How is cataplexy managed?

Management of Cataplexy

Sodium oxybate is the first-line treatment for cataplexy in narcolepsy patients, as it is FDA-approved for treating both cataplexy and excessive daytime sleepiness. 1, 2

First-Line Pharmacological Options

• Sodium oxybate (Xyrem/Xywav) is administered as a liquid in two divided doses at night, with the first dose at bedtime and the second dose 2.5-4 hours later 3
• Pitolisant, a histamine-3-receptor inverse agonist, is also effective for cataplexy management and has the advantage of not being a controlled substance 1
• Clinical trials have demonstrated that patients who discontinue sodium oxybate experience significant worsening in the average weekly number of cataplexy attacks compared to those who continue treatment 2

Second-Line Pharmacological Options

• Antidepressants are effective for cataplexy control, particularly those affecting norepinephrine and serotonin systems 4, 5:
  • Venlafaxine (an SNRI) is recommended as the second-line treatment based on its favorable benefit-risk ratio 5
  • Tricyclic antidepressants (imipramine, protriptyline) at lower doses than used for depression 6
  • SSRIs such as fluoxetine have shown efficacy with mean reductions of up to 92% in cataplexy episodes 7

Special Populations Considerations

• For pediatric patients:

  • Sodium oxybate is FDA-approved for treating cataplexy in children 7 years and older 2
  • Venlafaxine has been used successfully in children with cataplexy at doses ranging from 37.5 mg to 112.5 mg daily 8

• For elderly patients:

  • Careful monitoring is required when using sodium oxybate due to potential adverse effects 3
  • Dosing should be initiated at lower levels and titrated more gradually 4

Non-Pharmacological Management

• Behavioral modifications can help control cataplexy 4:

  • Maintain good sleep hygiene and regular sleep-wake schedules
  • Avoid heavy meals and alcohol
  • Schedule strategic short naps (15-20 minutes) around noon and late afternoon

• Occupational considerations 4, 9:

  • Patients should avoid shift work, on-call schedules, and jobs requiring continuous attention
  • Healthcare workers should assist with occupational accommodations for disabilities related to cataplexy
  • Referral to support services and groups like the Narcolepsy Institute or National Sleep Foundation

Monitoring and Follow-up

• Regular assessment of cataplexy frequency and severity 9
• Monitor for medication side effects, particularly with sodium oxybate (respiratory depression, enuresis, nausea, headache) 3
• Watch for cataplexy exacerbation if any medication affecting adrenergic systems is initiated 1

Referral to Sleep Specialist

• Primary care physicians should refer patients to a sleep specialist when narcolepsy with cataplexy is suspected 9
• Sleep specialists have expertise to properly differentiate narcolepsy from other causes of excessive daytime sleepiness 9
• Complex or treatment-resistant cases particularly benefit from specialist consultation 9

Common Pitfalls to Avoid

• Failure to recognize cataplexy as distinct from seizures or other neurological conditions can lead to misdiagnosis 9
• Inadequate treatment of both excessive daytime sleepiness and cataplexy components can worsen overall symptom burden 9
• Sodium oxybate carries an FDA black box warning as it may cause respiratory depression; use with caution in patients with respiratory conditions 3