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Advances in Promoting Wakefulness in Narcolepsy
Michael Thorpy M.D.
Montefiore Medical Center
and
the Albert Einstein College of Medicine
Bronx, New York
NESS, Boston, March 27, 2010
Narcolepsy Treatment Goals Reduce excessive sleepiness Control cataplexy
Other associated REM-related symptoms (sleep paralysis, hypnagogic and hypnopompic hallucinations)
Improve nighttime sleep Reduce psychosocial problems
Krahn LE et al. (2001), Mayo Clin Proc 76(2):185-194; Black J (2001), Central Nervous System News Special Edition 25-29; U.S. Xyrem Multicenter Study Group (2002), Sleep 25(1):42-49
Narcolepsy: Management Approaches
Excessive daytime sleepiness Structured nocturnal sleep Naps: scheduled and prn Stimulants or wake-promoting agents Sodium Oxybate
Cataplexy Antidepressants (TCA, SSRI, NERI) Sodium oxybate
Parkes D (1994), Sleep 17(suppl):S93-S96; Mitler MM et al. (1994), Sleep 17(4):352-371; Daly DD, Yoss RE (1976), Narcolepsy. In: Handbook of Clinical Neurology Vol. 15, Vinken PJ, Bruyn GW, eds. New York: Elsevier Publishing, pp836-852; Bassetti C, Aldrich MS (1996), Neurol Clin 14(3):545-571; Mamelak M et al. (1986), Sleep 9(1 pt 2):285-289
Narcolepsy: Management Approaches (Cont.)
Sleep fragmentation Sleep hygiene Hypnotics Sodium oxybate
Sleep disorders Hypnagogic Hallucinations – TCA’s, sodium oxybate Nightmares – TCA’s, sodium oxybate Sleep Paralysis – TCA’s, sodium oxybate Periodic Limb Movements – Dopamine agonists REM Sleep Behavior Disorder – Clonazepam, melatonin
Parkes D (1994), Sleep 17(suppl):S93-S96; Mitler MM et al. (1994), Sleep 17(4):352-371; Daly DD, Yoss RE (1976), Narcolepsy. In: Handbook of Clinical Neurology Vol. 15, Vinken PJ, Bruyn GW, eds. New York: Elsevier Publishing, pp836-852; Bassetti C, Aldrich MS (1996), Neurol Clin 14(3):545-571; Mamelak M et al. (1986), Sleep 9(1 pt 2):285-289
Narcolepsy: Management Approaches (Cont.)
General Personal and family counseling Support –
Narcolepsy Network State funded support programs
Sleep hygiene Naps
Treatment of Excessive Sleepiness
Daytime Sleepiness Stimulants
Methylphenidate Dextroamphetamine Methamphetamine
Modafinil/ Armodafinil Sodium Oxybate
Physicians’ Desk Reference (2005), Montvale, N.J.: Medical Economics Company; Nishino S, Mignot E (2005), Wake-promoting medications: basic mechanisms and pharmacology. In: Principles and Practice of Sleep Medicine, Kryger MH et al., eds. Philadelphia: ElsevierPhysicians’ Desk Reference (2005), Montvale, N.J.: Medical Economics Company; Nishino S, Mignot E (2005), Wake-promoting medications: basic mechanisms and pharmacology. In: Principles and Practice of Sleep Medicine, Kryger MH et al., eds. Philadelphia: Elsevier
Stimulants and Wake-Promoting Medications
C-IV
C-II
C-II
C-II
C-II
Schedule
3-55-60 mg/dayTablets, SR, LAMethylphenidate
15200-400 mg/dayTabletsModafinil
10-135-60 mg/dayCapsules, XRAmphetamine sulfate/saccharate/aspartate (Adderall)
4-55-60 mg/dayTabletsMethamphetamine (Desoxyn)
125-60 mg/dayTablets, SRDextroamphetamine
T1/2
(Hours)DoseFormulationsDrug
C-IV 15150-250 mg/dayTabletsArmodafinil
Alerting Agents
Sympathomimetic: enhance neurotransmission of dopamine, norepinephrine, serotonin
Caffeine: adenosine receptor antagonist Modafinil: specific mechanism remains unclear
Mechanism
Considerations for Use of Stimulants and Wake-Promoting Agents
Drug-drug interactions: CYP 450
Adverse effects: anxiety/nervousness,
restlessness, insomnia, headache, tremor,
dyskinesia, tachycardia, hypertension, psychosis
Abuse potential
Tolerance
Medial Prefrontal Cortex Regions (BA 10) Activated by Caffeine vs. Placebo During Verbal Working Memory
Adapted from Koppelstaetter et al. (2008)
Caffeine
Rx
Adapted from Killgore et al. (2008)
Clock Time
Sites of Action of Amphetamines
Courtesy of Thomas Scammell, MD.
Amphetamine Dopaminereuptake
transporter
VesicularMonoaminetransporter
Dopamine
Dopaminereceptors
MAO
+
High-dose Stimulants
58 patients who were taking high-dose stimulants for narcolepsy or idiopathic hypersomnia were compared with 58 control patients.
High dose stimulants were >120mg/day. The prevalence of psychosis, psychiatric
hospitalizations, tachyarrhythmias, polysubstance abuse, anorexia and weight loss were significantly increased in the stimulant group.
Auger et al. Risks of high dose stimulants in the treatment of disorders of excessive somnolence. A case control study. Sleep 2005;28:667-672
Pharmacotherapy: Sleepiness Modafinil
150 - 500 mg/day Moderate efficacy, long half life Best side effect profile Schedule IV, most expensive
Methylphenidate 5 - 100 mg/day Short half life formulation, variable dosing Used alone or in combination Sympathomimetic effects, mood alterations
Modafinil: Sites of Action Chemically unrelated to CNS stimulants Inhibits the dopamine transporter (DAT)
Contrary to amphetamine, may not induce release of dopamine
Activates wake-promoting neurons Inhibits norepinephrine transporter in the VLPO
Contrary to amphetamine, may not induce release of norepinephrine
Enhanced norepinephrine inhibits sleep promoting VLPO neurons
Stimulates hypocretin release Stimulates histamine release from the TMN
VLPO = Ventrolateral preoptic area
Modafinil: Sites of Action
VLPO = Ventrolateral preoptic area
Tuberomamillary nucleusStimulationHistamine
Lateral hypothalamusStimulationHypocretin
VLPOInhibition of the NE reuptake
transporter
Norepinephrine (NE)
Multiple arousal systemsInhibition of dopamine reuptake
transporter
Dopamine
Site of ActionMethod of actionNeurotransmitter
Proposed Sites of Action of Modafinil
Dopaminereuptake
transporter
Dopamine
Dopaminereceptors
MAO
MAO
Norepinephrinereuptake
transporter
Norepinephrine
Wake-promotingneurons
2 Norepinephrinereceptors
Sleep-promotingneurons
(GABA; VLPO)
Modafinil
+
-
–
Alerting Agents Stabilize Wakefulness
GABA
NorepinephrineHistamine
DopamineSerotonin
Acetylcholine
Wake
GABA(ventrolateral
Preopticarea)
Sleep
–
ModafinilAmphetamines
+
Modafinil
– NorepinephrineSerotonin
Pharmacokinetic Properties of Modafinil
Pharmacokinetics Linear, Independent of dose
Peak Plasma Concentration 2 - 4 hrs, Tmax delayed (~ 1 hr) by food
Plasma Protein Binding: Moderate (~60%)
Elimination Half-life 15 hrs
Metabolism: Metabolized by liver (~90%)
Urinary Excretion: < 10% of unchanged drug, All metabolites
-5.7+2.4+1.9
18.02.75.9
-4.4+1.9+2.1
17.43.06.1
ESSMSLTMWT
Narcolepsy II
-4.1+1.9+2.3
17.13.36.6
-3.5+1.8+2.3
17.92.95.8
ESSMSLTMWT
Narcolepsy I
---
---
-1.5+1.7-2.6
7.32.1
12.5
KSSMSLTPVT
SWD
-4.5+1.5
13.6-4.5+1.6
13.1ESSMWT
OSA II study
-4.6+1.2
14.27.4
--
--
ESSMSLT
OSA I study
Change from
baseline
BaselineChange from
baseline
Baseline
Modafinil 400mgModafinil 200mgMeasuresDisorder
Modafinil
MWT Sleep Latency: Split-Dose vs AM Dosing Regimens
MWT Sleep Latency: Split-Dose vs AM Dosing Regimens
Morning (9-11 AM)
Afternoon (1-3 PM)
Evening (5-7 PM)
Mea
n (
+S
EM
) M
WT
ch
ang
e fr
om
bas
elin
e
0
5
10
15
* †
400 mg split-dose
400 mg qd
200 mg qd
The % of patients able to sustain wakefulness was highest in the morning with the 400-mg single dose and in the evening with the split dose regimen
*P<.001 vs 200 mg qd†P<.05 vs 400 mg qd Schwartz JRL, et al. Clin Neuropharmacol. 2003;26:252-257.
N=32
MWT Sleep Latency: MWT Sleep Latency: Comparing Split-Dose RegimensComparing Split-Dose Regimens
MWT Sleep Latency: MWT Sleep Latency: Comparing Split-Dose RegimensComparing Split-Dose Regimens
Morning (9-11 AM)
Afternoon (1-3 PM)
Evening (5-7 PM)
% o
f p
atie
nts
aw
ake
for
20 m
inu
tes *
* 400 mg split-dose
400 mg qd
200 mg qd
*P<.05 vs 200 or 400 mg qdSchwartz JRL, et al. J Neurol Clin Neurosci. 2004; 27(2): 74-79.
600 mg split-dose
0
50
70
80
40
30
20
10
60
N=24
Armodafinil (Nuvigil)
R-(-)-modafinil
Longer acting isomer of modafinil
Half life approximately 3 x S-(-)-modafinil
Armodafinil
+2.69.5+1.312.1MWTNarcolepsy
--+3.02.3MSLTSWD
--+2.323.7MWTOSA II
+2.223.3+1.721.5MWTOSA I
Change from
baseline
Baseline Change from
Baseline
Baseline
Armodafinil 250mgArmodafinil 150mgMeasuresDisorder
Modafinil / armodafinil
N/A100-400mgnoFatigueEDS
Traumatic Brain Injury
N/A200-400mgnoFatigueChronic fatigue syndrome
N/A100-400mgnoEDSParkinson’s disease
N/A200-400mgnoFatigueMultiple Sclerosis
N/A100-400mgnoFatigueDepression
150 – 250mg200-400mgyesEDSNarcolepsy
150mg200-400mgyesEDSShift Work Disorder
150 – 250mg200-400mgyesEDSObstructive Sleep Apnea
ArmodafinilDoses studied
ModafinilDoses studied
FDA approvalSymptomsDiagnosis
4%6%Diarrhea
not reported3%Hypertension
1%4%Flu syndrome
6%6%Back pain
not reported7%Rhinitis
5%5%Insomnia
4%5%Anxiety
1%7%Nervousness
5%5%Dizziness
7%11%Nausea
17%34%Headache
ArmodafinilModafinilAdverse Effects
Modafinil / Armodafinil
Sodium Oxybate: Physiology Endogenous metabolite of GABA
Affects the GHB and GABA-B receptors
Neuromodulator
GABA
Dopamine
Serotonin
Endogenous opioids
Evidence for role as neurotransmitter
Synthesized in neurons, stored in vesicles, released via depolarization into synaptic cleft, reuptake, specific receptors
Sodium Oxybate: Pharmacokinetics
Absorption Tmax = 0.5 h-1.25 h
Dose proportionality Nonlinear kinetics
Distribution <1% protein bound
Metabolism Bioavailability ~25% (hepatic first-pass metabolism)
Diffuse cellular metabolismEnd product CO2 + H2O
No active metabolite
Elimination Predominantly metabolized
~5% unchanged in urine
T1/2 = 40-60 min
Food Slows bioavailability (AUC 30% with full meal)
AUC = area under the curve.
Sodium Oxybate: Sites of Action
GABA
Sodium Oxybate
H2N
OH
O
NaOOH
O
GABA-AGABA-B GHB receptor
-O
OH
O
Na+
Sodium Oxybate: CNS Pharmacology
Binds to GABAB receptor Antagonism and deletion of GABAB in animal
models inhibits sodium oxybate–induced sleep and some neuromodulation effects
Dual effect on noradrenergic locus coeruleus Inhibition during administration of sodium
oxybate Potentiation following cessation of treatment
Sodium Oxybate - Modafinil: 8-Week, Double Blind, Placebo-Controlled Trial Treatment Arms
N=222. SXB-22 .
*Placebo: sodium oxybate; †Placebos: modafinil + sodium oxybate; §Placebo: modafinil.
Data on file, Orphan Medical.
Sodium oxybate§6.0 g 9.0 g
n=50
200 to 600 mg/day
Modafinil*(unchanged dosing)
n=63
200 to 600 mg/day200 to 600 mg/day
Modafinil(single blinded *)
Placebo† (modafinil withdrawn)
n=55
200 to 600 mg/day
Week
6.0 g 9.0 gModafinilSodium oxybate
-4 0 4 8
n=54200 to 600 mg/day200 to 600 mg/day
Baseline Endpoint
N=230. SXB-22. MWT = Maintenance of Wakefulness Test.Data on file, Orphan Medical.
0
1
2
3
4
5
6
7
Placebo(modafinil withdrawn)
Modafinil Sodium oxybate
Modafinil +sodium oxybate
Dif
fere
nc
e o
f th
e m
ea
ns
(m
in)
Difference from placebo (modafinil withdrawn)
P<0.001
P=0.002
P<0.001
Sodium Oxybate - Modafinil: 8-Week, Placebo-Controlled Trial MWT Sleep Latency
Treatment SuggestionsMain Symptom: Severe or moderate daytime sleepiness: Modafinil
Moderate or mild sleepiness, and disturbed nocturnal sleep: Sodium oxybate
Severe sleepiness and severe cataplexy: Sodium oxybate and modafinil
Mild sleepiness and cataplexy: Sodium oxybate
Nocturnal sleep symptoms: Fragmented sleep, hypnagogic hallucinations and nightmares: Sodium oxybate
Agents Under Development Non-hypocretin-based therapies
Histaminergic H3 antagonist/inverse agonists Novel monoaminergic reuptake inhibitors Novel SWS enhancers TRH analogues
Hypocretin-based Therapy Hypocretin-1 Hypocretin peptide agonist Nonpeptide agonist Hypocretin cell transplantation Gene therapy
Immune-based therapies Steroids IVIg Plasmapheresis
** p<0.01 ANOVA with post-hoc, vs. N. Controls
Histamine in Sleep Disorders
0 400 600 800 10002 0 0
CSF histamine levels (pg / ml)
**
**
**
**
(B2) Hcrt-/N/C/med+
(B1) Hcrt-/N/C/med-
(C) Hcrt+/N/C/med-
(D1) Hcrt-/N/woC/med-
(D2) Hcrt-/N/woC/med+
(E) Hcrt+/N/woC/med-
(F1) IHS/med-
(F2) IHS/med+
(G) OSAS
(A) Neurological controls
Kanbayashi T, Kodama T, Kondo H, Satoh S, Inoue Y, Chiba S, Shimizu T, Nishino S. CSF histamine contents in narcolepsy, idiopathic hypersomnia and obstructive sleep apnea syndrome. Sleep. 2009 Feb 1;32(2):181-7.
Histamine and Sleep Histamine neurons project to practically all brain regions, including areas
important for vigilance control, such as the hypothalamus, basal forebrain, thalamus, cortex, and brainstem structures.
Hcrtr 1 is enriched in the ventromedial hypothalamic nucleus, tenia tecta, hippocampal formation, dorsal raphe, and locus coeruleus (LC).
Hcrtr 2 is enriched in the paraventricular nucleus, cerebral cortex, nucleus accumbens, ventral tegmental area, substantia nigra, and histaminergic TMN.
TMN exclusively expresses Hcrtr 2.
Hypocretin potently excites TMN histaminergic neurons through Hcrtr 2. Wake-promoting effects of hypocretins are totally abolished in histamine
H1 receptor KO mice, Therefore, the wake-promoting effects of hypocretin is dependent on the
histaminergic neurotransmission 1
1. Barbier AJ, Bradbury MJ. Histaminergic control of sleep-wake cycles: recent therapeutic advances for sleep and wake disorders. CNS Neurol Disord Drug Targets 2007;6:31-43.
Histamine Receptor Subtypes There are four histamine receptor subtypes, (H1R-H4R) All G protein coupled receptors (GPCRs). Greater than 50% of
the most successful pharmaceutical treatments are drugs that act via GPCRs pathways.
H1R blockers have sedative effects are anti-allergy. H2R based drugs are anti-ulcer drugs. H3R antagonists activate histaminergic neurons, increasing
histamine, and producing wakefulness. H4R is expressed in hematopoietic cells suggesting a strong
role in inflammatory and immunomodulatory processes.
Histaminergic H3R Antagonists H3R, presynaptic autoreceptor of histamine neurons.
Histamine inhibits its own synthesis and release by a negative feedback process and that these actions are mediated by H3 receptors.
Stimulation of H3R causes sedation, antagonism causes wakefulness.
H3R is densely located centrally in the hippocampus, amygdala, nucleus accumbens, globus pallidus, hypothalamus striatum, substantia nigra, and the cerebral cortex.
Peripherally, H3R are also located in the GI tract, airways and cardiovascular system.
H3R antagonists are being studied for sleep wake disorders, ADHD, epilepsy, cognitive impairment, schizophrenia, obesity, and neuropathic pain.
Histamine 3 receptor (H3R) antagonists
Effective in canines on sleepiness and cataplexy Promotes wakefulness in mice with ablation of hypocretin
neurons (ataxin-3)
H3R antagonists thioperamide, carboperamide, and ciproxifan have been tested in rats, mice and cats.
Increase in wakefulness without rebound hypersomnolence or increasing locomotor activity.
APD916 is currently in Phase 1 trials for narcolepsy by Arena Pharmaceuticals
1. Barbier AJ, Bradbury MJ. Histaminergic control of sleep-wake cycles: recent therapeutic advances for sleep and wake disorders. CNS Neurol Disord Drug Targets 2007;6:31-43.
Histaminergic H3R Inverse Agonists- Tiprolisant
Tiprolisant or BF2.649 is the first H3 inverse agonist that passed clinical Phase II trials in the treatment of EDS in narcolepsy.
In a pilot study single blinded with 22 patients, receiving a placebo followed by tiprolisant for one week, the ESS was reduced from baseline of 17.6, by 5.9 with tiprolisant compared to 1.0 for placebo.
Effect similar to modafinil.
Tiprolisant has been granted orphan drug status by the European Medicine Agency for the therapeutic treatment of narcolepsy.
Multiple other compounds in development: Conessine , JNJ-637940 , GSK 189254
Lin JS, Dauvilliers Y, Arnulf I, et al. An inverse agonist of the histamine H(3) receptor improves wakefulness in narcolepsy: studies in orexin-/- mice and patients. Neurobiol Dis 2008;30:74-83.
Hypocretin
Intracerebroventricular hypocretin replacement, intranasal hypocretin administration, hypocretin cell transplantation, hypocretin gene therapy, and hypocretin stem cell transplantation are being studied for narcolepsy.
Hypocretin-1 low permeability to the blood-brain barrier. Hypocretin-2 does not cross the blood-brain barrier. Hypocretin-1 more stable in the blood and CSF than
hypocretin-2. Hypocretin-1 binds with two to three times the affinity to
HCTR-1 than hypocretin-2
Systemic and ICV Hypocretin-1
Intra-cerebro-ventricular (ICV) hypocretin-1 can suppress cataplexy and improve sleep in narcoleptic mice and canines.
Not effective in hcrt2 mutated dogs.
Systemic administration of hypocretin-1 in canines with narcolepsy produces increases in activity levels, wake times, reduces sleep fragmentation, and has a dose dependent reduction in cataplexy.
Small peptide hypocretin analogues might be an alternative.
Intranasal hypocretin administration holds promise.
Intranasal Hypocretin-1
Intranasal hypocretin bypasses the blood brain barrier with the added benefits of onset of action within minutes and fewer peripheral side effects.
Intranasal delivery works through the olfactory and trigeminal nerves.
The mechanism of action is extracellular so there is no dependence on receptors or axonal transport for drug delivery.
Csf fluid levels are detectable after intranasal delivery of hypocretin. Intranasal hypocretin concentrations were highest in the
hypothalamus and the trigeminal nerve.
Hanson LR , Taheri M, Kamsheh L, et al. Intranasal administration of hypocretin 1 (orexin A) bypasses the blood-brain barrier and target the brain: a new strategy for the treatment of narcolepsy. . Drug Deliv Tech 2004;4:1-10.
Born J, Lange T, Kern W, et al.. Sniffing neuropeptides: a transnasal approach to the human brain. Nat Neurosci 2002;5:514-6.
Hypocretin Gene Therapy
Aimed at stimulating the production of hypocretin. Ectopic transgenic expression of hypocretin in mice
prevents cataplexy even with hypocretin neuron ablation.
Hypocretin gene therapy with viral vectors are a potential future treatment for narcolepsy-cataplexy.
Mieda M, Willie JT, Hara J, et al. Orexin peptides prevent cataplexy and improve wakefulness in an orexin neuron-ablated model of narcolepsy in mice. Proc Natl Acad Sci U S A 2004;101:4649-54.
Hypocretin Cell Transplantation
Normal subjects have approximately 70,000 hypocretin neurons and in narcolepsy-cataplexy, 85-95% of hypocretin neurons are lost.
A minimum of 10% of hypocretin producing cells need to be replaced for a therapeutic effect.
Transplantation is limited by graft survival and immune reactions. Transplantation of neonatal rat hypothalami into the brainstem of
adult rats produced poor graft survival. Donor supply may be a problem if the survival of grafts is
improved.
The barrier of graft survivability, graft reactions, and cost barriers could be reduced if genetically engineered cells or employing stem cell techniques were used instead.
Thyrotrophin-releasing Hormone Agonists
TRH is a small peptide of 3 amino acids
TRH receptor-1 is found predominantly in the hypothalamus. TRH receptor-2 is more widespread and in the reticular nucleus of
the thalamus.
TRH in high dose stimulates wakefulness and anticataplectic in the narcoleptic canine
TRH is excitatory on neurons and enhances dopamine and adrenergic transmission.
May promote wakefulness by direct effect on thalamocortical pathways
Nishino S, Arrigoni J, Shelton J, et al. Effects of thyrotropin-releasing hormone and its analogs on daytime sleepiness and cataplexy in canine narcolepsy. J Neurosci 1997;17:6401-8
Thyrotrophin-releasing hormone agonists
Three compounds had a significant impact on cataplexy, whereas only two of the three had benefit in excessive sleepiness.
Oral CG-3703 at two weeks was shown to reduced cataplexy and excessive sleepiness in a dose dependent manner. The effective dose in producing wakefulness was similar to a
reasonable dose of D-amphetamine. The action CG-3703 is due to enhancement of dopaminergic
effects.
TRH-degrading enzyme inhibitor, metallopeptidase, may be promising.
Nishino S, Arrigoni J, Shelton J, et al. Effects of thyrotropin-releasing hormone and its analogs on daytime sleepiness and cataplexy in canine narcolepsy. J Neurosci 1997;17:6401-8
Immune-based Therapies
Steroids: Ineffective in 1 human and 1 canine case
Plasmapheresis Little data available More invasive than IVIg
IVIg Effective in two studies
May need to be used early (<1 year of onset) No placebo controlled trials Generally safe but can cause life threatening side effects.
Intravenous Immunoglobulin (IVIg)
One case study 10 year old (Lecendreaux et al.) Sleepiness and cataplexy improved.
4 case studies (Dauvilliers et al.) Cataplexy improved.
4 cases (Zuberi et al.) Sleepiness improved more than cataplexy.
Lecendreux M, Maret S, Bassetti C, Mouren MC, Tafti M. Clinical efficacy of high-dose intravenous immunoglobulins near the onset of narcolepsy in a 10-year-old boy. J Sleep Res. 2003 Dec;12(4):347-8.
Yves Dauvilliers MD, Bertrand Carlander MD, François Rivier MD, PhD, Jacques Touchon MD, Mehdi Tafti, PhD. Successful management of cataplexy with intravenous immunoglobulins at narcolepsy onset Ann Neurol. 2004 Dec;56(6):905-8.
Zuberi SM, Mignot E, Ling L, McArthur I. Variable response to intravenous immunoglobulin therapy in childhood narcolepsy. J Sleep Res., 2004;13(suppl1) 828.
Future Directions
Other potential targets for reducing EDS will likely involve: Developing novel neuropeptides Targeting:
proteins such as circadian clock proteins,
specific ion channels such as prokineticin or neuropeptide S.
Conclusion
Pharmacological treatment of Narcolepsy involves not only treatment of Daytime Sleepiness and Cataplexy, but also Nocturnal Sleep.
Current treatment involves the use of Modafinil, Stimulants, Sodium Oxybate, adrenergic/serotonergic inhibitors.
New experimental treatment options for early onset narcolepsy include immune suppression treatments.
Future treatments may target hypocretin and histaminergic systems.