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Source: Dopp JM, Phillips BG. Sleep
Disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG,
Posey LM, eds. Pharmacotherapy: A Pathophysiologic
Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7990389.
Accessed June 4, 2012.
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- Sleep disorder characterized by excessive sleepiness and
sleep attacks at inappropriate times.
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- Precise cause unknown.
- Genetic component (3% of patients have first-degree
relative with disorder).
- Possible environmental influences.
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- The hypocretin/orexin neurotransmitter system
may be involved. Autoimmune process may cause destruction of hypocretin-producing
cells.
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- Affects 0.03–0.06% of adult Americans.
- Incidence may be higher in men than women.
- Usually occurs in second decade of life and increases in severity
through third and fourth decades.
- Can occur in children and adolescents.
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- Family history of narcolepsy
- Head injury
- Obesity
- History of meningitis or encephalitis
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- Complaints of:
- Excessive daytime sleepiness
- Sleep attacks that last up to 30 minutes
- Fatigue
- Impaired performance
- Disturbed nighttime sleep
- Multiple arousals during the night
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Means of Confirmation
and Diagnosis
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- Essential features include:
- Sleep attacks
- Cataplexy (sudden bilateral loss of muscle tone with collapse,
often precipitated by emotional situations)
- Hypnagogic hallucinations before sleep or during a sleep attack
- Sleep paralysis (flaccid muscles with full consciousness while
falling or waking from sleep)
- Sleep study demonstrating abrupt transition into REM sleep
necessary for diagnosis.
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- Maximize alertness during waking hours.
- Improve quality of life.
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- Encourage good sleep hygiene.
- Recommend 2 or more brief daytime naps daily; as little as
15 minutes may be beneficial.
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- Pharmacotherapy focuses on excessive daytime sleepiness
and cataplexy (Table 1).
- Excessive daytime somnolence
- Modafinil 200
mg each morning standard treatment.
- No evidence
of tolerance or withdrawal after abrupt discontinuation.
- Side effects include:
- Armodafinil (the active R-isomer of modafinil) is also available.
- Amphetamines and methylphenidate have higher likelihood of
abuse and tolerance.
- Selegiline may also be beneficial.
- Cataplexy
- Most effective treatments:
- Imipramine
- Protriptyline
- Nortriptyline
- Fluoxetine
- Venlafaxine
- Selegiline may also improve cataplexy.
- Sodium oxybate (γ-hydroxybutyrate;
potent sedative-hypnotic) improves excessive daytime sleepiness
and decreases episodes of sleep paralysis, cataplexy, and hypnagogic
hallucinations.
- Taken at bedtime and repeated 2.5–4
hours later.
- Side effects include:
- Nausea
- Somnolence
- Confusion
- Dizziness
- Incontinence
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