What specialty manages narcolepsy and cataplexy?

Management of Narcolepsy and Cataplexy: Specialty Care

Narcolepsy and cataplexy are optimally managed by sleep medicine specialists, with neurologists often serving as the primary specialists for these conditions. 1

Specialist Care Options

Sleep medicine specialists are typically the primary physicians who diagnose and manage narcolepsy and cataplexy. However, care often involves a multidisciplinary approach:

• Sleep Medicine Specialists: Experts in diagnosing and treating sleep disorders, they typically lead the management of narcolepsy
• Neurologists: Many neurologists specialize in sleep medicine and are well-equipped to manage narcolepsy
• Psychiatrists: May be involved when there are comorbid psychiatric symptoms or when psychotic features are present 2

Diagnostic Process

The diagnostic process typically involves:

• Comprehensive sleep history assessment using validated tools like the Epworth Sleepiness Scale (ESS) 1
• Overnight polysomnography (PSG) to rule out other sleep disorders
• Multiple Sleep Latency Test (MSLT) to confirm narcolepsy diagnosis
• Cerebrospinal fluid hypocretin-1 levels measurement in some cases 1

Treatment Approach

Pharmacological Management

The American Geriatrics Society recommends:

1. For excessive daytime sleepiness:

   • Modafinil as first-line treatment (starting at 100mg daily in elderly patients, typical range 200-400mg daily) 3, 1
   • Other stimulants like methylphenidate as alternatives
   • Pitolisant, a histamine H3 receptor antagonist/inverse agonist, for both excessive daytime sleepiness and cataplexy 4

2. For cataplexy:

   • Sodium oxybate (also improves daytime sleepiness, disrupted nocturnal sleep, hypnagogic hallucinations, and sleep paralysis) 3, 1
   • Antidepressants (TCAs, SSRIs, SNRIs) 3, 1

Non-pharmacological Management

• Regular sleep-wake schedule with adequate nighttime sleep
• Scheduled daytime naps
• Avoidance of heavy meals and alcohol
• Occupational counseling to avoid shift work and jobs requiring sustained attention 1

Follow-up and Monitoring

Regular follow-up is essential for:

• Monitoring medication efficacy and side effects
• Assessing residual sleepiness using tools like the ESS
• Evaluating any symptom exacerbation 3

When to Refer to a Sleep Specialist

Primary care physicians should refer patients to sleep specialists when:

• Narcolepsy or idiopathic hypersomnia is suspected
• The cause of sleepiness is unknown
• Patients are unresponsive to initial therapy 3

Common Pitfalls in Management

• Misdiagnosis: Narcolepsy can be misdiagnosed as a psychiatric disorder or epilepsy 5
• Incomplete treatment: Focusing only on excessive daytime sleepiness while neglecting cataplexy management
• Inadequate follow-up: These are typically lifelong disorders requiring ongoing management 3
• Failure to address quality of life: Untreated narcolepsy can significantly impact quality of life, causing depression, social withdrawal, and increased risk of accidents 1

Support Resources

Referral to support services and groups such as the Narcolepsy Institute or National Sleep Foundation can be beneficial for patients 3, 1