Medications
for improving cataplexy
Cataplexy occurs
in about half of all people with narcolepsy. Among those who have it,
some may have only one or two episodes in their whole lives, while
others can have 10 or 20 episodes each day. Thus, the decision
whether to treat cataplexy with a medication depends on how much
impact the cataplexy has on an individual’s life and the expected
risks of the medications.
Medications
can produce a 90% reduction in cataplexy, and in some patients
eliminate it entirely. As cataplexy can have a major impact on social
interactions, and sometimes safety, treatment can substantially
improve quality of life.
Most
of the time, hypnagogic
hallucinations and sleep
paralysisdo
not require treatment with medications. However, these symptoms often
improve with the medications that reduce cataplexy.
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Antidepressants. Antidepressant medications have been used for decades to reduce cataplexy. As there have been no large clinical studies examining the effects of these medications on cataplexy, guidelines on their use are mainly based on the clinical experience of narcolepsy specialists.13
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The rationale for using antidepressants is that these medications strongly suppress rapid-eye-movement (REM) sleep, and cataplexy is probably the occurrence of REM sleep paralysis during wakefulness. Antidepressants mainly suppress cataplexy by increasing levels of norepinephrine and serotonin in the brain.
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Venlafaxine (Effexor) is one of the most commonly used medications for reducing cataplexy because the dosing is convenient, side effects are uncommon, and it is often very effective. Venlafaxine increases brain levels of both norepinephrine and serotonin.
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Fluoxetine (Prozac) is also generally well tolerated and long lasting. It increases brain levels of serotonin and may be slightly less effective than venlafaxine in reducing cataplexy.
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Clomipramine (Anafranil) and protriptyline (Vivactil) are very potent in suppressing cataplexy, but they can produce dry mouth, constipation, and other bothersome side effects. Thus, one or the other is often used as an add-on medication for additional cataplexy control. For example, some patients may take venlafaxine as their daily medication for reducing cataplexy, and also take a low dose of clomipramine just before a party for additional protection. People with heart problems, seizures, or glaucoma should not take clomipramine or protriptyline.
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Sudden discontinuation of any of these antidepressant medications can produce rebound cataplexy: severe cataplexy that can last several hours. If someone wishes to stop one of these medications, the dose should be gradually reduce
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