Narcolepsy Medication

  • Author: Ali M Bozorg, MD; Chief Editor: Selim R Benbadis, MD   more...
 
Updated: Feb 19, 2010
 

Medication Summary

The main focus is symptomatic treatment of excessive somnolence and cataplexy with CNS stimulants and antidepressants. Stimulants improve wakefulness, while antidepressants such as clomipramine and fluoxetine reduce cataplectic attacks.

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CNS stimulants

Class Summary

These stimulants increase wakefulness, vigilance, and performance. They are thought to alter midbrain dopaminergic activity, but the precise mechanism of action is unknown. Interpatient variability in dose required to alleviate EDS is considerable and unpredictable. Some patients are relieved of daytime sleepiness completely with 5 mg of methylphenidate daily; others require higher doses. Initiate treatment at low doses and individualize the therapy.

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Pemoline (Cylert)

 

Initial drug of choice in children younger than 7 y with narcolepsy; has relatively little effect on blood pressure. The United States FDA concluded that the overall risk of liver toxicity from pemoline outweighs the benefits. In May 2005, Abbott chose to stop sales and marketing of their brand of pemoline (Cylert) in the United States. In October 2005, all companies that produced generic versions of pemoline also agreed to stop sales and marketing of pemoline.

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Methylphenidate (Ritalin)

 

Piperidine derivative most commonly prescribed; efficacy has been demonstrated in randomized, double-blind, dose-response, and placebo-controlled trials.

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Modafinil (Provigil)

 

Pharmacologically distinct from other stimulants, does not appear to act via dopaminergic system.

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Armodafinil (Nuvigil)

 

R-enantiomer of modafinil (mixture of R- and S-enantiomers). Elicits wake-promoting actions similar to sympathomimetic agents, although pharmacologic profile is not identical to sympathomimetic amines. In vitro, binds dopamine transporter and inhibits dopamine reuptake. Not a direct- or indirect-acting dopamine receptor agonist. Indicated to improve wakefulness in individuals with excessive sleepiness associated with narcolepsy, obstructive sleep apnea-hypopnea syndrome (OSAHS), or shift-work sleep disorder.

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Anticataplectic agents

Class Summary

Clomipramine, fluoxetine, and sodium oxybate treat cataplexy in patients with narcolepsy.

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Clomipramine (Anafranil)

 

Dibenzazepine compound belonging to family of tricyclic antidepressants, reduces frequency of cataplexy and other auxiliary symptoms in narcolepsy.

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Fluoxetine (Prozac)

 

SSRI that treats cataplexy. Fewer side effects than tricyclic antidepressants. Its toxicity profile is also lower.

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Sodium oxybate (Xyrem)

 

Also known as gamma hydroxybutyrate (GHB). It is a central nervous system depressant used to treat patients with EDS and cataplexy. The precise mechanism by which sodium oxybate produces an effect on cataplexy is unknown.

Because of sodium oxybate's history of abuse as a recreational drug, the FDA approved it as a Schedule III Controlled Substance. A limited distribution program that includes physician education, patient education, a patient and physician registry, and detailed patient surveillance has been established. Under the program, prescribers and patients will be able to obtain the product only through the Xyrem Success Program, using a single centralized pharmacy 1-866-997-3688. Available as an oral solution 500 mg/mL.

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Contributor Information and Disclosures
Author

Ali M Bozorg, MD  Assistant Professor, Comprehensive Epilepsy Program, Department of Neurology, University of South Florida

Ali M Bozorg, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, and American Epilepsy Society

Disclosure: Nothing to disclose.

Coauthor(s)

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Ortho McNeil Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Speaking, consulting

Specialty Editor Board

Carmel Armon, MD, MSc, MHS  Professor of Neurology, Tufts University School of Medicine; Chief, Division of Neurology, Baystate Medical Center

Carmel Armon, MD, MSc, MHS is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American College of Physicians, American Epilepsy Society, American Medical Association, American Neurological Association, American Stroke Association, Massachusetts Medical Society, Movement Disorders Society, and Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jose E Cavazos, MD, PhD, FAAN  Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, University of Texas Health Science Center at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center; Director of the Epilepsy Center, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Neurological Association, and Society for Neuroscience

Disclosure: Nothing to disclose.

Paul E Barkhaus, MD  Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Administration Medical Center

Paul E Barkhaus, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association

Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Ortho McNeil Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Speaking, consulting

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