Pharmacotherapy Challenges in the Treatment of Narcolepsy and Treatment-Emergent Psychiatric Symptoms
This poster was presented at the 30th annual Psych Congress, held Sept. 16-19, 2017, in New Orleans, Louisiana.
Introduction: Narcolepsy is a chronic condition causing dysregulation of sleep and wakefulness. In Narcolepsy type 1, cataplexy, described as episodes of emotionally-triggered transient muscle weakness is seen. Narcolepsy treatment often includes a stimulant to alleviate daytime sleepiness and an anti-catapletic agent. Stimulants and other centrally acting agents are associated with adverse psychiatric side effects and in susceptible patients, limit their tolerability.
Methods: A case report of a patient with refractory narcolepsy complicated by treatment emergent psychiatric side effects.
Results: A 22 year old female college student with history of narcolepsy with cataplexy presents to the outpatient psychiatry clinic referred by her sleep doctor after new onset mania in context of treatment with high dose amphetamine salts. Her narcolepsy symptoms were considered refractory as her symptoms did not respond to trials of other stimulants. In collaboration with her sleep doctor, amphetamine was discontinued and she was transitioned to sodium oxybate, a CNS depressant, for treatment of narcolepsy with cataplexy. However, sodium oxybate was stopped secondary to side effects of severe anxiety and mood lability. Patient required emergent psychiatric evaluation. She was subsequently started on low dose methylphenidate and low dose clonazepam twice daily for anxiety. Lamotrigine was added for mood stabilization.
Conclusions: Psychostimulants and certain nonstimulants used in treatment of narcolepsy are potentially destabilizing in susceptible individuals. Collaboration between providers and close monitoring are essential. In patients with a history of mania, studies suggest concomitant use of mood stabilizers and stimulants may mitigate the risks of treatment emergent mania.