A 32-year-old man comes to the office due to excessive sleepiness for the past several months. He says, "I am very worried that I will lose my job. I feel like napping all the time and once fell asleep while talking with a customer. The other day, I nearly had an accident when I fell asleep while driving." The patient is also concerned that he occasionally hears voices while falling asleep and finds himself "temporarily frozen" and unable to move on awakening. He has a history of hypertension controlled with hydrochlorothiazide. His family history is noncontributory. The patient does not smoke cigarettes or drink alcohol but does smoke marijuana a few times a month. Physical examination is remarkable for obesity and no other abnormalities. Which of the following is the most appropriate treatment for this patient?

Question

A 32-year-old man comes to the office due to excessive sleepiness for the past several months.  He says, "I am very worried that I will lose my job.  I feel like napping all the time and once fell asleep while talking with a customer.  The other day, I nearly had an accident when I fell asleep while driving."  The patient is also concerned that he occasionally hears voices while falling asleep and finds himself "temporarily frozen" and unable to move on awakening.  He has a history of hypertension controlled with hydrochlorothiazide.  His family history is noncontributory.  The patient does not smoke cigarettes or drink alcohol but does smoke marijuana a few times a month.  Physical examination is remarkable for obesity and no other abnormalities.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

This patient's excessive daytime sleepiness, hypnagogic hallucinations (on falling asleep), and sleep paralysis are suggestive of narcolepsy. Cataplexy (emotionally triggered loss of muscle tone) can also be seen. In addition to sleep hygiene and scheduled naps, medication to promote wakefulness may be necessary when sleepiness impairs daily functioning and poses safety risks. Modafinil, a nonamphetamine medication that promotes wakefulness, is considered a first-line pharmacotherapy as it reduces daytime sleepiness, is generally well tolerated, and has less abuse potential compared with traditional stimulants (eg, amphetamines, methylphenidate). These older drugs are effective but are generally used as second-line therapies due to a higher risk of adverse effects (eg, hypertension, tachycardia, psychosis, anorexia, abuse). Patients with significant cataplexy may also benefit from REM sleep-suppressing drugs, including antidepressants and sodium oxybate. (Choices A and F) Sedating drugs (eg, alcohol, benzodiazepines, antipsychotics) should be avoided in patients with narcolepsy, and hypnagogic/hypnopompic hallucinations do not require treatment with antipsychotic drugs (eg, quetiapine). (Choice B) Continuous positive airway pressure is used to treat obstructive sleep apnea. Such patients typically report daytime fatigue but do not have cataplexy and are less likely to experience hallucinations or sleep paralysis. (Choice C) Melatonin is often beneficial for circadian rhythm sleep disorders such as jet lag but not for narcolepsy. (Choice E) Pramipexole, a dopamine agonist, is used to treat symptoms of Parkinson disease and restless legs syndrome. It is not used to treat narcolepsy. Educational objective: Narcolepsy is characterized by excessive daytime sleepiness, cataplexy, hypnagogic/hypnopompic hallucinations, and sleep paralysis. Treatment includes sleep hygiene, scheduled naps, and avoidance of alcohol and drugs that cause drowsiness. When medications are needed to decrease daytime somnolence, wakefulness-promoting agents such as modafinil are preferred. References: Treatment options for narcolepsy. (http://www.ncbi.nlm.nih.gov/pubmed/27155860) A practical guide to the therapy of narcolepsy and hypersomnia syndromes. (http://www.ncbi.nlm.nih.gov/pubmed/23065655)

A 32-Year-Old Man Comes to the Office Due to Excessive