Medications Used in the Treatment of Narcolepsy
Alerting Agents (wake-promoting therapeutics and stimulants)
Occasionally, patients prefer to avoid medications and to take extra naps during the day instead. This approach may not provide enough daytime alertness to people suffering from excessive sleepiness associated with narcolepsy function adequately. In these cases, medications classified as alerting agents provide substantial improvements in their daytime alertness. However, for most patients with narcolepsy, alerting agents will not yield a normal degree of daytime alertness. Optimal improvement usually requires scheduled naps.
Modafinil (Provigil, Cephalon)
Modafinil is well tolerated, effective, and extensively studied in narcolepsy. It is often the first-line treatment for narcolepsy.
See Modafinil datasheet for information on dosage and side reactions
If treatment with modafinil alone is not sufficient, traditional stimulants are given with it.
Commonly used traditional stimulants for narcolepsy include methylphenidate and dextroamphetamine. Other amphetamines, amphetamine-analog agents, and sustained-release preparations are available.
Many people experience negative effects with these stimulants. It also may exacerbate sleepiness ( rebound hypersomnia) as the dose wears off. The patient may develop tolerance (tachyphylaxis) to the alerting effect with repeated dosing.
Common Side effects are: headache, gastrointestinal disturbance, anxiety, irritability, increased pulse, increased blood pressure
Amphetamines are frequently used for narcolepsy and are generally very effective.
See drug information for amphetamines for information about dosage, side effects and warnings.
Side effects: headache, gastrointestinal disturbance, anxiety, irritability, increased pulse, increased blood pressure - The side effects are often characterized as not as prominent as in amphetamines.
Commonly used agent for narcolepsy, effective.
See drug information for methyphenidate for information about dosage, side effects and warnings.
Pemoline (Cylert. Abbott)
Pemoline in normal doses is less effective in improving daytime sleepiness than methylphenidate, dextroamphetamine, or methamphetamine. This medication also has the potential for hepatotoxicity. Because of these reasons, it is used only when modafinil or traditional stimulants cannot be used. If you use this, regular liver function evaluation is recommended.
Side effects: hepatotoxicity, amphetamine-Iike side effects are generally less pronounced.
This medication was previously used frequently in narcolepsy. But potential for hepatic failure renders pemoline a second- or third-line agent.
See drug information for pemoline for information about dosage, side effects and important safety warnings.
Common initial dose - 1-2 mg once or twice daily
Mazindol is generally considered less effective as a stimulant.
See drug information for Mazindol for information about dosage, side effects and important safety warnings.
Medications useful in the treatment of cataplexy usually also improve hypnagogic/hypnopompic hallucinations and sleep paralysis. In general, tricyclic antidepressants (TCAs) are effective in ameliorating or eliminating symptoms of cataplexy. Dosage required is much less than that for depression. Disadvantage is the side effects.
Selective serotonin reuptake inhibitors (SSRIs) have also proven useful in treating cataplexy. Doses comparable to that required for depression are required. Also, SSRIs are not as effective as TCAs in some patients. SSRIs, however, may be better tolerated by some than TCAs.
Sodium oxybate (also known as gamma-hydroxybutyrate or GHB) had been used in Europe. It is now undergoing clinical trials in the US. It appears to be an effective anticataplectic agent, even in individuals with inadequate responses to other agents. GHB is highly effective in reducing nocturnal sleep disruptions and consolidating nocturnal sleep. It also exhibits an alerting effect during the day.
See Gamma-Hydroxybutyrate (GHB) for more information
Antidepressants with central nervous system noradrenergic activity have been reported in individual cases to provide effective treatment for cataplexy. Venlafaxine extended-release (Effexor ER) has been found to be particularly effective for cataplexy by a number of clinicians.
Common initial dose - 25 mg once or twice daily
Side effects: orthostatic hypotension, sedation, anticholinergic effects
TCAs are often more effective, but less tolerable than SSRls
See drug information for TCA for information about dosage, side effects and important safety warnings.
Common initial dose - 20 mg (Prozac and Paxil), 50 mg (Zoloft), daily
Side effects: nausea, insomnia, anxiety, decreased appetite
SSRIs may be less effective than TCAs. But thay are often better tolerated than TCAs.
More Info about side effects, interactions and safety concerns of Prozac, see: drug information for fluoxetine
More Info about side effects, interactions and safety concerns of Paxil, see: drug information for paroxetine
More Info about side effects, interactions and safety concerns of Zoloft, see: drug information for sertraline
Sodium oxybate (Xyrem, Orphan Medical)
Common initial dose - 1.5g at HS and 3-4 h later
Side effects: sedation, nausea, lightheadedness, dizziness
Remarks: usually well tolerated with time; improves nocturnal sleep disruption and can improve daytime sleepiness, FDA approval pending
Venlafaxine (Effexor XR, Wyeth Ayerst)
Common initial dose - 37.5 mg once daily
Side effects: nausea, dizziness, sedation
Venlafaxine is not well studied in cataplexy, but clinical reports are promising. It is generally better tolerated than TCAs.
For more Info about side effects, interactions and safety concerns of Venlafaxine, see: drug information for venlafaxine
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