P17 A review relating to the use of methylphenidate for narcolepsy in a paediatric patient

Aims To assess the potential of methylphenidate as a safe and effective treatment option for narcolepsy type 1 in a 14 year old male, and if so, to advise on dose and titration as applicable.

Method A literature search for all studies evaluating the use of MPH in narcolepsy was conducted. EMBASE via OVID (1946 to 09.01.2023), MEDLINE via OVID (1974 to 09.01.2023), and the Cochrane Library were searched for relevant studies, guidelines, and/or review. All studies were limited to patients aged less than 18 years old to fit patient demographics. It was not limited to narcolepsy subtypes as they were not built as key terms or MESH terms [RP1] in the literature libraries. Of note, studies where patients had narcolepsy type 2, or when narcolepsy subtypes were not defined, were not excluded from review to broaden search horizon and to investigate if MPH is effective in resolving EDS symptoms.

Results The studies selected for review were grouped into case series and individual case reports, each study independently evaluated using the Critical Appraisal Skills Programme principles. A total of 8 case series and 9 individual case reports were reviewed in this study. None of the studies had exclusion criteria set. All case series and reports reviewed, apart from the individual case report by Vorspan et al.,¹ have reported MPH as effective in partially or fully resolving EDS symptoms, with some studies further reporting improvement in school performance and social integration.² There is limited evidence to base recommendations the dosing of MPH as not all case reports included dosage information, and when provided, there was no rationale given for selected dosing regimens. There is a lack of information on duration required to see symptomatic improvement, or duration of MPH therapy required after symptomatic improvement, in the studies reviewed.

Conclusions After careful evaluation of the evidence found, given the partial or complete resolution of EDS in all literature reviewed despite their limited nature, and that treatment of cataplexy was not currently required due to the mild symptoms, methylphenidate was recommended as an option for treatment of narcolepsy type 1 in patient AS.

After establishing the pattern of which the patient experienced sleep attacks, it was decided to start MPH as Delmosart 18 mg modified-release once a day in the morning, after breakfast, following local formulary guidance on brand choice,³ at the lowest dose possible.

References

1. Vorspan F, Warot D, Consoli A, et al. Mania in a boy treated with modafinil for narcolepsy. American Journal of Psychiatry 2005;162:813–814.

2. Bayram AK, Per H, Ismailoğullari S, et al. Efficiency of a combination of pharmacological treatment and nondrug interventions in childhood narcolepsy. Neuropediatrics 2016;47:380–387.

3. South East London Integrated Medicines Optimisation Committee. Position Statement. Preferred choice of methylphenidate modified-release (MR) tablet brand for the treatment of attention deficit hyperactivity disorder (ADHD) in children and in adults (off-label) and for other off-label indications of narcolepsy and idiopathic hypersomnia. 2020. Online access. https://selondonccg.nhs.uk/wp-content/uploads/dlm_uploads/2021/09/APC-Position-Statement-PS-027-Methylphenidate-MR-FINAL-September-2020.pdf?UNLID=5210118572023215135131 (Accessed 15 February 2023).