1069 Less is Not Always Better: Status Cataplecticus Precipitated by Decreased Dosage of Venlafaxine.

Status cataplecticus is a rare manifestation with cataplexy occurring for hours or days without a refractory period. It can be precipitated by abrupt cessation of noradrenergic or serotonergic medications, addition of prazosin or by strong emotions. A 46 y/o African-American male was diagnosed with narcolepsy with cataplexy in his 20’s. MSLT showed MSL of 3.6 minutes with 2 SOREMP’s. Initially seen in our institution in 1998, his narcolepsy was managed with methylphenidate and fluoxetine. Cataplexy was described as slurred speech, momentary drowsiness with intact consciousness. Due to persistent sleep attacks on methylphenidate, he was switched to modafinil. Hypersomnia improved but cataplexy continued. In 2003, he participated in Xyrem trial studies with resolution of cataplexy. He failed to follow-up since. Patient re-established care in June 2017 to get medication refills. He reported narcolepsy was managed in an outside sleep clinic with venlafaxine 225 mg XL, modafinil 200mg tablet in the morning and 100 mg in the afternoon. 14 months after re-establishing care, patient called nursing triage due to repeated episodes of speech difficulty and to request for a higher dose of his medication. Patient was immediately seen in sleep clinic. While in clinic he was laughing with the front desk staff when he had buckling of knees, repeated episodes of slurred speech, loss of muscle tone with sagging of face and dropping of neck every few minutes. He was conscious during these episodes. It was noted that the last refill of venlafaxine was accidently reduced to 150 mg. Patient was prescribed his usual dose of venlafaxine 225mg, escorted to the pharmacy followed by administration of venlafaxine 225 mg. In clinic the following day, cataplexy had completely resolved with higher dose of venlafaxine. Re-assessment after 4 weeks showed good control of cataplexy with the correct dose of venlafaxine. Patient is currently being restarted on Xyrem. A case report in 2013 described status cataplecticus precipitated by abrupt withdrawal of venlafaxine. We report a case of status cataplecticus caused by accidental decreased dosage of venlafaxine. We hope to contribute to understanding the spectrum of etiology and presentation of this rare condition with this case.