How is narcolepsy treated?

Management of narcolepsy consists of medications and lifestyle changes. The goal of medications is to reduce daytime sleepiness and improve alertness.

MEDICATIONS

A number of medications with varying mechanisms of action in the brain are now available for the treatment of excessive daytime sleepiness (EDS).

Wake-promoting medications

These agents help patients stay awake during the day but do not treat cataplexy or other REM sleep-related signs of narcolepsy. Modafinil (Provigil®) or armodafinil (Nuvigil®) are often tried first because they have fewer side effects and are less addictive than traditional stimulants.

More recently approved medications are solriamfetol (Sunosi®) and pitolisant (Wakix®). Solriamfetol is used to improve wakefulness in adults with narcolepsy. Pitolisant (Wakix®) is the first medication approved to treat EDS in narcolepsy that is not classified as a controlled substance (substances with greater risk of abuse or addiction). Solriamfetol and pitolisant work on the brain in different ways than other available agents.

Sodium oxybate

Sodium oxybate (Xyrem®) is the only FDA-approved medication used to treat daytime sleepiness and cataplexy in patients with narcolepsy. It is taken in liquid form before bedtime and 2.5 to 4 hours later and not during the daytime. Due to its high sodium content, patients using sodium oxybate are advised to limit salt in the diet.

Stimulants

Once the mainstay of narcolepsy therapy, traditional stimulants such as amphetamine/dextroamphetamine or dextroamphetamine mixed salts (Adderall®, Dexedrine®) and methylphenidate (Ritalin®, Focalin®, Concerta®) are very effective for treating EDS but have a higher risk of side effects than wake-promoting agents. Stimulants can produce side effects similar to that seen with caffeine, such as agitation, nervousness and palpitations. They are generally started at a low dose and increased gradually as needed. Careful monitoring is required, as high blood pressure, heart arrhythmias (irregular heartbeats) and drug abuse have been reported.

Antidepressants

Cataplexy, hallucinations, disrupted nighttime sleep and sleep paralysis are often treated with two types of antidepressant medications: tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Examples of TCAs include protriptyline (Vivactil®), clomipramine (Anafranil®) and desipramine (Norpramin®). Examples of SSRIs include fluoxetine (Prozac®), atomoxetine (Strattera®) and sertraline (Zoloft®). SSRIs generally have fewer side effects than TCAs. These agents are prescribed off-label, meaning that clinical trials have not been performed and the FDA has not approved them for the treatment of narcolepsy.

It may take several weeks and/or several trials of different medications to find which one(s) work best for you and which dosage works best. Your doctor may also recommend avoiding antihistamine products (an ingredient in many cold products), as these products block the action of a substance in the blood (histamine) that helps you stay awake.

What lifestyle changes can help better manage narcolepsy?

Consider the following:

  • Follow a regular sleep/wake schedule. Go to bed and wake up at about the same time every day. Avoid intentional sleep loss, such as staying awake late on weekends.
  • Keep your bedroom quiet, dark, cool and comfortable. Do not watch TV or bring computers or phones into bed with you.
  • Avoid alcohol and caffeine (colas, coffee, teas, energy drinks and chocolate) for several hours before bedtime.
  • Avoid smoking, especially in the evening.
  • Exercise at least 20 minutes per day. Do not exercise within three hours of bedtime.
  • Don’t eat large, heavy meals or a lot of liquids close to bedtime.
  • Relax before bedtime. Take a warm bath, meditate, perform some gentle yoga moves, listen to soft music, expose yourself relaxing scents such as peppermint, eucalyptus or lavender.
  • Take short naps (20 to 30 minutes) at times when you are feeling most sleepy, if possible.

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