1026 Severe Sleep Inertia Managed with Bupropion

Abstract

Abstract Introduction Severe sleep inertia (SI) can often be managed with behavioral modifications and stimulants. This patient’s sleep inertia was resistant to such therapies but had remarkable improvement with Bupropion. Report of case(s) An 11-year-old male with a history of seizures presented with hypersomnolence, SI and difficulty arousing in the morning for 3 years. There was no reported cataplexy, with occasional hypnogogic hallucinations and sleep paralysis. Family denied witnessed apneas or snoring. He had previously undergone an adenotonsillectomy at 6 years of age for obstructive sleep apnea. When initially seen, he was not taking antiseizure medications, Epworth score was 14 and BMI was 30.5 kg/m2. Polysomnogram showed an AHI of 1.5 events/hour with REM latency of 179.5 minutes. Multiple sleep latency testing showed a mean sleep latency of 4 minutes, 7 seconds with 3 SOREM periods: consistent with narcolepsy. Melatonin and methylphenidate were initially prescribed, followed by dextroamphetamine-amphetamine, but were discontinued due to worsening hypersomnolence. Armodafinil improved his overall daytime sleepiness, however, severe SI persisted intermittently in the morning and with naps to the point of EMS being called on multiple occasions. EEG and brain-MRI were normal. For suspected cataplexy, venlafaxine was tried and not beneficial. Calcium-magnesium-potassium and sodium oxybate (XW) lead to no improvement in his SI. Therefore, Methylphenidate-20mg (MP) and then Armodafinil-50mg were added before bedtime, however, his SI persisted with frequently missed school. Bedtime Bupropion 150 mg was added with an immediate response. He has not missed school or daytime activities with Bupropion. Conclusion Sleep inertia is typically a characteristic of idiopathic hypersomnia rather than narcolepsy and is related to the abnormal transition of sleep to wakefulness resulting in reduced alertness, impaired performance, and desire to return to sleep. Such pronounced sleep inertia is atypical and caused significant quality of life impairment in our patient. Nighttime melatonin, XW, MP, and bupropion for SI has been described in the literature1. Our patient failed multiple treatments before bupropion which was immediately successful. Support (if any) 1. Treatment of severe morning sleep inertia with bedtime long-acting bupropion and/or long-acting methylphenidate in a series of 4 patients. Schenck, MD1 ; Golden, MD2 ; Millman, MD3