Management of Narcolepsy: Defining the Role of Modafinil
Alison M. Comer
Caroline M. Spencer
Narcolepsy is a chronic sleep disorder characterised by excessive daytime sleepiness, with or without cataplexy, sleep paralysis and hypnagogic hallucinations, with an estimated prevalence of 0.02 to 0.05% worldwide. The goal of managing narcolepsy is to keep patients as alert as possible during daytime hours and to minimise the incidence of cataplexy. A combination of nonpharmacological (lifestyle and behavioural modifications) and pharmacological treatments may be used to alleviate excessive daytime sleepiness. Stimulants such as amphetamines and methylphenidate have been the mainstay of pharmacological treatment, although a range of different agents have been used over several decades. Modafinil, a benzohydrylsulfinyl-acetamide derivative, has demonstrated good efficacy in the treatment of excessive daytime sleepiness, but has limited anticataplectic effects. In clinical studies modafinil 200 to 400 mg/day significantly improved subjective and objective measures of sleepiness and alertness compared with placebo. A long term study of up to 10 years' duration showed modafinil to have good to excellent efficacy in 64% of patients. Use of modafinil does not appear to be associated with the development of tolerance or dependence, and it is considered to have limited potential for abuse. Modafinil is generally well tolerated with few adverse effects, the most common being headache, nausea, nervousness and anxiety. It may be coadministered with drugs for treating cataplexy. The efficacy and the cost effectiveness of modafinil in the treatment of narcolepsy have not been compared with other available agents. Conclusions: Modafinil provides a useful alternative to traditional stimulants for the treatment of excessive daytime sleepiness associated with narcolepsy. It is well tolerated, may be taken in combination with medications for cataplexy, and shows long term efficacy without development of tolerance.
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