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Lemborexant is a dual orexin antagonist and is considered a safe and effective hypnotic. Dual orexin antagonists induce physiological sleep by blocking orexin receptors. Although the blockade of orexin signaling has triggered narcolepsy-like symptoms in rodents, there is currently no evidence of lemborexant inducing narcolepsy-like symptoms in humans. We describe the case of a 79-year-old Japanese woman with bipolar depression who experienced lemborexant-induced cataplexy and sleep attack. Her previous results on the Multiple Sleep Latency Test excluded the diagnosis of narcolepsy. She experienced narcolepsy-like symptoms on 2 occasions after she was administered lemborexant, in the context of hyperactive delirium, but not in a relaxed state. Her case suggests that lemborexant could trigger narcolepsy-like symptoms in patients with hyperactive delirium, even those with no history of narcolepsy. This case also emphasizes that clinicians must be very careful when they prescribe lemborexant to patients who experience hyperactive delirium. CITATION: Shibata S, Oda Y, Ohki N, et al. Narcolepsy-like symptoms triggered by lemborexant in the context of hyperactive delirium in a patient with bipolar depression: a case report. J Clin Sleep Med. 2022;18(5):1459–1462.

We describe the case of a 49-year-old Japanese male patient successfully treated with a paliperidone rechallenge following 2-year treatment with clozapine for treatment-resistant schizophrenia. He had responded well to conventional antipsychotic treatment for the initial psychotic episode but gradually developed dopamine supersensitivity; even treatment with paliperidone and another antipsychotic medication (a total up to 1700 mg in chlorpromazine-equivalent dose) had not improved his psychotic symptoms. Clozapine treatment produced temporary symptomatic relief, but the clozapine dose could not be increased to > 150 mg due to the patient’s intolerance. Following low-dose clozapine treatment for 2 years, a rechallenge with paliperidone monotherapy ameliorated his psychotic symptoms. This suggests that clozapine may have the potential to release the dopamine supersensitivity state. Our patient’s case indicates that for patients with dopamine supersensitivity psychosis, a rechallenge with a previously ineffective antipsychotic after clozapine treatment may be successful.

Objectives To investigate the appropriate timing, useful findings and combination of magnetic resonance imaging (MRI) and ultrasound (US) for predicting the radiographic progression in early rheumatoid arthritis (RA). Methods Forty-four active RA patients, who examined by both of MRI and US in the symptomatic wrist and finger joints, were recruited in Nagasaki University Hospital from 2010 to 2017 and treated by the treat-to-target therapeutic strategy for 1 year. MRI was evaluated by RA MRI scoring and US by Outcomes Measures in Rheumatology Clinical Trial, respectively. Plain radiographs were assessed by the Genant-modified Sharp score for the symptomatic side in the same manner as MRI and US. Radiographic progression was defined as an annual increase ≥0.75 at 1 year. Factors associated with radiographic progression were analysed. Also, the optimal combination of MRI and US at each timepoint was considered. Results Logistic regression model revealed that MRI-proven bone marrow oedema at baseline and 6 months and joint counts of power-Doppler grade ≥2 articular synovitis at 3 or 6 months were significantly associated with radiographic progression at 1 year. Conclusion This study may suggest the favourable timing and combination of MRI and US at each point to predict radiographic progression in patients with early-stage RA.

Background Periarticular osteoporosis is one of hallmark of rheumatoid arthritis (RA). However, until now the periarticular bone structure including bone mineral density have not been fully elucidated. High-resolution peripheral quantitative computed tomography (HR-pQCT) is a new technique with high spatial resolution that enables us to assess microarchitecture of cancellous and cortical bones that cannot be assessed by conventional X-ray examinations. Recently, few studies using HR-pQCT revealed that bone microarchitecture such as trabecular volumetric densities (Tb.vBMD) were different between RA and non-RA1, but these study had not compared findings of HR-pQCT with synovitis assessed by ultrasonography(US) or systemic osteoporosis. Objectives To investigate bone microarchitecture evaluated by HR-pQCT in RA. Methods This study included 21 RA patient. HR-pQCT imaging analyses quantified bone microarchitecture in 2,3 Metacarpal Head. We measured the bone mineral density (BMD) of lumber spine and femoral neck using Dual-Energy X-ray Absorptiometry (DXA). Synovitis and bone destruction were assessed by US and X-ray, respectively. Results Disease duration, age and disease activity were not correlated with bone microarchitecture. BMD of femoral neck was correlated with Tb.vBMD (r=0.84,p Conclusion This study revealed that bone destruction and synovitis were associated with bone microarchitecture and, the difference of treatment response by parameter of bone microarchitecture. However, this study was mainly transverse analysis and small samples, we need longitudinal analysis using larger samples. References [1] Feehan LM, Li LL, McKay HA. Micro-structural bone changes in early rheumatoid arthritis persist over 1-year despite use of disease modifying anti-rheumatic drug therapy. BMC Musculoskelet Disord 2017; 18(1): 521. Disclosure of Interests Naoki Iwamoto: None declared, Konosuke Watanabe: None declared, Tomohiro Koga: None declared, Shin-ya Kawashiri: None declared, Kunihiro Ichinose: None declared, Mami Tamai: None declared, Hideki Nakamura: None declared, Nozomi Ohki: None declared, Ko Chiba: None declared, Tomoki Origuchi: None declared, Makoto Osaki: None declared, Atsushi Kawakami Grant/research support from: Astellas Pharma, Consultant for: Astellas Pharma, Speakers bureau: Astellas Pharma