Diagnosing and Treating Excessive Daytime Sleepiness in Narcolepsy and Obstructive Sleep Apnea

At the 2021 Fall Managed Care Forum, Suresh Kotagal, MD, consultant in neurology, pediatrics, and sleep medicine at Mayo Clinic in Rochester, Minn., provided attendees with an overview of strategies for diagnosing and managing excessive daytime sleepiness in narcolepsy and obstructive sleep apnea (OSA).

In OSA, which affects approximately 5% of U.S. adults, daytime sleepiness persists in about 12% to 65% of patients, despite adequate treatment with options such as positive airway pressure. Residual daytime sleepiness is an important comorbidity of OSA that significantly impacts patients’ quality of life, Dr. Kotagal explained. “Pharmacological agents like modafinil, armodafinil, and solriamfetol may be prescribed as adjuncts to enhance daytime alertness and improve quality of life.”

Narcolepsy affects approximately 44 people per 100,000 each year, and its onset typically occurs in childhood and adolescence. Its diagnosis is often delayed, though, as the presentation of chronic sleepiness can be mistaken for laziness or depression. Daytime sleepiness is diagnosed and assessed via clinical evaluation, survey instruments, actigraphy, and nocturnal polysomnogram.

While there are several classes of drugs available to help manage narcolepsy, Dr. Kotagal noted some limitations in the current narcolepsy drug treatment recommendations, which include oxybates, stimulants, and norepinephrine–dopamine reuptake inhibitors. For example, quality of life measures have not been consistently evaluated in clinical trials, especially for the older preparations such as methylphenidate and amphetamines. The costs of drug treatment are also not routinely taken into consideration. “Sleep medicine specialists, patient support groups and third-party payor groups need to work together to achieve optimal outcomes,” he concluded.