Dr. Kushida:
This is CME on ReachMD, and I'm Dr. Clete Kushida. Here with me today is Dr. Michael Thorpy. We're discussing approaches to the management of narcolepsy.

So, Michael, would you mind introducing this very interesting case to us?

Dr. Thorpy:
Right. Well, I have a case of a 26-year-old female. She presented with 5 years of having excessive daytime sleepiness. She's getting more sleepy, falling asleep at inappropriate times and just general fatigue and sleepiness present all the time. But it was getting worse. In addition, she noticed that at night her sleep was a bit disrupted and that she would have very vivid dreams and occasional episodes of sleep paralysis that were occurring, which were unusual for her. And so she felt that these were not quite normal for her.

In addition to this, when we had a discussion, she indicated that she'd had some slurring of her voice and some clumsiness that came on when she was a bit emotional. It was rather embarrassing for her because she could be talking to someone, something emotional came up, and then her voice would start to slur and it was of great concern to her.

She was treated by her physician with amphetamine, dextroamphetamine salts, for attention deficit hyperactivity disorder, but these caused her to be very anxious and jittery. The physician wasn't quite sure what was going on and wondered if this was ADHD, but the medications had to be stopped. And so she was changed to a medication called modafinil, which is an alerting medication used in narcolepsy. But, again, she had similar sort of anxiety and stimulatory effects that were rather unpleasant.

About this time, she was referred to a sleep specialist and she underwent an all-night sleep study that shows she fell asleep very quickly, that she had a normal REM latency. So this was diagnostic for narcolepsy.

Treatment was then changed from the alerting medications to oxybate, and she was treated with twice-nightly low-sodium oxybate. She was taking, 3 g at bedtime 3 g in the middle of the night. But she had difficulty taking that second dose, and she often missed it because she slept through the night. So she was changed to the once-nightly oxybate and, again, with the same dose of 6 g, and this was effective for treating her sleepiness. And those symptoms that she had with emotion were felt to be cataplexy, and those cleared up with the oxybate.

So what do you think, Clete, about these dreams and the sleep paralysis at night? How commonly do we see this in patients with narcolepsy?

Dr. Kushida:
Yeah. So the vivid dreams, the sleep paralysis, those are definitely, in addition to the slurring of voice and clumsiness, those are the typical symptoms of narcolepsy type 1, including the excessive daytime sleepiness. And in addition, some of the vivid dreams might be occurring because of the fragmentation of the REM sleep, as well. So one of the things that kind of struck me was, you know, with the treatment initially with amphetamines and dextroamphetamine salts and then switching over to modafinil, Michael, you know, given that she's 26 years old, I was thinking that modafinil may or may not have been the best choice, especially given her age and being a woman. Could you comment on that a little bit?

Dr. Thorpy:
It is a common thing that many patients with narcolepsy get this misdiagnosis of attention deficit hyperactivity disorder and get put on either traditional stimulants or modafinil.

What do you think about the sleep study, results? How typical are they in narcolepsy, Clete?

Dr. Kushida:
Looking at the, particularly the MSLT [multiple sleep latency test] results, it's a pretty strong case for narcolepsy type 1. We always look at the nighttime study before to make sure that the patient has slept at least 6 hours and there's no signs of any other sleep disorders, which in this case, there were none. So the MSLT findings are definitely characteristic and very significant for a narcolepsy type 1.

Dr. Thorpy:
With that, our time is up and thank you for listening. We hope you found this case study useful.