Orexin deficiency and cardiometabolic risk in narcolepsy: mechanistic pathways and therapeutic implications
4 affiliations
- 1Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, United States
- 2Yale Center of Sleep Medicine, Yale New Haven Hospital, New Haven, Connecticut, United States
- 3Sleep Medicine Section, VA San Diego Healthcare System, San Diego, California, United States
- 4Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California San Diego, La Jolla, California, United States
Abstract
Narcolepsy type 1 (NT1) results from autoimmune destruction of orexin-producing neurons in the lateral hypothalamus. While traditionally viewed as a sleep disorder, accumulating evidence indicates that orexin deficiency produces widespread cardiometabolic consequences—including obesity, insulin resistance, dyslipidemia, metabolic-associated steatotic liver disease, and major adverse cardiovascular events—that cannot be fully explained by weight gain or medication effects alone. This review examines four overlapping mechanisms through which orexin deficiency drives cardiometabolic risk. First, loss of orexin disrupts the coupling of hunger drive with arousal and energy expenditure. Orexin neurons interact with neuropeptide Y (NPY)/agouti-related peptide (AgRP) and pro-opiomelanocortin (POMC) circuits and project to reward and cognitive control pathways; their absence impairs satiety signaling, blunts hedonic reward processing, and uncouples food intake from physical activity. Second, orexin has direct peripheral metabolic effects—enhancing beta-cell function, promoting adipocyte insulin sensitivity, and suppressing hepatic gluconeogenesis. Loss of these actions promotes insulin resistance, atherogenic dyslipidemia, and hepatic steatosis. Third, disrupted sleep architecture and autonomic dysfunction compound metabolic risk. Orexin loss produces state-dependent dysautonomia—reduced resting sympathetic drive with inadequate parasympathetic compensation during sleep—contributing to nondipping blood pressure and elevated cardiovascular risk. Disease-specific barriers, including cataplexy avoidance, further limit physical activity. Fourth, the autoimmune inflammatory process may contribute to systemic metabolic inflammation, though the extent of ongoing inflammation after neuronal loss remains uncertain. These mechanisms are interdependent and mutually reinforcing. Selective orexin receptor 2 agonists such as oveporexton offer the first opportunity to restore lost orexin signaling. Whether this translates into cardiometabolic improvements warrants systematic evaluation in future trials.
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BibTeX
@article{shukla2026orexin,
title = {{Orexin deficiency and cardiometabolic risk in narcolepsy: mechanistic pathways and therapeutic implications}},
author = {Anant Shukla and Jacqueline H. Geer and Brandon Nokes and Brian S. Wojeck},
journal = {Function},
year = {2026},
month = nov,
doi = {10.1152/function.90001.2026},
url = {https://doi.org/10.1152/function.90001.2026},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Orexin deficiency and cardiometabolic risk in narcolepsy: mechanistic pathways and therapeutic implications
AU - Anant Shukla
AU - Jacqueline H. Geer
AU - Brandon Nokes
AU - Brian S. Wojeck
PY - 2026
DA - 2026/11/03
JO - Function
DO - 10.1152/function.90001.2026
UR - https://doi.org/10.1152/function.90001.2026
AB - Narcolepsy type 1 (NT1) results from autoimmune destruction of orexin-producing neurons in the lateral hypothalamus. While traditionally viewed as a sleep disorder, accumulating evidence indicates that orexin deficiency produces widespread cardiometabolic consequences—including obesity, insulin resistance, dyslipidemia, metabolic-associated steatotic liver disease, and major adverse cardiovascular events—that cannot be fully explained by weight gain or medication effects alone. This review examines four overlapping mechanisms through which orexin deficiency drives cardiometabolic risk. First, loss of orexin disrupts the coupling of hunger drive with arousal and energy expenditure. Orexin neurons interact with neuropeptide Y (NPY)/agouti-related peptide (AgRP) and pro-opiomelanocortin (POMC) circuits and project to reward and cognitive control pathways; their absence impairs satiety signaling, blunts hedonic reward processing, and uncouples food intake from physical activity. Second, orexin has direct peripheral metabolic effects—enhancing beta-cell function, promoting adipocyte insulin sensitivity, and suppressing hepatic gluconeogenesis. Loss of these actions promotes insulin resistance, atherogenic dyslipidemia, and hepatic steatosis. Third, disrupted sleep architecture and autonomic dysfunction compound metabolic risk. Orexin loss produces state-dependent dysautonomia—reduced resting sympathetic drive with inadequate parasympathetic compensation during sleep—contributing to nondipping blood pressure and elevated cardiovascular risk. Disease-specific barriers, including cataplexy avoidance, further limit physical activity. Fourth, the autoimmune inflammatory process may contribute to systemic metabolic inflammation, though the extent of ongoing inflammation after neuronal loss remains uncertain. These mechanisms are interdependent and mutually reinforcing. Selective orexin receptor 2 agonists such as oveporexton offer the first opportunity to restore lost orexin signaling. Whether this translates into cardiometabolic improvements warrants systematic evaluation in future trials.
SN - 2633-8823
ER -