For professionals

Treating people who have idiopathic hypersomnia or narcolepsy

including hypersomnia medicines, interactions with hormone medicines, and resources for completing your treatment plan

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Medicines for idiopathic hypersomnia (IH) and narcolepsy

What medicines might I use to treat IH and narcolepsy?

The tables below show medicines that have reasonable evidence for use in treating person(s) with IH (PWIH) and/or person(s) with narcolepsy (PWN). An marks medicines the U.S. FDA has approved specifically to treat IH. An marks FDA approval for narcolepsy, which doesn’t differentiate between narcolepsy type 1 and 2. You can prescribe all other medicines off-label.

Each table includes a group of medicines with similar mechanisms of action, and the tables are organized roughly in order of the level of evidence for use. The side effects column includes notable side effects and complications. The notes column provides details about evidence for use in IH and/or narcolepsy, which ranges from randomized controlled trials to very small case series. For specific evidence-based guidelines regarding more thoroughly studied medicines, see the American Academy of Sleep Medicine’s article “Treatment of Central Disorders of Hypersomnolence.”

Symptoms that may be improved include:

GABA-B receptor agonists EDS C SSI SD Side effects Notes
Sodium oxybate* (such as Xyrem)
  • High sodium content
  • Nausea/vomiting
  • Dizziness
  • Enuresis
  • Tremors
  • CNS depression/somnolence
  • Depression and suicidality
  • Impaired motor function
  • Respiratory depression
Lower-sodium oxybate*† (such as Xywav)
  • Nausea/vomiting
  • Dizziness
  • Enuresis
  • Tremors
  • CNS depression/somnolence
  • Depression and suicidality
  • Impaired motor function
  • Respiratory depression
Extended-release sodium oxybate (such as Lumryz)
  • High sodium content
  • Nausea / vomiting
  • Dizziness
  • Enuresis
  • Tremors
  • CNS depression / somnolence
  • Depression and suicidality
  • Impaired motor function
  • Respiratory depression
  • Schedule III
  • Not to be taken with alcohol or sedative hypnotics, including anesthesia
Baclofen (such as Lioresal)  
  • Drowsiness
  • Dizziness
  • Weakness
  • Nausea
  • Confusion
  • Hypotension
  • Headache
  • Insomnia
  • Constipation
  • Urinary Frequency
  • Fatigue
  • In a study of 5 adolescents with narcolepsy type 1 (NT1), baclofen has been reported to improve sleep consolidation and excessive daytime sleepiness (Morse, 2019)
  • In a study of 2 adults with NT1, baclofen was reported to improve cataplexy (Lee, 2015)
  • In a study of 26 teens with NT1, baclofen didn’t help sleepiness or cataplexy (Huang, 2009)
  • Use of baclofen for IH or NT2 hasn’t been published, but might be considered for EDS based on the NT1 reports
Stimulants EDS C SSI SD Side effects Notes
Modafinil/armodafinil* (such as Provigil/Nuvigil)      
Solriamfetol* (such as Sunosi)      
  • Headache
  • Nausea
  • Decreased appetite
  • Insomnia
  • Anxiety
  • Blood pressure and heart rate increases
  • Schedule IV
  • Dual-acting norepinephrine-dopamine reuptake inhibitor (NDRI)
  • Use with caution in treating patients with a history or psychosis or bipolar disorder
  • See Abad 2021 for more info
Amphetamines and short- and long-acting derivatives* (such as Adderall)  
  • Mood and behavior changes
  • Dental problems
  • Cardiac problems
Methylphenidate and short-acting derivatives* (such as Concerta)      
  • Mood and behavior changes
  • Dental problems
  • Cardiac problems
Methylphenidate long-acting derivatives* (such as Jornay PM)    
  • Mood and behavior changes
  • Dental problems
  • Cardiac problems
  • Schedule II
  • A 2021 case series of 4 people with severe sleep inertia reported that long-acting methylphenidate given at bedtime can help sleep inertia (Schenck, 2021)
  • Delayed-release methylphenidate (Jornay PM) may have particularly convenient timing for treatment of SSI
Histamine antagonist/inverse agonists EDS C SSI SD Side effects Notes
Pitolisant* (such as Wakix)    
  • Pitolisant improved sleepiness in approximately ⅓ of PWIH whose symptoms did not respond well to other medications (Leu-Semenescu, 2014)
  • Clinical response can take from 2 to 8 weeks
GABA-A receptor antagonists EDS C SSI SD Side effects Notes
Clarithromycin (such as Biaxin)      
  • Increased mortality in people with heart disease
  • QT prolongation
  • Increased effective dose of hormonal medicines, including birth control (see below)
  • Abdominal pain
  • Diarrhea
  • Nausea
  • Vomiting
  • Dysgeusia
  • Acute hypersensitivity reactions
  • Hepatotoxicity
Flumazenil      
  • Dizziness
  • Anxiety
  • Mood disturbances
  • Headache
  • Insomnia
  • Cognitive dysfuction
  • A study of 153 PWH demonstrated a 62.6% response rate, with 39% choosing to continue treatment after the review period; adverse effects were common but did not often result in stopping treatment (see our journal article summary)
  • This is a custom compounded medicine; see our article “FAQs About Flumazenil Access“
Antidepressants EDS C SSI SD Side effects Notes
Antidepressants (see “Example brand names” section below)      
  • Vary by individual medicine
  • Using low dose TCAs (such as clomipramine 10 to 30 mg) is often very effective and may have fewer side effects than the SSRIs or SNRIs in normal doses
 Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and SNRIs (serotonin and noradrenaline reuptake inhibitors) are all used to lessen cataplexy by reducing REM sleep
Protriptyline (such as Vivactil)  
  • Cardiovascular including QT prolongation
  • Seizures
  • Confusion/anxiety
  • Dizziness
  • Nausea/vomiting
  • Weakness
Bupropion and long-acting derivatives (such as Wellbutrin XL)    
  • Agitation
  • Dry mouth
  • Constipation
  • Headache/migraine
  • Nausea/vomiting
  • Dizziness
  • Heavy sweating
  • Shakiness (tremor)
  • Insomnia
  • Blurred vision
  • Tachycardia/arrythmias
  • Confusion
  • Rash
  • Hostility
  • Suicidal thoughts and behaviors
  • Wake-promoting norepinephrine-dopamine reuptake inhibitor (NDRI)
  • A 2021 case series of 4 people with severe sleep inertia reported that long-acting bupropion given at bedtime can help sleep inertia (Schenck, 2021)
Selegiline (such as Emsam)      
  • Dizziness
  • Nausea
  • Pain
  • Headache
  • Insomnia
  • Rhinitis
  • Dyskinesia
  • Back pain
  • Stomatitis
  • Dyspepsia
  • Wake-promoting MAO-B inhibitor
  • Although selegiline was found to suppress REM sleep and increase sleep-onset and REM-onset latencies on both the PSG and MSLT (and people taking it reported significant improvement in daytime sleepiness, reduced number of naps needed, and reduced frequency of cataplexy), this medicine is not commonly prescribed for people with narcolepsy because of the high dosage required and potential for severe side effects, especially if one doesn’t follow the low-tyramine diet that is needed to prevent tyramine toxicity while taking MAO inhibitors (Mayer, 1995)
Selective norepinephrine reuptake inhibitors EDS C SSI SD Side effects Notes
Atomoxetine (such as Strattera)    
  • Constipation
  • Dry mouth
  • Nausea
  • Fatigue
  • Low appetite
  • Erectile dysfunction
  • Urinary hesitation/retention/dysuria
  • Dysmenorrhea
  • Hot flush
 See Mignot 2012
Reboxetine (such as Davedex)    
  • Dizziness
  • Dry mouth
  • Constipation
  • Nausea/vomiting
  • Sweating
  • Headache
  • Low appetite
  • Agitation/anxiety
  • Paraesthesia
  • Cardiac
  • Erectile dysfunction
  • Urinary hesitation/retention/dysuria
  • Approved in Europe, but not currently in the U.S.
  • See Mignot 2012 and Larrosa 2001
Other EDS C SSI SD Side effects Notes
Levothyroxine (such as Synthroid)      
  • Cardiac, including arrhythmia
  • Side effects are primarily those of hyperthyroidism due to overdosage
 A small case series suggested levothyroxine as a possible treatment for IH, especially for people with subclinical hypothyroidism (Shinno, 2009)
Caffeine (such as No Doz, drinks)      
  • Cardiac, including arrythmia
  • Nausea/vomiting
  • Increased urination
  • Agitation
 Although it is commonly used by people who have IH or narcolepsy, many people who have these disorders report that it has only limited benefit on their sleepiness
Carnitine supplements (such as Carnitor)      
  • Nausea/vomiting/diarrhea
  • Seizures
 A 2013 study of 30 people with NT1 reported that oral carnitine supplementation improved dozing time in the daytime (see our journal article summary)
Melatonin long-acting    
  • Dizziness
  • Drowsiness
  • Bed-wetting
  • Headache
  • Nausea
  • A case series of 10 people with polysymptomatic hypersomnia reported that 2 mg slow-release melatonin at bedtime shortened nocturnal sleep duration, decreased sleep drunkenness, and relieved daytime sleepiness in 50% (Montplaisir et al, 2001)
  • Other studies have shown that melatonin synchronizes circadian rhythms and improves onset, duration, and quality of sleep in conditions other than IH

How can I treat brain fog and automatic behaviors?

Currently, there are no medicines that specifically treat brain fog or automatic behaviors. However, improving EDS and impaired attention may also help these symptoms.

How can I treat sleep paralysis and sleep-related hallucinations?

  • These are REM-dissociative symptoms, like cataplexy. Therefore, all these symptoms may sometimes improve with medicines that suppress REM sleep, such as oxybates, TCAs, SSRIs, or SNRIs. Researchers haven’t yet studied this except for oxybates for sleep paralysis (Thorpy, 2021).
  • Our medical advisory board reports that some PWH have fewer problems with sleep paralysis and hallucinations if they avoid falling asleep supine (flat on their backs).
  • For sleep paralysis, specific forms of meditation may help (Jalal, 2020).

Refer your patients to Project Sleep’s “Sleep Paralysis and Hallucinations” content to get some ideas and understanding that can help with these symptoms.

What’s the risk of dependence for scheduled medicines?

The potential for misuse or abuse of scheduled medicines may cause clinicians and person(s) with hypersomnias (PWH) concerns about their long term use. Available data suggest that solriamfetol and modafinil have a low risk of abuse and that pitolisant does not seem to have addictive potential. Stimulants and oxybates have a higher abuse potential, although available data demonstrate that the risk in the IH and narcolepsy population is most likely lower than in the general population. For more information, see Ngo, 2022.

PWH may need to try different medicines and doses

As you work with a PWH to try different hypersomnia medicines, it may be helpful to keep in mind:

  • Some PWH may benefit from medicines in combination
  • PWH should avoid medicines and substances (such as alcohol and opioids) that can worsen daytime sleepiness
  • PWH may need to try several different doses
  • For stimulants, effectiveness may be improved by medicine holidays and/or different doses for different days, such as:
    • A usual dose for most days
    • A lower dose for days with better symptoms or fewer activities
    • A higher dose for days with worse symptoms or many activities planned
    • A higher dose for PWH who have worse symptoms during the luteal phase of their menstrual cycle (the 2 weeks before their period); although there isn’t yet research for this, there are anecdotal reports from PWH
  • If PWH could become pregnant, talk with them about the safety of their medicine during pregnancy and nursing, which may affect their medicine choice — visit our web page “Clinician support for pregnancy and safe baby care”

PWH still may not feel fully alert, even if they’re taking the medicines that work best for them. A good goal is for them to be most alert at important times of the day, such as during work, school, or while driving.

Recommendations for treatment approach and measuring effectiveness

For more information, see UpToDate’s flowchart for the “Symptomatic management of narcolepsy in adults,” much of which is applicable to treating IH. You can use the Idiopathic Hypersomnia Severity Scale (IHSS) PDF before and after starting a new treatment to help measure how well it works to ease symptoms. For PWN, you can use the Narcolepsy Severity Scale. The FOSQ (Functional Outcomes of Sleep Questionnaire) and ESS (Epworth Sleepiness Scale) are good options for people with any hypersomnia sleep disorder.


thumb_IHSS

Download the IHSS PDF

Clinical trials offer increased access to newer medicines

Referring PWH to clinical trials may not only help scientists better understand hypersomnias and their treatment, but it may allow PWH to try medicines that aren’t yet available in their home country nor approved for their diagnosis. Some clinical trials allow participants to continue taking the medicine for a period of time after the trial has ended. For more information, visit our “Currently-Recruiting Research Studies” page to see a list of clinical trials and other types of research studies looking for volunteers.

Refer PWH directly to our “International Patient Registry.” Researchers will contact PWH who join and indicate interest in participating in further research.

Access issues with hypersomnia medicines

For your patients

Some medicines may not be affordable or easily covered by insurance. Refer PWH to our web pages:

Some hypersomnia medicines interact with hormone medicines, including birth control, hormone replacement therapy, and gender-affirming therapy

When these medicines are taken together, the effective hormone dose may be affected. Therefore, you may need to change the hypersomnia medicines or hormone medicines (estrogens, progestins, or testosterones).

Note: This information is based on our consultation with gynecology and sleep medicine experts, and on review of clinical findings in publications and at professional conferences. 

Which common hypersomnia medicines may interact with hormone medicines?

Modafinil, armodafinil, and pitolisant are all P450 inducers. These medicines: 

  1. Induce cytochrome P450 3A4 (CYP3A4) liver enzymes
  2. Increase the breakdown of hormones
  3. Decrease the effective dose (bioavailability) of the hormone medicines

Clarithromycin, a long-term treatment for hypersomnias, is a P450 inhibitor and has the opposite effect. These medicines:

  1. Inhibit these liver enzymes
  2. Decrease the breakdown of hormones
  3. Increase the effective dose of the hormone medicines                        

Which hormone medicines may be affected?

  • Hormonal birth control, including:
    • Oral contraceptives 
    • Patches and rings   
    • Implants    
    • Emergency contraception  
  • Hormone replacement therapy to treat people with low or imbalanced hormones, such as those with menopause or low testosterone
  • Gender-affirming therapy for people making a transition to their gender identity

What may happen if PWH take these medicines together? 

It’s usually safe to use these hypersomnia medicines with hormone medicines. However, according to manufacturer data, the effective hormone dose can be decreased by 30 to 50% by modafinil or armodafinil, and by 10 to 32% by pitolisant. For clarithromycin, the effective hormone doses can be increased.

This interaction can lead to:

Less symptom control, such as not controlling hot flashes during menopause

A higher risk of pregnancy

Less medicine effectiveness, such as with gender-affirming therapy

More side effects, such as headaches or breakthrough menstrual bleeding

  • Review medicine interactions with the PWH, including all their prescription, over-the-counter, and herbal treatments
  • Be cautious when adding any other medicines that induce or inhibit P450 enzymes (for more info, see Lynch, 2007)
  • Caution PWH to avoid eating grapefruit or drinking grapefruit juice while on these medicines — grapefruit is a P450 inhibitor and can decrease hormone breakdown (for more info, see Monroe, 2013)

Together, you both may decide to:

  • Change the hypersomnia medicine to one that doesn’t interact with hormone medicines
  • Change the dose of the hormone medicine
  • Adjust the birth control method, such as to:
    • Switch to a different method of birth control that isn’t affected, such as an IUD
    • Shorten or eliminate the hormone-free interval of cyclic birth control methods
    • Change the hormone dose
    • Add a barrier method, such as also using a contraceptive diaphragm or condom

The table below suggests hormone dose changes for each hypersomnia medicine that may affect hormone medicines. (Hormonal birth control is discussed separately below.) These suggestions aren’t yet backed by studies, but they’re considered reasonable since manufacturer data show that the effective hormone dose is decreased by 30 to 50% by modafinil or armodafinil, and by 10 to 32% by pitolisant. Current data aren’t sufficient to specifically guide clarithromycin dosing.

Hypersomnia medicine Suggested adjustment for hormonal therapy other than birth control
Modafinil/armodafinil (such as Provigil/Nuvigil) Increase the hormone doses by up to double, titrating to symptom control or effect so as to use the lowest dose of hormones needed
Pitolisant (such as Wakix) Increase the hormone dose by up to 50%, titrating to symptom control or effect so as to use the lowest dose of hormone needed
Clarithromycin (such as Biaxin) Consider carefully and slowly reducing the hormone doses, as long as symptoms remain controlled or desired effects are maintained

Cardiovascular complications

Although P450 inducers should lower the available hormone doses, it’s necessary to avoid prescribing ethinyl estradiol doses of 50 mcg or higher. Safety data confirms this dose may cause cardiovascular complications such as stroke, heart attack, and venous thromboembolism.

Ask PWH about:

  • Side effects
  • Any variability in their use of modafinil, armodafinil, or pitolisant
    • Short “medicine holidays” of one or a few days to prevent tolerance are unlikely to change the effects of P450 inducers, so maintain any higher doses of hormones
    • Weeks-long medicine holidays will lower the P450 inducer effects, so consider temporarily lowering to the usual hormone doses
  • A P450 inducer’s effect may last for several weeks, because they increase enzyme activity by a slow process (for more info, see Brodie, 2012):
    • Modafinil and armodafinil’s effects may last for 1 month after a person stops taking them, according to their FDA labels
    • Pitolisant’s effect may last for 21 days after stopping it, according to its FDA label
  • A P450 inhibitor’s effect goes away faster:
    • Clarithromycin’s effect may last for more than 1 day after stopping it (Herrington, 2015)
    • Grapefruit juice’s effect may last for up to 2 to 7 days after stopping it (Imai, 2014)

Use the tables below and shared decision-making. Consider using one of these birth control methods to lower the possible side effects or complications from increased hormone doses:

  • Non-hormonal
  • Non-estrogen (progestin only)
  • Lower-hormone dose

How can I help PWH taking P450 inducers choose the best type of birth control for them?

Effectiveness is only one feature people may use to choose their preferred birth control method. Other features include safety, cost, access, ease of use, acceptability, STD prevention, and side effects.

Use the tables below and shared decision-making to help PWH choose the best type of birth control for them. Encourage them to use one or more of these options to lower their chance of getting pregnant:

  • Use a birth control method that isn’t affected by P450-inducing medicines, such as a copper or hormonal IUD, hormonal injection, vasectomy, or tubal ligation.
  • Use a highly-effective method.
  • Add a barrier method such as a contraceptive diaphragm or condoms.
  • If PWH choose pills, patches, or rings, use an extended or continuous regimen, which studies report is more effective than 3 weeks on, one week off (placebo). Inform PWH that this may cause breakthrough bleeding, but there are management options to help improve this.
  • If PWH choose combined oral contraceptive (COC) pills, using more than 20 mcg of ethinyl estradiol is more effective.
  • Encourage use of reminders for their birth control methods to avoid missing or late doses. Use reminders such as smartphone apps and digital tablet dispensers.

Birth control effectiveness

To describe the general effectiveness of birth control methods, experts often use a tier system, with 3 tiers of effectiveness. See the CDC’s “FIGURE 1: Effectiveness of family planning methods.”

Experts describe effectiveness through a typical use failure rate. A 1% typical use failure rate means that 1 out of every 100 people using the birth control method will become pregnant over the course of 1 year.

Top-tier birth control methods

These top-tier methods have a typical use failure rate of less than 1%, the lowest complications, highest satisfaction, lowest cost over time, and highest rate of continuous use.

Sterilization (vasectomy or tubal ligation)

Affected by P450-inducing medicines?

No

Copper intrauterine device (IUD)

Affected by P450-inducing medicines?

No

Notes

Copper IUDs don’t have any hormones to interact with P450-inducing hypersomnia medicines. 

Hormonal IUD

Affected by P450-inducing medicines?

No

Notes

Although hormonal IUDs contain progestin, they work locally to prevent pregnancy by thickening cervical mucus and thinning the uterine lining. This isn’t affected by P450-inducing hypersomnia medicines. 

Hormonal implants

Affected by P450-inducing medicines?

Yes

Notes

Researchers don’t know how much an implant’s effectiveness is lowered by a P450 inducer. Experts believe that even when taking a P450 inducer, the implant is still more effective than the lower-tier methods. For more info, see Lange, 2014. 

There’s consistent data that the implant can last up to 5 years when not taking P450 inducers. Therefore, when also taking P450 inducers, it’s reasonable to replace the implant at the typically-advised 3 years, although researchers haven’t yet studied this. 

Second-tier birth control methods

Progestin shots (such as Depo-Provera)

Affected by P450-inducing medicines?

No

Notes

Progestin shots have a 6% typical use failure rate. The progestin dose is much higher than for other second-tier methods, so effectiveness isn’t lowered by P450-inducing medicines (CDC MEC, 2016).

Contraceptive diaphragms

Affected by P450-inducing medicines?

No

Notes

This method’s 12% typical use failure rate is the highest in this tier. 

Combined oral contraceptives (COCs)

Affected by P450-inducing medicines?

Yes

Notes

These have a 9% typical use failure rate. Using COCs with more than 20 mcg of ethinyl estradiol or in an extended or continuous regimen is associated with higher ovulation inhibition and thus higher effectiveness.   

Progestin-only pills (minipills)

Affected by P450-inducing medicines?

Yes

Notes

These have a 9% typical use failure rate. The progestin-only pill is much less preferred for use with P450 inducers because progestins have more variable metabolism than estrogen. There is evidence that the drospirenone-only pill is more effective than one like norethindrone. 

Hormonal patches and rings

Affected by P450-inducing medicines?

Yes

Notes

These have a 9% typical use failure rate. Using the ring or patch in an extended or continuous regimen may result in higher ovulation inhibition and thus higher effectiveness.   

Can I increase oral birth control doses to help improve effectiveness when using P450 inhibitors?

Older guidelines based on expert opinion recommended using 50 mcg of ethinyl estradiol when using P450 inducers with COCs. However, progestin is now the primary method of ovulation suppression in modern COCs. (Estrogen is just used to balance the hormones and potentiate the effect.) For more info, see Reimers, 2016. Keep in mind that:

  • Modern COCs typically already include 1.5 to 2 times the ovulation-suppression dose of progestin. 
  • There is variability in individual metabolization of progestins.
  • Progestin-only pills are much less preferred for use with P450 inducers as discussed above.      

You may increase both estrogen and progestin by about 100% (double) for modafinil and armodafinil, and by about 50% for pitolisant, as long as the ethinyl estradiol dose remains under 50 mcg. These suggestions have not yet been backed by studies but are reasonable since manufacturer data indicates that these specific hypersomnia medicines can cause the effective hormone dose to be decreased by 30 to 50% by modafinil or armodafinil, and by 10 to 32% by pitolisant.

If a PWH is taking the hypersomnia medicine modafinil or armodafinil, consider increasing the hormone dose by having PWH either:

  • Take 2 “low-dose” COC pills per day, each containing 20 mcg of ethinyl estradiol and a progestin  
  • Take custom compounded COC pills (or separate prescriptions) for ethinyl estradiol and a progestin at double their standard dosages (such as with 40 mcg of ethinyl estradiol and a doubled progestin dose)
  • Take 2 progestin-only pills per day (much less preferred than COCs when using P450 inducers)

If a PWH is taking the hypersomnia medicine pitolisant, consider increasing the hormone dose by 50% by having PWH either: 

  • Take custom compounded pills (or separate prescriptions) with a 50% increase in both the standard 20 microgram of ethinyl estradiol and a 50% increase in the progestin. Or, much less preferred, take a 50% higher dose of a progestin-only contraceptive. 
  • Take 2 “low-dose” pills per day, each containing 20 mcg of ethinyl estradiol and a progestin. Or, much less preferred, take 2 progestin-only pills per day. Although this approach doubles the hormones and may provide more hormones than necessary, it remains a reasonable approach.

And for all of the above approaches, either:  

  • Reduce the pill-free (placebo) interval to 4 days instead of 7  
  • More preferably, skip the pill-free interval completely by prescribing continuous or extended contraception  

Note that using custom compounding or separate prescriptions for ethinyl estradiol and/or a progestin:  

  • May not be easily available. 
  • May not be easily covered by insurance (in the U.S.), and doubled doses may also not be easily covered. Read more about making an appeal to the insurance company if needed on our “Dealing with health insurance denials” web page.
  • May introduce more variability in the dosage. This is inherent with custom compounding and may affect the birth control effectiveness. 

Third-tier birth control methods

  • Internal and external condoms 
  • Withdrawal (pulling out before ejaculation)
  • Spermicides
  • Rhythm method (fertility-awareness based methods)

Affected by P450-inducing medicines?

No, none of these methods are affected

Notes

These methods have a typical use failure rate of 18 to 28%.  

Although none of these methods interact with P450-inducing medicines, their typical use effectiveness is very likely lower than that of hormonal contraceptives along with a P450-inducing medicine. 

Emergency contraception

The effectiveness of hormonal types of emergency contraception can also be negatively affected by P450-inducing medicines.

Copper IUD

Affected by P450-inducing medicines? 

No

Notes

This is the most effective type of emergency contraception if the copper IUD is inserted within 5 days of unprotected vaginal intercourse.

Levonorgestrel (such as Plan B)

Affected by P450-inducing medicines? 

Yes

Notes

Levonorgestrel is available over-the-counter, without a prescription, in the U.S.

The sooner a person takes it, the better it works, but they can take it up to 5 days after the unprotected intercourse.

Doubling the dose could theoretically counteract the effects of P450 inducers, but studies have not yet been done to confirm this.

Ulipristal acetate (such as Ella)

Affected by P450-inducing medicines?

Yes

Notes

Ulipristal acetate is twice as effective as levonorgestrel emergency contraception for people who are obese.

It can be taken up to 5 days after unprotected vaginal intercourse with no loss of effectiveness. In the U.S., a prescription is required.

It’s a progesterone receptor modulator. P450 inducers could theoretically reduce its effectiveness, but this hasn’t yet been studied. Doubling the dose could theoretically counteract the effects of P450 inducers, but studies have not yet been done to confirm this. 

Additional resources

Many medicines for other disorders also affect P450. For some of these other disorders, such as epilepsy, there are published recommendations for how to choose and adjust birth control when using P450-inducing medicines. Clinicians interested in more detail on management of these types of interactions may find recommendations such as the following useful: Reimers, 2016; Schwenkhagen, 2008.

Acknowledgements

  • Based on the 2018 HF Conference Presentation by Isabelle Arnulf, MD, PhD, HF Medical Advisory Board Member
  • OB/GYN review and vetting by Elezabeth Young, MD and Carrie Cwiak, MD, MPH, Director of the Complex Family Planning Division at Emory University School of Medicine
  • Sleep Medicine review and vetting by Lynn Marie Trotti, MD, MSc and Isabelle Arnulf, MD, PhD, Members, HF Medical Advisory Board
  • Contributions by Christopher T. Lang, MD
  • Contributions by Valerie Vanderlip, IBCLC

Completing the treatment plan

PWH have many needs that can’t be addressed by medicines. The following information and tools address their common treatment needs.

Treatment considerations for all PWH

Non-medicine treatment options for PWH

Refer PWH to our “Quality of life tips” web page where they’ll find ideas on non-medicine treatments and social support. Topics include naps, support groups, therapy, sleep hygiene, meditation, diet, exercise, and more. Also included are daily journal forms with instructions to help PWH find useful patterns, including how their medicines are affecting them.

Connecting PWH to the hypersomnia community for information and support

Cognitive behavioral therapy for hypersomnias (CBT-H)

If you’re interested in providing CBT-H treatment for PWH, review our journal article summary outlining methods of customizing the treatment for hypersomnias. The primary author will share the treatment manual upon request.

Preparing PWH for anesthesia, hospitalization, and medical emergencies

Treatment considerations for specific populations

Students needing accommodations

K-12 and college students will find information on accommodations and strategies for success on our web page “Going to school while coping with a hypersomnia.” We also include these clinician-specific PDF resources:

Workers needing accommodations or disability income

Refer people struggling with hypersomnia symptoms while at work to our web page “Planning for job accommodations and disability income.”

PWH planning for pregnancy or parenting babies

Visit our “Clinician support for pregnancy and safe baby care” web page for professionals to find considerations for people who have hypersomnias, vetted by OB/GYN, pediatrics, sleep medicine and lactation experts. On this page, you’ll find:

  • Inheritance patterns for idiopathic hypersomnia and narcolepsy types 1 and 2
  • Considerations for safe baby care when a parent has a hypersomnia
  • Pregnancy and nursing risk profiles for hypersomnia medicines
  • And more

Screening for undiagnosed or undertreated co-morbidities

Some PWH may have other health problems that make their symptoms worse. Consider screening for:

  • Other sleep disorders, such as obstructive sleep apnea, circadian rhythm disorders, or rapid eye movement (REM) sleep behavior disorder.
  • Anxiety and depression. Screen every 1 to 2 years because people with hypersomnias have a higher risk. Consider using the Patient Health Questionnaire-2 (PHQ-2) since other screening tests such as the PHQ-9 may show false results due to questions about fatigue, trouble concentrating, and fragmented sleep.
  • Autonomic dysfunction, which is associated with about a third of childhood primary hypersomnias. Symptoms such as postural fatigue, palpitations, headache, and dizziness can be mistaken as symptoms of the primary sleep disorder. Once hypersomnia medicines are started, these symptoms may be masked. Therefore, you should screen at the initial presentation of the sleep disorder, using autonomic reflex screens and focused questioning. Read more in this 2021 study. Adults also have increased rates of autonomic dysfunction, including POTS, that would benefit from early screening. See our journal article summary.
  • Anemias, including iron deficiency anemia, which can happen from blood loss. If blood loss is caused by a patient’s period (menstruation), consider continuous hormone therapy (such as birth control pills, IUD, implant, patch, or vaginal ring) which can help limit the menstrual bleeding that can cause iron deficiency anemia and fatigue.
  • Cardiovascular health. PWH may be at increased risk, although most of the available literature is focused on narcolepsy. Obesity and sleep fragmentation, which are known to be more common in narcolepsy, are also associated with cardiovascular disease.
  • Variation in hypersomnia symptoms with menstrual cycles. Hormone therapy may lessen hypersomnia symptoms.

How can I get continuing medical education (CME) credits for learning more about treating hypersomnias?

Visit our CME web page.

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Published Dec. 16, 2022 |
Revised Feb. 1, 2024
Complete update Oct. 9, 2023 |
Approved by our medical advisory board