An 18-year-old man comes to the physician for daytime sleepiness lasting several months. The patient recently started college, has difficulty staying awake during classes, and often falls asleep suddenly even though he "gets a good night's sleep." He typically goes to bed at 2 am and sleeps until at least 9 am, usually later. The patient's sleep pattern at night is fragmented. He wakes frequently but is usually able to go back to sleep within a few minutes. He does not snore or wake up gasping. The patient feels like "someone is in the room with me when I'm just falling asleep and I sometimes hear my name being called." His past medical history is otherwise insignificant. The patient does not use tobacco or alcohol. Blood pressure is 120/70 mm Hg and heart rate is 70/min. His body mass index is 23 kg/m². Which of the following is the best initial therapy for this patient?

Question

Quizplus · Accepted Answer

Explanation: The focus of therapy for patients with narcolepsy is on reducing excessive daytime sleepiness (EDS). Older stimulant medications (eg, methylphenidate, amphetamines) are effective but can be highly addictive and have severe side effects. Modafinil is a novel stimulant that has a better side effect profile and lower abuse potential; it is now the first-line pharmacotherapy for narcolepsy. Nonpharmacologic interventions are equally important in management of EDS. Patients can temporarily stall the powerful sleep drive of narcolepsy by taking scheduled naps during the day. Sleep fragmentation and insomnia are prominent features of narcolepsy, making good sleep hygiene necessary. Patients with narcolepsy do not necessarily need more sleep than normal patients; however they acquire their sleep during several, sometimes involuntary, sleep periods during the day. (Choice A) Therapeutic lumbar puncture is sometimes considered for initial treatment of normal-pressure hydrocephalus. (Choice B) Melatonin and light therapy are useful in patients with circadian rhythm disorders (eg, delayed sleep phase, advanced sleep phase). (Choice D) Hypnagogic/hypnopompic (falling asleep/waking) hallucinations do not require treatment with neuroleptic drugs (eg, quetiapine), and this patient does not exhibit other symptoms of a psychotic disorder (eg, schizophrenia). (Choice E) Valproic acid is effective in patients with absence seizures. Educational objective: Modafinil is generally considered first line pharmacotherapy for narcolepsy, and has good effectiveness with a tolerable side effect profile and low abuse potential. Older stimulants such as methylphenidate may also be useful. Behavioral interventions such as good sleep hygiene and scheduled naps are also recommended. References: Narcolepsy: clinical features, co-morbidities & treatment. (http://www.ncbi.nlm.nih.gov/pubmed/20308759)

An 18-Year-Old Man Comes to the Physician for Daytime Sleepiness