Management Of Excessive Sleepiness In Patients With Narcolepsy And OSA: Current Challenges And Future Prospects

Figures & data

Table 1 Instructions For Multiple Sleep Latency Testing

Before The MSLT	During The MSLT
Sleep logs/diary/actigraphy for at least one week	Maintain dark and quiet environment with room temperature set to patient’s comfort
Medication review and “washout” if indicated. Stimulant, stimulant-like medications, and REM-suppressing medications stopped two weeks prior. Other usual medications discussed with provider to ensure that stimulating or sedating effects of medications are minimized.	Avoid vigorous physical activity and stop any simulating activity 15 mins prior to each nap
Urine drug screen	Abstain from caffeine and alcohol
	Avoid lying down or falling asleep between naps
	Avoid bright lights and direct sunlight
	Abstain from smoking 30 mins prior to each nap
	Provide a light breakfast and light lunch

Note: Data from Littner et al.³⁴

Table 2 Pharmacologic Management For Excessive Daytime Sleepiness

Medication	Mechanism Of Action	Half-Life	Indication	Dosage	Side Effects	Ref
Modafinil	Not fully understood; Inhibits dopamine reuptake	15 hrs	Improve wakefulness in patients with EDS	100 mg-400 mg daily; up to 600 mg (off-label)	Headache Nausea Nervousness Anxiety Insomnia	^Citation80
Armodafinil (R-enantiomer of Modafinil)	Not fully understood; Inhibits dopamine reuptake	15 hrs	Improve wakefulness in patients with EDS	150 mg-250 mg daily	Headache Nausea Dizziness Insomnia	^Citation81
Methylphenidate	CNS stimulant; Inhibits reuptake and increases release of dopamine and norepinephrine	3.5 hrs	Improve wakefulness in patients with EDS	10 mg-60 mg daily in 2–3 divided doses	Nervousness Insomnia Anorexia Nausea Headache Dizziness Palpitations Hypertension Weight Loss Increased HR and BP Psychosis	^Citation61
Dextroamphetamines sulfate	CNS stimulant; Inhibits reuptake and increases release of dopamine and norepinephrine	11 hrs	Improve wakefulness in patients with EDS	5 mg-60 mg daily	Insomnia Anorexia Headache Xerostomia Emotional Lability Dizziness Palpitations Increased HR and BP Psychosis	^Citation82
Solriamfetol	Inhibits reuptake of dopamine and norepinephrine	7 hrs	Improve wakefulness in patients with EDS	75 mg-150 mg daily	Headache Nausea Insomnia Anxiety Decreased Appetite	^Citation60
Sodium Oxybate	Not fully understood; CNS depressant, possibly through binding to GABA-B receptors; MOA for effect on cataplexy unknown	0.5 to 1 hr	Improve wakefulness and decrease cataplexy in patients with narcolepsy	4.5 grams-9 grams nightly in 2 divided doses	Headache Nausea Dizziness Somnolence Enuresis Tremor Sleepwalking Confusion Depressive Symptoms	^Citation83
Pitolisant	H3 histamine receptor antagonist	10–12 hrs	Improve wakefulness in patients with narcolepsy	9 mg-36 mg daily	Headache Insomnia Nausea Anxiety Irritability	^Citation63

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