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Thorpy MJ, Siegel JM, Dauvilliers Y. REM sleep in narcolepsy. Sleep Med Rev 2024; 77:101976. [PMID: 39186901 DOI: 10.1016/j.smrv.2024.101976] [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: 11/16/2023] [Revised: 06/28/2024] [Accepted: 07/09/2024] [Indexed: 08/28/2024]
Abstract
Narcolepsy is mainly associated with excessive daytime sleepiness, but the characteristic feature is abnormal rapid eye movement (REM) sleep phenomena. REM sleep disturbances can manifest as cataplexy (in narcolepsy type 1), sleep paralysis, sleep-related hallucinations, REM sleep behavior disorder, abnormal dreams, polysomnographic evidence of REM sleep disruption with sleep-onset REM periods, and fragmented REM sleep. Characterization of REM sleep and related symptoms facilitates the differentiation of narcolepsy from other central hypersomnolence disorders and aids in distinguishing between narcolepsy types 1 and 2. A circuit comprising regions within the brainstem, forebrain, and hypothalamus is involved in generating and regulating REM sleep, which is influenced by changes in monoamines, acetylcholine, and neuropeptides. REM sleep is associated with brainstem functions, including autonomic control, and REM sleep disturbances may be associated with increased cardiovascular risk. Medications used to treat narcolepsy (and REM-related symptoms of narcolepsy) include stimulants/wake-promoting agents, pitolisant, oxybates, and antidepressants; hypocretin agonists are a potential new class of therapeutics. The role of REM sleep disturbances in narcolepsy remains an area of active research in pathophysiology, symptom management, and treatment. This review summarizes the current understanding of the role of REM sleep and its dysfunction in narcolepsy.
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Affiliation(s)
| | - Jerome M Siegel
- Department of Psychiatry and Brain Research Institute, University of California, Los Angeles, CA, USA; Department of Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Yves Dauvilliers
- Sleep and Wake Disorders Centre, Department of Neurology, Gui de Chauliac Hospital, University Montpellier, INSERM INM, France
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Dauvilliers Y, Roth T, Bogan R, Thorpy MJ, Morse AM, Roy A, Gudeman J. Efficacy of once-nightly sodium oxybate (FT218) on daytime symptoms in individuals with narcolepsy with or without concomitant alerting agent use: A post hoc analysis from the phase 3 REST-ON trial. Sleep Med 2024; 124:209-216. [PMID: 39321628 DOI: 10.1016/j.sleep.2024.09.024] [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: 07/03/2024] [Revised: 08/08/2024] [Accepted: 09/15/2024] [Indexed: 09/27/2024]
Abstract
OBJECTIVE/BACKGROUND Extended-release, once-nightly sodium oxybate (ON-SXB) significantly improved narcolepsy symptoms in participants in the phase 3, randomized, double-blind, placebo-controlled REST-ON trial. This post hoc analysis of REST-ON data evaluated ON-SXB efficacy in participants with or without concomitant alerting agent use. PATIENTS/METHODS Participants with narcolepsy aged >16 years were randomized 1:1 to ON-SXB (week 1: 4.5 g, weeks 2-3: 6 g, weeks 4-8: 7.5 g, weeks 9-13: 9 g) or placebo. Primary endpoints in this post hoc analysis included change from baseline in mean sleep latency on the Maintenance of Wakefulness Test (MWT), Clinical Global Impression-Improvement (CGI-I) rating, and number of weekly cataplexy episodes. The secondary endpoints were change from baseline in the Epworth Sleepiness Scale (ESS) score and in objective and subjective disrupted nighttime sleep parameters. Post hoc analyses assessed participants with and without alerting agent use across 6-, 7.5-, and 9-g doses. RESULTS In the modified intent-to-treat population, 119 (63 %) were (ON-SXB, n = 66; placebo, n = 53) and 71 (37 %) were not (ON-SXB, n = 31; placebo, n = 40) taking alerting agents. Regardless of alerting agent use, treatment with ON-SXB resulted in significant improvements vs placebo (all doses, P < 0.05) for MWT, CGI-I, and number of weekly cataplexy episodes. Significant improvements in ESS (all doses, P < 0.05) with ON-SXB vs placebo were observed in the alerting agent use cohort. Directional improvements in ESS were reported with all doses in the no alerting agent use group. CONCLUSIONS Regardless of concomitant alerting agent use, ON-SXB improved daytime and nighttime narcolepsy symptoms vs placebo.
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Affiliation(s)
- Yves Dauvilliers
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, Montpellier, France
| | - Thomas Roth
- Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Richard Bogan
- University of South Carolina School of Medicine, Columbia, SC, USA; Medical University of South Carolina, Charleston, SC, USA
| | | | - Anne Marie Morse
- Geisinger Commonwealth School of Medicine, Geisinger Medical Center, Janet Weis Children's Hospital, Danville, PA, USA
| | - Asim Roy
- Ohio Sleep Medicine Institute, Dublin, OH, USA
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Biscarini F, Barateau L, Pizza F, Plazzi G, Dauvilliers Y. Narcolepsy and rapid eye movement sleep. J Sleep Res 2024:e14277. [PMID: 38955433 DOI: 10.1111/jsr.14277] [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: 05/07/2024] [Revised: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024]
Abstract
Since the first description of narcolepsy at the end of the 19th Century, great progress has been made. The disease is nowadays distinguished as narcolepsy type 1 and type 2. In the 1960s, the discovery of rapid eye movement sleep at sleep onset led to improved understanding of core sleep-related disease symptoms of the disease (excessive daytime sleepiness with early occurrence of rapid eye movement sleep, sleep-related hallucinations, sleep paralysis, rapid eye movement parasomnia), as possible dysregulation of rapid eye movement sleep, and cataplexy resembling an intrusion of rapid eye movement atonia during wake. The relevance of non-sleep-related symptoms, such as obesity, precocious puberty, psychiatric and cardiovascular morbidities, has subsequently been recognized. The diagnostic tools have been improved, but sleep-onset rapid eye movement periods on polysomnography and Multiple Sleep Latency Test remain key criteria. The pathogenic mechanisms of narcolepsy type 1 have been partly elucidated after the discovery of strong HLA class II association and orexin/hypocretin deficiency, a neurotransmitter that is involved in altered rapid eye movement sleep regulation. Conversely, the causes of narcolepsy type 2, where cataplexy and orexin deficiency are absent, remain unknown. Symptomatic medications to treat patients with narcolepsy have been developed, and management has been codified with guidelines, until the recent promising orexin-receptor agonists. The present review retraces the steps of the research on narcolepsy that linked the features of the disease with rapid eye movement sleep abnormality, and those that do not appear associated with rapid eye movement sleep.
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Affiliation(s)
- Francesco Biscarini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lucie Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, 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
| | - 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
| | - Yves Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
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Wang M, Shen C, Liu X, Feng Z, Wang H, Han F, Xiao F. Executive function performance in children and adolescent patients with narcolepsy type 1. Sleep Med 2024; 119:342-351. [PMID: 38754344 DOI: 10.1016/j.sleep.2024.05.021] [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: 01/17/2024] [Revised: 04/25/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE The executive function profile in patients with narcolepsy type 1 (NT1) has been mentioned; however, limited research exists on children and adolescent patients with NT1.This study aims to assess executive function in children and adolescent patients with NT1 in China, examine potential influencing factors and evaluate the short-term treatment effect on executive function. METHODS 53 NT1 patients (36 males, age 12.2 ± 3.4 years) and 37 healthy controls (23 males, age 12.2 ± 2.5 years) underwent self-reported measures assessing subjective sleepiness, depression, anxiety and sleep quality. A comprehensive neuropsychological test was administered to assess executive function domains, including processing speed, inhibitory control, cognitive flexibility and working memory. These assessments were repeated in NT1 patients after three-day regular drug treatment. RESULTS NT1 patients exhibited higher levels of excessive daytime sleepiness, depression, anxiety, and poor sleep quality compared to healthy controls. Patients showed impaired processing speed, inhibitory control and cognitive flexibility (p < 0.05), whereas working memory was unaffected (p > 0.05). Regression analysis revealed that parameters from sleep monitoring, such as sleep efficiency and sleep latency, were correlated with executive function performance after controlling for age, gender, and education years. The short-term treatment led to improvements in inhibitory control, cognitive flexibility, and working memory. CONCLUSION The findings showed that executive function was impaired among children and adolescent patients with NT1, which was associated with objective sleep parameters. Furthermore, this study emphasizes the necessity of neuropsychological assessments and early interventions among children and adolescent NT1 patients.
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Affiliation(s)
- Mengmeng Wang
- School of Nursing, Peking University, Beijing, China; Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Chaoran Shen
- State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University, Beijing, China
| | - Xinran Liu
- School of Nursing, Peking University, Beijing, China; Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Zhaoyan Feng
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Huanhuan Wang
- School of Nursing, Peking University, Beijing, China; Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Fang Han
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China.
| | - Fulong Xiao
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China.
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Pan Y, Zhang X, Wen X, Yuan N, Guo L, Shi Y, Jia Y, Guo Y, Hao F, Qu S, Chen Z, Yang L, Wang X, Liu Y. Development and validation of a machine learning model for prediction of comorbid major depression disorder among narcolepsy type 1. Sleep Med 2024; 119:556-564. [PMID: 38810481 DOI: 10.1016/j.sleep.2024.05.045] [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: 12/21/2023] [Revised: 05/04/2024] [Accepted: 05/22/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Major depression disorder (MDD) forms a common psychiatric comorbidity among patients with narcolepsy type 1 (NT1), yet its impact on patients with NT1 is often overlooked by neurologists. Currently, there is a lack of effective methods for accurately predicting MDD in patients with NT1. OBJECTIVE This study utilized machine learning (ML) algorithms to identify critical variables and developed the prediction model for predicting MDD in patients with NT1. METHODS The study included 267 NT1 patients from four sleep centers. The diagnosis of comorbid MDD was based on Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5). ML models, including six full models and six compact models, were developed using a training set. The performance of these models was compared in the testing set, and the optimal model was evaluated in the testing set. Various evaluation metrics, such as Area under the receiver operating curve (AUC), precision-recall (PR) curve and calibration curve were employed to assess and compare the performance of the ML models. Model interpretability was demonstrated using SHAP. RESULT In the testing set, the logistic regression (LG) model demonstrated superior performance compared to other ML models based on evaluation metrics such as AUC, PR curve, and calibration curve. The top eight features used in the LG model, ranked by feature importance, included social impact scale (SIS) score, narcolepsy severity scale (NSS) score, total sleep time, body mass index (BMI), education years, age of onset, sleep efficiency, sleep latency. CONCLUSION The study yielded a straightforward and practical ML model for the early identification of MDD in patients with NT1. A web-based tool for clinical applications was developed, which deserves further verification in diverse clinical settings.
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Affiliation(s)
- Yuanhang Pan
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Xinbo Zhang
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Xinyu Wen
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Na Yuan
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Li Guo
- Department of Psychiatry, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Yifan Shi
- Department of Psychiatry, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Yuanyuan Jia
- Encerebropathy Department, No.2, Baoji Hospital of Traditional Chinese Medicine, Baoji, PR China.
| | - Yanzhao Guo
- Encerebropathy Department, No.10, Xi'an Hospital of Traditional Chinese Medicine, Xi'an, PR China.
| | - Fengli Hao
- Department of Neurology, Xi'an Daxing Hospital, Xi'an, PR China.
| | - Shuyi Qu
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Ze Chen
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Lei Yang
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Xiaoli Wang
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
| | - Yonghong Liu
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, PR China.
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Barateau L, Chenini S, Denis C, Lorber Q, Béziat S, Jaussent I, Dauvilliers Y. Narcolepsy Severity Scale-2 and Idiopathic Hypersomnia Severity Scale to better quantify symptoms severity and consequences in Narcolepsy type 2. Sleep 2024; 47:zsad323. [PMID: 38197577 DOI: 10.1093/sleep/zsad323] [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: 07/21/2023] [Revised: 12/14/2023] [Indexed: 01/11/2024] Open
Abstract
STUDY OBJECTIVES Narcolepsy type 2 (NT2) is an understudied central disorder of hypersomnolence sharing some similarities with narcolepsy type 1 and idiopathic hypersomnia (IH). We aimed: (1) to assess systematically the symptoms in patients with NT2, with self-reported questionnaires: Epworth Sleepiness Scale (ESS), Narcolepsy Severity Scale (NSS), IH Severity Scale (IHSS), and (2) to evaluate the responsiveness of these scales to treatment. METHODS One hundred and nine patients with NT2 (31.4 ± 12.2 years old, 47 untreated) diagnosed according to ICSD-3 were selected in a Reference Center for Narcolepsy. They all completed the ESS, subgroups completed the modified NSS (NSS-2, without cataplexy items) (n = 95) and IHSS (n = 76). Some patients completed the scales twice (before/during treatment): 42 ESS, 26 NSS-2, and 30 IHSS. RESULTS Based on NSS-2, all untreated patients had sleepiness, 58% disrupted nocturnal sleep, 40% hallucinations, and 28% sleep paralysis. On IHSS, 76% reported a prolonged nocturnal sleep, and 83% sleep inertia. In the independent sample, ESS and NSS-2 scores were lower in treated patients, with same trend for IHSS scores. After treatment, ESS, NSS-2, and IHSS total scores were lower, with a mean difference of 3.7 ± 4.1, 5.3 ± 6.7, and 4.1 ± 6.2, respectively. The minimum clinically important difference between untreated and treated patients were 2.1 for ESS, 3.3 for NSS-2, and 3.1 for IHSS. After treatment, 61.9% of patients decreased their ESS > 2 points, 61.5% their NSS-2 > 3 points, and 53.3% their IHSS > 3 points. CONCLUSIONS NSS-2 and IHSS correctly quantified symptoms' severity and consequences in NT2, with good performances to objectify response to medications. These tools are useful for monitoring and optimizing NT2 management, and for use in clinical trials.
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Affiliation(s)
- Lucie Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
- Institut des Neurosciences de Montpellier, University of Montpellier, Inserm-UM 1298, Montpellier, France
| | - Sofiene Chenini
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
| | - Claire Denis
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, France
| | - Quentin Lorber
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, France
| | - Séverine Béziat
- Institut des Neurosciences de Montpellier, University of Montpellier, Inserm-UM 1298, Montpellier, France
| | - Isabelle Jaussent
- Institut des Neurosciences de Montpellier, University of Montpellier, Inserm-UM 1298, Montpellier, France
| | - Yves Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
- Institut des Neurosciences de Montpellier, University of Montpellier, Inserm-UM 1298, Montpellier, France
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Evangelista E, Leu-Semenescu S, Pizza F, Plazzi G, Dauvilliers Y, Barateau L, Lambert I. Long sleep time and excessive need for sleep: State of the art and perspectives. Neurophysiol Clin 2024; 54:102949. [PMID: 38387329 DOI: 10.1016/j.neucli.2024.102949] [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: 12/12/2023] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
The mechanisms underlying the individual need for sleep are unclear. Sleep duration is indeed influenced by multiple factors, such as genetic background, circadian and homeostatic processes, environmental factors, and sometimes transient disturbances such as infections. In some cases, the need for sleep dramatically and chronically increases, inducing a daily-life disability. This "excessive need for sleep" (ENS) was recently proposed and defined in a European Position Paper as a dimension of the hypersomnolence spectrum, "hypersomnia" being the objectified complaint of ENS. The most severe form of ENS has been described in Idiopathic Hypersomnia, a rare neurological disorder, but this disabling symptom can be also found in other hypersomnolence conditions. Because ENS has been defined recently, it remains a symptom poorly investigated and understood. However, protocols of long-term polysomnography recordings have been reported by expert centers in the last decades and open the way to a better understanding of ENS through a neurophysiological approach. In this narrative review, we will 1) present data related to the physiological and pathological variability of sleep duration and their mechanisms, 2) describe the published long-term polysomnography recording protocols, and 3) describe current neurophysiological tools to study sleep microstructure and discuss perspectives for a better understanding of ENS.
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Affiliation(s)
- Elisa Evangelista
- Sleep Disorder Unit, Carémeau Hospital, Centre Hospitalo-Universitaire de Nîmes, France; Institute for Neurosciences of Montpellier (INM), Univ Montpellier, INSERM, Montpellier, France
| | - Smaranda Leu-Semenescu
- National Reference Center for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Paris, France; Sleep Disorders Clinic, Pitié-Salpêtrière Hospital, APHP-Sorbonne University, Paris, France
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Yves Dauvilliers
- Institute for Neurosciences of Montpellier (INM), Univ Montpellier, INSERM, Montpellier, France; Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
| | - Lucie Barateau
- Institute for Neurosciences of Montpellier (INM), Univ Montpellier, INSERM, Montpellier, France; Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
| | - Isabelle Lambert
- APHM, Timone hospital, Sleep Unit, Epileptology and Cerebral Rhythmology, Marseille, France; Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France.
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Roth T, Dauvilliers Y, Bogan RK, Plazzi G, Black J. Effects of oxybate dose and regimen on disrupted nighttime sleep and sleep architecture. Sleep Med 2024; 114:255-265. [PMID: 38244463 DOI: 10.1016/j.sleep.2023.12.015] [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: 09/29/2023] [Revised: 12/08/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024]
Abstract
Many components of sleep are disrupted in patients with narcolepsy, including sleep quality, sleep architecture, and sleep stability (ie, frequent awakenings/arousals and frequent shifts from deeper to lighter stages of sleep). Sodium oxybate, dosed twice nightly, has historically been used to improve sleep, and subsequent daytime symptoms, in patients with narcolepsy. Recently, new formulations have been developed to address the high sodium content and twice-nightly dosing regimen of sodium oxybate: low-sodium oxybate and once-nightly sodium oxybate. To date, no head-to-head trials have been conducted to compare the effects of each oxybate product. This review aims to give an overview of the existing scientific literature regarding the impact of oxybate dose and regimen on sleep architecture and disrupted nighttime sleep in patients with narcolepsy. Evidence from 5 key clinical trials, as well as supporting evidence from additional studies, suggests that sodium oxybate, dosed once- and twice-nightly, is effective in improving sleep, measures of sleep architecture, and disrupted nighttime sleep in patients with narcolepsy. Direct comparison of available efficacy and safety data between oxybate products is complicated by differences in trial designs, outcomes assessed, and statistical analyses; future head-to-head trials are needed to better understand the advantage and disadvantages of each agent.
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Affiliation(s)
| | - Yves Dauvilliers
- Sleep and Wake Disorders Centre, Department of Neurology, Gui de Chauliac Hospital, Montpellier, France; University of Montpellier, INSERM Institute Neuroscience Montpellier (INM), Montpellier, France
| | - Richard K Bogan
- Medical University of South Carolina, Charleston, SC, USA; Bogan Sleep Consultants, LLC, Columbia, SC, USA
| | - Giuseppe Plazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Jed Black
- Stanford University Center for Sleep Sciences and Medicine, Palo Alto, CA, USA; Jazz Pharmaceuticals, Palo Alto, CA, USA
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Dauvilliers Y, Roth T, Bogan R, Thorpy MJ, Morse AM, Roy A, Dubow J, Gudeman J. Efficacy of once-nightly sodium oxybate (FT218) in narcolepsy type 1 and type 2: post hoc analysis from the Phase 3 REST-ON Trial. Sleep 2023; 46:zsad152. [PMID: 37246913 PMCID: PMC10636255 DOI: 10.1093/sleep/zsad152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/11/2023] [Indexed: 05/30/2023] Open
Abstract
STUDY OBJECTIVES Post hoc analyses from the phase 3 REST-ON trial evaluated efficacy of extended-release once-nightly sodium oxybate (ON-SXB; FT218) vs placebo for daytime sleepiness and disrupted nighttime sleep in narcolepsy type 1 (NT1) and 2 (NT2). METHODS Participants were stratified by narcolepsy type and randomized 1:1 to ON-SXB (4.5 g, week 1; 6 g, weeks 2-3; 7.5 g, weeks 4-8; and 9 g, weeks 9-13) or placebo. Assessments included mean sleep latency on Maintenance of Wakefulness Test (MWT) and Clinical Global Impression-Improvement (CGI-I) rating (coprimary endpoints) and sleep stage shifts, nocturnal arousals, and patient-reported sleep quality, refreshing nature of sleep, and Epworth Sleepiness Scale (ESS) score (secondary endpoints) separately in NT1 and NT2 subgroups. RESULTS The modified intent-to-treat population comprised 190 participants (NT1, n = 145; NT2, n = 45). Significant improvements were demonstrated with ON-SXB vs placebo in sleep latency for NT1 (all doses, p < .001) and NT2 (6 and 9 g, p < .05) subgroups. Greater proportions of participants in both subgroups had CGI-I ratings of much/very much improved with ON-SXB vs placebo. Sleep stage shifts and sleep quality significantly improved in both subgroups (all doses vs placebo, p < .001). Significant improvements with all ON-SXB doses vs placebo in refreshing nature of sleep (p < .001), nocturnal arousals (p < .05), and ESS scores (p ≤ .001) were reported for NT1 with directional improvements for NT2. CONCLUSIONS Clinically meaningful improvements of a single ON-SXB bedtime dose were shown for daytime sleepiness and DNS in NT1 and NT2, with less power for the limited NT2 subgroup.
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Affiliation(s)
- Yves Dauvilliers
- Department of Neurology, Sleep-Wake Disorders Center, Gui-de-Chauliac Hospital, Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, Montpellier, France
| | - Thomas Roth
- Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Richard Bogan
- University of South Carolina School of Medicine, Columbia, SC, USA
- Medical University of SC, Charleston, SC, USA
| | | | - Anne Marie Morse
- Geisinger Commonwealth School of Medicine, Geisinger Medical Center, Janet Weis Children’s Hospital, Danville, PA, USA
| | - Asim Roy
- Ohio Sleep Medicine Institute, Dublin, OH, USA
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Barateau L, Pizza F, Chenini S, Peter-Derex L, Dauvilliers Y. Narcolepsies, update in 2023. Rev Neurol (Paris) 2023; 179:727-740. [PMID: 37634997 DOI: 10.1016/j.neurol.2023.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/29/2023]
Abstract
Narcolepsy type 1 (NT1) and type 2 (NT2), also known as narcolepsy with and without cataplexy, are sleep disorders that benefited from major scientific advances over the last two decades. NT1 is caused by the loss of hypothalamic neurons producing orexin/hypocretin, a neurotransmitter regulating sleep and wake, which can be measured in the cerebrospinal fluid (CSF). A low CSF level of hypocretin-1/orexin-A is a highly specific and sensitive biomarker, sufficient to diagnose NT1. Orexin-deficiency is responsible for the main NT1 symptoms: sleepiness, cataplexy, disrupted nocturnal sleep, sleep-related hallucinations, and sleep paralysis. In the absence of a lumbar puncture, the diagnosis is based on neurophysiological tests (nocturnal and diurnal) and the presence of the pathognomonic symptom cataplexy. In the revised version of the International Classification of sleep Disorders, 3rd edition (ICSD-3-TR), a sleep onset rapid eye movement sleep (REM) period (SOREMP) (i.e. rapid occurrence of REM sleep) during the previous polysomnography may replace the diurnal multiple sleep latency test, when clear-cut cataplexy is present. A nocturnal SOREMP is very specific but not sensitive enough, and the diagnosis of cataplexy is usually based on clinical interview. It is thus of crucial importance to define typical versus atypical cataplectic attacks, and a list of clinical features and related degrees of certainty is proposed in this paper (expert opinion). The time frame of at least three months of evolution of sleepiness to diagnose NT1 was removed in the ICSD-3-TR, when clear-cut cataplexy or orexin-deficiency are established. However, it was kept for NT2 diagnosis, a less well-characterized disorder with unknown clinical course and absence of biolo biomarkers; sleep deprivation, shift working and substances intake being major differential diagnoses. Treatment of narcolepsy is nowadays only symptomatic, but the upcoming arrival of non-peptide orexin receptor-2 agonists should be a revolution in the management of these rare sleep diseases.
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Affiliation(s)
- L Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France.
| | - F Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - S Chenini
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France
| | - L Peter-Derex
- Center for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon 1 University, Lyon, France; Lyon Neuroscience Research Center, PAM Team, Inserm U1028, CNRS UMR 5292, Lyon, France
| | - Y Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France.
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Maski K, Trotti LM. How should disrupted nocturnal sleep be characterized in narcolepsy type 1? Sleep 2022; 45:6573301. [PMID: 35460560 PMCID: PMC10139759 DOI: 10.1093/sleep/zsac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kiran Maski
- Department of Neurology, Harvard Medical School and Boston Children’s Hospital , Boston, MA , USA
| | - Lynn Marie Trotti
- Department of Neurology, Emory Sleep Center, Emory University School of Medicine , Atlanta, GA , USA
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Barateau L, Pizza F, Plazzi G, Dauvilliers Y. 50th anniversary of the ESRS in 2022-JSR special issue. J Sleep Res 2022; 31:e13631. [PMID: 35624073 DOI: 10.1111/jsr.13631] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/21/2023]
Abstract
This article addresses the clinical presentation, diagnosis, pathophysiology and management of narcolepsy type 1 and 2, with a focus on recent findings. A low level of hypocretin-1/orexin-A in the cerebrospinal fluid is sufficient to diagnose narcolepsy type 1, being a highly specific and sensitive biomarker, and the irreversible loss of hypocretin neurons is responsible for the main symptoms of the disease: sleepiness, cataplexy, sleep-related hallucinations and paralysis, and disrupted nocturnal sleep. The process responsible for the destruction of hypocretin neurons is highly suspected to be autoimmune, or dysimmune. Over the last two decades, remarkable progress has been made for the understanding of these mechanisms that were made possible with the development of new techniques. Conversely, narcolepsy type 2 is a less well-defined disorder, with a variable phenotype and evolution, and few reliable biomarkers discovered so far. There is a dearth of knowledge about this disorder, and its aetiology remains unclear and needs to be further explored. Treatment of narcolepsy is still nowadays only symptomatic, targeting sleepiness, cataplexy and disrupted nocturnal sleep. However, new psychostimulants have been recently developed, and the upcoming arrival of non-peptide hypocretin receptor-2 agonists should be a revolution in the management of this rare sleep disease, and maybe also for disorders beyond narcolepsy.
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Affiliation(s)
- Lucie Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France.,Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - 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
| | - Yves Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France.,Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
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13
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Zhang Z, Dauvilliers Y, Plazzi G, Mayer G, Lammers GJ, Santamaria J, Partinen M, Overeem S, Del Rio Villegas R, Sonka K, Peraita-Adrados R, Heinzer R, Wierzbicka A, Högl B, Manconi M, Feketeova E, da Silva AM, Bušková J, Bassetti CLA, Barateau L, Pizza F, Antelmi E, Gool JK, Fronczek R, Gaig C, Khatami R. Idling for Decades: A European Study on Risk Factors Associated with the Delay Before a Narcolepsy Diagnosis. Nat Sci Sleep 2022; 14:1031-1047. [PMID: 35669411 PMCID: PMC9166906 DOI: 10.2147/nss.s359980] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/03/2022] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Narcolepsy type-1 (NT1) is a rare chronic neurological sleep disorder with excessive daytime sleepiness (EDS) as usual first and cataplexy as pathognomonic symptom. Shortening the NT1 diagnostic delay is the key to reduce disease burden and related low quality of life. Here we investigated the changes of diagnostic delay over the diagnostic years (1990-2018) and the factors associated with the delay in Europe. PATIENTS AND METHODS We analyzed 580 NT1 patients (male: 325, female: 255) from 12 European countries using the European Narcolepsy Network database. We combined machine learning and linear mixed-effect regression to identify factors associated with the delay. RESULTS The mean age at EDS onset and diagnosis of our patients was 20.9±11.8 (mean ± standard deviation) and 30.5±14.9 years old, respectively. Their mean and median diagnostic delay was 9.7±11.5 and 5.3 (interquartile range: 1.7-13.2 years) years, respectively. We did not find significant differences in the diagnostic delay over years in either the whole dataset or in individual countries, although the delay showed significant differences in various countries. The number of patients with short (≤2-year) and long (≥13-year) diagnostic delay equally increased over decades, suggesting that subgroups of NT1 patients with variable disease progression may co-exist. Younger age at cataplexy onset, longer interval between EDS and cataplexy onsets, lower cataplexy frequency, shorter duration of irresistible daytime sleep, lower daytime REM sleep propensity, and being female are associated with longer diagnostic delay. CONCLUSION Our findings contrast the results of previous studies reporting shorter delay over time which is confounded by calendar year, because they characterized the changes in diagnostic delay over the symptom onset year. Our study indicates that new strategies such as increasing media attention/awareness and developing new biomarkers are needed to better detect EDS, cataplexy, and changes of nocturnal sleep in narcolepsy, in order to shorten the diagnostic interval.
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Affiliation(s)
- Zhongxing Zhang
- Center for Sleep Medicine, Sleep Research and Epileptology, Klinik Barmelweid AG, Barmelweid, Aargau, Switzerland
| | - Yves Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France.,Institute for Neurosciences of Montpellier INM, Univ Montpellier, INSERM, Montpellier, France
| | - Giuseppe Plazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Geert Mayer
- Neurology Department, Hephata Klinik, Schwalmstadt, Germany
| | - Gert Jan Lammers
- Sleep Wake Center SEIN Heemstede, Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands.,Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joan Santamaria
- Neurology Service, Institut de Neurociències Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Markku Partinen
- Helsinki Sleep Clinic, Vitalmed Research Center, Helsinki, Finland
| | - Sebastiaan Overeem
- Sleep Medicine Center Kempenhaeghe, Heeze, the Netherlands.,Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Rafael Del Rio Villegas
- Neurophysiology and Sleep Disorders Unit, Hospital Vithas Nuestra Señora de América, Madrid, Spain
| | - Karel Sonka
- Neurology Department and Centre of Clinical Neurosciences, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Rosa Peraita-Adrados
- Sleep and Epilepsy Unit - Clinical Neurophysiology Service, University General Hospital Gregorio Marañón, Research Institute Gregorio Marañón, University Complutense of Madrid, Madrid, Spain
| | - Raphaël Heinzer
- Center for Investigation and Research in Sleep, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Aleksandra Wierzbicka
- Department of Clinical Neurophysiology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Birgit Högl
- Neurology Department, Sleep Disorders Clinic, Innsbruck Medical University, Innsbruck, Austria
| | - Mauro Manconi
- Neurology Department, EOC, Ospedale Regionale di Lugano, Lugano, Ticino, Switzerland
| | - Eva Feketeova
- Neurology Department, Medical Faculty of P. J. Safarik University, University Hospital of L. Pasteur Kosice, Kosice, Slovak Republic
| | - Antonio Martins da Silva
- Serviço de Neurofisiologia, Hospital Santo António/Centro Hospitalar Universitário do Porto and UMIB-Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Jitka Bušková
- Department of Sleep Medicine, National Institute of Mental Health, Klecany, Czech Republic
| | - Claudio L A Bassetti
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Neurology, Sechenov First Moscow State University, Moscow, Russia
| | - Lucie Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France.,Institute for Neurosciences of Montpellier INM, Univ Montpellier, INSERM, Montpellier, France
| | - Fabio Pizza
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Elena Antelmi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Jari K Gool
- Sleep Wake Center SEIN Heemstede, Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands.,Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rolf Fronczek
- Sleep Wake Center SEIN Heemstede, Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands.,Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Carles Gaig
- Neurology Service, Institut de Neurociències Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ramin Khatami
- Center for Sleep Medicine, Sleep Research and Epileptology, Klinik Barmelweid AG, Barmelweid, Aargau, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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