Rapid Weight Gain in an Excessively Sleepy Girl With Asthma

Timothy D. Murphy, MD


October 09, 2020

The treatment of narcolepsy focuses first on attempts to reduce the EDS pharmacologically; timed naps or increased time in bed is not usually sufficient to reduce the EDS. Although many medications have been used to treat EDS, clinicians typically start with caffeine (usually inadequate) and then move to stronger stimulants, such as methylphenidate or amphetamine and dextroamphetamine in combination.

Failure of these agents might then lead to the use of modafinil (prescription without the failure of other therapies is often difficult). Monitoring of response and fairly frequent visits are required at this point. A selective serotonin reuptake inhibitor, such as fluoxetine, is often added to the regimen of patients with classic cataplexy. As was the case for this patient, the use of medications that might affect mood, attention, learning, and sleep requires close attention and collaboration between specialists in sleep medicine, neurology, and behavioral and general pediatrics.

In some patients, including this patient, sodium oxybate (gamma-hydroxybutyrate [GHB]) is required to treat the cataplexy and to lead to better daytime functioning.[18] The exact mechanism of action is unknown, but the evening dosing of GHB is associated with improved REM sleep at night, perhaps relieving the intrusion of REM during daytime wake periods associated with type 1 narcolepsy. Unfortunately, GHB is associated with abuse — it is often called the "date rape drug" — and is now tightly regulated. Prescription in the United States is limited to one US pharmacy, and a sleep physician is typically required to obtain and use this medication.

The finding of EDS requires exploration of nocturnal problems with sleep, including RLS, OSA, and behavioral insomnia that affects daytime functioning. Narcolepsy can be diagnosed as the cause of EDS on the basis of careful history-taking as well as the results of an NPSG and an MSLT.


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