Nocturnal rapid eyemovement sleep latency for identifying patients with narcolepsy/hypocretin deficiency

Importance Narcolepsy, a disorder associated with HLA-DQB1*06:02 and caused by hypocretin (orexin) deficiency, is diagnosed using the Multiple Sleep Latency Test (MSLT) following nocturnal polysomnography (NPSG). In many patients, a short rapid eyemovement sleep latency (REML) during the NPSG is also observed but not used diagnostically. OBJECTIVE To determine diagnostic accuracy and clinical utility of nocturnal REML measures in narcolepsy/ hypocretin deficiency. DESIGN, SETTING, AND PARTICIPANTS Observational study using receiver operating characteristic curves for NPSG REML and MSLT findings (sleep studies performed between May 1976 and September 2011 at university medical centers in the United States, China, Korea, and Europe) to determine optimal diagnostic cutoffs for narcolepsy/hypocretin deficiency compared with different samples: controls, patients with other sleep disorders, patients with other hypersomnias, and patients with narcolepsy with normal hypocretin levels. Increasingly stringent comparisons were made. In a first comparison, 516 age- and sex-matched patients with narcolepsy/hypocretin deficiencywere selected from 1749 patients and compared with 516 controls. In a second comparison, 749 successive patients undergoing sleep evaluation for any sleep disorders (low pretest probability for narcolepsy) were compared within groups by final diagnosis of narcolepsy/hypocretin deficiency. In the third comparison, 254 patients with a high pretest probability of having narcolepsywere compared within group by their final diagnosis. Finally, 118 patients with narcolepsy/hypocretin deficiencywere compared with 118 ageand sex-matched patients with a diagnosis of narcolepsy but with normal hypocretin levels. MAIN OUTCOME AND MEASURES Sensitivity and specificity of NPSG REML and MSLT as diagnostic tests for narcolepsy/hypocretin deficiency. This diagnosis was defined as narcolepsy associated with cataplexy plus HLA-DQB1*06:02 positivity (no cerebrospinal fluid hypocretin-1 results available) or narcolepsy with documented low (110 pg/mL) cerebrospinal fluid hypocretin-1 level. RESULTS Short REML (15 minutes) duringNPSGwas highly specific (99.2%[95%CI, 98.5%- 100.0%] of 516 and 99.6%[95%CI, 99.1%-100.0%] of 735) but not sensitive (50.6%[95%CI, 46.3%-54.9%] of 516 and 35.7%[95%CI, 10.6%-60.8%] of 14) for patients with narcolepsy/ hypocretin deficiency vs population-based controls or all patients with sleep disorders undergoing a nocturnal sleep study (area under the curve,0.799 [95%CI,0.771-0.826] and0.704 [95% CI,0.524-0.907], respectively). In patients with central hypersomnia and thus a high pretest probability for narcolepsy, short REML remained highly specific (95.4%[95%CI, 90.4%-98.3%] of 132) and similarly sensitive (57.4%[95%CI, 48.1%-66.3%] of 122) for narcolepsy/hypocretin deficiency (area under the curve,0.765 [95%CI,0.707-0.831]). Positive predictive value in this high pretest probability samplewas 92.1% (95%CI, 83.6%-97.0%). CONCLUSIONS AND RELEVANCE Among patients being evaluated for possible narcolepsy, short REML (15 minutes) at NPSG had high specificity and positive predictive value and may be considered diagnostic without the use of an MSLT; absence of short REML, however, requires a subsequent MSLT.