![]() In type 2 narcolepsy: characteristic findings on a sleep study without cataplexy or reduced hypocretin levels.OR low CSF hypocretin-1 ( orexin A) levels.≥ 1 episode of cataplexy PLUS characteristic findings on a sleep study.Daily periods of excessive daytime sleepiness for ≥ 3 months AND.Order sleep studies to confirm the diagnosis and refer to sleep medicine. ![]() Assess for cataplexy based on patient history and third-party reports.Recommend a sleep log for 1–2 weeks and/or actigraphy.Consider using a sleep questionnaire, e.g., the Epworth sleepiness scale.Rule out other causes of EDS, e.g., insufficient sleep, obstructive sleep apnea, or other sleep disorders.Hypna go gic hallucinations occur while going to sleep. Other : : depression, obesity, impotence or low sex drive, headaches, decreased functional performance.Automatic behavior: During narcoleptic episodes, patients often perform routine repetitive tasks automatically without conscious awareness of their environment.Hypnopompic hallucinations: experienced while waking up (less common than hypnagogic hallucinations).Hypnagogic hallucinations: vivid, often frightening visual or auditory hallucinations that occur as the patient falls asleep.Sleep paralysis: Complete p aralysis occurs for 1–2 minutes after waking or before falling asleep (either during a nocturnal or narcoleptic sleep episode, i.e., begins or ends with REM sleep).Usually resolves within a few seconds, at most two minutes.Typically manifests as partial cataplexy: isolated weakness of distinct muscle groups (e.g., neck muscles weaken and head tilts forward).The loss of muscle tone is similar to that observed during REM sleep.Typically manifests months or even years after EDS.Cataplexy : sudden muscle weakness in a fully conscious person, triggered by strong emotions (e.g., laughing, crying).One of the earliest manifestations of narcolepsy.Excessive daytime sleepiness ( EDS ): Affected individuals experience an irresistible urge to sleep and s udden, short sleep attacks ( The most common adverse reactions were headache, nausea, dizziness, decreased appetite, parasomnia, diarrhea, hyperhidrosis, anxiety, and vomiting. Due to the risks of CNS depression and abuse and misuse, Xywav is available only through a restricted program under a REMS called the Xywav and Xyrem REMS Program. Xywav has a Boxed Warning as a central nervous system (CNS) depressant, and for its potential for abuse and misuse. Sodium oxybate comes with warnings about high sodium content, but is the only previously approved treatment for both cataplexy and EDS in patients with narcolepsy. “This may help patients taking sodium oxybate better align with daily sodium intake recommendations including those by the American Heart Association.” Bogan, MD, FCCP, FAASM, associate clinical professor at the University of South Carolina School of Medicine, said in a statement. “Based on the efficacy demonstrated in the clinical program, the approval of Xywav is important for people living with cataplexy or EDS associated with narcolepsy,” Richard K. The company also announced plans to launch the drug by the end of 2020 following the implementation of a Risk Evaluation and Mitigation Strategy (REMS). When patients start the new treatment following sodium oxybate, Xywav treatment is initiated at the same dose and regimen as sodium oxybate and titrated as needed based on efficacy and tolerability. Multiple dosing options are available for both adult and pediatric patients and prescribers can titrate Xywav into unequal doses over the course of a night. Xywav showed statistically significant differences ( P <0.0001) in weekly number of cataplexy attacks and Epworth Sleepiness Scale scores compared to placebo. The approval is based on a phase 3 double-blind, placebo-controlled, randomized-withdrawal, multicenter that showed the efficacy and safety of the treatment of 201 patients. The oxybate drug, developed by Jazz Pharmaceuticals, is a composition of cations that result in 92% less sodium or approximately 1000-1500 mg per night less sodium than sodium oxybate at the recommended dosage of 6-9 grams. The US Food and Drug Administration (FDA) has approved Xywav (calcium, magnesium, potassium, and sodium oxybates) oral solution for the treatment of cataplexy and excessive daytime sleepiness (EDS) in patients at least 7 years old with narcolepsy.
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