38
Views
Open Access Peer-Reviewed
Case Report

Oral L-Carnitine used to treat narcoleptic type 1 patient during pregnancy - A case report

Felipe Barros1; Ana Carolina Rodrigues Aguilar2; Sergio Tufik1; Fernando Morgadinho Coelho1,2

DOI: 10.5935/1984-0063.20180035

 

ABSTRACT:

Narcolepsy type 1 is a sleep disorder characterized by excessive daytime sleepiness (EDS), sleep fragmentation, hypnagogic hallucinations, sleep paralysis, and cataplexy. Stimulant medications such as modafinil and amphetamines are the first-line medications for treating sleepiness. However, the management of narcolepsy during special circumstances of life such as pregnancy is complex. MMDM is a 34-year-old female with Narcolepsy type 1 treated with modafinil (400mg/d) and citalopram (20mg/d). Before she become pregnant, modafinil and citalopram were replaced for L-Carnitine 510mg/d with good outcome. She underwent an usual pregnancy and was submitted to a term cesarean delivery without child-birth complications. This is the first description of oral L-Carnitine such an alternative to treatment narcolepsy type 1 during pregnancy. Treat these patients is not easy but care narcolepsy pregnant is a challenging even bigger. In a disease without many treatment options, L-Carnitine can be used to treat daytime sleepiness during pregnancy in narcolepsy.

Keywords:
Narcolepsy; Pregnancy; L-Carnitine.

Citation: Barros F, Aguilar ACR, Tufik S, Coelho FM. Oral L-Carnitine used to treat narcoleptic type 1 patient during pregnancy - A case report. 11(4):215. doi:10.5935/1984-0063.20180035
Received: May 29 2018; Accepted: September 28 2018
 

INTRODUCTION

Narcolepsy type 1 is a sleep disorder characterized by excessive daytime sleepiness (EDS), sleep fragmentation, hypnagogic hallucinations, sleep paralysis, and cataplexy. Cataplexy and/or lower CSF hypocretin-1 levels define narcolepsy type 11. A multimodal approach with pharmacological and behavioral therapy is required for narcolepsy's treatment. It includes a regular sleep schedule, short snaps, and regular exercises. Stimulant medications such as modafinil and amphetamines are the first-line medications for treating EDS. Complementarily; REM-suppressant medications are the best option to avoid cataplexy, including sodium oxybate and the antidepressants.

However, the management of narcolepsy during special circumstances of life such as pregnancy is complex2. The majority of drugs used to treat narcolepsy is considered Class C.

Recently, a dysfunctional fatty acid-beta oxidation pathway with low serum acylcarnitine levels was related to narcolepsy. A randomized placebo-controlled trial in narcoleptic patients showed an improvement in somnolence after the supplementation of L-Carnitine3. In pregnant women, L-Carnitine supplementation for a variety of reasons showed no adverse effects4.

 

CASE REPORT

MMDM is a 34-year-old female with Narcolepsy type 1 with excessive daytime sleepiness, hypnagogic hallucinations, sleep paralysis, and cataplexy. She has hypothyroidism taking levothyroxine (75mcg in the morning). The initial Epworth Somnolence Score (ESS) was 23/24. She had sleep study without sleep-onset REM and/or associated comorbidities. The multiple sleep latency revealed a mean sleep latency of 5 minutes and of 5/5 sleep-onset REM periods (SOREMPs) and the CSF hypocretin-1 level was zero. After treatment with modafinil (400mg/d) and citalopram (20mg/d) the patient had a moderate improvement of EDS (EES=19/24) and cataplexy (10 episodes per day to 2 episodes per week)5.

Before she become pregnant, modafinil and citalopram were removed and L-Carnitine 510mg/d was began with good outcome of EDS (EES=20). She had ten episodes of cataplexy per month. No new environmental of personal issues were noted during the pregnancy. She underwent an usual pregnancy (gain about 7 Kg in total) and was submitted to a term cesarean delivery without child-birth complications (Apgar 9/10 and 3,7 Kg). She stopped breastfeeding after 9 months and restarted previous treatment.

 

DISCUSSION

This is the first description of oral L-Carnitine such an alternative to treatment narcolepsy type 1 during pregnancy6.

The natural history of narcolepsy during pregnancy is not completely understood. A retrospective study of 249 pregnant narcoleptic patients with cataplexy showed greater chance of complications, especially impaired glucose metabolism and anemia. Three patients had cataplexy during delivery. The option for cesarean procedure was higher in patients with cataplexy and the newborns did not have extra complications2.

Unfortunately, risks such as prematurity, low birth weight, and withdrawal symptoms are reported in patients on stimulants7. Authors believe that the risks of teratogenic effects of narcoleptic drugs such as amphetamines are overestimated, however these drugs are still considered class C during pregnancy and breastfeeding8. Recent study showed that patients with narcolepsy and cataplexy have higher prevalence of diabetes during pregnancy9.

Treat narcolepsy patients is not easy but care narcolepsy pregnant is a challenging even bigger. In a disease without many treatment options, L-Carnitine can be used to treat daytime sleepiness during pregnancy. Further double-blind randomized studies are important to clarify this matter and show the actual efficacy and safety of this drug in a very specific period of life.

 

REFERENCES

Overeem S, Mignot E, van Dijk JG, Lammers GJ. Narcolepsy: clinical features, new pathophysiologic insights, and future perspectives. J Clin Neurophysiol. 2001;18(2):78-105.
Maurovich-Horvat E, Kemlink D, Högl B, Frauscher B, Ehrmann L, Geisler P, et al.; European Narcolepsy Network. Narcolepsy and pregnancy: a retrospective European evaluation of 249 pregnancies. J Sleep Res. 2013;22(5):496-512.
Miyagawa T, Kawamura H, Obuchi M, Ikesaki A, Ozaki A, Tokunaga K, et al. Effects of oral L-carnitine administration in narcolepsy patients: a randomized, double-blind, cross-over and placebo-controlled trial. PloS One. 2013;8(1):e53707.
Miyagawa T, Miyadera H, Tanaka S, Kawashima M, Shimada M, Honda Y, et al. Abnormally low serum acylcarnitine levels in narcolepsy patients. Sleep. 2011;34(3):349-53A.
Fonseca Hde A, Lopes DA, Pereira D, Sguillar DA, Lopes E, Behrens NS, et al. The use of citalopram for the treatment of cataplexy. Sleep Sci. 2014;7(1):50-2.
Romigi A, Liguori C, Izzi F, Albanese M, Marchi A, Mancini C, et al. Oral L-carnitine as treatment for narcolepsy without cataplexy during pregnancy: a case report. J Neurol Sci. 2015;348(1-2):282-3.
Andrade C. Adverse Gestational Outcomes Associated With Attention- Deficit/Hyperactivity Disorder Medication Exposure During Pregnancy. J Clin Psychiatry. 2018;79(1).pii:18f12136.
Thorpy MJ, Dauvilliers Y. Clinical and practical considerations in the pharmacologic management of narcolepsy. Sleep Med. 2015;16(1):9-18.
Calvo-Ferrandiz E, Peraita-Adrados R. Narcolepsy with cataplexy and pregnancy: a case-control study. J Sleep Res. 2018;27(2):268-72.

© 2019 All rights reserved