Nonpharmacologic Management of IH
Figure 1 is a snapshot of potential treatments and strategies for their use in patients with IH. The vast majority of patients with IH (96%) endorse using at least 1 nonpharmacologic strategy for the management of their illness.1 The most common strategies in this regard include caffeine (endorsed by 82% of patients with IH), daytime naps (81%), and scheduled nocturnal sleep (75%). However, the effectiveness of these nonpharmacologic strategies for IH, on a 1 to 10 scale in which 10 is most effective, are universally rated as ineffective. Most effective were caffeine (still only 3.3 out of 10), nicotine (3.2 out of 10), and scheduled nocturnal sleep (3.0 out of 10). Daytime naps, exercise, diet, temperature manipulations, chewing gum, mindfulness, and yoga all received numerically lower scores.1
FDA Approved Option: Lower-Sodium Oxybate
The use of calcium, magnesium, potassium, and sodium oxybates—also known as lower-sodium oxybate—was the first treatment approved for IH by the US Food and Drug Administration (FDA). Lower-sodium oxybate contains 92% less sodium than sodium oxybate, is generally well tolerated, and improves both narcolepsy- and IH-related symptoms with concomitant improvement in health-related quality of life outcomes.3,4,5 Notably, ordinary sodium oxybate increases sodium intake to at least 1100 to 1640 mg daily from medication doses alone. As ordinary sodium oxybate dosing can elevate daily sodium intake to 70% or more of the recommended daily sodium intake from medication alone, treatment may increase CV risk by increasing blood pressure and elevating the risk of CV events such as strokes.6,7 Furthermore, patients with sleep disorders are significantly more likely to experience hypercholesterolemia (odds ratio [OR], 1.51), heart diseases (OR, 2.07), and hypertension (OR, 1.32) than the general population.8 Given that patients with IH have an elevated baseline CV risk compared with comparable individuals lacking sleep disorders, consideration of CV risk is crucial to optimizing CV outcomes in these patients.9
Off-Label Options2
IH is not only a disorder of excessive daytime sleepiness but may also present as an array of symptoms (sleep inertia; long, unrefreshing naps; long sleep time; brain fog; and other cognitive problems). Clinicians will most often need to individualize their approach to address the severity of each symptom. Moreover, as IH symptoms can vary over time, clinicians caring for these patients should monitor symptoms at each office visit and evaluate comorbid conditions to ensure that therapeutic strategies are optimized.2,10
