How do you manage daytime somnolence without a clear cause?

One of the newer agents for wakefulness-promoting agents is Sunosi, which has a higher affinity for DAT and NET compared to any other agent (Wellbutrin, Provigil, Nuvigil, Adderall).

I have a cohort of probably 5-10 patients now, mostly female in their late teens to early twenties, who report needing 10-14 hours of sleep per day and still not feeling refreshed. Excessive daytime somnolence (falling asleep in class or while driving). I tried modafinil and stimulants with modest success. Sent for sleep studies, and many of them were diagnosed with Idiopathic Hypersomnia. The treatment in those cases is Xywav, which is prescribed by sleep medicine, so it is an important diagnosis not to miss. It is one of the few times in my career when patients use the term "life-changing" with a treatment.

Throw a broad net out for the evaluation because we don't know how much has a physiological component and how much is mental/emotional.

At intake, I get a moderately comprehensive set of labs. Rating Scales like HAMA, HAM-D, PHQ-9, Epworth Sleepiness Scale, and a ROS (Review of Systems) are done. I review these before seeing the patient and ask specific questions about any "positive" answers. This takes time, but the patient has consulted me for their stated reason. My intakes last at least 1.5 hours (and we may need another "initial" visit to cover more information). Meanwhile, I am thinking of various differential diagnoses (it isn't always one problem).

It rarely helps to ask the patient if they snore. They usually answer no. Is there s...

I recommend light therapy in the morning, more exercise during the day, and judicious use of caffeine.

Great question, but I doubt many of us have really concrete guidelines we follow.

Here is what I would consider:

• Are they fishing for stimulants? Just need to rule this out first.
• I am assuming routine sleep study, and you coached them on sleep hygiene.
• I am also assuming labs were okay? CBC, CMP, Thiamine, TSH, B12, Folate, Vit D, Iron studies, Hormone Panel.
• Assuming all that is good, I would start talking about options with a LOT of patient education because we are probably in off-label treatments at this point.
• If I am really sure depression isn't part of the picture, we can skip any SSRI talk and really just start with Wellbutrin if they want to try something. But this is definitely off-label and needs a lot of education/documentation...

Polysomnography can be very helpful with diagnosis, and narcolepsy, while not that common, is treatable. Obstructive sleep apnea (OSA), also treated after PSG diagnosis, can be corrected. These two diagnoses, which are frequent causes of excessive daytime sleepiness, can be documented by PSG. Stimulants and CPAP help many people.