1203 When the Options Run Out… Less Is More… a Case of Pediatric Narcolepsy with Limited Treatment Options

Abstract Introduction We report a pediatric patient with Narcolepsy Type 1 with significant daytime impairment who faced challenges with the standard treatment options of pediatric narcolepsy. Report of case(s) The patient is a 16 year old female with confirmed diagnosis of narcolepsy type 1 (mean sleep latency 5 minutes, 4 sleep onset REM periods). Her symptoms (excessive daytime sleepiness (PDSS 26), cataplexy, hypnagogic/hypnopompic hallucinations and depression) gradually started at the age of 12 years of age and worsened overtime. Cataplexy initially involved eye and facial twitching that were triggered by laughter or anger which gradually progressed to generalized loss of tone. As the initial management of narcolepsy, she was started on atomoxetine with no change in symptoms. She transitioned to methylphenidate which improved her daytime sleepiness minimally but with no improvement of the cataplexy. Due to further adverse effects with stimulants, she started sodium oxybate with low dose dextroamphetamine. Initially, the combination improved wakefulness but then with dose titration, the patient developed severe depression and suicidal ideation after 8 months of use. She also demonstrated manic episodes and anorexia. With each treatment regimen, her depression and anxiety vacillated in severity. Lastly, a trial of pitolisant was titrated to 13.35 mg. She developed heart palpitations with the higher doses, so low dose Pitolisant 8.9 mg daily was continued. At this dose sleepiness improved, with some improvement in functionality. Venlafaxine 225 mg daily was added to the regimen to control cataplexy and depression with good benefit. With the low dose pitolisant and venlafaxine combination, she has been able to participate in extracurricular activities at school. Conclusion Pediatric narcolepsy can be challenging to treat as there are limited treatment options. We presented a case of a teen who had multiple symptoms of narcolepsy with coinciding depression and anxiety. Despite multiple drug regimens, her symptoms improved with off label use of Pitlosant , interestingly at low dose. Although clinical manifestations of pediatric narcolepsy may be life altering for the patient, close clinical follow up is imperative to screen for adverse effects after implementing a treatment plan. Support (if any) None