STATUS CATAPLECTICUS INDUCED BY WITHDRAWAL OF DULOXETINE

Abstract

SESSION TITLE: Fellows Sleep Disorders Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Status cataplecticus is defined as episodes of cataplexy with an increase in duration and severity of the attacks precipitated by minor or no emotional triggers without a refractory period. It’s a poorly understood rare phenomenon only described in case reports. We are presenting a case of status cataplecticus after the withdrawal of duloxetine CASE PRESENTATION: A 77-year-old female with a history of long-standing narcolepsy with cataplexy stable on methylphenidate 50 mg extended-release a day admitted to hospital for multiple brief periods of whole-body weakness. Patient reported progressively increasing episodes of cataplexy in the last few days with more than ten episodes one day before the presentation which would come on even minor or no emotional stimuli. She was able to recall all the episodes and each episode lasted less than one minute and denied having jerking movements of limbs, incontinence, and or tongue biting. She was also taking duloxetine 60 mg a day for chronic pain due to arthritis for the last one year. She was having issues with dry mouth since being started on duloxetine and stopped taking duloxetine one month before the presentation. Vital signs, physical examination, laboratory workup including CT head was unremarkable. She continued to have these episodes while admitted and were observed by the medical staff. She was started on a lower dose of duloxetine 20 mg twice daily and was observed in the hospital until she stopped having these episodes and discharged back to home without any further recurrence. She was counseled about the negative consequences of the abrupt withdrawal of the medications. DISCUSSION: Cataplexy is defined by REM intrusion into wakefulness clinically apparent as transient muscle weakness brought on by emotional triggers. Most triggers are positive emotions such as laughter, joking and affect the muscles of head and neck with knees and if severe enough can cause paralysis culminating in a fall, however, a typical cataplexy episode is followed by a refractory period of at least a few hours to days in which cataplexy is unlikely to happen again. In status cataplecticus these episodes become very frequent and increase in severity without any significant triggers and lack of refractory period and result in significant debilitation. Most of the cases of status cataplecticus have been described in patients withdrawing from serotonergic adrenergic medications such as SSRI, SNRI, and TCA’s. These medications help decrease REM sleep by increasing the levels of serotonin and norepinephrine and improve cataplexy. Withdrawal can lead to worsening cataplexy symptoms by disinhibiting neurons that promote REM sleep. CONCLUSIONS: Patients of Narcolepsy with Cataplexy should be educated about the possible side effect of withdrawal of SSRI, SNRI and TCA's that can lead to this rare often misdiagnosed phenomenon of status cataplecticus. Reference #1: Wang J, Greenberg H. Status cataplecticus precipitated by abrupt withdrawal of venlafaxine. J Clin Sleep Med. 2013;9(7):715-716. Published 2013 Jul 15. doi:10.5664/jcsm.2848 Reference #2: Martínez-Rodríguez JE, Iranzo A, Santamaría J, et al. Estado de mal catapléjico inducido por la retirada brusca de clomipramina [Status cataplecticus induced by abrupt withdrawal of clomipramine]. Neurologia. 2002;17(2):113-116. DISCLOSURES: no disclosure on file for Humberto Battistini; No relevant relationships by Rose Franco, source=Web Response No relevant relationships by Mohsin Hamid, source=Web Response