Narcolepsy

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Treatment

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

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

Drug Therapy
Stimulants are the mainstay of drug therapy for excessive daytime sleepiness and sleep attacks in narcolepsy patients. These include methylphenidate (Ritalin®), modafinil, dextroamphetamine, and pemoline.

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

Dosages of these medications are determined on a case-by-case basis, and they are generally taken in the morning and at noon. Other drugs, such as certain antidepressants and drugs that are still being tested in the United States, are also used to treat the predominant symptoms of narcolepsy.

The major side effects of these stimulants are irritability, anxiety, quickened heart rate, hypertension, substance abuse, and disturbances of nocturnal sleep. Methylphenidate and dextroamphetamine are known to cause hypertension. A common side effect of modafinil is headache, usually related to dose size, which occurs in up to 5 percent of patients. Pemoline poses a very low but noticeable risk for liver complication. None of these stimulants influence the occurrence of narcolepsy's auxiliary symptoms and usually are not used to treat them.

Modafinil does not carry the addiction potential that methylphenidate and dextroamphetamine do. In fact, the latest development in treatment is a new modafinil drug called Provigil®, which does not act as a stimulant and so does not produce side effects like anxiety and irritability. Provigil®'s therapeutic effects have been observed in maintenance of wakefulness test research, where patients have tripled their wakefulness.

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

Tricyclic antidepressants, such as imipramine or chlorimimipramine, are the most widely prescribed medications for the three subsymptoms of narcolepsy. In some cases, they have improved symptoms within two days. Side effects include dry mouth, blurred vision, and sweating, among others.

Selective serotonin reuptake inhibitors, such as fluoxetine (Prozac®), work especially well in treating cataplexy. These medications have even affected the frequency of sleep attacks in some cases. Cataplexy is often much worse in sleep-deprived patients with poor sleep hygiene; therefore, establishing good sleep practices may be the most important aspect of controlling cataplexy.

Recent Developments in Treatment and a Possible Cure
The study of narcolepsy in other animals has illuminated continuities between human narcolepsy and that found in dogs and mice. This information is being used to try to find the cause of the condition and to improve treatment for human narcolepsy. The inheritance of narcolepsy in dogs is distinct from human patterns and is much better defined. These studies have focused on the biochemical dissimilarities that exist between humans and other animals, dissimilarities that may lead to new treatment.

Currently, researchers are working with a gene they believe is responsible for narcolepsy. Comparison between the human gene map and the genes of dogs who suffer from narcolepsy has led to the discovery of a mutual deficiency in hypocretin, a chemical in the brain whose absence seems to correspond to narcolepsy. Narcoleptic dogs are being injected with this chemical in an attempt to affect the symptoms of narcolepsy and cataplexy. At this point, researchers expect that a version of this substance will be administered to human narcolepsy patients in the future. Treatment with hypocretin would not only treat the symptoms of narcolepsy but the underlying deficiency that may cause it; a cure for narcolepsy may exist in the future.

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