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Barateau L, Baillieul S, Andrejak C, Bequignon É, Boutouyrie P, Dauvilliers Y, Gagnadoux F, Geoffroy PA, Micoulaud-Franchi JA, Montani D, Monaca C, Patout M, Pépin JL, Philip P, Pilette C, Tamisier R, Trzepizur W, Jaffuel D, Arnulf I. Guidelines for the assessment and management of residual sleepiness in obstructive apnea-hypopnea syndrome: Endorsed by the French Sleep Research and Medicine Society (SFRMS) and the French Speaking Society of Respiratory Diseases (SPLF). Respir Med Res 2024; 86:101105. [PMID: 38861872 DOI: 10.1016/j.resmer.2024.101105] [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: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 06/13/2024]
Abstract
Excessive daytime sleepiness (EDS) is frequent among patients with obstructive sleep apnea hypopnea syndrome (OSAHS) and can persist despite the optimal correction of respiratory events (apnea, hypopnea and respiratory efforts), using continuous positive airway pressure (CPAP) or mandibular advancement device. Symptoms like apathy and fatigue may be mistaken for EDS. In addition, EDS has multi-factorial origin, which makes its evaluation complex. The marketing authorization [Autorisation de Mise sur le Marché (AMM)] for two wake-promoting agents (solriamfetol and pitolisant) raises several practical issues for clinicians. This consensus paper presents recommendations of good clinical practice to identify and evaluate EDS in this context, and to manage and follow-up the patients. It was conducted under the mandate of the French Societies for sleep medicine and for pneumology [Société Française de Recherche et de Médecine du Sommeil (SFRMS) and Société de Pneumologie de Langue Française (SPLF)]. A management algorithm is suggested, as well as a list of conditions during which the patient should be referred to a sleep center or a sleep specialist. The benefit/risk balance of a wake-promoting drug in residual EDS in OSAHS patients must be regularly reevaluated, especially in elderly patients with increased cardiovascular and psychiatric disorders risks. This consensus is based on the scientific knowledge at the time of the publication and may be revised according to their evolution.
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Affiliation(s)
- Lucie Barateau
- National Reference Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France; Sleep and Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac University Hospital, Montpellier, France; Institute of Neurosciences of Montpellier (INM), INSERM, University of Montpellier, France.
| | - Sébastien Baillieul
- Grenoble-Alpes university, HP2 Inserm laboratory, U1300, Pneumology and Physiology department, CHU Grenoble-Alpes, 38000 Grenoble, France; National Competence Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France
| | - Claire Andrejak
- Pneumology department, CHU Amiens-Picardie, 80054 Amiens, France; UR 4294 AGIR, Picardie Jules-Verne University, Amiens, France
| | - Émilie Bequignon
- ENT and oral maxillofacial surgery department, Intercommunal center Créteil, 94000 Créteil, France; CNRS, ERL 7000, Paris-Est Créteil University, 94010 Créteil, France
| | - Pierre Boutouyrie
- Pharmacology, Inserm PARCC U970, Georges-Pompidou European Hospital, Paris-Cité University, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Yves Dauvilliers
- National Reference Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France; Sleep and Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac University Hospital, Montpellier, France; Institute of Neurosciences of Montpellier (INM), INSERM, University of Montpellier, France
| | - Frédéric Gagnadoux
- National Competence Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France; Pneumology and Sleep Medicine department, Angers CHU, Angers, France; Inserm 1083, UMR CNRS 6015, MITOVASC, Angers university, 49000 Angers, France
| | - Pierre-Alexis Geoffroy
- Département de psychiatrie et d'addictologie, AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Bichat - Claude Bernard, 75018 Paris, France; Centre ChronoS, GHU Paris - Psychiatry & Neurosciences, 1 rue Cabanis, 75014 Paris, France; Université de Paris, NeuroDiderot, Inserm U1141, 75019 Paris, France
| | - Jean-Arthur Micoulaud-Franchi
- University Sleep medicine unit, Bordeaux CHU, place Amélie-Raba-Léon, Bordeaux, France; SANPSY UMR 6033, Bordeaux University, 33000 Bordeaux, France
| | - David Montani
- Université Paris-Saclay, AP-HP, INSERM UMR_S 999, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Christelle Monaca
- National Competence Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France; Clinical neurophysiology, sleep disorders unit, U1172 - LilNCog - Lille, neurosciences & cognition, Lille university, Lille CHU, 59000 Lille, France
| | - Maxime Patout
- R3S department, Sleep pathologies unit, University hospital group, AP-HP-Sorbonne university, AP-HP, Pitié-Salpêtrière site, 75013 Paris, France; Inserm, UMRS1158 experimental and clinical respiratory neurophysiology, Sorbonne university, 75005 Paris, France
| | - Jean-Louis Pépin
- Grenoble-Alpes university, HP2 Inserm laboratory, U1300, Pneumology and Physiology department, CHU Grenoble-Alpes, 38000 Grenoble, France; National Competence Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France
| | - Pierre Philip
- National Reference Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France; University Sleep medicine unit, Bordeaux CHU, place Amélie-Raba-Léon, Bordeaux, France; SANPSY UMR 6033, Bordeaux University, 33000 Bordeaux, France
| | - Charles Pilette
- Saint-Luc university clinics, Institute for experimental and clinical research (Pneumology unit), UC Louvain, Brussels, Belgium
| | - Renaud Tamisier
- Grenoble-Alpes university, HP2 Inserm laboratory, U1300, Pneumology and Physiology department, CHU Grenoble-Alpes, 38000 Grenoble, France; National Competence Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France
| | - Wojciech Trzepizur
- National Competence Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France; Pneumology and Sleep Medicine department, Angers CHU, Angers, France; Inserm 1083, UMR CNRS 6015, MITOVASC, Angers university, 49000 Angers, France
| | - Dany Jaffuel
- Pneumology department, Arnaud-de-Villeneuve hospital, Montpellier CHRU, Montpellier, France; Inserm U1046, physiology and experimental medicine, heart and muscle, Montpellier university, Montpellier, France
| | - Isabelle Arnulf
- National Reference Center for Rare Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, France; Pneumology department, Arnaud-de-Villeneuve hospital, Montpellier CHRU, Montpellier, France
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Ngo Q, Plante DT. An Update on the Misuse and Abuse Potential of Pharmacological Treatments for Central Disorders of Hypersomnolence. CURRENT SLEEP MEDICINE REPORTS 2022. [DOI: 10.1007/s40675-022-00227-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sarfraz N, Okuampa D, Hansen H, Alvarez M, Cornett EM, Kakazu J, Kaye AM, Kaye AD. pitolisant, a novel histamine-3 receptor competitive antagonist, and inverse agonist, in the treatment of excessive daytime sleepiness in adult patients with narcolepsy. Health Psychol Res 2022; 10:34222. [PMID: 35774905 PMCID: PMC9239364 DOI: 10.52965/001c.34222] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/12/2022] [Indexed: 02/07/2024] Open
Abstract
Narcolepsy is a debilitating sleep disorder that presents with excessive daytime sleepiness (EDS) and cataplexy, which is a sudden paralysis of muscle tone triggered by strong emotions such as laughing. It is also associated with many other disorders, including psychiatric disorders, neurologic illnesses, and medication side effects. Common causes of delayed and incorrect diagnoses of these conditions include lack of physician familiarity with narcolepsy symptoms and comorbidities which mask narcolepsy signs and symptoms. Current pharmacologic therapies include Modafinil and Armodafinil for EDS and sodium oxybate for cataplexy. This review discusses the epidemiology, pathophysiology, risk factors, presentation, treatment of narcolepsy, and the role of a novel drug, Pitolisant, in the treatment of EDS in adults with narcolepsy. Pitolisant is a histamine-3 receptor (H3R), competitive antagonist, and inverse agonist, acting through the histamine system to regulate wakefulness. It is a novel drug approved in August 2019 by the FDA, is not classified as a controlled substance, and is approved for use in Europe and the United States to treat EDS and cataplexy in narcolepsy. Recent phase II and III trials have shown that Pitolisant helps reduce the ESS score and cataplexy. In summary, based on comparative studies, recent evidence has shown that Pitolisant is non-inferior to Modafinil in the treatment of EDS but superior to Modafinil in reducing cataplexy.
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Affiliation(s)
- Noeen Sarfraz
- Department of Psychiatry, Louisiana State University Health Shreveport
| | - David Okuampa
- College of Medicine, Louisiana State University Health Shreveport
| | - Hannah Hansen
- College of Medicine, Louisiana State University Health Shreveport
| | - Mark Alvarez
- College of Medicine, Louisiana State University Health Shreveport
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport
| | | | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport
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Translational Approaches to Influence Sleep and Arousal. Brain Res Bull 2022; 185:140-161. [PMID: 35550156 PMCID: PMC9554922 DOI: 10.1016/j.brainresbull.2022.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/27/2022] [Accepted: 05/03/2022] [Indexed: 12/16/2022]
Abstract
Sleep disorders are widespread in society and are prevalent in military personnel and in Veterans. Disturbances of sleep and arousal mechanisms are common in neuropsychiatric disorders such as schizophrenia, post-traumatic stress disorder, anxiety and affective disorders, traumatic brain injury, dementia, and substance use disorders. Sleep disturbances exacerbate suicidal ideation, a major concern for Veterans and in the general population. These disturbances impair quality of life, affect interpersonal relationships, reduce work productivity, exacerbate clinical features of other disorders, and impair recovery. Thus, approaches to improve sleep and modulate arousal are needed. Basic science research on the brain circuitry controlling sleep and arousal led to the recent approval of new drugs targeting the orexin/hypocretin and histamine systems, complementing existing drugs which affect GABAA receptors and monoaminergic systems. Non-invasive brain stimulation techniques to modulate sleep and arousal are safe and show potential but require further development to be widely applicable. Invasive viral vector and deep brain stimulation approaches are also in their infancy but may be used to modulate sleep and arousal in severe neurological and psychiatric conditions. Behavioral, pharmacological, non-invasive brain stimulation and cell-specific invasive approaches covered here suggest the potential to selectively influence arousal, sleep initiation, sleep maintenance or sleep-stage specific phenomena such as sleep spindles or slow wave activity. These manipulations can positively impact the treatment of a wide range of neurological and psychiatric disorders by promoting the restorative effects of sleep on memory consolidation, clearance of toxic metabolites, metabolism, and immune function and by decreasing hyperarousal.
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Meskill GJ, Kallweit U, Zarycranski D, Caussé C, Finance O, Ligneau X, Davis CW. Pitolisant for the treatment of cataplexy in adults with narcolepsy. Expert Opin Orphan Drugs 2022. [DOI: 10.1080/21678707.2021.2022472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Gerard J. Meskill
- Tricoastal Narcolepsy and Sleep Disorders Center, Sugar Land, Texas, USA
| | - Ulf Kallweit
- Center for Narcolepsy, Hypersomnias and Daytime Sleepiness, Universität Witten/Herdecke, Witten, Germany
| | | | | | | | | | - Craig W. Davis
- Harmony Biosciences, Plymouth Meeting, Pennsylvania, USA
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6
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El-Solh AA, Rudraraju A, Pasrija D, Bui H. Pharmacotherapy of residual excessive sleepiness among continuous positive airway pressure (CPAP) treated patients with sleep apnea. Expert Opin Pharmacother 2022; 23:507-516. [PMID: 35045769 DOI: 10.1080/14656566.2022.2029408] [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: 12/12/2022]
Abstract
INTRODUCTION Patients with persistent sleepiness after adequate treatment of obstructive sleep apnea (OSA) with nasal continuous positive airway pressure (nCPAP) experience impaired cognition, reduced productivity, and worse quality of life. Although the mechanisms responsible for this phenomenon are not completely understood, neuroimaging studies have identified reduced gray matter in the frontal cortex and alterations in white matter integrity suggestive of axonal and myelin damage. The intermittent hypoxia with resulting oxidative injury is considered a prime culprit behind the loss of wake-promoting catecholaminergic neurons. AREAS COVERED This narrative review gives an overview of the pathophysiology and approaches to managing patients with residual sleepiness. The authors explore different targeted strategies aimed at improving selection of appropriate pharmacotherapy. EXPERT OPINION Wake-stimulant medications (modafinil and armodafinil) have demonstrated efficacy in reducing sleepiness in adequately treated OSA. The recent FDA approval of pitolisant and solriamfetol complements the use of modafinil by substituting for direct sympathomimetic agents. The distinctive pharmacologic profile and mode of action of each of these agents offer the opportunity of a personalized approach to the management of this disorder. Further studies should be conducted on the long-term effect of these agents alone or in combination on brain structural and functional changes.
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Affiliation(s)
- Ali A El-Solh
- Research and Development, The Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA.,Department of Epidemiology and Environmental Health; School of Public Health and Health Professions, University at Buffalo, USA
| | - Avantika Rudraraju
- Research and Development, The Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, USA
| | - Divij Pasrija
- Research and Development, The Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, USA
| | - Hoang Bui
- Research and Development, The Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA
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Di Ciano P, Hendershot CS, Le Foll B. Therapeutic Potential of Histamine H3 Receptors in Substance Use Disorders. Curr Top Behav Neurosci 2022; 59:169-191. [PMID: 35704272 DOI: 10.1007/7854_2022_372] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Substance use disorders are a leading cause of morbidity and mortality, and available pharmacological treatments are of modest efficacy. Histamine is a biogenic amine with four types of receptors. The histamine H3 receptor (H3R) is an autoreceptor and also an heteroreceptor. H3Rs are highly expressed in the basal ganglia, hippocampus and cortex, and regulate a number of neurotransmitters including acetylcholine, norepinephrine, GABA and dopamine. Its function and localization suggest that the H3R may be relevant to a number of psychiatric disorders and could represent a potential therapeutic target for substance use disorders. The purpose of the present review is to summarize preclinical studies investigating the effects of H3R agonists and antagonists on animal models of alcohol, nicotine and psychostimulant use. At present, the effects of H3R antagonists such as thioperamide, pitolisant or ciproxifan have been investigated in drug-induced locomotion, conditioned place preference, drug self-administration, reinstatement, sensitization and drug discrimination. For alcohol and nicotine, the effects of H3R ligands on two-bottle choice and memory tasks, respectively, have also been investigated. The results of these studies are inconsistent. For alcohol, H3R antagonists generally decreased the reward-related properties of ethanol, which suggests that H3R antagonists may be effective as a treatment option for alcohol use disorder. However, the effects of H3R antagonists on nicotine and psychostimulant motivation and reward are less clear. H3R antagonists potentiated the abuse-related properties of nicotine, but only a handful of studies have been conducted. For psychostimulants, evidence is mixed and suggests that more research is needed to establish whether H3R antagonists are a viable therapeutic option. The fact that different drugs of abuse have different brain targets may explain the differential effects of H3R ligands.
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Affiliation(s)
- Patricia Di Ciano
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Christian S Hendershot
- Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
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Clinical Impact of Pitolisant on Excessive Daytime Sleepiness and Cataplexy in Adults With Narcolepsy: An Analysis of Randomized Placebo-Controlled Trials. CNS Drugs 2022; 36:61-69. [PMID: 34935103 PMCID: PMC8732895 DOI: 10.1007/s40263-021-00886-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pitolisant, a selective histamine 3 receptor antagonist/inverse agonist, is indicated for the treatment of excessive daytime sleepiness or cataplexy in adults with narcolepsy. The efficacy and safety of pitolisant have been demonstrated in randomized placebo-controlled trials. When evaluating the results of randomized placebo-controlled trials, the clinical impact of a treatment can be assessed using effect size metrics that include Cohen's d (the standardized mean difference of an effect) and number needed to treat (NNT; number of patients that need to be treated to achieve a specific outcome for one person). OBJECTIVE The objective of this study was to evaluate the clinical impact of pitolisant for the reduction in excessive daytime sleepiness or cataplexy in adults with narcolepsy. METHODS This post hoc analysis incorporated data from two 7-week or 8-week randomized placebo-controlled trials (HARMONY 1, HARMONY CTP). Study medication was individually titrated, with a maximum possible pitolisant dose of 35.6 mg/day. Efficacy was assessed using the Epworth Sleepiness Scale (ESS) and weekly rate of cataplexy (HARMONY CTP only). Cohen's d was derived from the least-squares mean difference between treatment groups (pitolisant vs placebo), and NNTs were calculated from response rates. Treatment response was defined for excessive daytime sleepiness in two ways: (a) reduction in ESS score ≥ 3 or final ESS score ≤ 10 and (b) final ESS score ≤ 10. Treatment response was defined for cataplexy as a ≥ 25%, ≥ 50%, or ≥ 75% reduction in weekly rate of cataplexy. RESULTS The analysis population included 61 patients in HARMONY 1 (pitolisant, n = 31; placebo, n = 30) and 105 patients in HARMONY CTP (pitolisant, n = 54; placebo, n = 51). For pitolisant vs placebo, Cohen's d effect size values were 0.61 (HARMONY 1) and 0.86 (HARMONY CTP) based on changes in ESS scores, and 0.86 (HARMONY CTP) based on changes in weekly rate of cataplexy. NNTs for pitolisant were 3-5 for the treatment of excessive daytime sleepiness and 3-4 for the treatment of cataplexy. CONCLUSIONS The results of this analysis demonstrate the robust efficacy of pitolisant for the reduction in both excessive daytime sleepiness and cataplexy. These large effect sizes and low NNTs provide further evidence supporting the strength of the clinical response to pitolisant in the treatment of adults with narcolepsy. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT01067222 (February 2010), NCT01800045 (February 2013).
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Krief S, Berrebi‐Bertrand I, Nagmar I, Giret M, Belliard S, Perrin D, Uguen M, Robert P, Lecomte J, Schwartz J, Finance O, Ligneau X. Pitolisant, a wake-promoting agent devoid of psychostimulant properties: Preclinical comparison with amphetamine, modafinil, and solriamfetol. Pharmacol Res Perspect 2021; 9:e00855. [PMID: 34423920 PMCID: PMC8381683 DOI: 10.1002/prp2.855] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 01/04/2023] Open
Abstract
Several therapeutic options are currently available to treat excessive daytime sleepiness (EDS) in patients suffering from narcolepsy or obstructive sleep apnea. However, there are no comparisons between the various wake-promoting agents in terms of mechanism of action, efficacy, or safety. The goal of this study was to compare amphetamine, modafinil, solriamfetol, and pitolisant at their known primary pharmacological targets, histamine H3 receptors (H3R), dopamine, norepinephrine, and serotonin transporters, and in various in vivo preclinical models in relation to neurochemistry, locomotion, behavioral sensitization, and food intake. Results confirmed that the primary pharmacological effect of amphetamine, modafinil, and solriamfetol was to increase central dopamine neurotransmission, in part by inhibiting its transporter. Furthermore, solriamfetol increased levels of extracellular dopamine in the nucleus accumbens, and decreased the 3,4-dihydroxyphenyl acetic acid (DOPAC)/DA ratio in the striatum, as reported for modafinil and amphetamine. All these compounds produced hyperlocomotion, behavioral sensitization, and hypophagia, which are common features of psychostimulants and of compounds with abuse potential. In contrast, pitolisant, a selective and potent H3R antagonist/inverse agonist that promotes wakefulness, had no effect on striatal dopamine, locomotion, or food intake. In addition, pitolisant, devoid of behavioral sensitization by itself, attenuated the hyperlocomotion induced by either modafinil or solriamfetol. Therefore, pitolisant presents biochemical, neurochemical, and behavioral profiles different from those of amphetamine and other psychostimulants such as modafinil or solriamfetol. In conclusion, pitolisant is a differentiated therapeutic option, when compared with psychostimulants, for the treatment of EDS, as this agent does not show any amphetamine-like properties within in vivo preclinical models.
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Fabara SP, Ortiz JF, Anas Sohail A, Hidalgo J, Altamimi A, Tama B, Patel UK. Efficacy of Pitolisant on the Treatment of Narcolepsy: A Systematic Review. Cureus 2021; 13:e16095. [PMID: 34345566 PMCID: PMC8325524 DOI: 10.7759/cureus.16095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 12/03/2022] Open
Abstract
Narcolepsy is characterized by excessive daytime sleepiness (EDS) and cataplexy. Histamine neurons play an important role in enhancing wakefulness. The objective of our study was to evaluate the efficacy of pitolisant, a histamine 3 (H3)-receptor antagonist/inverse agonist, in patients with a high burden of narcolepsy symptoms. We conducted an advanced PubMed search strategy with inclusion and exclusion criteria. The outcome included the Epworth Sleepiness Scale (ESS) and adverse effects frequency. Our primary outcome included the mean ESS score at the endpoint and showed that pitolisant was superior to the placebo, but not non-inferior to modafinil. Adverse effects were less common and shorter in duration in the pitolisant group compared to the modafinil-treated patients. Pitolisant was efficacious in reducing excessive daytime sleepiness and cataplexy compared with placebo, and it was well-tolerated in patients with severe narcolepsy symptoms as compared with modafinil.
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Affiliation(s)
- Stephanie P Fabara
- General Medicine, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Juan Fernando Ortiz
- Neurology, Universidad San Francisco de Quito, Quito, ECU.,Neurology, Larkin Community Hospital, Miami, USA
| | | | - Jessica Hidalgo
- Internal Medicine, Universidad San Francisco de Quito, Quito, ECU
| | | | - Belen Tama
- Medicine, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Urvish K Patel
- Public Health and Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
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Davis CW, Kallweit U, Schwartz JC, Krahn LE, Vaughn B, Thorpy MJ. Efficacy of pitolisant in patients with high burden of narcolepsy symptoms: pooled analysis of short-term, placebo-controlled studies. Sleep Med 2021; 81:210-217. [PMID: 33721598 DOI: 10.1016/j.sleep.2021.02.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 01/12/2023]
Abstract
STUDY OBJECTIVE To evaluate the efficacy of pitolisant, a histamine 3 (H3)-receptor antagonist/inverse agonist, in adult patients with high burden of narcolepsy symptoms. METHODS Data were pooled from two randomized, placebo-controlled, 7- or 8-week studies of pitolisant (titrated to a potential maximum dose of 35.6 mg/day) in adults with narcolepsy. Analyses included three independent patient subgroups: Epworth Sleepiness Scale (ESS) baseline score ≥16, Maintenance of Wakefulness Test (MWT) sleep latency ≤8 min, and ≥15 cataplexy attacks per week. RESULTS The analysis populations included 118 patients for ESS (pitolisant, n = 60; placebo, n = 58), 105 for MWT (pitolisant, n = 59; placebo, n = 46), and 31 for cataplexy (pitolisant, n = 20; placebo, n = 11). On the ESS, least-squares mean change from baseline was significantly greater for pitolisant (-6.1) compared with placebo (-2.3; P < 0.001). Significantly more pitolisant-treated patients were classified as treatment responders: ESS score reduction ≥3, 69.0% in the pitolisant group versus 35.1% in the placebo group (P = 0.001); final ESS score ≤10, 36.2% versus 10.5%, respectively (P = 0.005). On the MWT, mean sleep latency increased from 3.5 min to 10.4 min with pitolisant and from 3.4 min to 6.8 min with placebo (P = 0.017). Least-squares mean change in the weekly rate of cataplexy was significantly greater for pitolisant (-14.5; baseline, 23.9; final, 9.4) compared with placebo (-0.1; baseline, 23.1; final, 23.0; P = 0.004). Headache was the most common adverse event with pitolisant. CONCLUSIONS Pitolisant, at once-daily doses up to 35.6 mg, was efficacious for reducing excessive daytime sleepiness and cataplexy in patients with severe narcolepsy symptom burden.
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Affiliation(s)
- Craig W Davis
- Harmony Biosciences, LLC, Plymouth Meeting, PA, USA.
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Time to Onset of Response to Pitolisant for the Treatment of Excessive Daytime Sleepiness and Cataplexy in Patients With Narcolepsy: An Analysis of Randomized, Placebo-Controlled Trials. CNS Drugs 2021; 35:1303-1315. [PMID: 34822113 PMCID: PMC8642365 DOI: 10.1007/s40263-021-00866-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pitolisant is approved in the USA and Europe for the treatment of excessive daytime sleepiness or cataplexy in adults with narcolepsy. OBJECTIVE Analyses evaluated the time to onset of clinical response during treatment with pitolisant. METHODS Data were obtained from two randomized, double-blind, 7-week or 8-week, placebo-controlled studies (HARMONY 1, HARMONY CTP). Study medication was individually titrated to a maximum dose of pitolisant 35.6 mg/day and then remained stable. Efficacy assessments included the Epworth Sleepiness Scale and weekly rate of cataplexy (calculated from patient diaries). Onset of clinical response was defined as the first timepoint at which there was statistical separation between pitolisant and placebo. RESULTS The analysis included 61 patients in HARMONY 1 (pitolisant, n = 31; placebo, n = 30) and 105 patients in HARMONY CTP (pitolisant, n = 54; placebo, n = 51). Onset of clinical response began at week 2 (HARMONY 1) or week 3 (HARMONY CTP) for the mean change in Epworth Sleepiness Scale score, and week 2 (HARMONY CTP) or week 5 (HARMONY 1) for the mean change in weekly rate of cataplexy, with further improvements observed in pitolisant-treated patients through the end of treatment. The percentage of treatment responders was significantly greater with pitolisant vs placebo beginning at week 3 for excessive daytime sleepiness (defined as an Epworth Sleepiness Scale score reduction ≥ 3) and week 2 for cataplexy (defined as a ≥ 50% reduction in weekly rate of cataplexy [HARMONY CTP]). CONCLUSIONS Onset of clinical response for excessive daytime sleepiness and/or cataplexy was generally observed within the first 2-3 weeks of pitolisant treatment in patients with narcolepsy. CLINICALTRIALS. GOV IDENTIFIER NCT01067222 (February 2010), NCT01800045 (February 2013).
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New drug approvals for 2019: Synthesis and clinical applications. Eur J Med Chem 2020; 205:112667. [DOI: 10.1016/j.ejmech.2020.112667] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
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Pallardo-Fernández I, Muñoz-Rodríguez JR, González-Martín C, Alguacil LF. Histamine H 3 receptor gene variants associated with drug abuse in patients with cocaine use disorder. J Psychopharmacol 2020; 34:1326-1330. [PMID: 33063610 DOI: 10.1177/0269881120961253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Preclinical work revealed significant interactions between ligands of the histamine H3 receptor and different drugs of abuse. In the case of psychostimulants, the results reported are somewhat controversial and human data are still scarce, despite the fact that an inverse agonist of the H3 receptor (pitolisant) has reached the market after approval for the treatment of narcolepsy. AIMS We have studied associations between histamine H3 receptor gene variants and cocaine use disorder to increase the knowledge of the possible involvement of histamine H3 receptor in drug abuse. METHODS Seven single nucleotide polymorphisms of the histamine H3 receptor gene were genotyped by using a multiplexing assay in 248 samples of subjects with cocaine use disorder and 500 randomized samples of subjects representative of the Spanish population. RESULTS The study of the epidemiological information associated to the samples revealed that subjects with cocaine use disorder broadly abused alcohol, tobacco and cannabinoids. Two single nucleotide polymorphisms (rs3787430 and rs74627870) were found significantly associated with the occurrence of addiction and one more (rs13042865) was specifically related to the severity of cocaine dependence within drug abusers. CONCLUSIONS The associations found in this study further extend the hypothesis that histamine H3 receptor function could be relevant in drug abuse in general and cocaine addiction in particular.
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Affiliation(s)
- Iñigo Pallardo-Fernández
- Facultad de Farmacia and Instituto de Estudio de las Adicciones IEA-CEU, Universidad San Pablo-CEU, Alcorcón, Spain
| | | | - Carmen González-Martín
- Facultad de Farmacia and Instituto de Estudio de las Adicciones IEA-CEU, Universidad San Pablo-CEU, Alcorcón, Spain
| | - Luis F Alguacil
- Facultad de Farmacia and Instituto de Estudio de las Adicciones IEA-CEU, Universidad San Pablo-CEU, Alcorcón, Spain
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Pépin JL, Georgiev O, Tiholov R, Attali V, Verbraecken J, Buyse B, Partinen M, Fietze I, Belev G, Dokic D, Tamisier R, Lévy P, Lecomte I, Lecomte JM, Schwartz JC, Dauvilliers Y. Pitolisant for Residual Excessive Daytime Sleepiness in OSA Patients Adhering to CPAP: A Randomized Trial. Chest 2020; 159:1598-1609. [PMID: 33121980 DOI: 10.1016/j.chest.2020.09.281] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/11/2020] [Accepted: 09/28/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Excessive daytime sleepiness (EDS) in individuals with OSA syndrome persisting despite good adherence to CPAP is a disabling condition. Pitolisant is a selective histamine H3-receptor antagonist with wake-promoting effects. RESEARCH QUESTION Is pitolisant effective and safe for reducing daytime sleepiness in individuals with moderate to severe OSA adhering to CPAP treatment but experiencing residual EDS? STUDY DESIGN AND METHODS In a multicenter, double-blind, randomized (3:1), placebo-controlled, parallel-design trial, pitolisant was titrated individually at up to 20 mg/day and taken over 12 weeks. The primary end point was change in the Epworth Sleepiness Scale (ESS) score in the intention-to-treat population. Key secondary end points were maintenance of wakefulness assessed by the Oxford Sleep Resistance Test, Clinical Global Impressions scale of severity, the patient's global opinion, EuroQoL quality-of-life questionnaire score, Pichot fatigue questionnaire score, and safety. RESULTS Two hundred forty-four OSA participants (82.8% men; mean age, 53.1 years; mean Apnea Hypopnea Index with CPAP, 4.2/h; baseline ESS score, 14.7) were randomized to pitolisant (n = 183) or placebo (n = 61). ESS significantly decreased with pitolisant compared with placebo (-2.6; 95% CI, -3.9 to -1.4; P < .001), and the rate of responders to therapy (ESS ≤ 10 or change in ESS ≥ 3) was significantly higher with pitolisant (71.0% vs 54.1%; P = .013). Adverse event occurrence (mainly headache and insomnia) was higher in the pitolisant group compared with the placebo group (47.0% and 32.8%, respectively; P = .03). No cardiovascular or other significant safety concerns were reported. INTERPRETATION Pitolisant used as adjunct to CPAP therapy for OSA with residual sleepiness despite good CPAP adherence significantly reduced subjective and objective sleepiness and improved participant-reported outcomes and physician-reported disease severity. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01071876; URL: www.clinicaltrials.gov; EudraCT N°: 2009-017248-14; URL: eudract.ema.europa.eu.
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Affiliation(s)
- Jean-Louis Pépin
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, and EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France.
| | - Ognian Georgiev
- Department of Internal Medicine, Pulmonology, Alexandrovska Hospital Medical University, Sofia, Bulgaria
| | - Rumen Tiholov
- Department of Internal Diseases, Sv. Ivan Rilski Multiprofile Hospital for Active Treatment, Kozloduy, Bulgaria
| | - Valérie Attali
- Neurophysiologie Respiratoire Expérimentale et Clinique UMRS1158, Sorbonne Université, INSERM, and Service des Pathologies du Sommeil (Departement R3S, DMU APPROCHES), Groupe Hospitalier Universitaire APHP-Sorbonne Université, Paris, France
| | - Johan Verbraecken
- Universitair Multidisciplinair Slaap Centrum, Edegem-Antwerp, Belgium
| | - Bertien Buyse
- Leuvens Universitair Centrum voor Slaap-en waakstoornissen, Department of Respiratory Diseases, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Markku Partinen
- Helsinki Sleep Clinic, Vitalmed Research Center, Department of Clinical Neurosciences, University of Helsinki, Finland
| | - Ingo Fietze
- Interdisziplinares Schlafmedizinisches Zentrum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Georgi Belev
- Pulmonology Division, Department of Internal Medicine, St. George Hospital Medical University, Plovdiv, Bulgaria
| | - Dejan Dokic
- Department of Pulmology and Allergy, Mother Teresa Medical University, Skopje, Macedonia
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, and EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Patrick Lévy
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, and EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Isabelle Lecomte
- Bioprojet, Paris, France; Department of Pulmology and Allergy, Mother Teresa Medical University, Skopje, Macedonia
| | | | | | - Yves Dauvilliers
- Centre National de Référence Narcolepsie, Unité du Sommeil, CHU Montpellier, Hôpital Gui-de-Chauliac, Service de Neurologie, Université de Montpellier, INSERM U1061, Montpellier, France
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Guevarra JT, Hiensch R, Varga AW, Rapoport DM. Pitolisant to Treat Excessive Daytime Sleepiness and Cataplexy in Adults with Narcolepsy: Rationale and Clinical Utility. Nat Sci Sleep 2020; 12:709-719. [PMID: 33117007 PMCID: PMC7567539 DOI: 10.2147/nss.s264140] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/13/2020] [Indexed: 11/23/2022] Open
Abstract
Narcolepsy is a sleep disorder marked by chronic, debilitating excessive daytime sleepiness and can be associated with cataplexy, sleep paralysis and sleep-related hallucinations. Pharmacological therapy for narcolepsy primarily aims to increase wakefulness and reduce cataplexy attacks. Pitolisant is a first-in-class agent utilizing histamine to improve wakefulness by acting as an antagonist/inverse agonist of the presynaptic histamine 3 receptor. This review summarizes the clinical efficacy, safety and tolerability of pitolisant in treating the symptoms of narcolepsy. Randomized and observational studies demonstrate pitolisant to be effective in treating both hypersomnolence and cataplexy while generally being well tolerated at prescribed doses. The most common adverse reactions include headache, insomnia and nausea.
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Affiliation(s)
- Jay T Guevarra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY10029, USA
| | - Robert Hiensch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY10029, USA
| | - Andrew W Varga
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY10029, USA
| | - David M Rapoport
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY10029, USA
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Harwell V, Fasinu PS. Pitolisant and Other Histamine-3 Receptor Antagonists-An Update on Therapeutic Potentials and Clinical Prospects. MEDICINES 2020; 7:medicines7090055. [PMID: 32882898 PMCID: PMC7554886 DOI: 10.3390/medicines7090055] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/27/2020] [Accepted: 08/27/2020] [Indexed: 12/13/2022]
Abstract
Background: Besides its well-known role as a peripheral chemical mediator of immune, vascular, and cellular responses, histamine plays major roles in the central nervous system, particularly in the mediation of arousal and cognition-enhancement. These central effects are mediated by the histamine-3 auto receptors, the modulation of which is thought to be beneficial for the treatment of disorders that impair cognition or manifest with excessive daytime sleepiness. Methods: A database search of PubMed, Google Scholar, and clinicaltrials.gov was performed in June 2020. Full-text articles were screened and reviewed to provide an update on pitolisant and other histamine-3 receptor antagonists. Results: A new class of drugs—histamine-3 receptor antagonists—has emerged with the approval of pitolisant for the treatment of narcolepsy with or without cataplexy. At the recommended dose, pitolisant is well tolerated and effective. It has also been evaluated for potential therapeutic benefit in Parkinson disease, epilepsy, attention deficit hyperactivity disorder, Alzheimer’s disease, and dementia. Limited studies have shown pitolisant to lack abuse potential which will be a major advantage over existing drug options for narcolepsy. Several histamine-3 receptor antagonists are currently in development for a variety of clinical indications. Conclusions: Although limited clinical studies have been conducted on this new class of drugs, the reviewed literature showed promising results for future additions to the clinical indications of pitolisant, and the expansion of the list of approved drugs in this class for a variety of indications.
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Update on Persistent Excessive Daytime Sleepiness in OSA. Chest 2020; 158:776-786. [PMID: 32147246 DOI: 10.1016/j.chest.2020.02.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/31/2020] [Accepted: 02/22/2020] [Indexed: 12/17/2022] Open
Abstract
OSA is a highly prevalent sleep disorder, and subjective excessive daytime sleepiness (EDS) is the cardinal symptom for which many individuals seek medical advice. Positive airway pressure (PAP) devices, first-line treatment for OSA, eliminates EDS in most patients. However, a subset of patients suffers from persistent EDS despite adherence to therapy. Multiple conditions, some reversible, could account for the residual sleepiness and need to be explored, requiring detailed history, review of PAP data from the smart card, and sometimes additional testing. When all known causes of EDS are excluded, in adequately treated subjects, the purported mechanisms could relate to long-term exposure to the OSA-related sleep fragmentation, sleep deprivation, and hypoxic injury to the arousal system, shifts in melatonin secretion, or altered microbiome. Independent of the mechanism, in well-treated OSA, pharmacological therapy with approved drugs can be considered. Modafinil is commonly prescribed to combat residual EDS, but more recently two drugs, solriamfetol, a dual dopamine-norepinephrine reuptake inhibitor, and pitolisant, a histamine H3 receptor inverse agonist, were approved for EDS. Solriamfetol has undergone randomized controlled trials for treatment of EDS associated with both OSA and narcolepsy, exhibiting robust efficacy. Solriamfetol is renally excreted, with no known drug interactions. Pitolisant, which is nonscheduled, has undergone multiple RCTs in narcolepsy, showing improvement in subjective and objective EDS and one OSA trial showing improvement in subjective EDS.
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Affiliation(s)
- Shuang Li
- Department of Pharmaceutical, Central Hospital of Linyi City, Yishui, Shandong, China
| | - Junyi Yang
- Department of Pharmaceutical, Central Hospital of Linyi City, Yishui, Shandong, China
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Abstract
Narcolepsy is a chronic, disabling neurologic disorder characterised by excessive daytime sleepiness (EDS) and, in up to 60% of patients, cataplexy. Treatments for narcolepsy are aimed at improving wakefulness (e.g. modafinil, armodafinil, stimulants), reducing cataplexy attacks (e.g. sodium oxybate, venlafaxine), and treating the symptoms of disturbed nocturnal sleep, sleep paralysis and sleep-related hallucinations (e.g. sodium oxybate). In general, medications that increase the release, or inhibit the reuptake, of norepinephrine or dopamine have wake-promoting effects and are useful in managing EDS, whereas medications that inhibit serotonin or norepinephrine reuptake have anticataplectic effects. Modulation of γ-aminobutyric acid B (GABAB) receptors or histamine H3 receptors (H3Rs) has effects on both EDS and cataplexy. Pitolisant, an H3R antagonist, and solriamfetol, a dopamine and norepinephrine reuptake inhibitor, are the most recently approved treatments for EDS associated with narcolepsy in the European Union (pitolisant) and the USA (pitolisant and solriamfetol). Several new agents are being developed and tested as potential treatments for EDS and cataplexy associated with narcolepsy; these agents include novel oxybate formulations (once-nightly [FT218]; low sodium [JZP-258]), a selective norepinephrine reuptake inhibitor (AXS-12), and a product combining modafinil and an astroglial connexin inhibitor (THN102). This review summarises the mechanisms of action, pharmacokinetics, efficacy, and safety/tolerability of recently approved and emerging treatments for narcolepsy.
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Affiliation(s)
- Michael J Thorpy
- Sleep-Wake Disorders Center, Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467-2509, USA.
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Thorpy MJ, Bogan RK. Update on the pharmacologic management of narcolepsy: mechanisms of action and clinical implications. Sleep Med 2019; 68:97-109. [PMID: 32032921 DOI: 10.1016/j.sleep.2019.09.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/21/2022]
Abstract
Narcolepsy is a chronic, debilitating neurological disorder of sleep-wake state instability. This instability underlies all narcolepsy symptoms, including excessive daytime sleepiness (EDS), symptoms of rapid eye movement (REM) sleep dysregulation (ie, cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis), and disrupted nighttime sleep. Several neurotransmitter systems promote wakefulness, and various neural pathways are involved in regulating REM sleep-related muscle atonia, providing multiple targets for pharmacologic intervention to reduce EDS and cataplexy. Medications approved by the US Food and Drug Administration (FDA) for the treatment of EDS in narcolepsy include traditional stimulants (eg, amphetamines, methylphenidate), wake-promoting agents (eg, modafinil, armodafinil), and solriamfetol, which mainly act on dopaminergic and noradrenergic pathways. Sodium oxybate (thought to act via GABAB receptors) is FDA-approved for the treatment of EDS and cataplexy. Pitolisant, a histamine 3 (H3)-receptor antagonist/inverse agonist, is approved by the European Medicines Agency (EMA) for the treatment of narcolepsy with or without cataplexy in adults and by the FDA for the treatment of EDS in adults with narcolepsy. Pitolisant increases the synthesis and release of histamine in the brain and modulates the release of other neurotransmitters (eg, norepinephrine, dopamine). Antidepressants that inhibit reuptake of serotonin and/or norepinephrine are widely used off label to manage cataplexy. In many patients with narcolepsy, combination treatment with medications that act via different neural pathways is necessary for optimal symptom management. Mechanism of action, pharmacokinetics, and abuse potential are important considerations in treatment selection and subsequent medication adjustments to maximize efficacy and mitigate adverse effects in the treatment of patients with narcolepsy.
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Affiliation(s)
- Michael J Thorpy
- Sleep-Wake Disorders Center, Montefiore Medical Center, Albert Einstein College of Medicine, 3411 Wayne Ave, Bronx, NY, 10467, USA.
| | - Richard K Bogan
- SleepMed Inc., Bogan Sleep Consultants, LLC, 1333 Taylor Street, Columbia, SC, USA.
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