shanghai, P. R. China.
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11
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Bassetti CLA, Kallweit U, Vignatelli L, Plazzi G, Lecendreux M, Baldin E, Dolenc-Groselj L, Jennum P, Khatami R, Manconi M, Mayer G, Partinen M, Pollmächer T, Reading P, Santamaria J, Sonka K, Dauvilliers Y, Lammers GJ. European guideline and expert statements on the management of narcolepsy in adults and children. J Sleep Res 2021; 30:e13387. [PMID: 34173288 DOI: 10.1111/jsr.13387] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Narcolepsy is an uncommon hypothalamic disorder of presumed autoimmune origin that usually requires lifelong treatment. This paper aims to provide evidence-based guidelines for the management of narcolepsy in both adults and children. METHODS The European Academy of Neurology (EAN), European Sleep Research Society (ESRS), and European Narcolepsy Network (EU-NN) nominated a task force of 18 narcolepsy specialists. According to the EAN recommendations, 10 relevant clinical questions were formulated in PICO format. Following a systematic review of the literature (performed in Fall 2018 and updated in July 2020) recommendations were developed according to the GRADE approach. RESULTS A total of 10,247 references were evaluated, 308 studies were assessed and 155 finally included. The main recommendations can be summarized as follows: (i) excessive daytime sleepiness (EDS) in adults-scheduled naps, modafinil, pitolisant, sodium oxybate (SXB), solriamfetol (all strong); methylphenidate, amphetamine derivatives (both weak); (ii) cataplexy in adults-SXB, venlafaxine, clomipramine (all strong) and pitolisant (weak); (iii) EDS in children-scheduled naps, SXB (both strong), modafinil, methylphenidate, pitolisant, amphetamine derivatives (all weak); (iv) cataplexy in children-SXB (strong), antidepressants (weak). Treatment choices should be tailored to each patient's symptoms, comorbidities, tolerance and risk of potential drug interactions. CONCLUSION The management of narcolepsy involves non-pharmacological and pharmacological approaches with an increasing number of symptomatic treatment options for adults and children that have been studied in some detail.
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Affiliation(s)
- Claudio L A Bassetti
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Ulf Kallweit
- Center for Narcolepsy/Hypersomnias, Clin. Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Witten, Germany
| | - Luca Vignatelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Michel Lecendreux
- AP-HP, Pediatric Sleep Center, CHU Robert-Debré, Paris, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome (CNR narcolepsie-hypersomnie), Paris, France
| | - Elisa Baldin
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Leja Dolenc-Groselj
- Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Neurology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Faculty of Health Sciences, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ramin Khatami
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Center of Sleep Medicine, Sleep Research and Epileptology, Clinic Barmelweid, Barmelweid, Switzerland
| | - Mauro Manconi
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Sleep Center, Faculty of Biomedical Sciences, Neurocenter of Southern Switzerland, Università della Svizzera Italiana, Lugano, Switzerland
| | - Geert Mayer
- Neurology Department, Hephata Klinik, Schwalmstadt, Germany.,Department of Neurology, Philipps-Universität Marburg, Marburg, Germany
| | - Markku Partinen
- Department of Clinial Neurosciences, Clinicum, Helsinki Sleep Clinic, Vitalmed Research Center, Terveystalo Biobank and Clinical Research, University of Helsinki, Helsinki, Finland
| | | | - Paul Reading
- Department of Neurology, James Cook University Hospital, Middlesbrough, UK
| | - Joan Santamaria
- Neurology Service, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Karel Sonka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, Sleep Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, University of Montpellier, INM INSERM, Montpellier, France
| | - Gert J Lammers
- Sleep Wake Centre SEIN, Heemstede, The Netherlands.,Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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Bassetti CLA, Kallweit U, Vignatelli L, Plazzi G, Lecendreux M, Baldin E, Dolenc-Groselj L, Jennum P, Khatami R, Manconi M, Mayer G, Partinen M, Pollmächer T, Reading P, Santamaria J, Sonka K, Dauvilliers Y, Lammers GJ. European guideline and expert statements on the management of narcolepsy in adults and children. Eur J Neurol 2021; 28:2815-2830. [PMID: 34173695 DOI: 10.1111/ene.14888] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIM Narcolepsy is an uncommon hypothalamic disorder of presumed autoimmune origin that usually requires lifelong treatment. This paper aims to provide evidence-based guidelines for the management of narcolepsy in both adults and children. METHODS The European Academy of Neurology (EAN), European Sleep Research Society (ESRS) and European Narcolepsy Network (EU-NN) nominated a task force of 18 narcolepsy specialists. According to the EAN recommendations, 10 relevant clinical questions were formulated in PICO format. Following a systematic review of the literature (performed in Fall 2018 and updated in July 2020) recommendations were developed according to the GRADE approach. RESULTS A total of 10,247 references were evaluated, 308 studies were assessed and 155 finally included. The main recommendations can be summarized as follows: (i) excessive daytime sleepiness in adults-scheduled naps, modafinil, pitolisant, sodium oxybate (SXB), solriamfetol (all strong), methylphenidate, amphetamine derivates (both weak); (ii) cataplexy in adults-SXB, venlafaxine, clomipramine (all strong) and pitolisant (weak); (iii) excessive daytime sleepiness in children-scheduled naps, SXB (both strong), modafinil, methylphenidate, pitolisant, amphetamine derivates (all weak); (iv) cataplexy in children-SXB (strong), antidepressants (weak). Treatment choices should be tailored to each patient's symptoms, comorbidities, tolerance and risk of potential drug interactions. CONCLUSION The management of narcolepsy involves non-pharmacological and pharmacological approaches with an increasing number of symptomatic treatment options for adults and children that have been studied in some detail.
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Affiliation(s)
- Claudio L A Bassetti
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Ulf Kallweit
- Center for Narcolepsy/Hypersomnias, Clin. Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Witten, Germany
| | - Luca Vignatelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Michel Lecendreux
- AP-HP, Pediatric Sleep Center, CHU Robert-Debré, Paris, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome (CNR narcolepsie-hypersomnie), Paris, France
| | - Elisa Baldin
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Leja Dolenc-Groselj
- Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Neurology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Faculty of Health Sciences, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ramin Khatami
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Center of Sleep Medicine, Sleep Research and Epileptology. Clinic Barmelweid, Barmelweid, Switzerland
| | - Mauro Manconi
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Sleep Center, Faculty of Biomedical Sciences, Neurocenter of Southern Switzerland, Università della Svizzera Italiana, Lugano, Switzerland
| | - Geert Mayer
- Neurology Department, Hephata Klinik, Schwalmstadt, Germany.,Department of Neurology, Philipps-Universität Marburg, Marburg, Germany
| | - Markku Partinen
- Department of Clinial Neurosciences, Clinicum, Helsinki Sleep Clinic, Vitalmed Research Center, Terveystalo Biobank and Clinical Research, University of Helsinki, Helsinki, Finland
| | | | - Paul Reading
- Department of Neurology, James Cook University Hospital, Middlesbrough, UK
| | - Joan Santamaria
- Neurology Service, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Karel Sonka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, Sleep Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, University of Montpellier, INM INSERM, Montpellier, France
| | - Gert J Lammers
- Sleep Wake Centre SEIN, Heemstede, The Netherlands.,Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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Wang YQ, Liu WY, Li L, Qu WM, Huang ZL. Neural circuitry underlying REM sleep: A review of the literature and current concepts. Prog Neurobiol 2021; 204:102106. [PMID: 34144122 DOI: 10.1016/j.pneurobio.2021.102106] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 04/25/2021] [Accepted: 06/09/2021] [Indexed: 01/09/2023]
Abstract
As one of the fundamental sleep states, rapid eye movement (REM) sleep is believed to be associated with dreaming and is characterized by low-voltage, fast electroencephalographic activity and loss of muscle tone. However, the mechanisms of REM sleep generation have remained unclear despite decades of research. Several models of REM sleep have been established, including a reciprocal interaction model, limit-cycle model, flip-flop model, and a model involving γ-aminobutyric acid, glutamate, and aminergic/orexin/melanin-concentrating hormone neurons. In the present review, we discuss these models and summarize two typical disorders related to REM sleep, namely REM sleep behavior disorder and narcolepsy. REM sleep behavior disorder is a sleep muscle-tone-related disorder and can be treated with clonazepam and melatonin. Narcolepsy, with core symptoms of excessive daytime sleepiness and cataplexy, is strongly connected with orexin in early adulthood.
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Affiliation(s)
- Yi-Qun Wang
- Department of Pharmacology, School of Basic Medical Sciences and State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Wen-Ying Liu
- Department of Pharmacology, School of Basic Medical Sciences and State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Lei Li
- Department of Pharmacology, School of Basic Medical Sciences and State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Wei-Min Qu
- Department of Pharmacology, School of Basic Medical Sciences and State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, 200032, China
| | - Zhi-Li Huang
- Department of Pharmacology, School of Basic Medical Sciences and State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, 200032, China.
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14
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Setnik B, McDonnell M, Mills C, Scart-Grès C, Robert P, Dayno JM, Schwartz JC. Evaluation of the abuse potential of pitolisant, a selective H3-receptor antagonist/inverse agonist, for the treatment of adult patients with narcolepsy with or without cataplexy. Sleep 2021; 43:5598311. [PMID: 31626696 PMCID: PMC7157189 DOI: 10.1093/sleep/zsz252] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/06/2019] [Indexed: 12/13/2022] Open
Abstract
Objectives To evaluate the human abuse potential of pitolisant, a selective histamine 3 (H3)-receptor antagonist/inverse agonist recently approved by the US Food and Drug Administration for the treatment of excessive daytime sleepiness in adult patients with narcolepsy. Methods Nondependent, recreational stimulant users able to distinguish phentermine HCl 60 mg from placebo in a drug discrimination test were randomized in a four-period, double-blind, crossover design to receive single doses of pitolisant 35.6 mg (therapeutic dose), pitolisant 213.6 mg (supratherapeutic dose), phentermine HCl 60 mg, and placebo. The primary endpoint was maximum effect (Emax) on the 100-point Drug Liking (“at this moment”) visual analog scale. Results In 38 study completers (73.7% male; 65.8% white; mean age, 33.3 years), mean Drug Liking Emax was significantly greater for phentermine versus pitolisant 35.6 mg (mean difference, 21.4; p < 0.0001) and pitolisant 213.6 mg (mean difference, 19.7; p < 0.0001). Drug Liking Emax was similar for pitolisant (both doses) and placebo. Similarly, for key secondary measures of Overall Drug Liking and willingness to Take Drug Again, mean Emax scores were significantly greater for phentermine versus pitolisant (both doses) and similar for pitolisant (both doses) versus placebo. The incidence of adverse events was 82.1% after phentermine HCl 60 mg, 72.5% after pitolisant 213.6 mg, 47.5% after pitolisant 35.6 mg, and 48.8% after placebo administration. Conclusions In this study, pitolisant demonstrated significantly lower potential for abuse compared with phentermine and an overall profile similar to placebo; this suggests a low risk of abuse for pitolisant. Clinical Trial Registration ClinicalTrials.gov NCT03152123. Determination of the abuse potential of pitolisant in healthy, nondependent recreational stimulant users. https://clinicaltrials.gov/ct2/show/NCT03152123.
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Affiliation(s)
- Beatrice Setnik
- Syneos Health, Raleigh, NC.,Department of Toxicology and Pharmacology, University of Toronto, Toronto, ON, Canada
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15
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Malter M, Neuneier J, Triller A, Kallweit U. [Narcolepsy in adults: Definition, etiology and treatment]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2020; 89:103-113. [PMID: 33339064 DOI: 10.1055/a-1244-2612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Narcolepsy is a hypersomnolence disorder of central origin that presents with a disturbance of the wake-sleep regulation. Lead symptoms consist of excessive daytime sleepiness and cataplexy. Nowadays, two types of narcolepsy are distinguished. Type 1 narcolepsy, formerly known as narcolepsy with cataplexy, is based on hypocretin deficiency. The cause of type 2 narcolepsy, formerly known as narcolepsy without cataplexy, remains mainly unknown. A multimodal approach is necessary for diagnosis. The mean latency between the onset of disease and diagnosis in Europe ranges 14 years. Narcolepsy has a major impact on workability and quality of life. The management of narcolepsy is usually life-long and includes non-pharmacological approaches and a symptomatic pharmacological treatment.
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Affiliation(s)
| | | | - Annika Triller
- Zentrum für Narkolepsie/Hypersomnien, Klin. Schlaf- und Neuroimmunologie, Institut für Immunologie, Universität Witten/Herdecke
| | - Ulf Kallweit
- Zentrum für Narkolepsie/Hypersomnien, Klin. Schlaf- und Neuroimmunologie, Institut für Immunologie, Universität Witten/Herdecke
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16
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Cid-Jofré V, Gárate-Pérez M, Clark PJ, Valero-Jara V, España RA, Sotomayor-Zárate R, Cruz G, Renard GM. Chronic modafinil administration to preadolescent rats impairs social play behavior and dopaminergic system. Neuropharmacology 2020; 183:108404. [PMID: 33197467 DOI: 10.1016/j.neuropharm.2020.108404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022]
Abstract
Some clinical trials are investigating modafinil (Mod) as a treatment for attentional deficit and hyperactivity disorder (ADHD) in children and adolescents. Mod increases dopamine (DA) levels in the reward system by blocking dopamine transporter (DAT). Social interactions are rewarding behaviors and evidence reveals the importance of reward circuitry in social interactions. Chronic psychostimulant treatments alter DA neurotransmission and associated behaviors. The aim of this work was to evaluate the effects of chronic Mod treatment during preadolescence on social play behavior, locomotor activity, and DA in nucleus accumbens (NAc). Preadolescent male Sprague-Dawley rats were injected with Mod (75 mg/kg i.p.) or vehicle for 14 days (PND22 to PND35). After that, we measured social play behavior, content and DA release in NAc by HPLC coupled to electrochemical detection, protein levels of DA type 2 receptor (D2) by Western blot and DA kinetic by fast-scan cyclic voltammetry (FSCV) in NAc. Regarding social play, the total number of pinning events decreased in the Mod group compared with the vehicle. The K+-stimulated DA release in NAc was significantly lower in Mod-treated rats compared with vehicle group. Also, Mod increases locomotor activity at the first injection, but this effect is almost completely lost at day 14 of Mod treatment. Chronic Mod treatment during preadolescence in rats impairs dopaminergic neurotransmission in NAc and decreases the capacity of rats to perceive rewarding effects of social play. Importantly, as Mod is being evaluated to treat ADHD in children and adolescents, potential effects on social behavior should be considered since this kind of behavior in this particular stage is crucial for neurodevelopment.
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Affiliation(s)
- Valeska Cid-Jofré
- Centro de Investigación Biomédica y Aplicada (CIBAP), Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Chile; Laboratorio de Alteraciones Reproductivas y Metabólicas, Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Chile
| | - Macarena Gárate-Pérez
- Centro de Investigación Biomédica y Aplicada (CIBAP), Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Chile
| | - Philip J Clark
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Viviana Valero-Jara
- Laboratorio de Alteraciones Reproductivas y Metabólicas, Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Chile
| | - Rodrigo A España
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Ramón Sotomayor-Zárate
- Laboratorio de Neuroquímica y Neurofarmacología, Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valparaíso, Chile
| | - Gonzalo Cruz
- Laboratorio de Alteraciones Reproductivas y Metabólicas, Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Chile.
| | - Georgina M Renard
- Centro de Investigación Biomédica y Aplicada (CIBAP), Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Chile.
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de Biase S, Pellitteri G, Gigli GL, Valente M. Evaluating pitolisant as a narcolepsy treatment option. Expert Opin Pharmacother 2020; 22:155-162. [PMID: 32941089 DOI: 10.1080/14656566.2020.1817387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
| | - Gaia Pellitteri
- Neurology Unit, Department of Neurosciences, University Hospital of Udine , Udine, Italy
| | - Gian Luigi Gigli
- Neurology Unit, Department of Neurosciences, University Hospital of Udine , Udine, Italy.,Department of Mathematics, Informatics and Physics (DMIF), University of Udine , Udine, Italy
| | - Mariarosaria Valente
- Neurology Unit, Department of Neurosciences, University Hospital of Udine , Udine, Italy.,Department of Medical Area (DAME), University of Udine , Udine, Italy
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Abstract
PURPOSE OF REVIEW Narcolepsy is a central disorder of hypersomnolence with symptoms of excessive daytime sleepiness, sleep paralysis, and cataplexy. Cataplexy is the sudden loss of muscle tone in either the face, neck, trunk, and/or limbs, leading to a loss of voluntary muscle control. This article reviews recent research on the clinical characteristics of cataplexy. RECENT FINDINGS Longitudinal research in adults suggests that there may be a remission of cataplectic severity after symptom stabilization. First-line treatment options for cataplexy include sodium oxybate and pitolisant, with many drugs such as AXS-12, FT218, and JZP258 under investigation. Patients with cataplexy reported greater limitations of daily activities such as driving and exercise compared to patients without cataplexy. Cataplexy remains a challenge for children and adults with narcolepsy and can interfere with daily activities. There is no cure for narcolepsy, but cataplexy can be well-managed with current and promising new treatment options on the horizon.
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Wilenius L, Partinen M. Attention-Deficit/Hyperactivity Disorder Patients May Have Undiagnosed Narcolepsy. Cureus 2020; 12:e8436. [PMID: 32642351 PMCID: PMC7336577 DOI: 10.7759/cureus.8436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Attention-deficit/hyperactivity disorder (ADHD) patients have many comorbidities. Narcoleptic patients have a big prevalence of ADHD (15%-30%). Both groups suffer from similar symptoms and benefit from the same class of medications. As such, narcolepsy could be masked in ADHD patients. Low serum ferritin has been found both in ADHD patients as well as in patients with narcolepsy. Materials & methods We enrolled 26 participants (14 ADHD patients and 12 controls). They answered several questionnaires, and blood samples were obtained from 20 participants. We had clear exclusion criteria. Results Using the Ullanlinna Narcolepsy Scale (UNS), we identified three possible narcolepsy patients within the ADHD group and no suspects in the control group. There was a statistically significant negative correlation between serum iron levels and ADHD symptom severity. No correlation was found measuring serum ferritin levels. Conclusions Narcolepsy may be more common within ADHD patients than in the general population. Some of these patients could benefit from a change in medication. Low serum iron and ferritin levels could be relevant in ADHD pathophysiology. This requires further exploratory research.
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Affiliation(s)
| | - Markku Partinen
- Helsinki Sleep Clinic, Vitalmed Research Center, Helsinki, FIN.,Clinical Neurosciences, University of Helsinki, Helsinki, FIN
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20
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Dauvilliers Y, Arnulf I, Szakacs Z, Leu-Semenescu S, Lecomte I, Scart-Gres C, Lecomte JM, Schwartz JC. Long-term use of pitolisant to treat patients with narcolepsy: Harmony III Study. Sleep 2020; 42:5540186. [PMID: 31529094 PMCID: PMC6802569 DOI: 10.1093/sleep/zsz174] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/08/2019] [Indexed: 11/14/2022] Open
Abstract
Study Objectives To asses the long-term safety and efficacy of pitolisant, an histamine H3-receptor antagonist, on narcolepsy. Methods This open-label, single-arm, pragmatic study, recruited adult patients with narcolepsy and Epworth Sleepiness Scale (ESS) score ≥12. After a titration period, patients were treated for up to 1 year with oral pitolisant once-a-day at up to 40 mg. Concomitant stimulants and anti-cataplectic agents were allowed. The primary endpoint was safety; secondary endpoints included ESS, cataplexy, and other diary parameters. Results Patients (n = 102, 75 with cataplexy) received pitolisant, for the first time in 73 of them. Sixty-eight patients (51 with cataplexy) completed the 12-month treatment. Common treatment-emergent adverse events were headache (11.8% of patients), insomnia (8.8%), weight gain (7.8%), anxiety (6.9%), depressive symptoms (4.9%), and nausea (4.9%). Seven patients had a serious adverse effect, unrelated to pitolisant except for a possibly related miscarriage. One-third of patients stopped pitolisant, mostly (19.6%) for insufficient benefit. ESS score decreased by 4.6 ± 0.6. Two-thirds of patients completing the treatment were responders (ESS ≤ 10 or ESS decrease ≥ 3), and one third had normalized ESS (≤10). Complete and partial cataplexy, hallucinations, sleep paralysis, and sleep attacks were reduced by 76%, 65%, 54%, 63%, and 27%, respectively. Pitolisant as monotherapy (43% of patients) was better tolerated and more efficacious on ESS than on add-on, but efficacy was maintained in this last case. Conclusions Long-term safety and efficacy of pitolisant on daytime sleepiness, cataplexy, hallucinations, and sleep paralysis is confirmed.
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Affiliation(s)
- Yves Dauvilliers
- Reference National Center for Narcolepsy, Sleep Unit, Department of Neurology, Gui-de-Chauliac Hospital, University of Montpellier 1, Montpellier, INSERM U1061, France
| | - Isabelle Arnulf
- Sleep Disorder Unit, Hôpital la Pitié-Salpêtrière, Paris, France
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Abstract
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.
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Affiliation(s)
- Yvette N Lamb
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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22
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Yeh JY, Shyu YC, Lee SY, Yuan SS, Yang CJ, Yang KC, Lee TL, Sun CC, Wang LJ. Comorbidity of Narcolepsy and Psychotic Disorders: A Nationwide Population-Based Study in Taiwan. Front Psychiatry 2020; 11:205. [PMID: 32269533 PMCID: PMC7109289 DOI: 10.3389/fpsyt.2020.00205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/02/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Narcolepsy is a chronic sleep disorder that is likely to have neuropsychiatric comorbidities. Psychotic disorders are characterized by delusion, hallucination, and reality impairments. This study investigates the relationship between narcolepsy and psychotic disorders. DESIGN AND METHODS This study involves patients who were diagnosed with narcolepsy between January 2002 and December 2011 (n = 258) and age- and gender-matched controls (n = 2580) from Taiwan's National Health Insurance database. Both the patients and the controls were monitored from January 1, 2002 to December 31, 2011 to identify any occurrence of a psychotic disorder. Drugs that have been approved for treating narcolepsy: immediate-release methylphenidate (IR-MPH), osmotic controlled-release formulations of methylphenidate (OROS-MPH), and modafinil, were analyzed. A multivariate logistic regression model was used to evaluate the potential comorbidity of narcolepsy with psychotic disorders. RESULTS During the study period, 8.1% of the narcoleptic patients exhibited comorbidity with a psychotic disorder, whereas only 1.5% of the control subjects (1.5%) had psychotic disorders (aOR, 4.07; 95% CI, 2.21-7.47). Of the narcolepsy patients, 41.5, 5.4, and 13.2% were treated with MPH-IR, MPH-OROS, and modafinil, accordingly. Pharmacotherapy for narcolepsy did not significantly affect the risk of exhibiting a psychotic disorder. CONCLUSIONS This nationwide study revealed that narcolepsy and psychotic disorders commonly co-occur. Pharmacotherapy for narcolepsy was not associated with the risk of psychotic disorders. Our findings serve as a reminder that clinicians must consider the comorbidity of narcolepsy and psychosis.
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Affiliation(s)
- Jia-Yin Yeh
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Chiau Shyu
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.,Institute of Molecular Biology, Academia Sinica, Taipei, Taiwan.,Department of Nursing, Department of Nutrition and Health Sciences, Research Center for Food and Cosmetic Safety, and Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Sheng-Yu Lee
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Shin-Sheng Yuan
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan
| | - Chun-Ju Yang
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.,Institute of Biopharmaceutical Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Kang-Chung Yang
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.,Institute of Biopharmaceutical Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Tung-Liang Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Chi-Chin Sun
- Department of Ophthalmology, Keelung, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Liang-Jen Wang
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Pascoe M, Bena J, Foldvary-Schaefer N. Effects of Pharmacotherapy Treatment on Patient-Reported Outcomes in a Narcolepsy and Idiopathic Hypersomnia Cohort. J Clin Sleep Med 2019; 15:1799-1806. [PMID: 31855165 PMCID: PMC7099187 DOI: 10.5664/jcsm.8088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVE We aimed to evaluate the association between patient-reported outcomes (PROs) and treatment regimen/standardized dose (STD), a measure of drug burden, in patients with narcolepsy type 1 (NT1)/type 2 (NT2) and idiopathic hypersomnia (IH). METHODS Patients age 18 years or older with NT1/NT2 and IH with baseline and ≥ 6-month follow-up during 2008-2010 were included. Changes in PROs (Epworth Sleepiness Scale [ESS], Fatigue Severity Scale [FSS], Patient Health Questionnaire 9 [PHQ-9], total sleep time [TST]) by diagnosis, treatment regimen (monotherapy versus polytherapy, sodium oxybate [SO] use), and STD were assessed by t tests and univariable/multivariable linear regressions, adjusting for patient characteristics. RESULTS A total of 92 patients (26 [28.3%] NT1, 27 [29.3%] NT2, 39 [42.4%] IH) were included (age 43.8 ± 14.8 years; 66 [71.7%] female). Baseline PROs suggested excessive daytime sleepiness (ESS 14.2 ± 5.2 [74% patients > 10]), significant fatigue (FSS 47.5 ± 12.9), and mild depression (PHQ-9 9.0 [4.0, 14.0] [49.4% ≥ 10]). At follow-up, ESS and PHQ-9 improved significantly overall and within diagnostic, monotherapy/polytherapy, and SO use groups (all P < .01). FSS improved significantly overall (P = .016), but improvements were not significant for IH, monotherapy, polytherapy, and non-SO using groups. In multivariable models, PRO changes were not significantly different between groups, but baseline STD was associated with worsening PHQ-9 across PHQ-9 change models, and ESS worsened with increasing STD at follow-up (P = .056). CONCLUSIONS Significant improvements in sleep-related PROs were seen with pharmacotherapy use, regardless of diagnosis or treatment type, highlighting the importance of individualized prescribing decisions for this population.
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Affiliation(s)
- Maeve Pascoe
- Sleep Disorders Center, Cleveland Clinic, Cleveland, Ohio
| | - James Bena
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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Lehert P, Falissard B. Multiple treatment comparison in narcolepsy: a network meta-analysis. Sleep 2019; 41:5102365. [PMID: 30239930 PMCID: PMC6289237 DOI: 10.1093/sleep/zsy185] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Indexed: 01/29/2023] Open
Abstract
Study Objectives Randomized controlled trials (RCTs) that compared the safety and efficacy of medical treatments for narcolepsy were analyzed using network meta-analysis. Methods The RCTs in narcolepsy were searched. Network meta-analysis compared efficacy and safety of multiple treatments, multi-arm studies, and multi-criteria treatment decisions, based on a random model that assumed heterogeneity between studies, with corrections for multi-arm studies. Results Fourteen RCTs, three drug treatments, and six doses were identified: sodium oxybate (6 and 9 g/d), modafinil (between 200 and 400 mg/d), and pitolisant (up to 20 and up to 40 mg/d). Significant heterogeneity (>50%) between studies was found in 12/14 studies for almost all endpoints, but between-design consistency was present. For ESS and MWT, sodium oxybate 9 g/d, modafinil, and pitolisant up to 40 mg/d had similar efficacy. Pitolisant 40 mg/d and sodium oxybate 9 g/d in two nightly doses had similar efficacy in reducing cataplexy. A good safety profile characterized by a TEAE incidence risk ratio (IRR) <1.5 was found for all the compared treatments, except for sodium oxybate 9 g/d. Although no significant difference was found, Pitolisant 40 mg was shown with the best P scores for the benefit/risk (BR) ratio. Conclusions Modafinil (200–400 mg/d), sodium oxybate 9 g/d, and pitolisant up to 40 mg/d had similar efficacy in reducing excessive day time sleepiness. Only sodium oxybate 9 g/d and pitolisant up to 40 mg/d were shown with a comparable beneficial effect on cataplexy. Overall, Pitolisant was found with the best P score on the BR ratio Clinical Trial Registration PROSPERO 2017 CRD42017054686. Efficacy, safety, and benefit-risk comparison of alternative treatments in narcolepsy: a network multiple comparisons of treatment meta-analysis. http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017054686.
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Affiliation(s)
- Philippe Lehert
- Faculty of Medicine, University of Melbourne, Melbourne, Australia.,Faculty of Economics, University of Louvain, Mons, Belgium
| | - Bruno Falissard
- Centre de Recherche en Epidemiologie et Santé des Populations, CESP/INSERM, Paris, France
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25
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Thorpy MJ, Bogan RK. Update on the pharmacologic management of narcolepsy: mechanisms of action and clinical implications. Sleep Med 2019; 68:97-109. [PMID: 32032921 DOI: 10.1016/j.sleep.2019.09.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/21/2022]
Abstract
Narcolepsy is a chronic, debilitating neurological disorder of sleep-wake state instability. This instability underlies all narcolepsy symptoms, including excessive daytime sleepiness (EDS), symptoms of rapid eye movement (REM) sleep dysregulation (ie, cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis), and disrupted nighttime sleep. Several neurotransmitter systems promote wakefulness, and various neural pathways are involved in regulating REM sleep-related muscle atonia, providing multiple targets for pharmacologic intervention to reduce EDS and cataplexy. Medications approved by the US Food and Drug Administration (FDA) for the treatment of EDS in narcolepsy include traditional stimulants (eg, amphetamines, methylphenidate), wake-promoting agents (eg, modafinil, armodafinil), and solriamfetol, which mainly act on dopaminergic and noradrenergic pathways. Sodium oxybate (thought to act via GABAB receptors) is FDA-approved for the treatment of EDS and cataplexy. Pitolisant, a histamine 3 (H3)-receptor antagonist/inverse agonist, is approved by the European Medicines Agency (EMA) for the treatment of narcolepsy with or without cataplexy in adults and by the FDA for the treatment of EDS in adults with narcolepsy. Pitolisant increases the synthesis and release of histamine in the brain and modulates the release of other neurotransmitters (eg, norepinephrine, dopamine). Antidepressants that inhibit reuptake of serotonin and/or norepinephrine are widely used off label to manage cataplexy. In many patients with narcolepsy, combination treatment with medications that act via different neural pathways is necessary for optimal symptom management. Mechanism of action, pharmacokinetics, and abuse potential are important considerations in treatment selection and subsequent medication adjustments to maximize efficacy and mitigate adverse effects in the treatment of patients with narcolepsy.
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Affiliation(s)
- Michael J Thorpy
- Sleep-Wake Disorders Center, Montefiore Medical Center, Albert Einstein College of Medicine, 3411 Wayne Ave, Bronx, NY, 10467, USA.
| | - Richard K Bogan
- SleepMed Inc., Bogan Sleep Consultants, LLC, 1333 Taylor Street, Columbia, SC, USA.
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26
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Narcolepsy — clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol 2019; 15:519-539. [DOI: 10.1038/s41582-019-0226-9] [Citation(s) in RCA: 204] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2019] [Indexed: 12/15/2022]
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27
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Tzeng NS, Hsing SC, Chung CH, Chang HA, Kao YC, Mao WC, Yang CCH, Kuo TBJ, Chen TY, Chien WC. The Risk of Hospitalization for Motor Vehicle Accident Injury in Narcolepsy and the Benefits of Stimulant Use: A Nationwide Cohort Study in Taiwan. J Clin Sleep Med 2019; 15:881-889. [PMID: 31138389 DOI: 10.5664/jcsm.7842] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/21/2019] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVES To examine the risk of hospitalization for motor vehicle accident injury (MVAI) in patients with narcolepsy and the effects of stimulant use on MVAI occurrence in patients with narcolepsy. METHODS This is a population-based, retrospective cohort study using Taiwan's National Health Insurance Research Database between 2000 and 2013. We included patients with narcolepsy based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, 347. The case and matched control participants were selected in a ratio of 1:3, and the traffic accident (ICD-9-CM codes: E810-E819) plus injury codes (ICD-9-CM codes: 800.xx-999.xx) due to MVAI following hospitalization were used for the study outcome. The type of injury, causes, intentionality, and the effects of stimulant use on patients with narcolepsy were also assessed. RESULTS A total of 1,316 participants were enrolled, including 329 participants with narcolepsy and 987 participants without narcolepsy. During a 14-year follow-up period, a total of 104 participants had MVAI, of whom 47 (1,559.54 per 100,000 person-years) belonged to the narcolepsy cohort and 57 (556.21 per 100,000 person-years) to the non-narcolepsy cohort. After adjusting for covariates, the risk of hospitalization for MVAI among participants with narcolepsy was still significantly higher than those without narcolepsy (adjusted hazard ratio = 6.725; 95% confidence interval = 4.421-10.231; P < .001). The use of modafinil or methylphenidate, as monotherapy or combined treatment, was associated with a lower risk of MVAI in the narcolepsy cohort. CONCLUSIONS Patients with narcolepsy may have a higher risk of hospitalization for MVAI and stimulant use could mitigate such risk.
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Affiliation(s)
- Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Chun Hsing
- Center for Healthcare Quality Management, Cheng Hsin General Hospital.,Department of Health Care Management, College of Health Technology, National Taipei University of Nursing and Heath Sciences
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Chen Kao
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Department of Psychiatry, Tri-Service General Hospital, Song-Shan Branch, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Chung Mao
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Cheryl C H Yang
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,Sleep Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Terry B J Kuo
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,Sleep Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,Sleep Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
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28
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Morse AM, Kelly-Pieper K, Kothare SV. Management of Excessive Daytime Sleepiness in Narcolepsy With Baclofen. Pediatr Neurol 2019; 93:39-42. [PMID: 30595352 DOI: 10.1016/j.pediatrneurol.2018.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 08/17/2018] [Accepted: 10/30/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Narcolepsy is a disabling sleep-wake disorder characterized by the pentad symptoms of excessive daytime sleepiness, sleep paralysis, sleep fragmentation, sleep-related hallucinations, and cataplexy. There is no curative therapy for narcolepsy. Treatment is therefore symptom directed. Symptom management is generally directed at improving excessive daytime sleepiness, sleep fragmentation, and cataplexy. First-line treatment for excessive daytime sleepiness is typically daily use of wake-promoting agents, such as modafinil or armodafinil, or stimulant therapy, such as methylphenidate or amphetamines. Alternatively, sodium oxybate can be used nightly for improved cataplexy, sleep consolidation, and following day wakefulness. These therapies can be limited in some patients because of inadequate efficacy, poor tolerability, or side effects. METHODS We describe five narcolepsy patients with severe excessive daytime sleepiness who had an inadequate response or experienced side effects with the initial therapies but had a positive response to treatment with baclofen. RESULTS These patients reported subjective improvement in sleep maintenance without fragmentation and daytime sleepiness. Average Epworth Sleepiness Scale assessment before treatment was 15.8 with post-treatment assessment being 10.4 (P < 0.05). CONCLUSIONS Baclofen may be an effective treatment for excessive daytime sleepiness and sleep fragmentation in narcolepsy and warrants further study.
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Affiliation(s)
- Anne M Morse
- Department of Child Neurology, Geisinger Medical Center, Janet Weis Children's Hospital, Danville, Pennsylvania; Department of Sleep Medicine, Geisinger Medical Center, Janet Weis Children's Hospital, Danville, Pennsylvania
| | - Kristin Kelly-Pieper
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Cohen Children's Medical Center, Lake Success, New York; Pediatric Neurology Service Line for Northwell Health, Department of Pediatrics & Neurology, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, Lake Success, New York
| | - Sanjeev V Kothare
- Pediatric Neurology Service Line for Northwell Health, Department of Pediatrics & Neurology, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, Lake Success, New York; Division of Pediatric Neurology, Department of Pediatrics, Cohen Children's Medical Center, Lake Success, New York; Pediatric Sleep Program (Neurology), Department of Pediatrics, Cohen Children's Medical Center, Lake Success, New York.
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29
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Abstract
Narcolepsy is a chronic disorder characterized by symptoms of excessive daytime sleepiness, irresistible sleep attacks that may be accompanied by cataplexy brought on by emotions, sleep paralysis, and hypnagogic hallucinations. This is a review of 32 empirical articles on health-related quality of life (HRQoL) published in peer-reviewed journals over the past 37 years. Deleterious implications on education, recreation, driving, sexual life, and personality are associated with the disease with a consequent negative psychosocial impact. Sleepiness has an important influence on HRQoL, more than the other symptoms of this disorder that have disrupting roles, too. Therefore, patients with narcolepsy need assistance not only for medication prescription but also in terms of psychological and social support. It is also of importance to assess patients with narcolepsy carefully in terms of depressive symptoms because they may have a major impact on HRQoL with important clinical implications.
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30
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Sahni AS, Carlucci M, Malik M, Prasad B. Management Of Excessive Sleepiness In Patients With Narcolepsy And OSA: Current Challenges And Future Prospects. Nat Sci Sleep 2019; 11:241-252. [PMID: 31695533 PMCID: PMC6815780 DOI: 10.2147/nss.s218402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/09/2019] [Indexed: 01/09/2023] Open
Abstract
Excessive daytime sleepiness (EDS) can be caused by insufficient sleep but is also a manifestation of medical or sleep disorders and a side effect of medications. It impacts quality of life and creates safety concerns in the home, at work, and on the roads. Screening questionnaires can be used to estimate EDS, but further evaluation is necessary. EDS is a common symptom of both narcolepsy and obstructive sleep apnea (OSA). Polysomnography and multiple sleep latency testing are used to diagnose these disorders. However, isolating the primary etiology of EDS can be challenging and may be multifactorial. Untreated OSA can show polysomnographic findings that are similar to narcolepsy. The effects of sleep deprivation and certain medications can also affect the polysomnographic results. These challenges can lead to misdiagnosis. In addition, narcolepsy and OSA can occur as comorbid disorders. If EDS persists despite adequate treatment for either disorder, a comorbid diagnosis should be sought. Thus, despite advances in clinical practice, appropriate management of these patients can be challenging. This review is focused on EDS due to OSA and narcolepsy and addresses some of the challenges with managing this patient population.
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Affiliation(s)
- Ashima S Sahni
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Melissa Carlucci
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Malik Malik
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Bharati Prasad
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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31
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Choi YW, Song JH, Kim TW, Kim SM, Cho IH, Hong SC. Two Cases of Narcoleptic patients with sleep paralysis as a Chief Complaint. SLEEP MEDICINE RESEARCH 2018. [DOI: 10.17241/smr.2018.00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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32
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de Biase S, Gigli GL, Valente M. Important decisions in choosing the pharmacotherapy for narcoleptics. Expert Opin Pharmacother 2018; 20:483-486. [PMID: 30592648 DOI: 10.1080/14656566.2018.1561861] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Stefano de Biase
- a Neurology Unit, Department of Neurosciences , University Hospital of Udine , Udine , Italy
| | - Gian Luigi Gigli
- a Neurology Unit, Department of Neurosciences , University Hospital of Udine , Udine , Italy.,b DMIF , University of Udine , Udine , Italy
| | - Mariarosaria Valente
- a Neurology Unit, Department of Neurosciences , University Hospital of Udine , Udine , Italy.,c Department of Medicine , University of Udine Medical School , Udine , Italy
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33
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Szabo ST, Thorpy MJ, Mayer G, Peever JH, Kilduff TS. Neurobiological and immunogenetic aspects of narcolepsy: Implications for pharmacotherapy. Sleep Med Rev 2018; 43:23-36. [PMID: 30503715 DOI: 10.1016/j.smrv.2018.09.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 09/22/2018] [Accepted: 09/27/2018] [Indexed: 01/19/2023]
Abstract
Excessive daytime sleepiness (EDS) and cataplexy are common symptoms of narcolepsy, a sleep disorder associated with the loss of hypocretin/orexin (Hcrt) neurons. Although only a few drugs have received regulatory approval for narcolepsy to date, treatment involves diverse medications that affect multiple biochemical targets and neural circuits. Clinical trials have demonstrated efficacy for the following classes of drugs as narcolepsy treatments: alerting medications (amphetamine, methylphenidate, modafinil/armodafinil, solriamfetol [JZP-110]), antidepressants (tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors), sodium oxybate, and the H3-receptor inverse agonist/antagonist pitolisant. Enhanced catecholamine availability and regulation of locus coeruleus (LC) norepinephrine (NE) neuron activity is likely central to the therapeutic activity of most of these compounds. LC NE neurons are integral to sleep/wake regulation and muscle tone; reduced excitatory input to the LC due to compromise of Hcrt/orexin neurons (likely due to autoimmune factors) results in LC NE dysregulation and contributes to narcolepsy/cataplexy symptoms. Agents that increase catecholamines and/or LC activity may mitigate EDS and cataplexy by elevating NE regulation of GABAergic inputs from the amygdala. Consequently, novel medications and treatment strategies aimed at preserving and/or modulating Hcrt/orexin-LC circuit integrity are warranted in narcolepsy/cataplexy.
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Affiliation(s)
- Steven T Szabo
- Duke University Medical Center, Durham, NC, USA; Durham Veterans Affairs Medical Center, Durham, NC, USA.
| | | | | | - John H Peever
- University of Toronto, Toronto, Ontario M5S 3G5, Canada.
| | - Thomas S Kilduff
- Center for Neuroscience, Biosciences Division, SRI International, Menlo Park, CA 94025, USA.
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Romigi A, Vitrani G, Lo Giudice T, Centonze D, Franco V. Profile of pitolisant in the management of narcolepsy: design, development, and place in therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:2665-2675. [PMID: 30214155 PMCID: PMC6124464 DOI: 10.2147/dddt.s101145] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Narcolepsy is a rare sleep disorder characterized by excessive daytime sleepiness and rapid eye movement sleep dysregulation, manifesting as cataplexy and sleep paralysis, as well as hypnagogic and hypnopompic hallucinations. Disease onset may occur at any age, although adolescents and young adults are mainly affected. Currently, the diagnosis delay ranges from 8 to 10 years and drug therapy may only attenuate symptoms. Pitolisant is a first-in-class new drug currently authorized by the European Medicines Agency to treat narcolepsy with or without cataplexy in adults and with an expanded evaluation for the treatment of neurologic diseases such as Parkinson’s disease and epilepsy. This article reviews the pharmacokinetic and pharmacodynamic profile of pitolisant, highlighting its effectiveness and safety in patients with narcolepsy. We performed a systematic review of the literature using PubMed, Embase, and Google Scholar. We report on the efficacy and safety data of pitolisant in narcoleptic patients regarding cataplexy episodes and subjective and objective daytime sleepiness. The development program of pitolisant was characterized by eight Phase II/III studies. One proof-of-concept study followed by two pivotal studies, three randomized controlled trials, and two open studies were evaluated. Our review confirmed the effectiveness of pitolisant in treating major clinically relevant narcolepsy symptoms, including cataplexy, as compared to placebo. In addition, pitolisant revealed a safe profile when compared with placebo and active comparators. Headache, insomnia, and nausea were the prominent side effects. Further long-term randomized controlled trials comparing the efficacy of pitolisant with active comparators (ie, modafinil and sodium oxybate) may clarify its real place in therapy and its possible use as a first-line agent on the basis of its safety and tolerability.
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Affiliation(s)
- Andrea Romigi
- IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli (IS), Italy,
| | - Giuseppe Vitrani
- IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli (IS), Italy,
| | | | - Diego Centonze
- IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli (IS), Italy, .,Department of System Medicine, University of Rome Tor Vergata Rome, Italy
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