Narcolepsy: Update on Diagnosis and Treatment Phyllis C. Zee, MD, PhD Benjamin and Virginia T. Boshes Professor in Neurology Professor of Neurobiology Director Center for Circadian and Sleep Medicine Director Sleep Disorders Center Northwestern University Feinberg School of Medicine Solomon A. Briggs
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Narcolepsy: Update on Diagnosis and Treatment...Swiss Narcolepsy Scale • The Swiss Narcolepsy Scale (SNS) is a brief subjective questionnaire that screens for the occurrence of several
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Narcolepsy: Update on Diagnosis and Treatment
Phyllis C. Zee, MD, PhDBenjamin and Virginia T. Boshes Professor in Neurology
Professor of NeurobiologyDirector Center for Circadian and Sleep Medicine
Director Sleep Disorders CenterNorthwestern University Feinberg School of Medicine
Solomon A. Briggs
• Daytime sleepiness (all patients)
– Typically moderate to severe
• Cataplexy (50% of patients)
– Brief episodes of muscle weakness triggered by strong emotions, such as laughter (can be very subtle)
Espana RA, et al. Sleep. 2011;34:845-858. Scammel TE. Ann Neurol. 2003;53:154-166. AASM. International Classification of Sleep Disorders. 3rd ed. 2014; Darien, IL; American Academy of Sleep Medicine.
Common Associated Disorders
1) Concomitant sleep disorders– Obstructive and central sleep apnea in 10-20%
– Periodic limb movements in 40-60%
– REM sleep behavior disorder in in 10-30%
– Sleepwalking, sleep talking, night terrors in ~20%
2) Mild obesity: BMI increased by ~15% on average
3) Depression in ~25%
Comorbidity Prevalence: Targeted Diagnoses
Population prevalence of targeted diagnoses, narcolepsy versus control; For all comparisons versus controls P<0.0001
Black J, et al. Presented at the 27th Annual Meeting of the Associated Professional Sleep Societies, LLC (APSS); June 1–5, 2013; Baltimore, MD
Narcolepsy: Impact on Functioning
Impaired Activities of Daily Living
Impaired Social/
Occupational FunctioningIncreased risk
of domestic and
occupational accidents
Tendency to fail in school and difficulty maintaining employment
Difficulty maintaining relationships
AASM. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.Daniels E, et al. J Sleep Res. 2001;10(1):75-81.
Disorder of both sleep and wake: Brain state instability
• Role of hypocretin /orexin cell loss- decreased levels- receptor mutation (rare)
• Acquired autoimmune disorder
• Genetic Contributions
Pathophysiology of Narcolepsy
Narcoleptic Control
Lateral hypothalamicbrain tissue
Loss of hypocretin containing neurons
Nishino et al. Ann Neurol. 2001;50:381; Peyron et al. Nat Med. 2000;6:991.
CSF Hypocretin Levels
0
100
200
300
400
500
600
Control
(n = 47)
Narcolepsy
With
Cataplexy
(n = 101)
Narcolepsy
Without
Cataplexy
(n = 20)
CS
F H
yp
oc
reti
n, p
g/m
L
Adapted from Mignot E, et al. Arch Neurol. 2002;59:1553-1562.
47 10
3
88
18
0
3
Narcolepsy Diagnostic Criteria
Positive MSLT: mean sleep latency ≤ 8 min and ≥2 SOREMPs
PSG: Short REM sleep latency ≤ 15 min
ICSD-3 DSM-5
Type 1 Type 2
Sleepiness for ≥3 months
daily periods of irrepressible need to sleep or daytime lapses into sleep
recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping
Plus one of the following:
Cataplexy also must have positive MSLT
none at least a few times/month
CSF Hypocretin
≤110 pg/ml or ≤1/3 normal values
>110 pg/ml or >1/3 normal values
≤110 pg/ml or ≤1/3 normal values
MSLT Positive MSLT Positive MSLT Positive MSLT
PSG Short REM latency Short REM latency Short REM latency
Summary
• Clinical history is essential
• Cataplexy is pathognomonic
• Disrupted nocturnal sleep (increased number of arousals, WASO and lighter sleep)
• Self report measures
– Epworth sleepiness scale
– Swiss narcolepsy scale
• Sleep laboratory tests
– Polysomnography
– MSLT-nap series
• HLA Typing
• CSF hypocretin/orexin levels
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.
Situation Chance of Dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (eg, a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car while stopped for a few minutes in traffic
Epworth Sleepiness Scale
Johns. Sleep. 1991;14:540.
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Condition1
Mean (SD)
ESS Score Range
An ESS of 0-8 = normal, 9-12 = mild, 13-16 = moderate, >16 = severe sleepiness2
Narcolepsy (n=13) 17.5 (3.5) 13-23
Normal subjects (n=30) 5.9 (2.2) 2-10
1. Johns et al. Sleep. 1991;14:540; 2. Hirshkowitz et al. Evaluating sleepiness. In: Principles and Practice of Sleep Medicine. 2011.
Mean ESS Scores in Narcolepsy andNormal Populations
Swiss Narcolepsy Scale
• The Swiss Narcolepsy Scale (SNS) is a brief subjective questionnaire that screens for the occurrence of several behavioral symptoms that may be associated with narcolepsy with cataplexy.1
• Purpose: Designed to screen for a symptom profile that might be suggestive of narcolepsy with cataplexy1
• Population: Patients with EDS in whom the clinician may want to screen for potential narcolepsy with cataplexy2
1. Bassetti CL. Spectrum of narcolepsy. In: Baumann CR, Bassetti CL, Scammell TE, eds. Narcolepsy: Pathophysiology, Diagnosis, and Treatment. Springer Science+Business Media; 2011:309-319.2. Sturzenegger C, Bassetti CL. The clinical spectrum of narcolepsy with cataplexy: a reappraisal. J Sleep Res. 2004;13(4):395-406.
Swiss Narcolepsy Scale• Assessments: Measures frequency of 5 potential symptoms1:
Q1 – Inability to fall asleep Q2 – Feeling bad or not well rested in the morningQ3 – Taking a nap during the dayQ4 – Weak knees/buckling of the knees during emotions such as laughing, happiness, or angerQ5 – Sagging of the jaw during emotions such as laughing, happiness, or anger
• Method: Patient self-report1
• Time required: Consists of 5 questions and takes only a few minutes to complete1
• swissnarcolepsyscale.com
1. Bassetti CL. Spectrum of narcolepsy. In: Baumann CR, Bassetti CL, Scammell TE, eds. Narcolepsy: Pathophysiology, Diagnosis, and Treatment. Springer Science+Business Media; 2011:309-319.2. Sturzenegger C, Bassetti CL. The clinical spectrum of narcolepsy with cataplexy: a reappraisal. J Sleep Res. 2004;13(4):395-406.
Swiss Narcolepsy Scale
• Scoring: Frequency for each behavioral complaint is rated on a 5-point scale, from 1, indicating “never,” to 5, indicating “almost always.” Each question is weighted by a positive or negative factor, with the score calculated using the following equation: (6×Q1 + 9×Q2 – 5×Q3 – 11×Q4 –13×Q5 +20).1,2
• Interpretation: An SNS score <0 is suggestive of narcolepsy with cataplexy.1,2
• Validation: In patients with narcolepsy with cataplexy, an SNS score <0 was shown to have a sensitivity of 96% and specificity of 98%.2
1. Bassetti CL. Spectrum of narcolepsy. In: Baumann CR, Bassetti CL, Scammell TE, eds. Narcolepsy: Pathophysiology, Diagnosis, and Treatment. Springer Science+Business Media; 2011:309-319.2. Sturzenegger C, Bassetti CL. The clinical spectrum of narcolepsy with cataplexy: a reappraisal. J Sleep Res. 2004;13(4):395-406.
Sturzenegger C, Bassetti CL. The clinical spectrum of narcolepsy with cataplexy: a reappraisal. J Sleep Res. 2004;13(4):395-406.
Goals of Treatment
• Reduce daytime sleepiness
• Control ancillary symptoms:
– Cataplexy
– Nightmares and hallucinations
– Sleep paralysis
– Disturbed nocturnal sleep
• Improve psychosocial and work functioning
• Improve safety of patient and public
• What is the severity of symptoms?
- affecting work performance
• Lifestyle of the patient• how might that effect their dosing
schedule?
• Is there flexibility in their life?
• Age and comorbidities• Hypertension? (dangers of classic
stimulant meds and black box warnings)
• Depression/psych issues?
Initial Treatment Considerations
General• Assessment and treatment of co-morbid disorders (sleep
apnea, restless legs, psychiatric and neurologic disorders
• Behavioral and environmental factors- Sleep hygiene
- Structured nocturnal sleep and wake times- Naps: scheduled and PRN
- Temperature (night (cooler); Day: core warming and distal cooling
- Light therapy
- Exercise
- Diet
Social Factors
- Personal and family counseling
- Narcolepsy support groups
Multimodal Approach
1. NHLBI Working Group on Insomnia. 1998. NIH Publication 98-4088. 2. Kupfer DJ, Reynolds CF. N Engl J Med. 1997;336:341-346. 3. Lippmann S, et al. South Med J.2001;94:866-873.
Sleep Hygiene
• Regular sleep/wake cycle1-3
• Regular exercise in the morning and/or afternoon1,3
• Increase exposure to bright light during the day2
• Avoid exposure to bright light during the night1,3
• Avoid heavy meals or drinking within 3 hours of bedtime1
• Enhance sleep environment1,3
• Avoid caffeine, alcohol, and nicotine1,3
• Relaxing routine1-3
• Temperature regulation
Alerting Agents
• Caffeine: adenosine receptor antagonist
• Sympathomimetic: enhance neurotransmission of dopamine, norepinephrine, serotonin
• Modafinil: specific mechanism remains unclear
• Histamine receptor 3 agonists (H3R)
• Hypocretin stimulation
Mechanism
AASM, American Academy of Sleep Medicine.Morgenthaler T, et al. Sleep. 2007;30:1705-1711. Littner M, et al. Sleep. 2001;24:451-466.
AASM Practice Parameters for Narcolepsy: Excessive Sleepiness