Correct!
5. Any of the above
There are a variety of options for treating narcolepsy (5). Appropriate precautions should be reviewed with each medication. Most begin with sodium oxybate (or the low sodium alternative calcium/magnesium/potassium/sodium oxybate) or modafinil (or its entamomer armodafinil). Solriamfetol a dopamine/norepinephrine reuptake inhibitor (DNRI), was recently approved as was pitolisant, a nonscheduled, first-in-class histamine3 (H3) receptor antagonist/inverse agonist.
There are many factors that play into the choice including ease of prescribing. For example, sodium oxybate needs to be prescribed by an approved prescriber and the drug comes from a single US pharmacy so it takes time and is costly. Approval by insurance is also a problem due to cost and some will insist on a trial of amphetamines first because they are inexpensive. The patient ideally has a bed partner to ensure awakening in the middle of the night to take a second dose, since these are very short acting. It puts narcoleptics into deep sleep and I have had patients refuse because they were concerned they would not get up when their babies cried, etc. Modafinil and amphetamines can be prescribed easily and are safe. There’s less experience with the newer agents solriamfetol and pitolisant which are also very costly.
I usually recommend referral to a sleep specialist for treatment of narcolepsy. Recently, modafinil and other stimulants have come under increasing scrutiny by State Boards of Pharmacy.
This patient was treated with modafinil. With a diagnosis of narcolepsy and cataplexy he was med boarded and left the military. When last seen he was working and not on any medications, possibly using strategic napping to control symptoms.
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