1352 Treatment Considerations in Co-Morbid Schizophrenia and Narcolepsy: A Case Report

Abstract Introduction Narcolepsy affects approximately 1 in 2000 people and causes disabling sleepiness. Schizophrenia affects 1 in 133 people and confers significant impairments across domains. Rates of co-occurrence are not exactly known. One cohort study observed 8.1% of persons with narcolepsy (PWN) as having a psychosis comorbidity and a 4-fold greater risk for psychosis in PWN. Some wakefulness promoting medications used in narcolepsy treatment, such as modafinil, methylphenidate and amphetamine, may exacerbate psychosis by increasing dopamine activity. There are case reports of sodium oxybate exacerbating psychosis. We explore a case of a patient with co-morbid narcolepsy and schizophrenia, and discuss the treatment considerations encountered. Report of case(s) A 21-year-old man with was admitted for auditory hallucinations and bizarre behaviour. He put his cell phone in his microwave to prevent his conversations from being overheard. He was diagnosed with schizophrenia. The patient had a polysomnographic confirmed diagnosis of narcolepsy with cataplexy that predated this by 9 years. His methylphenidate extended-release 20mg was discontinued for concerns that it was precipitating psychosis. He was previously intolerant to modafinil (emotional numbing) and Concerta (appetite suppression) as per chart review. Paliperidone was effective for psychosis but worsened sleepiness, which was disabling. A retrial of modafinil worsened auditory hallucinations and delusions of persecution, and discontinued. He was discharged on paliperidone IM with well-controlled psychosis but sleepiness remained. Conclusion As an outpatient, caffeine 100mg up to 4x per day PRN was trialed but insufficient in promoting improvements to wakefulness. A new pitolisant was was successful in treatment without exacerbation of psychosis. Unfortunately, after 8 weeks of treatment, the patient lost access to pitolisant for one month due to insurance coverage issues, during which his irresistible sleepiness and cataplexy returned. The pitolsant was restarted upon insurance approval, and his wakefulness and cataplexy again improved. He remains stable on pitolisant 40mg and paliperidone 75mg IM q4 weekly. He has residual but non-disabling sleepiness. In conclusion, some traditional stimulants may worsen psychosis in PWN. Pitolisant, an inverse H3 agonist, which does not theoretically affect dopamine pathways, may be a suitable treatment for sleepiness and cataplexy in comorbid psychosis. Support (if any)