1
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Vringer M, Zhou J, Gool JK, Bijlenga D, Lammers GJ, Fronczek R, Schinkelshoek MS. Recent insights into the pathophysiology of narcolepsy type 1. Sleep Med Rev 2024; 78:101993. [PMID: 39241492 DOI: 10.1016/j.smrv.2024.101993] [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: 12/22/2023] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 09/09/2024]
Abstract
Narcolepsy type 1 (NT1) is a sleep-wake disorder in which people typically experience excessive daytime sleepiness, cataplexy and other sleep-wake disturbances impairing daily life activities. NT1 symptoms are due to hypocretin deficiency. The cause for the observed hypocretin deficiency remains unclear, even though the most likely hypothesis is that this is due to an auto-immune process. The search for autoantibodies and autoreactive T-cells has not yet produced conclusive evidence for or against the auto-immune hypothesis. Other mechanisms, such as reduced corticotrophin-releasing hormone production in the paraventricular nucleus have recently been suggested. There is no reversive treatment, and the therapeutic approach is symptomatic. Early diagnosis and appropriate NT1 treatment is essential, especially in children to prevent impaired cognitive, emotional and social development. Hypocretin receptor agonists have been designed to replace the attenuated hypocretin signalling. Pre-clinical and clinical trials have shown encouraging initial results. A better understanding of NT1 pathophysiology may contribute to faster diagnosis or treatments, which may cure or prevent it.
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Affiliation(s)
- Marieke Vringer
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake center, Heemstede, the Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jingru Zhou
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake center, Heemstede, the Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jari K Gool
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake center, Heemstede, the Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anatomy & Neurosciences, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Compulsivity, Impulsivity and Attention, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Denise Bijlenga
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake center, Heemstede, the Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Gert Jan Lammers
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake center, Heemstede, the Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rolf Fronczek
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake center, Heemstede, the Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mink S Schinkelshoek
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake center, Heemstede, the Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands.
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2
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Tang SH, Min J, Zhang X, Uwah E, Griffis HM, Cielo CM, Fiks AG, Mindell JA, Tapia IE, Williamson AA. Incidence of pediatric narcolepsy diagnosis and management: evidence from claims data. J Clin Sleep Med 2024; 20:1141-1151. [PMID: 38450539 PMCID: PMC11217630 DOI: 10.5664/jcsm.11104] [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: 11/02/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
STUDY OBJECTIVES The purpose of this study was to characterize the incidence of pediatric narcolepsy diagnosis, subsequent care, and potential sociodemographic disparities in a large US claims database. METHODS Merative MarketScan insurance claims (n = 12,394,902) were used to identify youth (6-17 years of age) newly diagnosed with narcolepsy (International Classification of Diseases, 10th revision codes). Narcolepsy diagnosis and care 1 year postdiagnosis included polysomnography with Multiple Sleep Latency Test, pharmacological care, and clinical visits. Potential disparities were examined by insurance coverage and child race and ethnicity (Medicaid-insured only). RESULTS The incidence of narcolepsy diagnosis was 10:100,000, primarily type 2 (69.9%). Most diagnoses occurred in adolescents with no sex differences, but higher rates in Black vs White youth with Medicaid. Two thirds had a prior sleep disorder diagnosis and 21-36% had other co-occurring diagnoses. Only half (46.6%) had polysomnography with Multiple Sleep Latency Test (± 1 year postdiagnosis). Specialty care (18.9% pulmonary, 26.9% neurology) and behavioral health visits were rare (34.4%), although half were prescribed stimulant medications (51.0%). Medicaid-insured were 86% less likely than commercially insured youth to have any clinical care and 33% less likely to have polysomnography with Multiple Sleep Latency Test. CONCLUSIONS Narcolepsy diagnoses occurred in 0.01% of youth, primarily during adolescence, and at higher rates for Black vs White children with Medicaid. Only half overall had evidence of a diagnostically required polysomnography with Multiple Sleep Latency Test, underscoring potential misdiagnosis. Many patients had co-occurring conditions, but specialty and behavioral health care were limited. Results suggest misdiagnosis, underdiagnosis, and limited narcolepsy treatment, as well as possible disparities. Results highlight the need to identify determinants of evidence-based pediatric narcolepsy diagnosis and management. CITATION Tang SH, Min J, Zhang X, et al. Incidence of pediatric narcolepsy diagnosis and management: evidence from claims data. J Clin Sleep Med. 2024;20(7):1141-1151.
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Affiliation(s)
- Si Hao Tang
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jungwon Min
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Xuemei Zhang
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Christopher M Cielo
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander G Fiks
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jodi A Mindell
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Ignacio E Tapia
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Ariel A Williamson
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- The Ballmer Institute, University of Oregon, Portland, Oregon
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3
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Trotti LM, Nichols KJ. Narcolepsy type 2: phenotype is fundamental. Sleep 2024; 47:zsae047. [PMID: 38452192 PMCID: PMC11082467 DOI: 10.1093/sleep/zsae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Indexed: 03/09/2024] Open
Affiliation(s)
- Lynn Marie Trotti
- Department of Neurology and Emory Sleep Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Kendall J Nichols
- Department of Neurology and Emory Sleep Center, Emory University School of Medicine, Atlanta, GA, USA
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4
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Gauffin H, Boström I, Berntsson SG, Kristoffersson A, Fredrikson M, Landtblom AM. Characterization of the Increase in Narcolepsy following the 2009 H1N1 Pandemic in Sweden. J Clin Med 2024; 13:652. [PMID: 38337347 PMCID: PMC10856509 DOI: 10.3390/jcm13030652] [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: 12/17/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: In the context of the H1N1 pandemic and the Pandemrix vaccination campaign, an increased number of narcolepsy cases were noted in several countries. In Sweden, this phenomenon was attributed to the effect of the Pandemrix vaccination in the first place. Studies from China indicated that narcolepsy could occur as a consequence of the H1N1 infection itself. We performed an analysis of the increase, with a specific interest in age and sex distribution. We also aimed to validate the origin of the excess cases, post hoc. (2) Methods: Data for narcolepsy patients (ICD code G 47.4, both type 1 and type 2) distributed by sex and age at 5-year intervals, annually between 2005 and 2017, were retrieved from the National Patient Register. Information on the total population was collected from the Swedish Population Register. (3) Results: The number of narcolepsy cases increased markedly from 2009 to 2014 compared to the period before 2009. A particular increase in 2011 among children and teenagers was observed. The sex ratio did not change significantly during the study period. (4) Conclusions: Our results support an association between the increased prevalence of narcolepsy cases and Pandemrix vaccination, but the effect of the virus itself cannot be ruled out as a contributing factor.
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Affiliation(s)
- Helena Gauffin
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health, Linköping University, 58185 Linköping, Sweden; (H.G.); (I.B.); (M.F.); (A.-M.L.)
| | - Inger Boström
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health, Linköping University, 58185 Linköping, Sweden; (H.G.); (I.B.); (M.F.); (A.-M.L.)
| | | | - Anna Kristoffersson
- Department of Medical Sciences, Neurology, Uppsala University, 75185 Uppsala, Sweden;
| | - Mats Fredrikson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health, Linköping University, 58185 Linköping, Sweden; (H.G.); (I.B.); (M.F.); (A.-M.L.)
| | - Anne-Marie Landtblom
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health, Linköping University, 58185 Linköping, Sweden; (H.G.); (I.B.); (M.F.); (A.-M.L.)
- Department of Medical Sciences, Neurology, Uppsala University, 75185 Uppsala, Sweden;
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5
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Blattner M, Maski K. Central Disorders of Hypersomnolence. Continuum (Minneap Minn) 2023; 29:1045-1070. [PMID: 37590822 DOI: 10.1212/con.0000000000001265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE The goals of this article are to describe the clinical approach to and management of patients with central disorders of hypersomnolence, and to understand and differentiate available diagnostic tools. LATEST DEVELOPMENTS Updated clinical practice guidelines for the treatment of central disorders of hypersomnolence and narcolepsy specifically highlight new treatment options. Approval for a lower-sodium oxybate formulation that contains 92% less sodium than the standard sodium oxybate for the treatment of narcolepsy and idiopathic hypersomnia adds to the number of medications available for these disorders, allowing for a more tailored management of symptoms. ESSENTIAL POINTS Central disorders of hypersomnolence are characterized by excessive daytime sleepiness that impacts daily functions. These disorders can be differentiated by obtaining a detailed clinical sleep history and by a thoughtful interpretation of sleep diagnostic testing. Tailoring treatment approaches to meet the needs of individuals and accounting for medical and psychiatric comorbidities may improve quality of life.
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6
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Blattner M, Maski K. Narcolepsy and Idiopathic Hypersomnia. Sleep Med Clin 2023; 18:183-199. [PMID: 37120161 DOI: 10.1016/j.jsmc.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Narcolepsy types 1 and 2 and idiopathic hypersomnia are primary Central Nervous System (CNS) disorders of hypersomnolence characterized by profound daytime sleepiness and/or excessive sleep need. Onset of symptoms begins typically in childhood or adolescence, and children can have unique presentations compared with adults. Narcolepsy type 1 is likely caused by immune-mediated loss of orexin (hypocretin) neurons in the hypothalamus; however, the causes of narcolepsy type 2 and idiopathic hypersomnia are unknown. Existing treatments improve daytime sleepiness and cataplexy but there is no cure for these disorders.
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Affiliation(s)
- Margaret Blattner
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Kiran Maski
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, BCH3443, Boston, MA 02115, USA.
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7
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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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8
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van der Hoeven AE, Fronczek R, Schinkelshoek MS, Roelandse FWC, Bakker JA, Overeem S, Bijlenga D, Lammers GJ. Intermediate hypocretin-1 cerebrospinal fluid levels and typical cataplexy: their significance in the diagnosis of narcolepsy type 1. Sleep 2022; 45:zsac052. [PMID: 35554594 PMCID: PMC9113791 DOI: 10.1093/sleep/zsac052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/01/2022] [Indexed: 12/15/2022] Open
Abstract
STUDY OBJECTIVES The diagnosis of narcolepsy type 1 (NT1) is based upon the presence of cataplexy and/or a cerebrospinal fluid (CSF) hypocretin-1/orexin-A level ≤ 110 pg/mL. We determined the clinical and diagnostic characteristics of patients with intermediate hypocretin-1 levels (111-200 pg/mL) and the diagnostic value of cataplexy characteristics in individuals with central disorders of hypersomnolence. METHODS Retrospective cross-sectional study of 355 people with known CSF hypocretin-1 levels who visited specialized Sleep-Wake Centers in the Netherlands. For n = 271, we had full data on cataplexy type ("typical" or "atypical" cataplexy). RESULTS Compared to those with normal hypocretin-1 levels (>200 pg/mL), a higher percentage of individuals with intermediate hypocretin-1 levels had typical cataplexy (75% or 12/16 vs 9% or 8/88, p < .05), and/or met the diagnostic polysomnographic (PSG) and Multiple Sleep Latency Test (MSLT) criteria for narcolepsy (50 vs 6%, p < .001). Of those with typical cataplexy, 88% had low, 7% intermediate, and 5% normal hypocretin-1 levels (p < .001). Atypical cataplexy was also associated with hypocretin deficiency but to a lesser extent. A hypocretin-1 cutoff of 150 pg/mL best predicted the presence of typical cataplexy and/or positive PSG and MSLT findings. CONCLUSION Individuals with intermediate hypocretin-1 levels or typical cataplexy more often have outcomes fitting the PSG and MSLT criteria for narcolepsy than those with normal levels or atypical cataplexy. In addition, typical cataplexy has a much stronger association with hypocretin-1 deficiency than atypical cataplexy. We suggest increasing the NT1 diagnostic hypocretin-1 cutoff and adding the presence of clearly defined typical cataplexy to the diagnostic criteria of NT1. Clinical trial information: This study is not registered in a clinical trial register, as it has a retrospective database design.
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Affiliation(s)
- Adrienne Elisabeth van der Hoeven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Mink Sebastian Schinkelshoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | | | - Jaap Adriaan Bakker
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Denise Bijlenga
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Gert Jan Lammers
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Sleep-Wake Center, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
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9
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Hsu CW, Tseng PT, Tu YK, Lin PY, Wang LJ, Hung CF, Yang YH, Kao HY, Yeh CB, Lai HC, Chen TY. Month of birth and the risk of narcolepsy: a systematic review and meta-analysis. J Clin Sleep Med 2021; 18:1113-1120. [PMID: 34893148 DOI: 10.5664/jcsm.9816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The aim of this study is to evaluate the relationship between the month of birth (MOB) and the risk of narcolepsy. METHODS We conducted a systematic review of electronic databases, namely PubMed, Embase, and Cochrane CENTRAL, from their inception to September 30, 2021. We also added data on narcolepsy from the National Database in Taiwan. Then we extracted the relative risk ratios (RR) of narcolepsy in each month of birth to that of the general population and transformed them from month of birth to season. A random-effects model was used to calculate pooled RRs from the meta-analysis and 95% confidence interval (CI). RESULTS The current meta-analysis analyzed seven studies and included 3776 patients from eight areas. The RR was highest in March (RR 1.11 [95% CI 0.99-1.26]) or August (1.11 [0.98-1.26]) and lowest in April (0.90 [0.78-1.03]). However, none of the MOBs reached statistical significance. Moreover, the patterns of the three continents were different. In North America, the highest and lowest significant risks were found in March (1.47 [1.20-1.79]) and September (0.75 [95% CI 0.56-0.99]). In Asia, the notable lowest risk was in April (0.80 [0.66-0.97]). In Europe, the risk of narcolepsy is not significantly related to any MOB. In terms of seasons, only spring births in North America had a significantly higher risk (1.21 [1.06-1.38]). CONCLUSIONS The findings indicated that the risk of narcolepsy and MOB differed across the three continents. This study indicates the important role of environmental factors in narcolepsy. SYSTEMATIC REVIEW REGISTRATION Registry: PROSPERO; Identifier: CRD42020186660.
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Affiliation(s)
- Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital
| | - Liang-Jen Wang
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Fa Hung
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Hsu Yang
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi County, Taiwan.,Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi County, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hung-Yu Kao
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Bin Yeh
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Hsiao-Ching Lai
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
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10
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Mekonnen A, Stimac G. An Unusual Case of Type 1 Narcolepsy in an Ethiopian Patient. Ethiop J Health Sci 2021; 31:205-208. [PMID: 34158768 PMCID: PMC8188103 DOI: 10.4314/ejhs.v31i1.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Narcolepsy is a chronic disabling central neurological disorder of daytime hypersomnia. It is categorized into two subtypes-type 1 (N1) and type 2 (N2). Symptoms of N1 commonly include excessive daytime sleepiness (EDS), cataplexy, sleep paralysis, hypnogogic/hypnopompic hallucinations, and disturbed nighttime sleep. Ethnic differences have been observed, but they have not been reported in an Ethiopian patient to date. Case Detail We report a 39-year-old Ethiopian patient with type 1 narcolepsy whose diagnosis was delayed for three decades despite severe symptoms. Her quality of life was significantly impaired and included EDS, sleep fragmentation, and depression. The mean sleep latency (MSL) for five naps was 1.3 minutes. Sleep-onset rapid eye movement (REM) periods (SOREMPs) were present in all five nap periods. HLA-typing and a CSF hypocretin level testing were not performed. Modafinil 300mg was prescribed, which improved her quality of life. Conclusion In developing countries where diagnostic studies are not available, practitioners should pay special attention to a detailed history and look for classic symptoms of narcolepsy to establish an early diagnosis and improve quality of life.
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Affiliation(s)
- Asefa Mekonnen
- Rockville Internal Medicine Group Department of Sleep Medicine, 1201 Seven Locks Rd Suite 111, Rockville, ND
| | - Gregory Stimac
- Georgetown University School of Medicine, 3800 Reservoir Rd NW, 20007
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11
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Ingram DG, Jesteadt L, Crisp C, Simon SL. Treatment and care delivery in pediatric narcolepsy: a survey of parents, youth, and sleep physicians. J Clin Sleep Med 2021; 17:875-884. [PMID: 33283753 DOI: 10.5664/jcsm.9054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
STUDY OBJECTIVES To describe the most commonly used treatments in pediatric narcolepsy and their perceived effectiveness, as well as to elicit key stakeholder perspectives on the most optimal manner in which care ought to be delivered to youth with narcolepsy. METHODS A cross-sectional survey of youth with narcolepsy, parents, and sleep physicians. RESULTS Complete survey results were available for 35 youth with narcolepsy, 116 parents, and 30 sleep physicians. Overall there was general agreement among family and physicians regarding most effective treatments, including both pharmacologic (stimulants, sodium oxybate, and modafinil/armodafinil) and nonpharmacologic (sleep schedule, exercise, diet) approaches. There was a stronger interested in cannabidiol oil (CBD) from families compared to physicians. Both families and physicians also endorsed a need for multispecialty care, ideally delivered in a same day setting and including specialists in mental health, social work, and nutrition. Quality measures were felt to be important but are not currently tracked by most sleep physicians. Qualitative responses highlight the value families place on providers who listen well and remain open-minded. CONCLUSIONS Our results suggest strong support by key stakeholders for an interdisciplinary approach to care for youth with narcolepsy.
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Affiliation(s)
| | | | | | - Stacey L Simon
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
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12
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Fronczek R, Arnulf I, Baumann CR, Maski K, Pizza F, Trotti LM. To split or to lump? Classifying the central disorders of hypersomnolence. Sleep 2021; 43:5810298. [PMID: 32193539 PMCID: PMC7420691 DOI: 10.1093/sleep/zsaa044] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/10/2020] [Indexed: 01/20/2023] Open
Abstract
The classification of the central disorders of hypersomnolence has undergone multiple iterations in an attempt to capture biologically meaningful disease entities in the absence of known pathophysiology. Accumulating data suggests that further refinements may be necessary. At the 7th International Symposium on Narcolepsy, a group of clinician-scientists evaluated data in support of keeping or changing classifications, and as a result suggest several changes. First, idiopathic hypersomnia with long sleep durations appears to be an identifiable and meaningful disease subtype. Second, idiopathic hypersomnia without long sleep time and narcolepsy without cataplexy share substantial phenotypic overlap and cannot reliably be distinguished with current testing, and so combining them into a single disease entity seems warranted at present. Moving forward, it is critical to phenotype patients across a wide variety of clinical and biological features, to aid in future refinements of disease classification.
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Affiliation(s)
- Rolf Fronczek
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.,Sleep-Wakecentre SEIN, Heemstede, The Netherlands
| | - Isabelle Arnulf
- Sorbonne University, National Reference Center for Rare Hypersomnia, Pitie-Salpetriere Hospital, Paris, France
| | - Christian R Baumann
- Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kiran Maski
- Department of Neurology, Harvard Medical School, Boston Children's Hospital, Boston, MA
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lynn Marie Trotti
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
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Abstract
PURPOSE OF REVIEW The presentation of sleep issues in childhood differs from the presentation in adulthood and may be more subtle. Sleep issues may affect children differently than adults, and distinct treatment approaches are often used in children. RECENT FINDINGS Sodium oxybate was approved by the US Food and Drug Administration (FDA) in October 2018 for an expanded indication of treatment of sleepiness or cataplexy in patients with narcolepsy type 1 or narcolepsy type 2 aged 7 years or older, with side effect and safety profiles similar to those seen in adults. Restless sleep disorder is a recently proposed entity in which restless sleep, daytime sleepiness, and often iron deficiency are observed, but children do not meet the criteria for restless legs syndrome or periodic limb movement disorder. SUMMARY Children's sleep is discussed in this article, including normal sleep patterns and effects of insufficient sleep. Sleep disorders of childhood are reviewed, including insomnia, obstructive sleep apnea, restless legs syndrome, parasomnias, narcolepsy, and Kleine-Levin syndrome. Children with neurologic issues or neurodevelopmental disorders frequently have sleep disorders arising from an interaction of heterogeneous factors. Further attention to sleep may often be warranted through a polysomnogram or referral to a pediatric sleep specialist. Sleep disorders may cause indelible effects on children's cognitive functioning, general health, and well-being, and awareness of sleep disorders is imperative for neurologists who treat children.
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14
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Barker EC, Flygare J, Paruthi S, Sharkey KM. Living with Narcolepsy: Current Management Strategies, Future Prospects, and Overlooked Real-Life Concerns. Nat Sci Sleep 2020; 12:453-466. [PMID: 32765142 PMCID: PMC7371435 DOI: 10.2147/nss.s162762] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/17/2020] [Indexed: 12/21/2022] Open
Abstract
Narcolepsy is a neurological disorder of the sleep-wake cycle characterized by excessive daytime sleepiness (EDS), cataplexy, nighttime sleep disturbances, and REM-sleep-related phenomena (sleep paralysis, hallucinations) that intrude into wakefulness. Dysfunction of the hypocretin/orexin system has been implicated as the underlying cause of narcolepsy with cataplexy. In most people with narcolepsy, symptom onset occurs between the ages of 10 and 35 years, but because the disorder is underrecognized and testing is complex, delays in diagnosis and treatment are common. Narcolepsy is treated with a combination of lifestyle modifications and medications that promote wakefulness and suppress cataplexy. Treatments are often effective in improving daytime functioning for individuals with narcolepsy, but side effects and/or lack of efficacy can result in suboptimal management of symptoms and, in many cases, significant residual impairment. Additionally, the psychosocial ramifications of narcolepsy are often neglected. Recently two new pharmacologic treatment options, solriamfetol and pitolisant, have been approved for adults, and the indication for sodium oxybate in narcolepsy has been expanded to include children. In recent years, there has been an uptick in patient-centered research, and promising new diagnostic and therapeutic options are in development. This paper summarizes current and prospective pharmacological therapies for treating both EDS and cataplexy, discusses concerns specific to children and reproductive-age women with narcolepsy, and reviews the negative impact of health-related stigma and efforts to address narcolepsy stigma.
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Affiliation(s)
- Emily C Barker
- Case Western Reserve University School of Medicine, Department of Pediatrics, Cleveland, OH, USA
| | | | - Shalini Paruthi
- Sleep Medicine and Research Center, St. Luke’s Hospital, St. Louis, MO, USA
- Saint Louis University School of Medicine, Departments of Medicine and Pediatrics, St. Louis, MO, USA
| | - Katherine M Sharkey
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Psychiatry & Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
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15
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Scheer D, Schwartz SW, Parr M, Zgibor J, Sanchez-Anguiano A, Rajaram L. Prevalence and incidence of narcolepsy in a US health care claims database, 2008-2010. Sleep 2020; 42:5475508. [PMID: 31004158 DOI: 10.1093/sleep/zsz091] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 03/12/2019] [Indexed: 01/03/2023] Open
Abstract
STUDY OBJECTIVES To determine the prevalence and incidence of narcolepsy using a large US health care claims database. METHODS The Truven Health MarketScan Commercial Dissertation Database (THMCDD) was used to estimate prevalence and incidence of narcolepsy, with and without cataplexy, by age groups, gender, and region among patients under age 66 years with continuous enrollment for years 2008-2010. THMCDD contains health claims information for more than 18 million people. Prevalence was expressed as cases/100 000 persons. Average annual incidence (using varying criteria for latency between the diagnostic tests, polysomnograph coupled with multiple sleep latency test [MSLT], and the diagnosis) was expressed as new cases/100 000 persons/year. RESULTS There were 8 444 517 continuously enrolled patients and 6703 diagnosed with narcolepsy (prevalence overall: 79.4/100 000; without cataplexy: 65.4/100 000; with cataplexy: 14.0/100 000). On the basis of the three definitions of incidence, overall average annual incidence was 7.67, 7.13, and 4.87/100 000 persons/year. Incidence for narcolepsy without cataplexy was generally several times higher than narcolepsy with cataplexy. Prevalence and incidence were approximately 50% greater for females compared to males across most age groups. Prevalence was highest among the 21-30 years age group, with incidence highest among enrollees in their early 20s and late teens. Regionally, the North Central United States had the highest prevalence and incidence, whereas the West was the lowest. CONCLUSION We found greater prevalence and incidence of narcolepsy (including without cataplexy) than most previous studies. The increased proportions in females, enrollees in their early 20s, and US regional differences require further study. Increased awareness and early identification is critical in the management of this burdensome condition.
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Affiliation(s)
- Darren Scheer
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL.,Department of Epidemiology and Pharmacovigilance, Biotech Research Group Corp., Tampa, FL.,Pharmaceutical Development Group Inc., Tampa, FL.,Pharmacovigilance and Epidemiology, Spotline Inc., San Jose, CA
| | - Skai W Schwartz
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
| | - Maria Parr
- EviCore Healthcare, Department of Sleep Medicine, Franklin, TN
| | - Janice Zgibor
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
| | - Aurora Sanchez-Anguiano
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
| | - Lakshminarayan Rajaram
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
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16
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Kawai R, Watanabe A, Fujita S, Hirose M, Esaki Y, Arakawa C, Iwata N, Kitajima T. Utility of the sleep stage sequence preceding sleep onset REM periods for the diagnosis of narcolepsy: a study in a Japanese cohort. Sleep Med 2020; 68:9-17. [PMID: 31999982 DOI: 10.1016/j.sleep.2019.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/14/2019] [Accepted: 04/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The minimum narcolepsy criteria "mean sleep latency (MSL) ≤8 min and ≥2 sleep onset rapid eye movement (REM) periods (SOREMPs) on polysomnography (PSG) and the multiple sleep latency test (MSLT)," according to The International Classification of Sleep Disorders, Third Edition (ICSD-3), are not specific to narcolepsy. Recently, the characteristic sleep stage sequences preceding SOREMPs in narcolepsy have received attention, but their diagnostic utility remains unclear. METHODS We retrospectively reviewed PSG/MSLT records and chart data for 102 Japanese patients with hypersomnia and at least one SOREMP. We examined the sporadic rates of two sleep stage sequences preceding the SOREMPs-wakefulness or stage 1 to REM (W/S1→R) and stage 2 to REM (S2→R)-comparing these between patient groups with narcolepsy type 1 (N = 28), narcolepsy type 2 (N = 19), and other hypersomnia (N = 55). We also examined the utility of three simple indices using the occurrence of W/S1→R SOREMPs for distinguishing between narcolepsy and other hypersomnia in patients who satisfied the minimum narcolepsy criteria. RESULTS W/S1→R SOREMPs were significantly more frequent in narcolepsy than in other hypersomnia, and this tendency was also observed even in the patients who satisfied the minimum narcolepsy criteria. The three indices had moderate sensitivities and specificities for distinguishing between narcolepsy and other hypersomnia in patients satisfying the minimum narcolepsy criteria. CONCLUSIONS The W/S1→R pattern was observed significantly more frequently in narcolepsy than in other hypersomnia, suggesting it may help with differentiating narcolepsy from other hypersomnia in patients demonstrating the narcolepsy criteria, although its ability to do so may be modest.
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Affiliation(s)
- Ryoko Kawai
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Akiko Watanabe
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Shiho Fujita
- Department of Laboratory Medicine, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Marina Hirose
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yuichi Esaki
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Chiaki Arakawa
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Tsuyoshi Kitajima
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
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17
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Miskoff JA, Chaudhri M. A Case of Off-label Sodium Oxybate in an 11-Year-Old with Narcolepsy. Cureus 2019; 11:e4057. [PMID: 31016084 PMCID: PMC6464478 DOI: 10.7759/cureus.4057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Narcolepsy is a rare chronic condition which affects sleep architecture. It may manifest in childhood or adolescence by causing excessive daytime sleepiness, sleep attacks, and hallucinations. Research suggests that there is a significant delay in diagnosis with the mean age being 10 to 15 years from onset of symptoms. Although narcolepsy is predominantly associated with loss of hypocretin (orexin), the role of genetics is complementary to the diagnosis. In addition, clinical manifestations of symptoms vary in presentation and severity from case to case. Therefore, this report provides an opportunity to review pediatric narcolepsy including the diagnostic workup and clinical response to sodium oxybate. This particular case describes an 11-year-old boy meeting the clinical and diagnostic criteria for narcolepsy. Clinically, the patient had a very positive response to treatment with sodium oxybate, which at the time of initiating therapy was off-label for patients under the age of 18.
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Affiliation(s)
- Jeffrey A Miskoff
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Moiuz Chaudhri
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
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18
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Cairns A, Trotti LM, Bogan R. Demographic and nap-related variance of the MSLT: results from 2,498 suspected hypersomnia patients: Clinical MSLT variance. Sleep Med 2018; 55:115-123. [PMID: 30785052 DOI: 10.1016/j.sleep.2018.12.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/12/2018] [Accepted: 12/17/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to enhance our understanding of clinical trends in sleep and rapid eye movement (REM) propensity on the multiple sleep latency test (MSLT). Demographic variables of interest included early childhood/advanced age, gender, race, and REM-suppressant use. METHODS Nocturnal sleep studies and 5-nap MSLTs were retrieved from a large repository of deidentified studies from various US sleep clinics between 2007 and 2015. Studies were signal processed, human-edited, and underwent rigorous quality assurance for inclusion. RESULTS The final sample consisted of N = 2498 MSLTs (24.2% Black; 34.2% Men; Age 4-89). In adults (age ≥ 21), sleep propensity modestly decreased across nap (90% at nap 1 to 80% at nap 5; p < 0.001). Children ≤12 years were least likely to fall asleep on any nap (∼55% at nap 5). REM propensity troughed at nap 4 (13%) and varied with age. Advanced age (≥60 years; OR: 0.28, p < 0.001), REM-suppressant use (OR:0.52, p < 0.001), and female sex (men OR: 1.48, p = 0.012) was associated with a decreased proportion of ≥2 REMs in adjusted logistic models. Children often demonstrated only 1 REM and generally had long sleep latencies, yielding a low proportion of MSLTs consistent with narcolepsy (11.0% vs. 19.2% and 16.8% in those between 13-20 and 21-59, respectively; p = 0.003). CONCLUSIONS MSLT outcomes vary greatly across age, gender, and use of psychotropic medication. Demographic variance should be considered when interpreting MSLT results. Robust age effect question the appropriateness of the MSLT as currently designed and implemented for children and older adults.
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Affiliation(s)
| | - Lynn Marie Trotti
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Bogan
- SleepMed, Inc. Columbia, SC, USA; The University of South Carolina Medical School, Columbia, SC, USA; Bogan Sleep Consultants, LLC, Columbia, SC, USA
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19
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Villa KF, Reaven NL, Funk SE, McGaughey K, Black J. Changes in Medical Services and Drug Utilization and Associated Costs After Narcolepsy Diagnosis in the United States. AMERICAN HEALTH & DRUG BENEFITS 2018; 11:137-145. [PMID: 29910845 PMCID: PMC5973250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 01/30/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Healthcare utilization and the cost implications associated with undiagnosed and/or misdiagnosed narcolepsy have not been evaluated, and there is scant literature characterizing the newly diagnosed population with narcolepsy with respect to treatment patterns and resource utilization. OBJECTIVE To analyze the changes in medication use, healthcare utilization, and the associated costs after a new diagnosis of narcolepsy. METHODS In this retrospective cohort study, we used data from the Truven Health Analytics MarketScan Research Databases, between January 2006 and March 2013, to identify patients who had a probable new diagnosis of narcolepsy-defined as a de novo medical claim for a multiple sleep latency test-which was preceded by ≥6 months of continuous insurance and was followed by a de novo diagnosis of narcolepsy. The utilization and cost of medical services and the percentage of patients filling prescriptions for narcolepsy-related medications were evaluated in 3 consecutive 1-year periods from the date of a positive multiple sleep latency test result (ie, index date), and each year's findings were compared with the annualized results from the 6-month preindex period. RESULTS A total of 3757 patients who met the definition of a new diagnosis of narcolepsy were identified. The total medical service utilization decreased each year from a preindex average of 28.2 visits per patient per year (PPPY) to 26.9 visits (P <.05), 23.1 visits (P <.0001), and 22.5 visits (P <.0001) PPPY in years 1, 2, and 3 postdiagnosis, respectively. In each outpatient service category, the medical services utilization decreased from preindex to year 3 postdiagnosis, including hospital outpatient and physician visits (P <.0001), and other outpatient and emergency department visits (P <.05). The percentage of patients receiving narcolepsy-related medications increased from 54.0% preindex to 77.4%, 70.0%, and 66.9% for years 1, 2, and 3 postindex (all P <.0001 vs preindex). The total medical service cost PPPY was $12,159 preindex and decreased to $10,708, $8543, and $9136 in years 1, 2, and 3 postindex (all P <.0001 vs preindex). CONCLUSIONS In this study, the confirmation of a diagnosis of narcolepsy was associated with decreasing utilization and associated costs of medical services in the first 3 years after diagnosis. The total costs encompassing medical services and pharmacy costs were relatively stable during this period.
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Affiliation(s)
- Kathleen F Villa
- Executive Director, Health Economics & Outcomes Research, Jazz Pharmaceuticals, Palo Alto, CA
| | | | - Susan E Funk
- Sr VP, Data Analytics, Strategic Health Resources
| | | | - Jed Black
- Senior Fellow, Sleep and CNS Medicine, Jazz Pharmaceuticals, and Adjunct Professor, Stanford University, Palo Alto, CA
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20
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Abstract
Narcolepsy is a sleep disorder that can manifest in childhood or adolescence by causing excessive sleepiness, hallucinations, sleep attacks, or cataplexy. There is often a significant delay in diagnosis with the mean time being 15 years from the onset of symptoms, which may lead to further exacerbations and a high comorbidity burden. Although narcolepsy is predominantly associated with loss of hypocretin (orexin), the role of genetics is poorly understood and, therefore, is complementary to the diagnosis but not confirmatory. We present the case of a child who was misdiagnosed as suffering from schizophrenia only to later uncover narcolepsy with cataplexy. Even though she did not meet strict criteria for narcolepsy type 1, her history and objective data were consistent enough to make an official diagnosis. In addition, her clinical response to treatment was very positive, further supporting narcolepsy as the most likely underlying condition. This presentation highlights the importance of continued education and research to reduce the risk of delay in diagnosis or misdiagnosis.
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Affiliation(s)
| | - Moiuz Chaudhri
- Medicine, Jersey Shore University Medical Center, Neptune City, USA
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21
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Prasad B, Saxena R, Goel N, Patel SR. Genetic Ancestry for Sleep Research: Leveraging Health Inequalities to Identify Causal Genetic Variants. Chest 2018; 153:1478-1496. [PMID: 29604255 DOI: 10.1016/j.chest.2018.03.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/02/2018] [Accepted: 03/19/2018] [Indexed: 02/08/2023] Open
Abstract
Recent evidence has highlighted the health inequalities in sleep behaviors and sleep disorders that adversely affect outcomes in select populations, including African-American and Hispanic-American subjects. Race-related sleep health inequalities are ascribed to differences in multilevel and interlinked health determinants, such as sociodemographic factors, health behaviors, and biology. African-American and Hispanic-American subjects are admixed populations whose genetic inheritance combines two or more ancestral populations originating from different continents. Racial inequalities in admixed populations can be parsed into relevant groups of mediating factors (environmental vs genetic) with the use of measures of genetic ancestry, including the proportion of an individual's genetic makeup that comes from each of the major ancestral continental populations. This review describes sleep health inequalities in African-American and Hispanic-American subjects and considers the potential utility of ancestry studies to exploit these differences to gain insight into the genetic underpinnings of these phenotypes. The inclusion of genetic approaches in future studies of admixed populations will allow greater understanding of the potential biological basis of race-related sleep health inequalities.
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Affiliation(s)
- Bharati Prasad
- Department of Medicine, University of Illinois at Chicago, and Jesse Brown VA Medical Center, Chicago, IL.
| | - Richa Saxena
- Center for Genomic Medicine and Department of Anesthesia, Pain, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Namni Goel
- Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sanjay R Patel
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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22
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Ruoff C, Rye D. The ICSD-3 and DSM-5 guidelines for diagnosing narcolepsy: clinical relevance and practicality. Curr Med Res Opin 2016; 32:1611-1622. [PMID: 27359185 DOI: 10.1080/03007995.2016.1208643] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Narcolepsy is a chronic neurological disease manifesting as difficulty with maintaining continuous wake and sleep. Clinical presentation varies but requires excessive daytime sleepiness (EDS) occurring alone or together with features of rapid-eye movement (REM) sleep dissociation (e.g., cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis), and disrupted nighttime sleep. Narcolepsy with cataplexy is associated with reductions of cerebrospinal fluid (CSF) hypocretin due to destruction of hypocretin peptide-producing neurons in the hypothalamus in individuals with a specific genetic predisposition. Updated diagnostic criteria include the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and International Classification of Sleep Disorders Third Edition (ICSD-3). DSM-5 criteria require EDS in association with any one of the following: (1) cataplexy; (2) CSF hypocretin deficiency; (3) REM sleep latency ≤15 minutes on nocturnal polysomnography (PSG); or (4) mean sleep latency ≤8 minutes on multiple sleep latency testing (MSLT) with ≥2 sleep-onset REM-sleep periods (SOREMPs). ICSD-3 relies more upon objective data in addition to EDS, somewhat complicating the diagnostic criteria: 1) cataplexy and either positive MSLT/PSG findings or CSF hypocretin deficiency; (2) MSLT criteria similar to DSM-5 except that a SOREMP on PSG may count as one of the SOREMPs required on MSLT; and (3) distinct division of narcolepsy into type 1, which requires the presence of cataplexy or documented CSF hypocretin deficiency, and type 2, where cataplexy is absent, and CSF hypocretin levels are either normal or undocumented. We discuss limitations of these criteria such as variability in clinical presentation of cataplexy, particularly when cataplexy may be ambiguous, as well as by age; multiple and/or invasive CSF diagnostic test requirements; and lack of normative diagnostic test data (e.g., MSLT) in certain populations. While ICSD-3 criteria reflect narcolepsy pathophysiology, DSM-5 criteria have greater clinical practicality, suggesting that valid and reliable biomarkers to help standardize narcolepsy diagnosis would be welcomed.
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Affiliation(s)
- Chad Ruoff
- a Center for Sleep Sciences and Medicine, and Department of Psychiatry and Behavioral Sciences , Stanford University School of Medicine , Palo Alto , CA , USA
| | - David Rye
- b Department of Neurology and Program in Sleep , Emory University School of Medicine , Atlanta , GA , USA
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23
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Berkowski JA, Shelgikar AV. Disorders of Excessive Daytime Sleepiness Including Narcolepsy and Idiopathic Hypersomnia. Sleep Med Clin 2016; 11:365-78. [DOI: 10.1016/j.jsmc.2016.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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24
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Maski K. Understanding Racial Differences in Narcolepsy Symptoms May Improve Diagnosis. Sleep 2015; 38:1663-4. [PMID: 26446120 DOI: 10.5665/sleep.5130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 09/26/2015] [Indexed: 11/03/2022] Open
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25
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Andlauer O. Optimising the diagnosis of narcolepsy: looking deeper into sleep studies. Sleep Med 2015; 16:1556-7. [PMID: 26481276 DOI: 10.1016/j.sleep.2015.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Olivier Andlauer
- Newham Centre for Mental Health, East London NHS Foundation Trust, Cherry Tree Way, Glen Road, Plaistow, E13 8SP London, UK.
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