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Suggest Treatment For Persistent Daytime Sleepiness
Question: Persistent daytime sleepiness and need for daytime napping has been affecting my QOL. I finally was referred to a sleep specialist, had an overnight sleep study and diagnosed with mod-severe OSA. I was placed on CPAP.
When this did not help, a year later I was asked to repeat the sleep study with MSLT. The study was performed in-hospital using my own CPAP machine. The overnight study was not significantly different from the prior study; the MSLT was remarkably abnormal. All 4 daytime opportunities to nap showed non-REM sleep occurring with average latency of TWO minutes.
I was thereafter placed on modafinil with a diagnosis of idiopathic hypersomnia without long sleep time. I have been titrated up to 300 mg (100 mg x 2 q am and 100 mg q afternoon) with no effect. Am I correct that there is no specific FDA-approved treatment for IHS and that modafinil is used as it would be for narcolepsy? What alternatives exist other than amphetamine-like drugs?
Co-incidentally, I have been diagnosed with a parasomnia, for which nighttime klonipin 0.5 mg is prescribed by the same sleep doctor. When is CSF examined in patients such as me?
I also take Seroquel for my MDD w/psychotic features. Because it took so long to find an antipsychotic that would work to control my psychoses, my psychiatrist is unwilling to stop it. What should I do?
When this did not help, a year later I was asked to repeat the sleep study with MSLT. The study was performed in-hospital using my own CPAP machine. The overnight study was not significantly different from the prior study; the MSLT was remarkably abnormal. All 4 daytime opportunities to nap showed non-REM sleep occurring with average latency of TWO minutes.
I was thereafter placed on modafinil with a diagnosis of idiopathic hypersomnia without long sleep time. I have been titrated up to 300 mg (100 mg x 2 q am and 100 mg q afternoon) with no effect. Am I correct that there is no specific FDA-approved treatment for IHS and that modafinil is used as it would be for narcolepsy? What alternatives exist other than amphetamine-like drugs?
Co-incidentally, I have been diagnosed with a parasomnia, for which nighttime klonipin 0.5 mg is prescribed by the same sleep doctor. When is CSF examined in patients such as me?
I also take Seroquel for my MDD w/psychotic features. Because it took so long to find an antipsychotic that would work to control my psychoses, my psychiatrist is unwilling to stop it. What should I do?
Brief Answer:
Consultation
Detailed Answer:
Hello, and thanks for your question.
You describe hypersomnolence during the day that is affecting your quality of life. This is in the setting of Seroquel and Klonopin use, and a sleep study negative for OSA proper. Modafinil is also not helping.
As I see it, you are on two very sedating drugs -- Seroquel and Klonopin. These alone could be causing your problems. I would recommend stopping the Klonopin altogether (under the careful supervision of your doctor). The Seroquel could be cross-titrated to a less sedating antipsychotic like Abilify or Latuda, but this does run a real risk of relapse to psychotic depression, which you need to consider.
CSF does not need to be examined in your case.
Amphetamines are sometimes used for hypersomnolence during the day, but taking a downer at night (Klonopin) and an upper during the day (a stimulant) is a recipe for disaster. Better to address the sedating medications first before using a stimulant of any kind.
Please remember to rate and close this answer when you are finished and satisfied.
In the future, for continuity of care, I encourage you to contact me directly at my private link below. After you ask a direct question, it would be my pleasure to be your dedicated personal physician on this website. My name is Dr. Sheppe, and I am an XXXXXXX doctor working in New York City at NewYork-Presbyterian Hospital, ranked #1 for Psychiatry in the United States (tinyurl.com/psyrank). For a personalized comprehensive evaluation, treatment recommendations, and individual therapy, ask me at HealthCareMagic at this private link: tinyurl.com/DrSheppeAnswers
Consultation
Detailed Answer:
Hello, and thanks for your question.
You describe hypersomnolence during the day that is affecting your quality of life. This is in the setting of Seroquel and Klonopin use, and a sleep study negative for OSA proper. Modafinil is also not helping.
As I see it, you are on two very sedating drugs -- Seroquel and Klonopin. These alone could be causing your problems. I would recommend stopping the Klonopin altogether (under the careful supervision of your doctor). The Seroquel could be cross-titrated to a less sedating antipsychotic like Abilify or Latuda, but this does run a real risk of relapse to psychotic depression, which you need to consider.
CSF does not need to be examined in your case.
Amphetamines are sometimes used for hypersomnolence during the day, but taking a downer at night (Klonopin) and an upper during the day (a stimulant) is a recipe for disaster. Better to address the sedating medications first before using a stimulant of any kind.
Please remember to rate and close this answer when you are finished and satisfied.
In the future, for continuity of care, I encourage you to contact me directly at my private link below. After you ask a direct question, it would be my pleasure to be your dedicated personal physician on this website. My name is Dr. Sheppe, and I am an XXXXXXX doctor working in New York City at NewYork-Presbyterian Hospital, ranked #1 for Psychiatry in the United States (tinyurl.com/psyrank). For a personalized comprehensive evaluation, treatment recommendations, and individual therapy, ask me at HealthCareMagic at this private link: tinyurl.com/DrSheppeAnswers
Above answer was peer-reviewed by :
Dr. Raju A.T
Dr. Sheppe
Thank you for your response to my previous question concerning my idiopathic hypersomnia without long sleep time. I put to you the following questions in follow-up: a) The diagnosis of MDD w/psychotic features has existed for about a year. My psychiatrist and I tried MANY combinations of meds until we landed on the one I am currently on, and Abilify was one of those meds. It was not helpful and caused significant weight gain. I am not familiar with Latuda. Can it be combined with lamotrigine and paroxetine without complications? I am anticipating a tremendous disagreement with my psychiatrist if I propose changing my regimen as I HAVE had relapse of the psychotic features before finally finding success with the seroquel. I was not taking the seroquel for 72 hours before the sleep study/MSLT and the klonipin had not yet been started. (b) When I was first started on klonipin about 6 months ago it was because I was having significant parasomnia m/b sleepwalking and preparing meals in the middle of the night and leaving the stove or oven on. Clearly this was not acceptable and was a safety risk to those in the household, so I clearly saw the need for something to address this problem. My sleep/pulmonary physician settled on klonipin. It had a tremendous hangover effect, and the current dose is 1/2 the previous dose. I no longer feel drugged in the am. If not klonipin to address the parasomnia, then what other options do I have?
The first sleep study diagnosed the OSA; the second sleep study was done on auto-CPAP.
Thank you for your response to my previous question concerning my idiopathic hypersomnia without long sleep time. I put to you the following questions in follow-up: a) The diagnosis of MDD w/psychotic features has existed for about a year. My psychiatrist and I tried MANY combinations of meds until we landed on the one I am currently on, and Abilify was one of those meds. It was not helpful and caused significant weight gain. I am not familiar with Latuda. Can it be combined with lamotrigine and paroxetine without complications? I am anticipating a tremendous disagreement with my psychiatrist if I propose changing my regimen as I HAVE had relapse of the psychotic features before finally finding success with the seroquel. I was not taking the seroquel for 72 hours before the sleep study/MSLT and the klonipin had not yet been started. (b) When I was first started on klonipin about 6 months ago it was because I was having significant parasomnia m/b sleepwalking and preparing meals in the middle of the night and leaving the stove or oven on. Clearly this was not acceptable and was a safety risk to those in the household, so I clearly saw the need for something to address this problem. My sleep/pulmonary physician settled on klonipin. It had a tremendous hangover effect, and the current dose is 1/2 the previous dose. I no longer feel drugged in the am. If not klonipin to address the parasomnia, then what other options do I have?
The first sleep study diagnosed the OSA; the second sleep study was done on auto-CPAP.
Brief Answer:
Latuda
Detailed Answer:
Latuda is a newer atypical neuroleptic similar to Abilify. It is safe to combine with your other medications. Switching from Seroquel would certainly be a risk, don't get me wrong. But if sleep is more of a problem for you in life, then Latuda is an antipsychotic that is less sedating.
In place of Klonopin, you could try psychotherapy such as cognitive behavioral therapy for sleep (CBT-S). You could also try trazodone, or prazosin. There are several options such as these to replace Klonopin.
Please remember to rate and close this answer when you are finished and satisfied. See my link above.
Latuda
Detailed Answer:
Latuda is a newer atypical neuroleptic similar to Abilify. It is safe to combine with your other medications. Switching from Seroquel would certainly be a risk, don't get me wrong. But if sleep is more of a problem for you in life, then Latuda is an antipsychotic that is less sedating.
In place of Klonopin, you could try psychotherapy such as cognitive behavioral therapy for sleep (CBT-S). You could also try trazodone, or prazosin. There are several options such as these to replace Klonopin.
Please remember to rate and close this answer when you are finished and satisfied. See my link above.
Above answer was peer-reviewed by :
Dr. Deepak
Since the klonipin was prescribed to address/eliminate the parasomnia behaviors and not to induce sleep (though I understand it DOES do that), would the other choices you indicate above have evidence to do the same as the klonipin?
Brief Answer:
Followup
Detailed Answer:
Yes, they function similarly in that regard.
Dr. Sheppe
Followup
Detailed Answer:
Yes, they function similarly in that regard.
Dr. Sheppe
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Above answer was peer-reviewed by :
Dr. Yogesh D
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