Narcolepsy and genes

A study reports that almost all cases of narcolepsy are linked by specific genetic variants.

Imagine standing in line at the supermarket when a sudden, irresistible bout of sleep — a “sleep attack” — that lasts anywhere from a few seconds to several minutes, overtakes you. Next, imagine this happening as you ride the train home from work. Painfully, such uncomfortable scenarios may be common to people who suffer from narcolepsy. Now European researchers have discovered that a specific allele or variant of a particular gene, which is within the human leukocyte antigen (HLA) system and related to immune function, is connected to this unusual brain disorder. "This almost 100 percent association with HLA is somehow unique to narcolepsy and suggests a causal implication," lead author Mehdi Tafti, professor at the University of Lausanne, stated in a press release. The ground-breaking research appears in thecurrent issue of Sleep.

Narcolepsy defined

A rare but often disabling brain disorder, narcolepsy with cataplexy is estimated to affect about one in every 3,000 Americans while additional cases of the disorder without the cataplexy component may also exist. People with narcolepsy experience repeated daily episodes of an irrepressible need to sleep or lapses into sleep, which may occur suddenly. Cataplexy is another common symptom of the disorder and involves sudden muscle weakness — usually in the legs but also in the face and neck — that is caused by strong emotions such as laughter. Narcolepsy affects both males and female equally and appears throughout the world, though unevenly. It is most common in Japan, for instance, while being very rare in Israel. The condition is life-long and symptoms, including “sleep attacks” and cataplexy, generally start in childhood or adolescence, though in some cases they begin later in life. 

Narcolepsy is considered to be both underrecognized and underdiagnosed, in part due to the difficulty of finding an appropriate diagnostic test. It is known, for example, that most patients with narcolepsy do not produce hypocretin in a deep part of the brain called the hypothalamus; prior studies have also identified five common genetic variants linked to narcolepsy with cataplexy. “Because of the discovery of the HLA association, narcolepsy is believed to be an autoimmune disease,” wrote the authors in their study. “The discovery of hypocretin (orexin) deficiency in narcolepsy with cataplexy raised the possibility that hypothalamic hypocretin-producing neurons might be the target of an autoimmune attack, motivating the search for potential genetic mechanisms.”

Seeking, then, a more precise explanation of the condition, a team of European researchers investigated HLA-DQB1, the previously identified five variants linked to the condition as well as 10 other potential variants in a sample of 1,261 European patients who have narcolepsy with cataplexy symptoms. These same patients also made their complete diagnostic work-up and their DNA freely available to the study effort. After matching these patients with 1,422 controls, the researchers began high-resolution genotyping to identify genetic variants including those in the HLA system.

Remarkably, they discovered a more definite relationship between the disorder and the genetic variants than they expected. Their results showed that participants with the HLA allele DQB1*06:02 were 251 times more likely to have narcolepsy with cataplexy than participants without the allele. In fact, the scientists discovered that DQB1*06:02 had a negative predictive value of 99.32 percent. This means that nearly 100 percent of patients who suffer narcolepsy with cataplexy are DQB1*06:02 positive. “An overwhelming portion of genetic risk for narcolepsy with cataplexy is found at DQB1locus,” wrote the authors in their study. “Since DQB1*06:02 positive subjects are at 251-fold increase in risk for narcolepsy … DQB1 genotyping may be relevant to public health policy.” More proof, then, that as human genome studies unfold, the more personal — and more effective — medicine should soon become.

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Study: Narcolepsy could be caused by the immune system

According to a recent study, narcolepsy might be caused by an immune system attack, meaning it could be tested for by a blood test, and treatment may center around the immune system.

A new study has uncovered evidence that most cases of narcolepsy are caused by a misguided immune system attack -- something that has been long suspected but unproven.

Experts said the finding, reported Dec. 18 in Science Translational Medicine, could lead to a blood test for the sleep disorder, which can be difficult to diagnose.

It also lays out the possibility that treatments that focus on the immune system could be used against the disease.

"That would be a long way out," said Thomas Roth, director of the Sleep Disorders and Research Center at Henry Ford Hospital, in Detroit.

"If you're a narcolepsy patient now, this isn't going to change your clinical care tomorrow," added Roth, who was not involved in the study.

Still, he said, the findings are "exciting," and advance the understanding of narcolepsy.

Narcolepsy causes a range of symptoms, the most common being excessive sleepiness during the day. But it may be best known for triggering potentially dangerous "sleep attacks." In these, people fall asleep without warning, for anywhere from a few seconds to a few minutes.

About 70 percent of people with narcolepsy have a symptom called cataplexy -- sudden bouts of muscle weakness. That's known as type 1 narcolepsy, and it affects roughly one in 3,000 people, according to the U.S. National Institute of Neurological Disorders and Stroke.

Research shows that those people have low levels of a brain chemical called hypocretin, which helps you stay awake. And experts have believed the deficiency is probably caused by an abnormal immune system attack on the brain cells that produce hypocretin.

"Narcolepsy has been suspected of being an autoimmune disease," said Dr. Elizabeth Mellins, a senior author of the study and an immunology researcher at Stanford University School of Medicine, in California.

"But," she said, "there's never really been proof of immune system activity that's any different from normal activity."

Mellins thinks her team has uncovered "very strong evidence" of just such an underlying problem.

The researchers found that people with narcolepsy have a subgroup of T cells in their blood that react to particular portions of the hypocretin protein -- but narcolepsy-free people do not. T cells are a key part of immune system defenses against infection.

That finding was based on 39 people with type 1 narcolepsy, and 35 people without the disorder -- including four sets of twins in which one twin was affected and the other was not.

It's known that genetic susceptibility plays a role in narcolepsy. And the theory, Mellins explained, is that in people with that inherent risk, certain environmental triggers may cause an autoimmune reaction against the body's own hypocretin.

Infections are the main culprit, and there is already evidence that the H1N1 "swine" flu is one trigger. In China, Mellins noted, there was an upswing in childhood narcolepsy cases after the H1N1 flu pandemic of 2009.

And in 2010, a cluster of narcolepsy cases in Europe was linked to a particular H1N1 vaccine that contained an "adjuvant" designed to induce a stronger immune system response. That vaccine, called Pandemrix, is no longer in use.

All of that led experts to speculate that in some genetically vulnerable people, the H1N1 virus could cause T cells to mistakenly attack hypocretin-producing brain cells.

And in the current study, Mellins's team found that segments of the H1N1 virus were similar to portions of the hypocretin protein -- the same portions that activated narcolepsy patients' T cells. They say that supports the idea that certain infections confuse T cells into attacking hypocretin-producing cells.

An expert on sleep welcomed the new study.

"They're providing more-compelling evidence that this is an autoimmune disease," said Dr. Nathaniel Watson, an associate professor of neurology at the University of Washington in Seattle, and a member of the board of directors for the American Academy of Sleep Medicine.

He and Mellins both said the results could have practical use, too. For one, researchers may be able to develop a blood test to help objectively diagnose narcolepsy.

Right now, Watson said, narcolepsy can be difficult to pinpoint, because the most common symptom -- daytime sleepiness -- has far more common causes. The most common, he noted, is simple: Not going to bed early enough.

So to diagnose narcolepsy, people may have to spend 24 hours in a sleep lab or, in some cases, have a lumbar puncture (spinal tap) to measure hypocretin in the spinal fluid.

Mellins said that if an autoimmune reaction is the cause of type 1 narcolepsy, it might be possible to treat with an immune-suppressing therapy.

The problem, though, is that once people develop full-blown symptoms, their hypocretin-producing cells have already been knocked off.

"We'd need some kind of pre-clinical marker of the disease to be able to intervene," said Watson at the University of Seattle.

Roth of Henry Ford Hospital agreed. "The big challenge is, how will you identify the people to treat?"

Three of the study authors reported they are inventors on a patent to use the hypocretin protein segments to diagnose narcolepsy. Stanford owns the intellectual property rights for this use.

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