Other Topics

Narcolepsy

• Treatments:
  • Modafinil
    • First line pharmacologic agent:
      • Good control of sleepiness
      • Well tolerated
      • Ilicit use is rare.
      • No tolerance
    • Mechanism of action is not understood, but it's a non-amphetamine. May increase dopaminergic signaling.
    • Many trials: significant improvement in 200mg/day and 400mg/day. Start 200, can increase to 400.
    • Instruction: take dose in AM.  Some Canadian guidelines say take it in early afternoon as well, but pts report PM dose interferes with sleep.
    • Side Effects (uncommon):
      • Headache, nausea, dry mouth, anorexia.
      • High BP (dose dependent), SJS, caution in pts with heart arrhythmias.
      • Metabolized by P450 enzymes that interfere with OCP (use alternative contraception)
  • Methylphenidate
    • Amphetamine-based CNS stimulant. 
    • Considered 2nd line b/c many sympathomimetic S/E
    • Dose: 10mg BID (last one no later than 3pm)
    • S/E
      • Increases systolic BP by 5mmHg
      • Some reports of "sudden death" in children and adults (link unknown).
      • Can exacerbate psychosis/anorexia, lower seizure threshold.
  • Amphetamines
    • Dextraoamphetamine (5mg bid) and methamphetamine (5mg bid)
      • Amphetamine salts (Adderall)
    • Most potent wakefulness-promoting drugs. 
    • Same S/E problems as methylphenidate.