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Zhan Q, Deng L, Ding Y, Wang F, Han F, Zhou B, Xie L. The value of using ELISA to detect orexin-A in cerebrospinal fluid in the diagnosis of narcolepsy. Medicine (Baltimore) 2024; 103:e38539. [PMID: 38875396 PMCID: PMC11175925 DOI: 10.1097/md.0000000000038539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 03/12/2024] [Accepted: 05/20/2024] [Indexed: 06/16/2024] Open
Abstract
Orexin in cerebrospinal fluid (CSF) is a neuropeptide synthesized by a cluster of neurons in the lateral hypothalamus. It mainly functions to maintain arousal, regulate feeding, and participate in reward mechanisms. Radioimmunoassay (RIA) and enzyme-linked immunosorbent assay (ELISA) can detect CSF orexin. At present, RIA is widely used but is limited by various conditions, which is not conducive to its widespread development. We aimed to determine whether ELISA can replace RIA in detecting orexin in CSF. We investigated the results of 20 patients with central disorders of hypersomnolence, including 11 with narcolepsy type 1, 2 with narcolepsy type 2, 5 with idiopathic hypersomnia, and 2 with other causes of somnolence. RIA and ELISA were used to detect CSF orexin, and P values <.05 were considered to be significant. In the narcolepsy and non-narcolepsy type 1 groups, there was no correlation between the RIA and ELISA results (P > .05). In the narcolepsy type 1 group, the ELISA and RIA results were significantly different (P < .05), but this was not observed in the non-narcolepsy type 1 group (P > .05). The accuracy of ELISA to detect CSF orexin was lower than that of RIA (P < .05). ELISA cannot replace RIA in the measurement of CSF orexin, and RIA is recommended as the first choice when narcolepsy is suspected.
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Affiliation(s)
- Qingqing Zhan
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Liying Deng
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Yongmin Ding
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Fen Wang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Fang Han
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People’s Hospital, Beijing, People’s Republic of China
| | - Bing Zhou
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People’s Hospital, Beijing, People’s Republic of China
| | - Liang Xie
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
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2
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Tran TTT, Nguyen THN, Dauvilliers Y, Liblau R, Nguyen XH. Absence of specific autoantibodies in patients with narcolepsy type 1 as indicated by an unbiased random peptide-displayed phage screening. PLoS One 2024; 19:e0297625. [PMID: 38442093 PMCID: PMC10914298 DOI: 10.1371/journal.pone.0297625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/10/2024] [Indexed: 03/07/2024] Open
Abstract
Narcolepsy type 1 (NT1) is an enigmatic sleep disorder characterized by the selective loss of neurons producing orexin (also named hypocretin) in the lateral hypothalamus. Although NT1 is believed to be an autoimmune disease, the orexinergic neuron-specific antigens targeted by the pathogenic immune response remain elusive. In this study, we evaluated the differential binding capacity of various peptides to serum immunoglobin G from patients with NT1 and other hypersomnolence complaints (OHCs). These peptides were selected using an unbiased phage display technology or based on their significant presence in the serum of NT1 patients as identified from previous studies. Although the subtractive biopanning strategy successfully enriched phage clones with high reactivity against NT1 serum IgG, the 101 randomly selected individual phage clones could not differentiate the sera from NT1 and OHC. Compared to the OHC control group, serum from several NT1 patients exhibited increased reactivity to the 12-mer peptides derived from TRBV7, BCL-6, NRXN1, RXRG, HCRT, and RTN4 proteins, although not statistically significant. Collectively, employing both unbiased and targeted methodologies, we were unable to detect the presence of specific autoantibodies in our NT1 patient cohort. This further supports the hypothesis that the autoimmune response in NT1 patients likely stems primarily from T cell-mediated immunity rather than humoral immunity.
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Affiliation(s)
- Thi-Tuyet Trinh Tran
- Department of Biobank, Hi-Tech Center and Vinmec-VinUni Institute of Immunology, Vinmec Healthcare system, Hanoi, Vietnam
| | - Thi-Hong Nhung Nguyen
- Department of Biobank, Hi-Tech Center and Vinmec-VinUni Institute of Immunology, Vinmec Healthcare system, Hanoi, Vietnam
| | - Yves Dauvilliers
- Department of Neurology, Sleep-Wake Disorder Center, CHU Montpellier, Montpellier, France
| | - Roland Liblau
- Department of Inflammatory Diseases of the Central Nervous System: Mechanisms and Therapies, Toulouse Institute for Infection and Inflammatory Diseases, University of Toulouse, Toulouse, France
| | - Xuan-Hung Nguyen
- Department of Biobank, Hi-Tech Center and Vinmec-VinUni Institute of Immunology, Vinmec Healthcare system, Hanoi, Vietnam
- College of Health Sciences, VinUnivesity, Hanoi, Vietnam
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3
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Wang H, Jia M. Analysis of thyroid function and related factors in narcolepsy patients. Sci Rep 2023; 13:18494. [PMID: 37898692 PMCID: PMC10613271 DOI: 10.1038/s41598-023-45321-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/18/2023] [Indexed: 10/30/2023] Open
Abstract
The loss of hypocretin is thought to be the main pathophysiological mechanism of narcolepsy. There is strong evidence that hypocretin is related to the regulation of endocrine functions and depression. To explore thyroid hormone levels in narcolepsy patients was our aim. In addition, further is to analyze the relationship between thyroid hormone levels and sleep quality, anxiety, and depression in narcolepsy patients. There are 40 patients with narcolepsy and 40 healthy controls (HCs) were conducted. Blood samples were explored for thyroid function. Correlation analysis between thyroid hormones and clinical characteristics of narcolepsy was performed using Pearson or Spearman. Narcolepsy patients had significantly lower free thyroxine (FT4) levels in comparison to controls (p < 0.001). No subject was diagnosed with primary hypothyroidism. There were 4 (10%) subjects with subclinical hypothyroidism. The serum FT4 levels were positively correlated with HAMA14 score (r = - 0.343, p = 0.030) by Pearson correlation analysis. The serum TSH levels and HAMD24 score (r = - 0.807 p ˂0.001), and ESS score (r = - 0.317, p = 0.046) both showed a negative correction. Hypocretin deficiency may be associated with the regulation of thyroid hormones in narcolepsy patients. The serum thyroid hormones may affect the severity and neuropsychological functions of narcolepsy patients.
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Affiliation(s)
- Hongli Wang
- Department of Pain Management, The Second Hospital of Shandong University, Jinan, 250033, Shandong, China
| | - Mingrui Jia
- Department of Pain Management, The Second Hospital of Shandong University, Jinan, 250033, Shandong, China.
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Zhan Q, Wang L, Liu N, Yuan Y, Deng L, Ding Y, Wang F, Zhou J, Xie L. Serum metabolomics study of narcolepsy type 1 based on ultra-performance liquid chromatography-tandem mass spectrometry. Amino Acids 2023; 55:1247-1259. [PMID: 37689600 PMCID: PMC10689557 DOI: 10.1007/s00726-023-03315-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/07/2023] [Indexed: 09/11/2023]
Abstract
Narcolepsy is a chronic and underrecognized sleep disorder characterized by excessive daytime sleepiness and cataplexy. Furthermore, narcolepsy type 1 (NT1) has serious negative impacts on an individual's health, society, and the economy. Currently, many sleep centers lack the means to measure orexin levels in the cerebrospinal fluid. We aimed to analyze the characteristics of metabolite changes in patients with NT1, measured by ultra-performance liquid chromatography-tandem mass spectrometry. A principal component analysis (PCA), an orthogonal partial least square discriminant analysis (OPLS-DA), t tests, and volcano plots were used to construct a model of abnormal metabolic pathways in narcolepsy. We identified molecular changes in serum specimens from narcolepsy patients and compared them with control groups, including dehydroepiandrosterone, epinephrine, N-methyl-D-aspartic acid, and other metabolites, based on an OPLS-loading plot analysis. Nine metabolites yielded an area under the receiver operating curve > 0.75. Meanwhile, seven abnormal metabolic pathways were correlated with differential metabolites, such as metabolic pathways; neuroactive ligand‒receptor interaction; and glycine, serine, and threonine metabolism. To our knowledge, this is the first study to reveal the characteristic metabolite changes in sera from NT1 patients for the selection of potential blood biomarkers and the elucidation of NT1 pathogenesis.
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Affiliation(s)
- Qingqing Zhan
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Lili Wang
- Institute of Neuroscience, School of Basic Medical Sciences, Chongqing Medical University, 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Nan Liu
- Institute of Neuroscience, School of Basic Medical Sciences, Chongqing Medical University, 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Yuqing Yuan
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Liying Deng
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yongmin Ding
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Fen Wang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Jian Zhou
- Institute of Neuroscience, School of Basic Medical Sciences, Chongqing Medical University, 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China.
| | - Liang Xie
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China.
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Somach RT, Jean ID, Farrugia AM, Cohen AS. Mild Traumatic Brain Injury Affects Orexin/Hypocretin Physiology Differently in Male and Female Mice. J Neurotrauma 2023; 40:2146-2163. [PMID: 37476962 PMCID: PMC10701510 DOI: 10.1089/neu.2023.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
Traumatic brain injury (TBI) is known to affect the physiology of neural circuits in several brain regions, which can contribute to behavioral changes after injury. Disordered sleep is a behavior that is often seen after TBI, but there is little research into how injury affects the circuitry that contributes to disrupted sleep regulation. Orexin/hypocretin neurons (hereafter referred to as orexin neurons) located in the lateral hypothalamus normally stabilize wakefulness in healthy animals and have been suggested as a source of dysregulated sleep behavior. Despite this, few studies have examined how TBI affects orexin neuron circuitry. Further, almost no animal studies of orexin neurons after TBI have included female animals. Here, we address these gaps by studying changes to orexin physiology using ex vivo acute brain slices and whole-cell patch clamp recording. We hypothesized that orexin neurons would have reduced afferent excitatory activity after injury. Ultimately, this hypothesis was supported but there were additional physiological changes that occurred that we did not originally hypothesize. We studied physiological properties in orexin neurons approximately 1 week after mild traumatic brain injury (mTBI) in 6-8-week-old male and female mice. mTBI was performed with a lateral fluid percussion injury between 1.4 and 1.6 atmospheres. Mild TBI increased the size of action potential afterhyperpolarization in orexin neurons from female mice, but not male mice and reduced the action potential threshold in male mice, but not in female mice. Mild TBI reduced afferent excitatory activity and increased afferent inhibitory activity onto orexin neurons. Alterations in afferent excitatory activity occurred in different parameters in male and female animals. The increased afferent inhibitory activity after injury is more pronounced in recordings from female animals. Our results indicate that mTBI changes the physiology of orexin neuron circuitry and that these changes are not the same in male and female animals.
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Affiliation(s)
- Rebecca T. Somach
- Department of Anesthesiology and Critical Care Medicine, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Neuroscience Graduate Group, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ian D. Jean
- Department of Anesthesiology and Critical Care Medicine, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anthony M. Farrugia
- Department of Anesthesiology and Critical Care Medicine, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Akiva S. Cohen
- Department of Anesthesiology and Critical Care Medicine, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Neuroscience Graduate Group, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abad VC. Pharmacological options for narcolepsy: are they the way forward? Expert Rev Neurother 2023; 23:819-834. [PMID: 37585269 DOI: 10.1080/14737175.2023.2249234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Narcolepsy is an under-recognized, rare neurologic disorder of hypersomnolence that is associated with increased mortality and medical and psychiatric co-morbidities. Narcolepsy exerts a substantial economic burden on patients and society. There is currently no cure, and life-long symptomatic therapy is needed. Available drugs do not modify the disease course. AREAS COVERED This manuscript provides an overview of narcolepsy symptoms, diagnosis, pathophysiology, current pharmacotherapies, and emerging treatments. Gaps and unresolved issues in diagnosis and management of narcolepsy are discussed to answer whether pharmacological options are the way forward. EXPERT OPINION Diagnostic criteria for narcolepsy (ICSD-3) need revision and greater clarity. Improved recognition of cataplexy and other symptoms through educational outreach, new biomarkers, improved test scoring through artificial intelligence algorithms, and use of machine learning may facilitate earlier diagnosis and treatment. Pharmacological options need improved symptomatic therapy in addition to targeted therapies that address the loss of hypocretin signaling. Optimal narcolepsy care also needs a better understanding of the pathophysiology, recognition of the different phenotypes in narcolepsy, identification of at-risk individuals and early recognition of symptoms, better diagnostic tools, and a database for research and disease monitoring of treatment, side-effects, and comorbidities.
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Affiliation(s)
- Vivien C Abad
- Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences Stanford University, Redwood, CA, USA
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Wang J, Yan Z, Dong X, Li J, Zhao L, Zhang X, Lv C, Zhao Z, Strohl KP, Han F. Diurnal changes in blood pressure and heart rate in children with narcolepsy with cataplexy. J Sleep Res 2023; 32:e13736. [PMID: 36163423 DOI: 10.1111/jsr.13736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
The hypocretin neurons in the lateral hypothalamus are connected not only to brain alertness systems but also to brainstem nuclei that regulate blood pressure and heart rate. The premise is that regulation of blood pressure and heart rate is altered and affected by methylphenidate, a stimulant drug in children with narcolepsy with cataplexy. The changes in 24-hr ambulatory systolic and diastolic blood pressure and heart rate were compared among pre-treated narcolepsy with cataplexy patients (40 males, 10 females), with mean age 10.4 ± 3.5 years (M ± SD, range 5-17 years) with values from 100 archival age-sex-body mass index matched controls. Patients had a lower diurnal systolic blood pressure (-6.5 mmHg; p = 0.000) but higher heart rate (+11.0 bpm; p = 0.000), particularly evident in the waketime, while diastolic blood pressure was comparable. With methylphenidate (18 mg sustained release at 08:00 hours), patients with narcolepsy with cataplexy had higher systolic blood pressure (+4.6 mmHg, p = 0.015), diastolic blood pressure (+3.3 mmHg, p = 0.005) and heart rate (+7.1 bpm, p = 0.028) during wake time, but nighttime cardiovascular values were unchanged from pre-treated values; amplitude variation in cardiovascular values was unchanged over 24 hr. In conclusion, children with narcolepsy with cataplexy had downregulation blood pressure profile but a higher heart rate, and lesser non-dipping profiles. Daytime methylphenidate treatment increases only waketime blood pressure and further elevated heart rate values.
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Affiliation(s)
- Jingyu Wang
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China.,Department of Respiratory and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Zhihui Yan
- Institute of Materia Medica, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinnan, China
| | - Xiaosong Dong
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Jing Li
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Long Zhao
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Xueli Zhang
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Changjun Lv
- Department of Respiratory and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Ziyan Zhao
- Institute of Materia Medica, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinnan, China
| | - Kingman P Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Case Western Reserve University, and Cleveland Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Fang Han
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
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8
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Repeated measures of hypocretin-1 in Danish and Italian patients with narcolepsy and in controls. Sleep Med 2023; 101:213-220. [PMID: 36427467 DOI: 10.1016/j.sleep.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 09/15/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVES The assay currently used worldwide to measure cerebrospinal fluid hypocretin-1 (CSF-hcrt-1) for diagnosing narcolepsy uses a competitive radioimmunoassay with polyclonal anti-hcrt-1 antibodies. This assay detects multiple hypocretin-1 immunoreactive species in the CSF that are all derived from full-length hcrt-1. We aimed to revalidate CSF-hcrt-1 cut-offs for narcolepsy type 1 (NT1) diagnosis and to evaluate temporal changes in CSF-hcrt-1 levels in patients suspected of having central hypersomnia. METHOD We carried out a repeat lumbar puncture with a mean follow-up of 4.0 years, to measure CSF-hcrt-1 in patients suspected of having central hypersomnia in a follow-up study. Data from CSF samples of patients with NT1 and of controls without known hypersomnia, from the Italian-Stanford and Danish populations, were examined using a receiver-operating characteristic analysis. RESULTS The optimal CSF-hcrt-1 cut-offs for identifying NT1 were 129 pg/ml and 179 pg/ml for the Italian-Stanford and Danish populations, respectively. The sensitivity was 0.93-0.99 and the specificity was 1. Follow-up lumbar puncture measurements of CSF-hcrt-1 were obtained from 73 patients. 30 of 32 patients with low CSF-hcrt-1 levels continued to be categorized as low, with an unaltered diagnosis; two patients showed a marked increase in CSF-hcrt-1, attaining normal values at follow-up. One of these patients relapsed to low CSF-hcrt-1 after follow-up. All 41 patients with normal CSF-hcrt-1 at baseline had normal CSF-hcrt-1 at follow-up. CONCLUSION CSF-hcrt-1 measurement can provide an accurate test for diagnosing NT1, although it is important to validate the CSF-hcrt-1 cut-off for specific testing locations. Stable CSF-hcrt-1 levels support the already established prognosis of narcolepsy as permanent once the disorder has fully developed.
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Chavda V, Chaurasia B, Umana GE, Tomasi SO, Lu B, Montemurro N. Narcolepsy-A Neuropathological Obscure Sleep Disorder: A Narrative Review of Current Literature. Brain Sci 2022; 12:1473. [PMID: 36358399 PMCID: PMC9688775 DOI: 10.3390/brainsci12111473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/22/2022] [Accepted: 10/28/2022] [Indexed: 08/29/2023] Open
Abstract
Narcolepsy is a chronic, long-term neurological disorder characterized by a decreased ability to regulate sleep-wake cycles. Some clinical symptoms enter into differential diagnosis with other neurological diseases. Excessive daytime sleepiness and brief involuntary sleep episodes are the main clinical symptoms. The majority of people with narcolepsy experience cataplexy, which is a loss of muscle tone. Many people experience neurological complications such as sleep cycle disruption, hallucinations or sleep paralysis. Because of the associated neurological conditions, the exact pathophysiology of narcolepsy is unknown. The differential diagnosis is essential because relatively clinical symptoms of narcolepsy are easy to diagnose when all symptoms are present, but it becomes much more complicated when sleep attacks are isolated and cataplexy is episodic or absent. Treatment is tailored to the patient's symptoms and clinical diagnosis. To facilitate the diagnosis and treatment of sleep disorders and to better understand the neuropathological mechanisms of this sleep disorder, this review summarizes current knowledge on narcolepsy, in particular, genetic and non-genetic associations of narcolepsy, the pathophysiology up to the inflammatory response, the neuromorphological hallmarks of narcolepsy, and possible links with other diseases, such as diabetes, ischemic stroke and Alzheimer's disease. This review also reports all of the most recent updated research and therapeutic advances in narcolepsy. There have been significant advances in highlighting the pathogenesis of narcolepsy, with substantial evidence for an autoimmune response against hypocretin neurons; however, there are some gaps that need to be filled. To treat narcolepsy, more research should be focused on identifying molecular targets and novel autoantigens. In addition to therapeutic advances, standardized criteria for narcolepsy and diagnostic measures are widely accepted, but they may be reviewed and updated in the future with comprehension. Tailored treatment to the patient's symptoms and clinical diagnosis and future treatment modalities with hypocretin agonists, GABA agonists, histamine receptor antagonists and immunomodulatory drugs should be aimed at addressing the underlying cause of narcolepsy.
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Affiliation(s)
- Vishal Chavda
- Department of Pathology, Stanford of School of Medicine, Stanford University Medical Centre, Palo Alto, CA 94305, USA
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj 44300, Nepal
| | - Giuseppe E. Umana
- Department of Neurosurgery, Associate Fellow of American College of Surgeons, Trauma and Gamma-Knife Centre, Cannizzaro Hospital Catania, 95100 Catania, Italy
| | | | - Bingwei Lu
- Department of Pathology, Stanford of School of Medicine, Stanford University Medical Centre, Palo Alto, CA 94305, USA
| | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), University of Pisa, 56100 Pisa, Italy
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10
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Pérez-Carbonell L, Mignot E, Leschziner G, Dauvilliers Y. Understanding and approaching excessive daytime sleepiness. Lancet 2022; 400:1033-1046. [PMID: 36115367 DOI: 10.1016/s0140-6736(22)01018-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/10/2022] [Accepted: 05/19/2022] [Indexed: 10/14/2022]
Abstract
Excessive daytime sleepiness (EDS) is a public health issue. However, it remains largely undervalued, scarcely diagnosed, and poorly supported. Variations in the definition of EDS and limitations in clinical assessment lead to difficulties in its epidemiological study, but the relevance of this symptom from a socioeconomic perspective is inarguable. EDS might be a consequence of several behavioural issues leading to insufficient or disrupted sleep, as well as a consequence of sleep disorders including sleep apnoea syndrome, circadian disorders, central hypersomnolence disorders (narcolepsy and idiopathic hypersomnia), other medical or psychiatric conditions, or medications. Furthermore, EDS can have implications for health as it is thought to act as a risk factor for other conditions, such as cardiovascular and neurodegenerative disorders. Because of the heterogeneous causes of EDS and the complexity of its pathophysiology, management will largely depend on the cause, with the final aim of making treatment specific to the individual using precision medicine and personalised medicine.
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Affiliation(s)
| | - Emmanuel Mignot
- Center for Narcolepsy, Stanford University, Palo Alto, CA, USA
| | - Guy Leschziner
- Sleep Disorders Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK; Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Yves Dauvilliers
- Centre National de Référence Narcolepsie Hypersomnies, Unité des Troubles du Sommeil, Département de Neurologie, Hôpital Gui-de-Chauliac, Inserm INM, Université Montpellier, Montpellier, France
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11
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Hédou J, Cederberg KL, Ambati A, Lin L, Farber N, Dauvilliers Y, Quadri M, Bourgin P, Plazzi G, Andlauer O, Hong SC, Huang YS, Leu-Semenescu S, Arnulf I, Taheri S, Mignot E. Proteomic biomarkers of Kleine-Levin syndrome. Sleep 2022; 45:zsac097. [PMID: 35859339 PMCID: PMC9453623 DOI: 10.1093/sleep/zsac097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 03/21/2022] [Indexed: 07/23/2023] Open
Abstract
STUDY OBJECTIVES Kleine-Levin syndrome (KLS) is characterized by relapsing-remitting episodes of hypersomnia, cognitive impairment, and behavioral disturbances. We quantified cerebrospinal fluid (CSF) and serum proteins in KLS cases and controls. METHODS SomaScan was used to profile 1133 CSF proteins in 30 KLS cases and 134 controls, while 1109 serum proteins were profiled in serum from 26 cases and 65 controls. CSF and serum proteins were both measured in seven cases. Univariate and multivariate analyses were used to find differentially expressed proteins (DEPs). Pathway and tissue enrichment analyses (TEAs) were performed on DEPs. RESULTS Univariate analyses found 28 and 141 proteins differentially expressed in CSF and serum, respectively (false discovery rate <0.1%). Upregulated CSF proteins included IL-34, IL-27, TGF-b, IGF-1, and osteonectin, while DKK4 and vWF were downregulated. Pathway analyses revealed microglial alterations and disrupted blood-brain barrier permeability. Serum profiles show upregulation of Src-family kinases (SFKs), proteins implicated in cellular growth, motility, and activation. TEA analysis of up- and downregulated proteins revealed changes in brain proteins (p < 6 × 10-5), notably from the pons, medulla, and midbrain. A multivariate machine-learning classifier performed robustly, achieving a receiver operating curve area under the curve of 0.90 (95% confidence interval [CI] = 0.78-1.0, p = 0.0006) in CSF and 1.0 (95% CI = 1.0-1.0, p = 0.0002) in serum in validation cohorts, with some commonality across tissues, as the model trained on serum sample also discriminated CSF samples of controls versus KLS cases. CONCLUSIONS Our study identifies proteomic KLS biomarkers with diagnostic potential and provides insight into biological mechanisms that will guide future research in KLS.
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Affiliation(s)
- Julien Hédou
- Department of Psychiatry and Behavioral Sciences, Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, CA, USA
| | - Katie L Cederberg
- Department of Psychiatry and Behavioral Sciences, Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, CA, USA
| | - Aditya Ambati
- Department of Psychiatry and Behavioral Sciences, Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, CA, USA
| | - Ling Lin
- Department of Psychiatry and Behavioral Sciences, Center for Sleep Sciences and Medicine, Stanford University, Palo Alto, CA, USA
| | - Neal Farber
- Kleine-Levin Syndrome Foundation, Boston, MA, USA
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases, Narcolepsy-Rare Hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, Univ Montpellier, Montpellier, France
- Department of Neurology, Institute for Neurosciences of Montpellier INM, Univ Montpellier, INSERM, Montpellier, France
| | | | - Patrice Bourgin
- Sleep Disorders Center, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna and IRCCS Institute of Neurological Sciences, Bologna, Italy
| | | | - Seung-Chul Hong
- Department of Psychiatry, St. Vincent’s Hospital, Catholic University of Korea, Seoul, South Korea
| | - Yu-Shu Huang
- Department of Child Psychiatry and Sleep Center, Chang Gung Memorial Hospital and University, Taoyuan, Taiwan
| | - Smaranda Leu-Semenescu
- Sleep Disorders, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne, National Reference Center for Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Paris, France
| | - Isabelle Arnulf
- Sleep Disorders, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne, National Reference Center for Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Paris, France
- Sorbonne University, Institut Hospitalo-Universitaire, Institut du Cerveau et de la Moelle, Paris, France
| | - Shahrad Taheri
- Department of Medicine and Clinical Research Core, Weill Cornell Medicine—Qatar, Qatar Foundation—Education City, Doha, Qatar
| | - Emmanuel Mignot
- Corresponding author. Emmanuel Mignot, Center for Narcolepsy and Related Disorders, Stanford University, 3165 Porter Drive, Palo Alto, CA 94305, USA.
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van der Hoeven AE, Fronczek R, Schinkelshoek MS, Roelandse FWC, Bakker JA, Overeem S, Bijlenga D, Lammers GJ. Intermediate hypocretin-1 cerebrospinal fluid levels and typical cataplexy: their significance in the diagnosis of narcolepsy type 1. Sleep 2022; 45:zsac052. [PMID: 35554594 PMCID: PMC9113791 DOI: 10.1093/sleep/zsac052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/01/2022] [Indexed: 12/15/2022] Open
Abstract
STUDY OBJECTIVES The diagnosis of narcolepsy type 1 (NT1) is based upon the presence of cataplexy and/or a cerebrospinal fluid (CSF) hypocretin-1/orexin-A level ≤ 110 pg/mL. We determined the clinical and diagnostic characteristics of patients with intermediate hypocretin-1 levels (111-200 pg/mL) and the diagnostic value of cataplexy characteristics in individuals with central disorders of hypersomnolence. METHODS Retrospective cross-sectional study of 355 people with known CSF hypocretin-1 levels who visited specialized Sleep-Wake Centers in the Netherlands. For n = 271, we had full data on cataplexy type ("typical" or "atypical" cataplexy). RESULTS Compared to those with normal hypocretin-1 levels (>200 pg/mL), a higher percentage of individuals with intermediate hypocretin-1 levels had typical cataplexy (75% or 12/16 vs 9% or 8/88, p < .05), and/or met the diagnostic polysomnographic (PSG) and Multiple Sleep Latency Test (MSLT) criteria for narcolepsy (50 vs 6%, p < .001). Of those with typical cataplexy, 88% had low, 7% intermediate, and 5% normal hypocretin-1 levels (p < .001). Atypical cataplexy was also associated with hypocretin deficiency but to a lesser extent. A hypocretin-1 cutoff of 150 pg/mL best predicted the presence of typical cataplexy and/or positive PSG and MSLT findings. CONCLUSION Individuals with intermediate hypocretin-1 levels or typical cataplexy more often have outcomes fitting the PSG and MSLT criteria for narcolepsy than those with normal levels or atypical cataplexy. In addition, typical cataplexy has a much stronger association with hypocretin-1 deficiency than atypical cataplexy. We suggest increasing the NT1 diagnostic hypocretin-1 cutoff and adding the presence of clearly defined typical cataplexy to the diagnostic criteria of NT1. Clinical trial information: This study is not registered in a clinical trial register, as it has a retrospective database design.
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Affiliation(s)
- Adrienne Elisabeth van der Hoeven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Mink Sebastian Schinkelshoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | | | - Jaap Adriaan Bakker
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Denise Bijlenga
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Gert Jan Lammers
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
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13
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Guo J, Xu L, Wang J, Li C, Zhang C, Dong X, Zuo Y, Wen Y, Xiao F, Spruyt K, Han F. The month of birth has a seasonal effect in Chinese patients with narcolepsy and cataplexy. J Clin Sleep Med 2022; 18:461-467. [PMID: 34432630 PMCID: PMC8804987 DOI: 10.5664/jcsm.9626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES We assessed the yearly seasonal, environmental effects on birth pattern in Chinese patients later diagnosed with narcolepsy and cataplexy and explored if this effect persisted in patients with symptoms onset date before, following, and after the 2009 H1N1 pandemic. METHODS A total of 1,942 patients with birth data information and diagnosed narcolepsy with cataplexy were included in this study. The birth month and seasonal effect of 1,064 patients born from 1970 to 2000 were compared to controls (n = 2,028,714) from the general population. Furthermore, birth season effect in 1,373 patients with definite disease onset month were compared among patients with onset date before (n = 595), following (from January 2010 to December 2010) (n = 325), and after (n = 453) the H1N1 pandemic. RESULTS Patients with narcolepsy and cataplexy had a significantly different seasonality from the general population (P = .027). The monthly distribution of birth month yielded a peak in November (odds ratio = 1.23 [95% confidence interval, 1.01-1.49], P = .042) and a trough in April (odds ratio = 0.68 [95% confidence interval, 0.52-0.88], P = .004). No significant difference was observed in the birth month across patients with symptom onset dates before, following, and after the 2009 H1N1 pandemic (P = .603). CONCLUSIONS This finding across many years of seasonal effect in Chinese narcolepsy cataplexy supports a role for early-life environmental influences on disease development. CITATION Guo J, Xu L, Wang J, et al. The month of birth has a seasonal effect in Chinese patients with narcolepsy and cataplexy. J Clin Sleep Med. 2022;18(2):461-467.
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Affiliation(s)
- Jingjing Guo
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Liyue Xu
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Jingyu Wang
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Chenyang Li
- Peking University School of Nursing, Beijing, China
| | - Chi Zhang
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Xiaosong Dong
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Yuhua Zuo
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Yongfei Wen
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Fulong Xiao
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | | | - Fang Han
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China,Address correspondence to: Fang Han, MD, Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Peking University People’s Hospital, Beijing, 100044, China;
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Hamit G, Ayca O, Omer B, Nevra O, Aynur O. Association of circadian locomotor output cycles kaput rs1801260 and hypocretin receptor 1 rs2271933 polymorphisms in patients with chronic migraine and sleep disorder. NEUROL SCI NEUROPHYS 2022. [DOI: 10.4103/nsn.nsn_195_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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15
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Senel G, Karadeniz D. Neuroanatomical and Etiological Approaches to Secondary Narcolepsy. NEUROL SCI NEUROPHYS 2022. [DOI: 10.4103/nsn.nsn_5_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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16
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Geng C, Yang Z, Xu P, Zhang H. Vitamin B12 deficiency is associated with narcolepsy. Clin Neurol Neurosurg 2021; 212:107097. [PMID: 34942572 DOI: 10.1016/j.clineuro.2021.107097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/02/2021] [Accepted: 12/17/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Narcolepsy can be defined as a sleep disorder. However, whether changes in the serum vitamin B12 levels are involved in the pathophysiological mechanism of narcolepsy remains unclear. Our study aimed to assess whether vitamin B12 levels are independently related to the occurrence of narcolepsy. METHODS The serum folate, vitamin B12, and homocysteine levels of 40 patients with narcolepsy and 40 age- and gender-matched healthy controls (HC) were retrospectively analyzed. According to the results of the univariate logistic analysis, a multiple logistic regression model was constructed to predict the independent influencing indicators. RESULTS Serum folic acid and vitamin B12 levels in the narcolepsy group were significantly reduced. Moreover, through the sex subgroup, males in the narcolepsy group had lower serum vitamin B12 levels. Multivariate logistic regression revealed serum vitamin B12 to be independently associated with narcolepsy (p < 0.05; odds ratio=0.97; 95% confidence interval: 0.95-0.98). CONCLUSION Decreased serum vitamin B12 levels are independently associated with the development of narcolepsy, which illustrates the complex relationship between vitamin B12 and narcolepsy. Future studies should explore whether vitamin B12 supplementation can improve the symptoms of patients.
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Affiliation(s)
- Chaofan Geng
- Henan University People's Hospital; Henan Provincial People's Hospital, Zhengzhou 450003, China
| | - Zhenzhen Yang
- Zhengzhou University People's Hospital; Henan Provincial People's Hospital, Zhengzhou 450003, China
| | - Pengfei Xu
- Henan University People's Hospital; Henan Provincial People's Hospital, Zhengzhou 450003, China
| | - Hongju Zhang
- Henan University People's Hospital; Henan Provincial People's Hospital, Zhengzhou 450003, China; Zhengzhou University People's Hospital; Henan Provincial People's Hospital, Zhengzhou 450003, China.
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17
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Postiglione E, Barateau L, Pizza F, Lopez R, Antelmi E, Rassu AL, Vandi S, Chenini S, Mignot E, Dauvilliers Y, Plazzi G. Narcolepsy with intermediate cerebrospinal level of hypocretin-1. Sleep 2021; 45:6460454. [PMID: 34902030 DOI: 10.1093/sleep/zsab285] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/19/2021] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES To describe the phenotype of narcolepsy with intermediate cerebrospinal hypocretin-1 levels (CSF hcrt-1). METHODS From 1600 consecutive patients with narcolepsy from Bologna and Montpellier sleep centers we selected patients with intermediate CSF hcrt-1 levels (110-200 pg/ml). Clinical, neurophysiological and biological data were contrasted for the presence of cataplexy, HLA-DQB1*06:02, and median CSF hcrt-1 levels (149.34 pg/mL). RESULTS Forty-five (55% males, aged 35 ± 17 years) patients (2.8% of all cases) were included. Thirty-three (73%) were HLA-DQB1*06:02, 29 (64%) reported cataplexy (21, 72.4% with typical features), and 5 (11%) had presumed secondary etiology. Cataplexy was associated with other core narcolepsy symptoms, increased sleep onset REM periods, and nocturnal sleep disruption. Cataplexy and irrepressible daytime sleep were more frequent in HLA DQB1*06:02 positive patients. Lower CSF hcrt-1 levels were associated with hallucinations. CONCLUSION Narcolepsy with intermediate CSF hcrt-1 level is a rare condition with heterogeneous phenotype. HLA DQB1*06:02 and lower CSF hcrt-1 were associated with typical narcolepsy features, calling for future research to distinguish incomplete from secondary narcolepsy forms.
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Affiliation(s)
- Emanuela Postiglione
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Lucie Barateau
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,National Reference Network for Narcolepsy, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, France
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Régis Lopez
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,National Reference Network for Narcolepsy, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, France
| | - Elena Antelmi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Anna-Laura Rassu
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France
| | - Stefano Vandi
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Sofiene Chenini
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,National Reference Network for Narcolepsy, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France
| | - Emmanuel Mignot
- Center for Sleep Sciences and Medicine, Stanford University Medical School, Palo Alto, California
| | - Yves Dauvilliers
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,National Reference Network for Narcolepsy, Gui-de-Chauliac Hospital, University Hospital Center, Montpellier, France.,Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, France
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
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18
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Lalovic B, Majid O, Aluri J, Landry I, Moline M, Hussein Z. Population Pharmacokinetics and Exposure-Response Analyses for the Most Frequent Adverse Events Following Treatment With Lemborexant, an Orexin Receptor Antagonist, in Subjects With Insomnia Disorder. J Clin Pharmacol 2020; 60:1642-1654. [PMID: 32666570 PMCID: PMC7689791 DOI: 10.1002/jcph.1683] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/03/2020] [Indexed: 01/04/2023]
Abstract
Lemborexant is a novel orexin receptor antagonist approved in the United States and Japan for the treatment of insomnia. This article describes the population pharmacokinetics (PK) of lemborexant and the relationship of its daily steady-state exposure (Cav,ss ) to the probability of most frequent treatment-emergent adverse events (TEAEs). The 12 230-observation, 1892-subject PK data set included data from 12 clinical studies with predominantly female subjects (66%) ranging in age from 18 to 88 years and from 37 to 168 kg in body weight. The 1664-subject exposure-response data set included data from 3 late-stage studies. Lemborexant pharmacokinetics were described by a 3-compartment model with combined first- and zero-order absorption with lag time and linear elimination. Oral clearance decreased with increasing body mass index (exponent, -0.428), increasing alkaline phosphatase levels (exponent, -0.118), and was 26% lower in the elderly (≥65 years). Across the adverse event analysis, the frequency of subjects experiencing TEAEs during active treatment ranged from approximately 3% to 8%, in the range estimated for placebo. With and without adjustment for age, lemborexant exposure (Cav,ss ) was not a clinically meaningful linear predictor of the probability of specific TEAEs: somnolence, nasopharyngitis, flu/influenza, urinary tract infection, upper respiratory tract infection, or headache. Given the small effect sizes of covariates of the PK model and a low degree of association of lemborexant TEAEs and exposure over the range of phase 3 (therapeutic) 5- and 10-mg doses, lemborexant can be safely administered without the need for dose adjustment.
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19
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Profaizer T, Pole A, Monds C, Delgado JC, Lázár-Molnár E. Clinical utility of next generation sequencing based HLA typing for disease association and pharmacogenetic testing. Hum Immunol 2020; 81:354-360. [PMID: 32499099 DOI: 10.1016/j.humimm.2020.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 04/22/2020] [Accepted: 05/02/2020] [Indexed: 12/17/2022]
Abstract
HLA associations have been linked to many diseases and are important for risk assessment of drug hypersensitivity reactions. The increasing number of HLA alleles discovered generated a list of ambiguities that cannot be resolved with the current clinical assays, which commonly include sequence-specific oligonucleotide probe (SSOP) genotyping, and real-time PCR with melting curve analysis. HLA typing by next-generation sequencing (NGS) has recently been adopted by clinical laboratories for transplantation testing, as it provides unambiguous and cost-effective HLA typing. The goal of this study was to evaluate the feasibility of using NGS-based HLA-B and DQ genotyping for clinical HLA disease association testing, and provide direct comparison with the currently used clinical tests, including SSOP genotyping, and real-time PCR with melting curve analysis. While the real-time PCR method is easy and inexpensive to perform, ambiguities are rapidly increasing as more and more HLA alleles are discovered. SSOP genotyping identifies the alleles present but limitations include ambiguities and underreporting less common alleles. Our data show that HLA typing by NGS is superior to the existing clinical methods for identifying HLA alleles associated with disease or drug hypersensitivity, and offers a viable approach for high volume clinical diagnostic laboratories.
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Affiliation(s)
- Tracie Profaizer
- ARUP Institute for Clinical and Experimental Pathology, United States.
| | - Ann Pole
- Histocompatibility & Immunogenetics Laboratory, University of Utah Health, Salt Lake City, UT 84108, United States.
| | - Cassandra Monds
- ARUP Institute for Clinical and Experimental Pathology, United States.
| | - Julio C Delgado
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84108, United States.
| | - Eszter Lázár-Molnár
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84108, United States.
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20
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Kawai R, Watanabe A, Fujita S, Hirose M, Esaki Y, Arakawa C, Iwata N, Kitajima T. Utility of the sleep stage sequence preceding sleep onset REM periods for the diagnosis of narcolepsy: a study in a Japanese cohort. Sleep Med 2020; 68:9-17. [PMID: 31999982 DOI: 10.1016/j.sleep.2019.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/14/2019] [Accepted: 04/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The minimum narcolepsy criteria "mean sleep latency (MSL) ≤8 min and ≥2 sleep onset rapid eye movement (REM) periods (SOREMPs) on polysomnography (PSG) and the multiple sleep latency test (MSLT)," according to The International Classification of Sleep Disorders, Third Edition (ICSD-3), are not specific to narcolepsy. Recently, the characteristic sleep stage sequences preceding SOREMPs in narcolepsy have received attention, but their diagnostic utility remains unclear. METHODS We retrospectively reviewed PSG/MSLT records and chart data for 102 Japanese patients with hypersomnia and at least one SOREMP. We examined the sporadic rates of two sleep stage sequences preceding the SOREMPs-wakefulness or stage 1 to REM (W/S1→R) and stage 2 to REM (S2→R)-comparing these between patient groups with narcolepsy type 1 (N = 28), narcolepsy type 2 (N = 19), and other hypersomnia (N = 55). We also examined the utility of three simple indices using the occurrence of W/S1→R SOREMPs for distinguishing between narcolepsy and other hypersomnia in patients who satisfied the minimum narcolepsy criteria. RESULTS W/S1→R SOREMPs were significantly more frequent in narcolepsy than in other hypersomnia, and this tendency was also observed even in the patients who satisfied the minimum narcolepsy criteria. The three indices had moderate sensitivities and specificities for distinguishing between narcolepsy and other hypersomnia in patients satisfying the minimum narcolepsy criteria. CONCLUSIONS The W/S1→R pattern was observed significantly more frequently in narcolepsy than in other hypersomnia, suggesting it may help with differentiating narcolepsy from other hypersomnia in patients demonstrating the narcolepsy criteria, although its ability to do so may be modest.
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Affiliation(s)
- Ryoko Kawai
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Akiko Watanabe
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Shiho Fujita
- Department of Laboratory Medicine, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Marina Hirose
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yuichi Esaki
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Chiaki Arakawa
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Tsuyoshi Kitajima
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
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21
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Sleep and neurological autoimmune diseases. Neuropsychopharmacology 2020; 45:129-140. [PMID: 31302665 PMCID: PMC6879573 DOI: 10.1038/s41386-019-0463-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/17/2019] [Accepted: 07/02/2019] [Indexed: 12/17/2022]
Abstract
Neurological autoimmune diseases are characterized by an inappropriate immune response that by mistake targets the nervous system. As a result, patients experiment a number of neurological manifestations that may include insomnia, excessive daytime sleepiness, cataplexy, central hypoventilation, and REM sleep behavior disorder. Polysomnographic evaluation may reveal disorganized sleep architecture involving both NREM and REM sleep, and REM sleep intrusions into wakefulness. The study of sleep disorders in the setting of autoimmune diseases (e.g., narcolepsy, anti-IgLON5 disease, paraneoplastic neurological syndromes) shows that an abnormal immune-mediated (humoral or cellular) response target the neuronal structures (e.g., brainstem, hypothalamus) and neurotransmitters systems (e.g., hypocretin) that regulate sleep resulting in sleep impairment. It is a window to examine the link between the autoimmune system and the sleep regulation at the molecular, cellular, and anatomic level.
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22
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Morse AM, Kelly-Pieper K, Kothare SV. Management of Excessive Daytime Sleepiness in Narcolepsy With Baclofen. Pediatr Neurol 2019; 93:39-42. [PMID: 30595352 DOI: 10.1016/j.pediatrneurol.2018.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 08/17/2018] [Accepted: 10/30/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Narcolepsy is a disabling sleep-wake disorder characterized by the pentad symptoms of excessive daytime sleepiness, sleep paralysis, sleep fragmentation, sleep-related hallucinations, and cataplexy. There is no curative therapy for narcolepsy. Treatment is therefore symptom directed. Symptom management is generally directed at improving excessive daytime sleepiness, sleep fragmentation, and cataplexy. First-line treatment for excessive daytime sleepiness is typically daily use of wake-promoting agents, such as modafinil or armodafinil, or stimulant therapy, such as methylphenidate or amphetamines. Alternatively, sodium oxybate can be used nightly for improved cataplexy, sleep consolidation, and following day wakefulness. These therapies can be limited in some patients because of inadequate efficacy, poor tolerability, or side effects. METHODS We describe five narcolepsy patients with severe excessive daytime sleepiness who had an inadequate response or experienced side effects with the initial therapies but had a positive response to treatment with baclofen. RESULTS These patients reported subjective improvement in sleep maintenance without fragmentation and daytime sleepiness. Average Epworth Sleepiness Scale assessment before treatment was 15.8 with post-treatment assessment being 10.4 (P < 0.05). CONCLUSIONS Baclofen may be an effective treatment for excessive daytime sleepiness and sleep fragmentation in narcolepsy and warrants further study.
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Affiliation(s)
- Anne M Morse
- Department of Child Neurology, Geisinger Medical Center, Janet Weis Children's Hospital, Danville, Pennsylvania; Department of Sleep Medicine, Geisinger Medical Center, Janet Weis Children's Hospital, Danville, Pennsylvania
| | - Kristin Kelly-Pieper
- Division of Pediatric Pulmonology and Cystic Fibrosis Center, Cohen Children's Medical Center, Lake Success, New York; Pediatric Neurology Service Line for Northwell Health, Department of Pediatrics & Neurology, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, Lake Success, New York
| | - Sanjeev V Kothare
- Pediatric Neurology Service Line for Northwell Health, Department of Pediatrics & Neurology, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, Lake Success, New York; Division of Pediatric Neurology, Department of Pediatrics, Cohen Children's Medical Center, Lake Success, New York; Pediatric Sleep Program (Neurology), Department of Pediatrics, Cohen Children's Medical Center, Lake Success, New York.
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23
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Capittini C, De Silvestri A, Terzaghi M, Scotti V, Rebuffi C, Pasi A, Manni R, Martinetti M, Tinelli C. Correlation between HLA-DQB1*06:02 and narcolepsy with and without cataplexy: approving a safe and sensitive genetic test in four major ethnic groups. A systematic meta-analysis. Sleep Med 2018; 52:150-157. [DOI: 10.1016/j.sleep.2018.08.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 07/24/2018] [Accepted: 08/21/2018] [Indexed: 01/06/2023]
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Intravenous Immunoglobulin Therapy Administered Early after Narcolepsy Type 1 Onset in Three Patients Evaluated by Clinical and Polysomnographic Follow-Up. Behav Neurol 2018; 2018:1671072. [PMID: 30410634 PMCID: PMC6205306 DOI: 10.1155/2018/1671072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/26/2018] [Indexed: 11/17/2022] Open
Abstract
Narcolepsy type 1 is a rare disabling sleep disorder mainly characterized by excessive daytime sleepiness and cataplexy, an emotion-triggered sudden loss of muscle tone. Patients have a selective degeneration of hypocretin-producing neurons in the dorsolateral posterior hypothalamus with growing evidence supporting the hypothesis of an autoimmune mechanism. Few case studies that reported intravenous immunoglobulin therapy (IVIg) suggest the efficacy of IVIg when administered early after disease onset, but the results are controversial. In these retrospective case observations, IVIg cycles were initiated within one to four months after cataplexy onset in a twenty-seven-year-old man, a ten-year-old girl, and a seven-year-old boy, all three with early onset typical narcolepsy type 1. Efficacy of treatment (three IVIg cycles of 1 g/kg administered at four-week intervals) was evaluated based on clinical, polysomnographic, and multiple sleep latency test (mean latency and SOREM) follow-up. Two patients reported decreased cataplexy frequency and ameliorated daytime sleepiness, but no significant amelioration of polysomnographic parameters was observed. Given the possibility of spontaneous improvement of cataplexy frequency with self-behavioral adjustments, these observations would need to be confirmed by larger controlled studies. Based on the present study and current literature, proof of concept is still missing thus prohibiting the consideration of IVIg as an efficient treatment option.
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AlShareef SM, Smith RM, BaHammam AS. Kleine-Levin syndrome: clues to aetiology. Sleep Breath 2018; 22:613-623. [PMID: 29532411 PMCID: PMC6133116 DOI: 10.1007/s11325-017-1617-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/19/2017] [Accepted: 12/29/2017] [Indexed: 12/22/2022]
Abstract
Kleine-Levin syndrome (KLS) is the commonest recurrent sleep disorder, with a prevalence of 1-2 per million population. Clear diagnostic criteria are now defined, but effective treatment remains elusive. The significant body of published literature allows consideration of possible aetiological mechanisms, an understanding of which could guide the development of therapeutic strategies. Functional imaging studies have been inconclusive; although diencephalic abnormalities are a common finding, no consistent pattern has emerged, and these studies have not revealed the mechanism(s) underlying the development of the abnormalities detected. An autoimmune aetiology is consistent with the available data. In this review, we argue that, in order to further our understanding of KLS, there needs to be a co-ordinated international effort to standardise approaches to functional imaging studies, genetic analyses that specifically address the possibility of an autoimmune aetiology, and clinical trials of immunosuppressive therapies.
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Affiliation(s)
- Saad Mohammed AlShareef
- Department of Internal Medicine, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Richard Mark Smith
- Division of Medicine and Therapeutics, Ipswich Hospital NHS Trust and University of Suffolk, Heath Road, Ipswich, Suffolk, IP4 5PD UK
| | - Ahmed Salem BaHammam
- The University Sleep Disorders Center and National Plan for Science and Technology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Filardi M, Pizza F, Antelmi E, Pillastrini P, Natale V, Plazzi G. Physical Activity and Sleep/Wake Behavior, Anthropometric, and Metabolic Profile in Pediatric Narcolepsy Type 1. Front Neurol 2018; 9:707. [PMID: 30197622 PMCID: PMC6117389 DOI: 10.3389/fneur.2018.00707] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/03/2018] [Indexed: 12/26/2022] Open
Abstract
Objectives: Regular physical activity is routinely recommended in children and adolescents suffering from narcolepsy type 1 (NT1), but controlled studies analyzing its influence on sleep/wake behavior, metabolic, and anthropometric profile in pediatric NT1 are lacking. Methods: Fifty consecutive drug-naïve NT1 children and adolescents were assessed through actigraphic, clinical, and metabolic evaluations. Patients were compared with respect to their engagement in leisure-time physical activities (LTPA): patients engaged in LTPA (n = 30) and patients not engaged (No-LTPA, n = 20), respectively. Results: LTPA patients presented lower BMI, with different BMI categories distribution and higher HDL cholesterol, when compared with No-LTPA subjects. Increased night-sleep duration, higher sleep quality, and reduction of nap frequency were documented through actigraphy in LTPA subjects. Subjective sleepiness, as measured by ESS-CHAD, was also lower in LTPA subjects while cataplexy frequency proved similar between the two groups. Discussion: In pediatric NT1 patients, regular engagement in LTPA is associated with significant differences on sleepiness, anthropometric and metabolic profile and objectively assessed sleep/wake behavior. Engagement in LTPA is beneficial and should be strongly encouraged in pediatric NT1 patients.
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Affiliation(s)
- Marco Filardi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna (ISNB), Azienda Unità Sanitaria Locale (AUSL) di Bologna, Bologna, Italy
| | - Elena Antelmi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna (ISNB), Azienda Unità Sanitaria Locale (AUSL) di Bologna, Bologna, Italy
| | - Paolo Pillastrini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Natale
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna (ISNB), Azienda Unità Sanitaria Locale (AUSL) di Bologna, Bologna, Italy
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Abstract
PURPOSE OF REVIEW This article provides a clinical approach to the appropriate investigation and diagnosis of sleep disorders commonly seen by neurologists. RECENT FINDINGS Home sleep apnea testing in appropriate situations can replace laboratory polysomnography in many cases of uncomplicated sleep apnea. Multiple sleep latency tests must be performed meticulously and interpreted in the clinical setting to avoid overdiagnoses of narcolepsy. Human leukocyte antigen testing has limited utility in establishing a diagnosis of narcolepsy because a positive test has low specificity. Rapid eye movement (REM) sleep behavior disorder is frequently the first manifestation of an evolving synucleinopathy, and a careful history and neurologic examination are needed to determine other early features of these disorders. SUMMARY A meticulous history from the patient, supplemented by collateral history from an observer, is essential to establishing the diagnosis of sleep disorders. Judicious supplementary use of investigations, such as laboratory polysomnography, home sleep apnea testing, wrist actigraphy, and multiple sleep latency tests, can confirm the correct diagnosis. This article describes an approach to the sleepy patient, the patient with neuromuscular disease and possible sleep-disordered breathing, the patient with restless legs syndrome, and young and older patients with abnormal movements during sleep.
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Cavalier Y, Kothare SV. The Association of Schizophrenia and Narcolepsy in Adolescents. Pediatr Neurol 2018; 83:56-57. [PMID: 29622485 DOI: 10.1016/j.pediatrneurol.2018.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Yefim Cavalier
- Department of Medicine, New York University Medical Center, New York, New York.
| | - Sanjeev V Kothare
- Department of Neurology & Pediatrics, Pediatric Sleep Program, New York University Medical Center, New York, New York
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29
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The clinical spectrum of childhood narcolepsy. Sleep Med Rev 2018; 38:70-85. [DOI: 10.1016/j.smrv.2017.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/19/2022]
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Laperchia C, Xu YZ, Mumba Ngoyi D, Cotrufo T, Bentivoglio M. Neural Damage in Experimental Trypanosoma brucei gambiense Infection: Hypothalamic Peptidergic Sleep and Wake-Regulatory Neurons. Front Neuroanat 2018. [PMID: 29535612 PMCID: PMC5835115 DOI: 10.3389/fnana.2018.00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Neuron populations of the lateral hypothalamus which synthesize the orexin (OX)/hypocretin or melanin-concentrating hormone (MCH) peptides play crucial, reciprocal roles in regulating wake stability and sleep. The disease human African trypanosomiasis (HAT), also called sleeping sickness, caused by extracellular Trypanosoma brucei (T. b.) parasites, leads to characteristic sleep-wake cycle disruption and narcoleptic-like alterations of the sleep structure. Previous studies have revealed damage of OX and MCH neurons during systemic infection of laboratory rodents with the non-human pathogenic T. b. brucei subspecies. No information is available, however, on these peptidergic neurons after systemic infection with T. b. gambiense, the etiological agent of 97% of HAT cases. The present study was aimed at the investigation of immunohistochemically characterized OX and MCH neurons after T. b. gambiense or T. b. brucei infection of a susceptible rodent, the multimammate mouse, Mastomysnatalensis. Cell counts and evaluation of OX fiber density were performed at 4 and 8 weeks post-infection, when parasites had entered the brain parenchyma from the periphery. A significant decrease of OX neurons (about 44% reduction) and MCH neurons (about 54% reduction) was found in the lateral hypothalamus and perifornical area at 8 weeks in T. b. gambiense-infected M. natalensis. A moderate decrease (21% and 24% reduction, respectively), which did not reach statistical significance, was found after T. b. brucei infection. In two key targets of diencephalic orexinergic innervation, the peri-suprachiasmatic nucleus (SCN) region and the thalamic paraventricular nucleus (PVT), densitometric analyses showed a significant progressive decrease in the density of orexinergic fibers in both infection paradigms, and especially during T. b. gambiense infection. Altogether the findings provide novel information showing that OX and MCH neurons are highly vulnerable to chronic neuroinflammatory signaling caused by the infection of human-pathogenic African trypanosomes.
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Affiliation(s)
- Claudia Laperchia
- Department of Neuroscience Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Yuan-Zhong Xu
- Department of Neuroscience Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Dieudonné Mumba Ngoyi
- Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of Congo
| | - Tiziana Cotrufo
- Department of Neuroscience Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Marina Bentivoglio
- Department of Neuroscience Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,National Institute of Neuroscience (INN), Verona Unit, Verona, Italy
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Bjorefeldt A, Illes S, Zetterberg H, Hanse E. Neuromodulation via the Cerebrospinal Fluid: Insights from Recent in Vitro Studies. Front Neural Circuits 2018; 12:5. [PMID: 29459822 PMCID: PMC5807333 DOI: 10.3389/fncir.2018.00005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 01/11/2018] [Indexed: 12/11/2022] Open
Abstract
The cerebrospinal fluid (CSF) occupies the brain's ventricles and subarachnoid space and, together with the interstitial fluid (ISF), forms a continuous fluidic network that bathes all cells of the central nervous system (CNS). As such, the CSF is well positioned to actively distribute neuromodulators to neural circuits in vivo via volume transmission. Recent in vitro experimental work in brain slices and neuronal cultures has shown that human CSF indeed contains neuromodulators that strongly influence neuronal activity. Here we briefly summarize these new findings and discuss their potential relevance to neural circuits in health and disease.
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Affiliation(s)
- Andreas Bjorefeldt
- Department of Physiology, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
- Department of Neuroscience, Brown University, Providence, RI, United States
| | - Sebastian Illes
- Department of Physiology, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular Neuroscience, UCL Institute of Neurology, University College London, London, United Kingdom
- United Kingdom Dementia Research Institute, University College London, London, United Kingdom
| | - Eric Hanse
- Department of Physiology, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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Affiliation(s)
- Jun Zhang
- Department of Neurology, Peking University People's Hospital, 11, Xi Zhi Men Nan Da Jie, Xi Chen Qu, Beijing 100044, China
| | - Fang Han
- Department of Respiratory Medicine, Peking University People's Hospital, 11, Xi Zhi Men Nan Da Jie, Xi Chen Qu, Beijing 100044, China.
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Abstract
The discovery of the orexin system represents the single major progress in the sleep field of the last three to four decades. The two orexin peptides and their two receptors play a major role in arousal and sleep/wake cycles. Defects in the orexin system lead to narcolepsy with cataplexy in humans and dogs and can be experimentally reproduced in rodents. At least six orexin receptor antagonists have reached Phase II or Phase III clinical trials in insomnia, five of which are dual orexin receptor antagonists (DORAs) that target both OX1 and OX2 receptors (OX2Rs). All clinically tested DORAs induce and maintain sleep: suvorexant, recently registered in the USA and Japan for insomnia, represents the first hypnotic principle that acts in a completely different manner from the current standard medications. It is clear, however, that in the clinic, all DORAs promote sleep primarily by increasing rapid eye movement (REM) and are almost devoid of effects on slow-wave (SWS) sleep. At present, there is no consensus on whether the sole promotion of REM sleep has a negative impact in patients suffering from insomnia. However, sleep onset REM (SOREM), which has been documented with DORAs, is clearly an undesirable effect, especially for narcoleptic patients and also in fragile populations (e.g. elderly patients) where REM-associated loss of muscle tone may promote an elevated risk of falls. Debate thus remains as to the ideal orexin agent to achieve a balanced increase in REM and non-rapid eye movement (NREM) sleep. Here, we review the evidence that an OX2R antagonist should be at least equivalent, or perhaps superior, to a DORA for the treatment of insomnia. An OX2R antagonist may produce more balanced sleep than a DORA. Rodent sleep experiments show that the OX2R is the primary target of orexin receptor antagonists in sleep modulation. Furthermore, an OX2R antagonist should, in theory, have a lower narcoleptic/cataplexic potential. In the clinic, the situation remains equivocal, since OX2R antagonists are in early stages: MK-1064 has completed Phase I, and MIN202 is currently in clinical Phase II/III trials. However, data from insomnia patients have not yet been released. Promotional material suggests that balanced sleep is indeed induced by MIN-202, whereas in volunteers MK-1064 has been reported to act similarly to DORAs.
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Affiliation(s)
- Laura H Jacobson
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, 30 Royal Parade, Parkville, VIC, 3052, Australia
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Sui Chen
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Sanjida Mir
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Daniel Hoyer
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, 30 Royal Parade, Parkville, VIC, 3052, Australia.
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, 3010, Australia.
- Department of Chemical Physiology, The Scripps Research Institute, 10550 N. Torrey Pines Road, La Jolla, CA, 92037, USA.
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Attention impairments and ADHD symptoms in adult narcoleptic patients with and without hypocretin deficiency. PLoS One 2017; 12:e0182085. [PMID: 28763482 PMCID: PMC5538711 DOI: 10.1371/journal.pone.0182085] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 07/12/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Attentional complaints are common in narcolepsy patients and can overlap with daytime sleepiness features. Few studies attempted to characterize attentional domains in narcolepsy leading to controversial results. We aimed to assess the impact of hypocretin deficiency on attentional functioning by comparing performances on the attention network test (ANT) of narcoleptic patients with hypocretin deficiency (narcolepsy type 1-NT1) versus patients without hypocretin deficiency (narcolepsy type 2-NT2) and healthy controls. We also addressed frequency and severity of psychopathological symptoms and their influence on performances on ANT. METHODS Twenty-one NT1 patients, fifteen NT2 patients and twenty-two healthy controls underwent the ANT, which allows assessing three separate attentional processes (alerting, orienting and executive control), and a psychometric assessment including questionnaires on attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, anxiety and depression symptoms. RESULTS NT1 and NT2 patients presented with slower reaction times compared to controls. NT1 patients exhibited an impairment of alerting network relative to NT2 and healthy controls, while orienting and executive control networks efficiency were comparable between groups. NT1 and NT2 displayed higher severity of ADHD inattentive domain than controls, NT1 patients also displayed higher severity of ADHD hyperactive domain and depressive symptoms. In NT1, ADHD and depressive symptoms were positively correlated. CONCLUSIONS Despite a shared slowing of reaction times in both NT1 and NT2, a selective impairment of alerting network was present only in hypocretin deficient patients. Clinicians should carefully consider attentional deficits and psychopathological symptoms, including ADHD symptoms, in the clinical assessment and management of patients with narcolepsy.
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Abstract
Narcolepsy is a chronic sleep disorder that has a typical onset in adolescence and is characterized by excessive daytime sleepiness, which can have severe consequences for the patient. Problems faced by patients with narcolepsy include social stigma associated with this disease, difficulties in obtaining an education and keeping a job, a reduced quality of life and socioeconomic consequences. Two subtypes of narcolepsy have been described (narcolepsy type 1 and narcolepsy type 2), both of which have similar clinical profiles, except for the presence of cataplexy, which occurs only in patients with narcolepsy type 1. The pathogenesis of narcolepsy type 1 is hypothesized to be the autoimmune destruction of the hypocretin-producing neurons in the hypothalamus; this hypothesis is supported by immune-related genetic and environmental factors associated with the disease. However, direct evidence in support of the autoimmune hypothesis is currently unavailable. Diagnosis of narcolepsy encompasses clinical, electrophysiological and biological evaluations, but simpler and faster procedures are needed. Several medications are available for the symptomatic treatment of narcolepsy, all of which have quite good efficacy and safety profiles. However, to date, no treatment hinders or slows disease development. Improved diagnostic tools and increased understanding of the pathogenesis of narcolepsy type 1 are needed and might lead to therapeutic or even preventative interventions.
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Affiliation(s)
- Birgitte R Kornum
- Molecular Sleep Laboratory, Department of Clinical Biochemistry, Rigshospitalet, Forskerparken, Nordre Ringvej 69, 2600 Glostrup, Denmark.,Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Stine Knudsen
- Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias, Oslo University Hospital, Oslo, Norway
| | - Hanna M Ollila
- Department of Psychiatry and Behavioral Sciences, Center for Sleep Sciences, Stanford University, Stanford, California, USA
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, AUSL di Bologna, Bologna, Italy
| | - Poul J Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Yves Dauvilliers
- Sleep Unit, Narcolepsy Reference Center, Department of Neurology, Gui de Chauliac Hospital, INSERM 1061, Montpellier, France
| | - Sebastiaan Overeem
- Sleep Medicine Center Kempenhaeghe, Heeze, The Netherlands.,Department of Industrial Design, Eindhoven University of Technology, Eindhoven, The Netherlands
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Ruoff C, Rye D. The ICSD-3 and DSM-5 guidelines for diagnosing narcolepsy: clinical relevance and practicality. Curr Med Res Opin 2016; 32:1611-1622. [PMID: 27359185 DOI: 10.1080/03007995.2016.1208643] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Narcolepsy is a chronic neurological disease manifesting as difficulty with maintaining continuous wake and sleep. Clinical presentation varies but requires excessive daytime sleepiness (EDS) occurring alone or together with features of rapid-eye movement (REM) sleep dissociation (e.g., cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis), and disrupted nighttime sleep. Narcolepsy with cataplexy is associated with reductions of cerebrospinal fluid (CSF) hypocretin due to destruction of hypocretin peptide-producing neurons in the hypothalamus in individuals with a specific genetic predisposition. Updated diagnostic criteria include the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and International Classification of Sleep Disorders Third Edition (ICSD-3). DSM-5 criteria require EDS in association with any one of the following: (1) cataplexy; (2) CSF hypocretin deficiency; (3) REM sleep latency ≤15 minutes on nocturnal polysomnography (PSG); or (4) mean sleep latency ≤8 minutes on multiple sleep latency testing (MSLT) with ≥2 sleep-onset REM-sleep periods (SOREMPs). ICSD-3 relies more upon objective data in addition to EDS, somewhat complicating the diagnostic criteria: 1) cataplexy and either positive MSLT/PSG findings or CSF hypocretin deficiency; (2) MSLT criteria similar to DSM-5 except that a SOREMP on PSG may count as one of the SOREMPs required on MSLT; and (3) distinct division of narcolepsy into type 1, which requires the presence of cataplexy or documented CSF hypocretin deficiency, and type 2, where cataplexy is absent, and CSF hypocretin levels are either normal or undocumented. We discuss limitations of these criteria such as variability in clinical presentation of cataplexy, particularly when cataplexy may be ambiguous, as well as by age; multiple and/or invasive CSF diagnostic test requirements; and lack of normative diagnostic test data (e.g., MSLT) in certain populations. While ICSD-3 criteria reflect narcolepsy pathophysiology, DSM-5 criteria have greater clinical practicality, suggesting that valid and reliable biomarkers to help standardize narcolepsy diagnosis would be welcomed.
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Affiliation(s)
- Chad Ruoff
- a Center for Sleep Sciences and Medicine, and Department of Psychiatry and Behavioral Sciences , Stanford University School of Medicine , Palo Alto , CA , USA
| | - David Rye
- b Department of Neurology and Program in Sleep , Emory University School of Medicine , Atlanta , GA , USA
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Sansa G, Gavaldà A, Gaig C, Monreal J, Ercilla G, Casamitjana R, Ribera G, Iranzo A, Santamaria J. Exploring the presence of narcolepsy in patients with schizophrenia. BMC Psychiatry 2016; 16:177. [PMID: 27245445 PMCID: PMC4888670 DOI: 10.1186/s12888-016-0859-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 05/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are several case reports of patients with narcolepsy and schizophrenia, but a systematic examination of the association of both disorders has not been done. The aim of this work is to assess the frequency of narcolepsy with cataplexy in a large consecutive series of adult patients with schizophrenia and schizoaffective disorder. METHODS We screened 366 consecutive patients with schizophrenia or schizoaffective disorder with a sleep questionnaire and the Epworth Sleepines scale (ESS) exploring narcoleptiform symptoms. Those who screened positive were assessed by a sleep specialist, and offered an HLA determination. CSF hypocretin-1 determination was proposed to those who were HLA DQB1*06:02 positive. RESULTS On the screening questionnaire, 17 patients had an ESS score ≥11 without cataplexy, 15 had cataplexy-like symptoms with an ESS score < 11, and four had an ESS score ≥11 plus cataplexy-like symptoms. Of those, 24 patients were evaluated by a sleep specialist. Five of these 24 were HLA DQB1*06:02 positive, and three of these five subjects underwent lumbar puncture showing normal hypocretin-1 levels. CONCLUSIONS Our results suggest that narcolepsy with cataplexy is not an unrecognized disease in adult patients with schizophrenia or schizoaffective disorder.
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Affiliation(s)
- Gemma Sansa
- Neurology Service and Multidisciplinary Sleep Disorders Unit, Hospital Parc Taulí, Sabadell, Spain.
| | - Alba Gavaldà
- Neuropsychology Department, Neurology Service. Hospital Parc Taulí, Sabadell, Spain
| | - Carles Gaig
- Neurology Service and Multidisciplinary Sleep Disorders Unit, Hospital Clínic of Barcelona, Barcelona, Spain
| | - José Monreal
- Psychiatry Service, Hospital Parc Taulí, Sabadell, Spain
| | - Guadalupe Ercilla
- Immunology Laboratory, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Roser Casamitjana
- Biochemistry and Molecular Genetics Laboratory, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic of Barcelona, Barcelona, Spain
| | - Gisela Ribera
- Neurology Service and Multidisciplinary Sleep Disorders Unit, Hospital Parc Taulí, Sabadell, Spain
| | - Alex Iranzo
- Neurology Service and Multidisciplinary Sleep Disorders Unit, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Joan Santamaria
- Neurology Service and Multidisciplinary Sleep Disorders Unit, Hospital Clínic of Barcelona, Barcelona, Spain
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39
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What Does One Sleep-Onset REM Period—During Either Nocturnal Polysomnography or Multiple Sleep Latency Test—Mean in Differential Diagnosis of Central Hypersomnias? J Clin Neurophysiol 2016; 32:364-8. [PMID: 26241245 DOI: 10.1097/wnp.0000000000000192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The differentiation of narcolepsy without cataplexy from idiopathic hypersomnia is based on the number of sleep-onset rapid eye movement periods (SOREMPs) observed by multiple sleep latency test (MSLT) and nocturnal polysomnography. The main aim of this study was to investigate the utility of SOREMP in differential diagnosis of central hypersomnias. METHODS The authors retrospectively evaluated consecutive 101 patients with a normal polysomnography other than the presence of SOREMP and/or REM without atonia and a latency of ≤8 minutes in MSLT. RESULTS The authors classified patients as follows: 52 patients had at least 2 SOREMPs (narcolepsy group), 23 had no SOREMPs (idiopathic hypersomnia group), and 26 patients had only 1 SOREMP (intermediate group). In polysomnographic recordings, both mean sleep latency and REM latency were significantly shorter in the narcolepsy (P = 0.012, P < 0.001, respectively) and intermediate groups (P = 0.005 and P = 0.035, respectively) compared with the idiopathic hypersomnia group. In MSLT recordings, sleep latency was 2.7 ± 2.2 minutes in the narcolepsy group, 3.6 ± 1.4 minutes in the intermediate group, and 5.2 ± 2.7 minutes in the idiopathic hypersomnia group (P < 0.001). The mean REM latency and sleep stages SOREMPs arised from were similar between the narcolepsy and intermediate groups. CONCLUSIONS To date, SOREMPs in MSLT and polysomnography remain the sole electrodiagnostic feature that discriminates narcolepsy without cataplexy from idiopathic hypersomnia. Different parameters or combined criteria are being increasingly investigated to increase the sensitivity and specificity of MSLT. The findings showed an altered instability of REM sleep not only in patients with 2 or more SOREMPs in MSLT but also in patients with one SOREMP.
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Wang JY, Han F, Dong SX, Li J, An P, Zhang XZ, Chang Y, Zhao L, Zhang XL, Liu YN, Yan H, Li QH, Hu Y, Lv CJ, Gao ZC, Strohl KP. Cerebrospinal Fluid Orexin A Levels and Autonomic Function in Kleine-Levin Syndrome. Sleep 2016; 39:855-60. [PMID: 26943469 DOI: 10.5665/sleep.5642] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 12/14/2015] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Kleine-Levin syndrome (KLS) is a rare disorder of relapsing sleepiness. The hypothesis was that the syndrome is related to a change in the vigilance peptide orexin A. METHODS From 2002 to 2013, 57 patients with relapsing hypersomnolence were clinically assessed in a referral academic center in Beijing, China, and 44 (28 males and 16 females; mean age 18.3 ± 8.9 y (mean ± standard deviation, range 9-57 y) were determined to have clinical and behavioral criteria consistent with KLS. Cerebrospinal fluid orexin A levels and diurnal blood pressure were measured in relapse versus remission in a subgroup of patients. RESULTS Presenting symptoms included relapsing or remitting excessive sleepiness-associated parallel complaints of cognitive changes (82%), eating disorders (84%); depression (45%); irritability (36%); hypersexuality (18%); and compulsions (11%). Episodes were 8.2 ± 3.3 days in duration. In relapse, diurnal values for blood pressure and heart rate were lower (P < 0.001). In a subgroup (n = 34), cerebrospinal fluid orexin A levels were ∼31% lower in a relapse versus remission (215.7 ± 81.5 versus 319.2 ± 95.92 pg/ml, P < 0.001); in three patients a pattern of lower levels during subsequent relapses was documented. CONCLUSIONS There are lower orexin A levels in the symptomatic phase than in remission and a fall and rise in blood pressure and heart rate, suggesting a role for orexin dysregulation in KLS pathophysiology.
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Affiliation(s)
- Jing Yu Wang
- Binzhou Medical University Hospital, Shandong Province, China
| | - Fang Han
- Binzhou Medical University Hospital, Shandong Province, China.,Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Song X Dong
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Jing Li
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Pei An
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Xiao Zhe Zhang
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Yuan Chang
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Long Zhao
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Xue Li Zhang
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Ya Nan Liu
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Han Yan
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Qing Hua Li
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Yan Hu
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Chang Jun Lv
- Binzhou Medical University Hospital, Shandong Province, China
| | - Zhan Cheng Gao
- Department of Pulmonary Medicine, Peking University People's Hospital, Beijing, China
| | - Kingman P Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Case Western Reserve University, and Cleveland Louis Stokes VA Medical Center, Cleveland, OH
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Abstract
Much of the understanding of the hypocretin/orexin (HCRT/OX) system in sleep-wake regulation came from narcolepsy-cataplexy research. The neuropeptides hypocretin-1 and -2/orexin-A and -B (HCRT-1 and -2/OX-A and -B, respectively), as we know, are intimately involved in the regulation wakefulness. The HCRT/OX system regulates sleep-wake control through complex interactions between monoaminergic/cholinergic (wake-promoting) and gamma-aminobutyric acid-ergic (sleep-promoting) neuronal systems. Deficiency of HCRT/OX results in loss of sleep-wake control or stability with consequent unstable transitions between wakefulness to nonrapid eye movement and rapid eye movement sleep. This manifests clinically as abnormal daytime sleepiness with sleep attacks and cataplexy. Research on the development of HCRT/OX agonists and antagonists for the treatment of sleep disorders has dramatically increased with the US Food and Drug Administration approval of the first-in-class dual HCRT/OX receptor antagonist for the treatment of insomnia. This review focuses on the origin, mechanisms of HCRT/OX receptors, clinical progress, and applications for the treatment of sleep disorders.
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Affiliation(s)
- Matthew Chow
- Department of Psychiatry and Behavioral Sciences, Division of Sleep Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Michelle Cao
- Department of Psychiatry and Behavioral Sciences, Division of Sleep Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
A number of autoantibodies, some paraneoplastic, are associated with sleep disorders. Morvan syndrome and limbic encephalitis, associated with voltage-gated potassium channel-complex antibodies, principally against CASPR2 and LGI1, can result in profound insomnia and rapid eye movement sleep behavior disorder (RBD). Patients with aquaporin-4 antibodies and neuromyelitis optica may develop narcolepsy in association with other evidence of hypothalamic dysfunction, sometimes as the initial presentation. Central sleep apnea and central neurogenic hypoventilation are found in patients with anti-N-methyl-d-aspartate receptor antibody encephalitis, and obstructive sleep apnea, stridor, and hypoventilation are prominent features of a novel tauopathy associated with IgLON5 antibodies. In addition, paraneoplastic diseases may involve the hypothalamus and cause sleep disorders, particularly narcolepsy and RBD in those with Ma1 and Ma2 antibodies. Patients with antineuronal nuclear autoantibodies type 2 may develop stridor. Several lines of evidence suggest that narcolepsy is an autoimmune disorder. There is a strong relationship with the human leukocyte antigen (HLA) DQB1*06:02 haplotype and polymorphisms in the T-cell receptor alpha locus and purinergic receptor P2Y11 genes. Patients with recent-onset narcolepsy may have high titers of antistreptococcal or other antibodies, although none has yet been shown to be disease-specific but, supporting an immune basis, recent evidence indicates that narcolepsy in children can be precipitated by one type of vaccination against the 2009-2010 H1N1 influenza pandemic.
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Affiliation(s)
- Michael H Silber
- Center for Sleep Medicine and Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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44
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Tseng CM, Chen YT, Tao CW, Ou SM, Hsiao YH, Li SY, Chen TJ, Perng DW, Chou KT. Adult narcoleptic patients have increased risk of cancer: A nationwide population-based study. Cancer Epidemiol 2015; 39:793-7. [PMID: 26651437 DOI: 10.1016/j.canep.2015.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND The comorbidity profile, especially cancer risk, of narcoleptic patients has seldom been explored. We used a nationwide database to evaluate the risk of cancer among adult narcoleptic patients. METHODS We conducted the cohort study using National Health Insurance Research Database from 2000 to 2009. Standardized incidence ratios (SIRs) of cancers were calculated to compare the cancer incidence of the study cohort with that of the general population. RESULTS 2833 narcoleptic patients were identified after excluding patients with antecedent malignancy and age younger than 18 years old. The study cohort was observed for 15,913 person-years during a 10-year period. The median follow-up interval was 5.6 ± 3.0 years. Seventy-four cancers occurred in during the follow-up. The risk of all cancers was found significantly increased in adult narcoleptic patients (SIR 1.32; 95% CI, 1.04-1.66, p=0.0248). Regarding sex, the overall cancer risk was increased in female patients (SIR 1.52; 95% CI, 1.05-2.13, p=0.026). Furthermore, females were found to have more head and neck cancers (SIR 6.17; 95% CI, 1.66-15.80, p=0.009) and gastric cancers (SIR 4.87; 95% CI, 1.31-12.48, p=0.02). For males, the incidence of overall and specific cancer types was not significantly increased. CONCLUSIONS Adult narcoleptic patients had a higher risk for cancer. Further research is warranted to elucidate the mechanism underlying its association.
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Affiliation(s)
- Ching-Min Tseng
- Division of Respiratory Therapy, Department of Medicine, Cheng Hsin General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yung-Tai Chen
- Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chi-Wei Tao
- Division of Respiratory Therapy, Department of Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Shuo-Ming Ou
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Han Hsiao
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Szu-Yuan Li
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kun-Ta Chou
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Center of Sleep Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
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Kornum BR, Pizza F, Knudsen S, Plazzi G, Jennum P, Mignot E. Cerebrospinal fluid cytokine levels in type 1 narcolepsy patients very close to onset. Brain Behav Immun 2015; 49:54-8. [PMID: 25771509 PMCID: PMC4567452 DOI: 10.1016/j.bbi.2015.03.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/02/2015] [Accepted: 03/05/2015] [Indexed: 11/17/2022] Open
Abstract
Type 1 narcolepsy is caused by a loss of hypocretin (orexin) signaling in the brain. Genetic data suggests the disorder is caused by an autoimmune attack on hypocretin producing neurons in hypothalamus. This hypothesis has however not yet been confirmed by consistent findings of autoreactive antibodies or T-cells in patient samples. One explanation for these negative results may be that the autoimmune process is no longer active when patients present to the clinic. With increasing awareness in recent years, more and more patients have been diagnosed closer and closer to disease onset. In this study, we tested whether an active immune process in the brain could be detected in these patients, as reflected by increased cytokine levels in the cerebrospinal fluid (CSF). Using multiplex analysis, we measured the levels of 51 cytokines and chemokines in the CSF of 40 type 1 narcolepsy patients having varying disease duration. For comparison, we used samples from 9 healthy controls and 9 patients with other central hypersomnia. Cytokine levels did not differ significantly between controls and patients, even in 5 patients with disease onset less than a month prior to CSF sampling.
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Affiliation(s)
- Birgitte Rahbek Kornum
- Center for Sleep Sciences and Medicine, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, CA, USA; Molecular Sleep Laboratory, Department of Diagnostics, Rigshospitalet, Glostrup, Denmark; Danish Center for Sleep Medicine, Department of Neurophysiology, University of Copenhagen, Rigshospitalet, Glostrup, Denmark.
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, AUSL di Bologna, Bologna, Italy
| | - Stine Knudsen
- Danish Center for Sleep Medicine, Department of Neurophysiology, University of Copenhagen, Rigshospitalet, Glostrup, Denmark; Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias, Oslo University Hospital, Ullevål, Norway
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, AUSL di Bologna, Bologna, Italy
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Neurophysiology, University of Copenhagen, Rigshospitalet, Glostrup, Denmark
| | - Emmanuel Mignot
- Center for Sleep Sciences and Medicine, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, CA, USA
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46
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Khan Z, Trotti LM. Central Disorders of Hypersomnolence: Focus on the Narcolepsies and Idiopathic Hypersomnia. Chest 2015; 148:262-273. [PMID: 26149554 DOI: 10.1378/chest.14-1304] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The central disorders of hypersomnolence are characterized by severe daytime sleepiness, which is present despite normal quality and timing of nocturnal sleep. Recent reclassification distinguishes three main subtypes: narcolepsy type 1, narcolepsy type 2, and idiopathic hypersomnia (IH), which are the focus of this review. Narcolepsy type 1 results from loss of hypothalamic hypocretin neurons, while the pathophysiology underlying narcolepsy type 2 and IH remains to be fully elucidated. Treatment of all three disorders focuses on the management of sleepiness, with additional treatment of cataplexy in those patients with narcolepsy type 1. Sleepiness can be treated with modafinil/armodafinil or sympathomimetic CNS stimulants, which have been shown to be beneficial in randomized controlled trials of narcolepsy and, quite recently, IH. In those patients with narcolepsy type 1, sodium oxybate is effective for the treatment of both sleepiness and cataplexy. Despite these treatments, there remains a subset of hypersomnolent patients with persistent sleepiness, in whom alternate therapies are needed. Emerging treatments for sleepiness include histamine H3 antagonists (eg, pitolisant) and possibly negative allosteric modulators of the gamma-aminobutyric acid-A receptor (eg, clarithromycin and flumazenil).
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Affiliation(s)
- Zeeshan Khan
- Emory Sleep Center, Emory University School of Medicine, Atlanta, GA
| | - Lynn Marie Trotti
- Emory Sleep Center, Emory University School of Medicine, Atlanta, GA.
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Abstract
OBJECTIVE To understand the effects of Whipple's disease (WD) of the brain on sleep function. METHODS Clinical and polysomnographic studies of two patients with severe disruption of sleep due to WD: a 48-year-old female with primary WD of the brain and a 41-year-old male with secondary WD of the brain. RESULTS The patient with primary WD had hypersomnolence with severe obstructive sleep apnoea, reduced sleep efficiency, frequent waking and sleep fragmentation. The patient with secondary WD was also hypersomnolent with oculomastictory myorhythmia. He was shown to have severe sleep initiation insomnia with poor sleep efficiency, severe obstructive sleep apnoea/hypopnoea and oculomasticatory myorhythmia at sleep-wake transitions. CONCLUSION WD of the brain may affect sleep biology in its primary and secondary forms leading to hypersomnolence from obstructive sleep apnoea, sleep fragmentation, reduced sleep efficiency, sleep initiation insomnia and intrusive oculomasticatory myorhythmia.
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Affiliation(s)
- P K Panegyres
- From the Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth, Western Australia 6005
| | - J Goh
- From the Neurodegenerative Disorders Research Pty Ltd, 4 Lawrence Avenue, West Perth, Western Australia 6005
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48
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Palomba M, Seke-Etet PF, Laperchia C, Tiberio L, Xu YZ, Colavito V, Grassi-Zucconi G, Bentivoglio M. Alterations of orexinergic and melanin-concentrating hormone neurons in experimental sleeping sickness. Neuroscience 2015; 290:185-95. [PMID: 25595977 DOI: 10.1016/j.neuroscience.2014.12.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 12/12/2014] [Accepted: 12/23/2014] [Indexed: 01/24/2023]
Abstract
Human African trypanosomiasis or sleeping sickness is a severe, neglected tropical disease caused by the extracellular parasite Trypanosoma brucei. The disease, which leads to chronic neuroinflammation, is characterized by sleep and wake disturbances, documented also in rodent models. In rats and mice infected with Trypanosoma brucei brucei, we here tested the hypothesis that the disease could target neurons of the lateral hypothalamus (LH) containing orexin (OX)-A or melanin-concentrating hormone (MCH), implicated in sleep/wake regulation. In the cerebrospinal fluid of infected rats, the OX-A level was significantly decreased early after parasite neuroinvasion, and returned to the control level at an advanced disease stage. The number of immunohistochemically characterized OX-A and MCH neurons decreased significantly in infected rats during disease progression and in infected mice at an advanced disease stage. A marked reduction of the complexity of dendritic arborizations of OX-A neurons was documented in infected mice. The evaluation of NeuN-immunoreactive neurons did not reveal significant neuronal loss in the LH of infected mice, thus suggesting a potential selective vulnerability of OX-A and MCH neurons. Immunophenotyping and quantitative analysis showed in infected mice marked activation of microglial cells surrounding OX-A neurons. Day/night oscillation of c-Fos baseline expression was used as marker of OX-A neuron activity in mice. In control animals Fos was expressed in a higher proportion of OX-A neurons in the night (activity) phase than in the day (rest) phase. Interestingly, in infected mice the diurnal spontaneous Fos oscillation was reversed, with a proportion of OX-A/Fos neurons significantly higher at daytime than at nighttime. Altogether the findings reveal a progressive decrease of OX-A and MCH neurons and dysregulation of OX-A neuron diurnal activity in rodent models of sleeping sickness. The data point to the involvement of these peptidergic neurons in the pathogenesis of sleep/wake alterations in the disease and to their vulnerability to inflammatory signaling.
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Affiliation(s)
- M Palomba
- Department of Neurological and Movement Sciences, University of Verona, Italy
| | - P F Seke-Etet
- Department of Neurological and Movement Sciences, University of Verona, Italy
| | - C Laperchia
- Department of Neurological and Movement Sciences, University of Verona, Italy
| | - L Tiberio
- Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Y-Z Xu
- Department of Neurological and Movement Sciences, University of Verona, Italy
| | - V Colavito
- Department of Neurological and Movement Sciences, University of Verona, Italy
| | - G Grassi-Zucconi
- Department of Neurological and Movement Sciences, University of Verona, Italy
| | - M Bentivoglio
- Department of Neurological and Movement Sciences, University of Verona, Italy.
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Lopez R, Barateau L, Chenini S, Dauvilliers Y. Preliminary results on CSF biomarkers for hypothalamic dysfunction in Kleine–Levin syndrome. Sleep Med 2015; 16:194-6. [DOI: 10.1016/j.sleep.2014.07.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/10/2014] [Accepted: 07/28/2014] [Indexed: 11/29/2022]
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50
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Han F, Lin L, Schormair B, Pizza F, Plazzi G, Ollila HM, Nevsimalova S, Jennum P, Knudsen S, Winkelmann J, Coquillard C, Babrzadeh F, Strom TM, Wang C, Mindrinos M, Fernandez Vina M, Mignot E. HLA DQB1*06:02 negative narcolepsy with hypocretin/orexin deficiency. Sleep 2014; 37:1601-8. [PMID: 25197808 DOI: 10.5665/sleep.4066] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 04/25/2014] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES To identify rare allelic variants and HLA alleles in narcolepsy patients with hypocretin (orexin, HCRT) deficiency but lacking DQB1*06:02. SETTINGS China (Peking University People's Hospital), Czech Republic (Charles University), Denmark (Golstrup Hospital), Italy (University of Bologna), Korea (Catholic University), and USA (Stanford University). DESIGN CSF hypocretin-1, DQB1*06:02, clinical and polysomnographic data were collected in narcolepsy patients (552 with and 144 without cataplexy) from 6 sites. Numbers of cases with and without DQB1*06:02 and low CSF hypocretin-1 were compiled. HLA class I (A, B, C), class II (DRBs, DQA1, DQB1, DPA1, and DPB1), and whole exome sequencing were conducted in 9 DQB1*06:02 negative cases with low CSF hypocretin-1. Sanger sequencing of selected exons in DNMT1, HCRT, and MOG was performed to exclude mutations in known narcolepsy-associated genes. MEASUREMENTS AND RESULTS Classic narcolepsy markers DQB1*06:02 and low CSF hypocretin-1 were found in 87.4% of cases with cataplexy, and in 20.0% without cataplexy. Nine cases (all with cataplexy) were DQB1*06:02 negative with low CSF hypocretin-1, constituting 1.7% [0.8%-3.4%] of all cases with cataplexy and 1.8% [0.8%-3.4%] of cases with low CSF hypocretin independent of cataplexy across sites. Five HLA negative subjects had severe cataplexy, often occurring without clear triggers. Subjects had diverse ethnic backgrounds and HLA alleles at all loci, suggesting no single secondary HLA association. The rare subtype DPB1*0901, and homologous DPB1*10:01 subtype, were present in 5 subjects, suggesting a secondary association with HLA-DP. Preprohypocretin sequencing revealed no mutations beyond one previously reported in a very early onset case. No new MOG or DNMT1 mutations were found, nor were suspicious or private variants in novel genes identified through exome sequencing. CONCLUSIONS Hypocretin, MOG, or DNMT1 mutations are exceptional findings in DQB1*06:02 negative cases with hypocretin deficiency. A secondary HLA-DP association may be present in these cases. These represent particularly difficult diagnostic challenges.
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Affiliation(s)
- Fang Han
- Department of Pulmonary Medicine, the Peking University People's Hospital, Beijing, China
| | - Ling Lin
- Center for Sleep Sciences and Medicine, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA
| | - Barbara Schormair
- Institute of Human Genetics, Technische Universität München, Munich, Germany and Institute of Human Genetics, Helmholtz Zentrum München-German Research Center for Environmental Health, Neuherberg, Germany
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna and IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna and IRCCS Institute of Neurological Sciences, Bologna, Italy
| | - Hanna M Ollila
- Center for Sleep Sciences and Medicine, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA
| | - Sona Nevsimalova
- Department of Neurology, Charles University in Prague, 1st Faculty of Medicine, Czech Republic
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Glostrup Hospital, University of Copenhagen, Denmark
| | - Stine Knudsen
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Glostrup Hospital, University of Copenhagen, Denmark and Norwegian Resource Center for ADHD, TS and Narcolepsy (NK), Oslo University Hospital, Ullevål, Norway
| | - Juliane Winkelmann
- Center for Sleep Sciences and Medicine, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA and Institute of Human Genetics, Technische Universität München, Munich, Germany and Institute of Human Genetics, Helmholtz Zentrum München-German Research Center for Environmental Health, Neuherberg, Germany
| | - Cristin Coquillard
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Farbod Babrzadeh
- Stanford Genome Technology Center, Stanford University, Palo Alto, CA
| | - Tim M Strom
- Institute of Human Genetics, Technische Universität München, Munich, Germany and Institute of Human Genetics, Helmholtz Zentrum München-German Research Center for Environmental Health, Neuherberg, Germany
| | - Chunlin Wang
- Stanford Genome Technology Center, Stanford University, Palo Alto, CA
| | - Michael Mindrinos
- Stanford Genome Technology Center, Stanford University, Palo Alto, CA
| | | | - Emmanuel Mignot
- Center for Sleep Sciences and Medicine, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA
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