Factors in Selecting Optimal Therapy for Patients With Narcolepsy


Comprehensive insight on the factors that should inform which therapeutic approach, including novel agents such as solriamfetol, should be used to manage narcolepsy.


Chris Winter, MD: Age is a factor. We know that oxybates are approved for kids who are quite young. That’s a factor. Pregnancy is always a factor with any medication, so we want to make sure individuals who could become pregnant or are pregnant understand the different mechanisms of actions of the drugs and the relative risks they carry. Some medications like oxybate don’t play well with alcohol, so if an individual is known to drink significantly, particularly in the evening—maybe a young grad student who might be prone to more drinking—we want to talk about that as well.

Some of the drugs for narcolepsy interact with other drugs, and birth control pills are often something that we think about. Modafinil, armodafinil, even Wakix, or pitolisant—we want to make sure we’re letting patients know that this drug could affect the metabolism of your birth control pill and make it slightly less effective. We’re looking at concurrent psychiatric conditions and the other medications that the patient might be taking for those or other disorders, including depression and anxiety. All those things may predispose the clinician to choose 1 drug over another. The final thing I would say is, do you have a patient who’s predominantly type 2 excessively sleepy, or do you have a patient who struggles with sleepiness and cataplexy? If cataplexy is a big feature in a patient’s life, we may want to consider a drug like oxybate or pitolisant earlier in the process to get that cataplexy under control.

There are several drugs on the horizon that are quite exciting in terms of new therapies for narcolepsy. We can always use new therapies for patients with narcolepsy. As wonderful as the drugs we have are, there’s still a pretty big population of individuals who are improved, who benefit from the drugs, but still continue to be sleepier than they should be. We have sodium oxybate Xyrem and then a combination of oxybate called Xywav that has to be taken when patients go to bed and then 2½ to 4 hours later. There’s a drug on the horizon that would be a once-nightly formulation, so it would eliminate that patient having to get up in the middle of the night to take it. I’m always optimistic that drugs like pitolisant will get a pediatric indication. There’s work being done to make that happen. There are also medications that directly involve orexin. Some medications utilize orexin as a sleep aid. Some drugs on the horizon related to narcolepsy could enhance or promote orexin functionality that would help an individual stabilize and make their wakefulness more reliable during the day.

We have another medication, solriamfetol, that is FDA approved for narcolepsy. It goes by Sunosi. It’s interesting because as sleep doctors, we’ve been following the development of this drug for some time. It too is a medication being used when individuals wake up. Its approval is not only for narcolepsy but also for some people with excessive sleepiness related to things like sleep apnea. It’s a very effective drug, very easy drug to add on to other medications. The feedback from patients has been that the drug is quite effective and very well tolerated.

One of the balancing points with all medications that we use to treat narcolepsy is that sometimes, as you wake people up, you can create anxious feelings, jitteriness, or heart rate elevations. We’ve found with solriamfetol that sometimes those symptoms are quite minimized, that patients find that they like the effectiveness of the drug, but it also makes them feel a little more comfortable when they take it. It’s a very easy drug. We can give up to 150 mg of that drug per day, so it’s another great option in line with drugs like modafinil and armodafinil for individuals to take when they’re awake to help them improve or stabilize wakefulness during the day.

Transcript edited for clarity.

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