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

Pharmacological treatments certainly are required for the majority of patients with narcolepsy, but some of the behavioral treatments can be useful adjunctive treatment to help them when they are on medications, can't they? What sort of non-pharmacological treatments do you advise your patients?

Dr. Kushida:
Yeah. So one of the things is naps can sometimes be of benefit, and it's not unusual for us to have to write letters here to the schools and also to the workplaces to allow individuals to take some naps during the time that they're either at school or at work. So naps can sometimes help relieve the excessive daytime sleepiness that they might have.

Dr. Thorpy:
Well, that's right. And besides the naps, one of the things I find very helpful for patients is really emphasizing the importance of maintaining a regular sleep-wake schedule. Going to bed at the same time, getting up at the same time in the morning. And then there are things like alcohol and caffeine. Fortunately, in my experience, a lot of patients with narcolepsy tend to avoid those things. They don't like alcohol because it does impair their cognitive effect when they're sleepy. So in some ways it’s a good thing that they are avoiding it. And also with the caffeine, because anxiety is a common comorbidity with narcolepsy, I think a lot of narcolepsy patients try to avoid caffeine because they don't like the stimulation of it.

But for the majority of patients, they need medications. And now when would you consider, Clete, using either an alerting medication or using a medication like oxybate in a patient with narcolepsy?

Dr. Kushida:
Yeah. So one thing that I've been relying on a lot these days is to really take a deep dive looking at their nighttime sleep. If I get a sense that their sleep is being highly fragmented, they're having a lot of arousals or awakenings during sleep, coupled with the significant daytime sleepiness or sleep attacks, then that would be the time that I would really consider offering oxybate, just because of its ability to consolidate sleep, and it works on the daytime sleepiness. Another thing is, you know, for narcolepsy type 1, because it has this action plus it can also effectively manage the cataplexy, that would be kind of like the treatment of choice. And then one thing to always consider is, if they have difficulty waking up for the second dose, you can switch them to once-nightly oxybate and also to consider about if they need low sodium, then there's also low-sodium mixed salt preparation of oxybate.

Dr. Thorpy:
Yeah. So when we have a narcolepsy patient, we need to consider what their main concerns are. And as you mentioned, some patients, their main concerns may be around nighttime sleep and the disruption there and difficulty sleeping at night and those abnormal REM sleep phenomena, such as nightmares. 

And then there may be the cataplexy. Fortunately, the cataplexy is a little easier to treat. And of course, some of the problems with prescribing the right medication for the patient are the barriers to medication use, which is the insurance carriers, and this can make it quite difficult, can’t it, Clete?

Dr. Kushida:
Yes, absolutely. Sometimes it's difficult to get these medications approved by insurers. And one other thing that's also important is that like any medication, these medications have side effects or additional considerations, such as if there's a woman in childbearing age, we would be concerned about things like modafinil or armodafinil and also pitolisant to some degree. So there are things that we would look at as well as their overall health. As mentioned, do they have hypertension, heart failure, or kidney failure? Then you would consider maybe a low-sodium preparation of oxybate.

Dr. Thorpy:
Well, with that, our time is up. Thank you for a great discussion. And we'd like to thank our audience for tuning in to this series. And thank you very much, Dr. Kushida, for joining me in these presentations.