Question
A 21-year-old girl comes to the physician for evaluation after a minor motor vehicle collision. While driving down a residential street, a young boy ran out in front of her, chasing after a ball. She applied the brakes of her vehicle and avoided hitting the boy, but then she suddenly experienced generalized weakness that rendered her unable to operate the vehicle and collided at low speed with a parked car. One minute later, she recovered her strength. She was uninjured. She has had several similar episodes of transient generalized weakness over the past month, once during an argument with her mother and another time while watching her favorite comedy movie. She has also had excessive daytime sleepiness for 18 months despite 9 hours of sleep nightly and 2 daily naps. She has fallen asleep in class several times. She often sees intensely bright colors as she is falling asleep. During this time, she is often unable to move; this inability to move is very distressing to her. Which of the following is the most appropriate nighttime pharmacotherapy for this patient?
| A. |
Quetiapine
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| B. |
Guanfacine
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| C. |
Modafinil
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| D. |
Sodium oxybate
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Show Answer
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Correct Answer � D
Explanation
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Ans-D-Sodium oxybate
Quetiapine
Quetiapine, an atypical antipsychotic, is a first-line treatment option for psychotic disorders, which can manifest with hallucinations. However, this patient’s hypnagogic hallucinations are occurring in the context of narcolepsy, for which atypical antipsychotics are not an adequate treatment.
Guanfacine
Guanfacine, an a2 adrenergic agonist, is used in the treatment of tics associated with Tourette syndrome. However, this patient does not display motor or vocal tics and is therefore unlikely to have Tourette syndrome. Guanfacine is not used in the treatment of cataplexy.
Modafinil
Modafinil is a recommended treatment option for patients with narcolepsy who have persistent excessive daytime sleepiness despite lifestyle modifications (e.g., > 7.5 hours of sleep per night and scheduled daytime naps). However, modafinil does not treat cataplexy, which is this patient’s most disabling symptom. In addition, modafinil is a stimulant and should not be taken at night.
Sodium oxybate
Sodium oxybate is the preferred drug for severe cataplexy in narcolepsy. It lowers the number of cataplexy attacks and improves nighttime sleep, thereby reducing excessive daytime sleepiness. Considering it is a powerful, rapidly acting sedative, sodium oxybate is taken at night. Caution should be exercised in the prescription of sodium oxybate, as it has a high potential for abuse. Overdose can cause respiratory depression, coma, and death.
