Narcolepsy: Treatments, Supplement Evidence and Safety

Table of contents

• Evidence summary
• What narcolepsy is
• How it works
• The evidence-based treatments
• Supplement and lifestyle evidence
• What works and what does not
• Risks and side effects
• Important interactions
• Who should avoid
• Dosage and how to take
• Animal and in-vitro evidence
• Funding and source roles
• Frequently asked questions
• Sources and funding notes

Evidence summary

These tables distinguish clinical recommendations, trial results, observational associations and evidence gaps. They are not a uniform ranking of independent evidence.

Claim	Evidence reviewed	Source	Funding / conflict	Interpretation / limits
Sodium oxybate: cataplexy and wakefulness	Six short RCTs in the review, with different subsets and doses for each outcome. MWT improvement at 9 g/night: +5.18 minutes. Cataplexy dose reporting differs between the abstract and main Results.	Alshaikh 2012	All six underlying trials privately industry-funded; review partly supported by a Saudi public science program, with no financial conflicts declared.	Short trials; allocation methods often unclear. Not all six contributed to each pooled endpoint.
Pitolisant: daytime sleepiness and cataplexy	Post-hoc analysis of two 7–8-week RCTs: pooled Epworth effect d=0.73. NNTs vary with response definition and endpoint.	Meskill 2022	Bioprojet trials; Harmony analysis, statistical/writing support and publication charges. Four authors Harmony employees; Schwartz Bioprojet cofounder; Meskill paid advisory/speaker ties.	Short sponsor-funded analysis; cataplexy NNTs came from HARMONY CTP only.
Modafinil / armodafinil recommendations	AASM adult recommendations: strong for modafinil, conditional for armodafinil.	AASM guideline	AASM funded development; author NIH grants, company relationships and abstentions are disclosed.	Recommendations do not establish a strong/moderate outcome-certainty grade.
Other AASM adult recommendations	Strong: pitolisant, sodium oxybate, solriamfetol. Conditional: dextroamphetamine and methylphenidate.	AASM guideline	AASM-funded; author conflicts managed with disclosed abstentions.	Medication selection requires individual assessment; recommendations are not a universal first-line order.
Scheduled naps and regular sleep	Small varied behavioral studies; some alertness findings, inconsistent sleep-attack results.	Marín Agudelo 2014	Authors declared no competing interests; funding not stated. UPenn hosts this copy.	Adjunctive evidence with small samples, varying schedules and limited long-term follow-up.
L-carnitine	One crossover RCT analysed 28 people. Logged dozing averaged 49 versus 58 minutes/day; one-tailed p=.048. Epworth, quality-of-life and other symptom outcomes were not significant.	Miyagawa 2013; Salles 2022	Trial: Japanese government grants and company-founded/endowed foundations; three research-company employees. Review: CNPq grant.	Eight weeks per treatment; borderline subjective primary result, no objective sleep-latency test.
Vitamin D association	51 cases and 55 matched controls; lowest-quartile OR 5.34 unadjusted and 3.63 after BMI adjustment (95% CI 1.06–12.46).	Carlander 2011	No funding/support reported; no competing interests declared. Complete financial provenance not established.	Case-control association; no supplementation intervention or proof of cause.
Melatonin for narcolepsy symptoms	The clinical sources reviewed here do not establish routine narcolepsy symptom treatment. General melatonin safety information answers a different question.	NCCIH melatonin information	Institutional education; underlying evidence finances not exhaustively traced.	No narcolepsy efficacy or dose established by these cited sources.
Omega-3 for narcolepsy symptoms	The cited clinical evidence in this article does not establish routine omega-3 treatment for daytime sleepiness or cataplexy.	Scope of this review	No specific omega-3 efficacy trial is evaluated here.	Evidence gap in this review; not proof that no study exists.

What narcolepsy is

Narcolepsy causes persistent daytime sleepiness and can include cataplexy, sleep paralysis, hallucinations around sleep and fragmented nighttime sleep. Type 1 diagnosis can involve low cerebrospinal-fluid hypocretin or cataplexy with diagnostic sleep-test findings; both are not required. Type 2 lacks cataplexy and hypocretin is generally normal. Diagnosis requires a sleep specialist and appropriate testing (NINDS educational booklet, 2017).

How it works

NT1 is associated with loss of orexin/hypocretin-producing neurons. Genetic and immune findings support an immune-mediated hypothesis, but the precise cause is unresolved. HLA associations are background evidence; their mention in a vitamin D case-control paper is not new proof of mechanism (NINDS, 2017; Rauf 2025 background review; Carlander 2011).

Rauf’s 2025 narrative review reports no specific funding and no conflicts. Its selection counts and some date/reference pairings are inconsistent. It is used for broad mechanistic background, with clinical definitions supported separately (Rauf 2025; NINDS, 2017).

The evidence-based treatments

The 2021 AASM clinical practice guideline gives strong adult recommendations for modafinil, pitolisant, sodium oxybate and solriamfetol, and conditional recommendations for armodafinil, dextroamphetamine and methylphenidate. AASM funded development; NIH grants supported individual authors. The indexed abstract and disclosure statement were accessible; full outcome-level certainty tables were not. These recommendation labels should not be read as high/moderate certainty grades or a head-to-head drug ranking (AASM guideline).

Treatment	Evidence reviewed	Outcome	Limitations
Sodium oxybate; XYWAV is a separate mixed-salt formulation	Six RCTs in a 2012 sodium-oxybate review (Alshaikh 2012).	MWT +5.18 minutes (95% CI 2.59–7.78) at 9 g/night, two studies. Cataplexy pooled difference −8.5 attacks/week (−15.3 to −1.6), two studies; the main Results describes 4.5 g/night while the abstract describes usually 9 g/night. CGI response RR 2.42 (1.77–3.32).	Different outcome subsets and reporting inconsistencies; mostly 4–8-week trials, one 12-week trial. All six privately industry-funded. Do not transfer trial outcomes to every oxybate formulation (XYWAV label).
Pitolisant	Post-hoc HARMONY 1 and HARMONY CTP analyses; 61 and 105 participants in the respective pitolisant/placebo comparisons (Meskill 2022).	Epworth study-specific d=.61 and .86; pooled d=.73. CTP cataplexy d=.86. NNT 3–5 for sleepiness and 3–4 for cataplexy, depending on response threshold.	Seven/eight weeks; not prespecified or powered for these post-hoc analyses. Sponsor-funded; selected populations and last-observation-carried-forward analysis limit generalization.
Modafinil / armodafinil	AASM clinical recommendations (AASM 2021).	Strong for modafinil; conditional for armodafinil.	Recommendation strength is distinct from outcome certainty. Original trial-by-trial results are not independently replicated here.
Solriamfetol	AASM adult clinical recommendation (AASM 2021).	Strong recommendation for narcolepsy.	This guideline recommendation does not by itself supply an outcome-level high-certainty grade. Prescribing precautions require the medicine label (SUNOSI label).

Pitolisant finance: Bioprojet sponsored the underlying trials. Harmony sponsored this later analysis, statistical and medical-writing support, and open-access charges. Davis, Zarycranski, Doliba and Dayno were Harmony employees; Schwartz was a Bioprojet cofounder. Meskill disclosed Harmony/Jazz advisory and speaker roles. Data were not publicly available. AASM’s strong recommendation is a separate clinical judgment; Maski abstained from developing or voting on pitolisant, sodium-oxybate and solriamfetol recommendations (Meskill 2022; AASM disclosures).

Sodium-oxybate finance: the review reported Saudi National Plan for Science and Technology support through King Saud University and no financial conflicts. All six included trials were privately industry-funded. Sequence generation/allocation concealment were inadequately described, some missing outcome data could not be obtained, and there were too few trials to assess publication bias reliably (Alshaikh 2012).

Supplement and lifestyle evidence

The following efficacy claims use human study results. Mechanistic and animal findings are not treated as proof of narcolepsy treatment benefit. Product labels may include nonhuman safety evidence.

Intervention	Human evidence	Finding	Study dose / duration	Funding / conflict	Limits
Naps / regular sleep	Small varied behavioral studies (Marín Agudelo 2014).	Some alertness findings; a 16-person trial found no significant sleep-attack frequency change.	Schedules varied; individualize with the treating team.	No competing interests declared; funding not stated. Hosting by UPenn does not establish funding.	Adjunctive; no formal evidence-level assessment in this review, limited long-term trials.
L-carnitine	One Japanese crossover trial; review adds three pregnancy case reports (Miyagawa 2013; Salles 2022).	28 completers: logged dozing 49±34 versus 58±37 minutes/day, one-tailed p=.048. Nap frequency, Epworth, quality of life, cataplexy and sleep paralysis did not significantly improve.	510 mg/day; eight weeks per treatment within a 16-week crossover; concomitant narcolepsy medicines permitted.	Government grants and company-founded/endowed foundations; three research-company employees. Review: CNPq 126739/2020-0.	Subjective primary measure; no formal washout or objective sleep-latency test. No adverse events observed in this small trial is limited reassurance.
Vitamin D	Case-control study: 51 cases / 55 controls (Carlander 2011).	Median 25(OH)D 59.45 versus 74.73 nmol/L; lowest-quartile OR 5.34, BMI-adjusted 3.63 (1.06–12.46). No association with symptom severity measures.	No supplementation intervention.	No support reported; no competing interests declared.	Diet and sun exposure unmeasured; reverse causation possible. Does not establish treatment benefit or a universal deficiency cutoff.
Melatonin	General safety/education sources (NCCIH).	These sources do not establish narcolepsy symptom efficacy.	No narcolepsy treatment dose established by the cited evidence.	Page-specific underlying study finance not exhaustively traced.	Evidence gap in this review; no claim of an exhaustive trial census.
Omega-3	No omega-3 narcolepsy efficacy study evaluated in this article.	Routine benefit for sleepiness/cataplexy not established by the cited clinical evidence.	No validated narcolepsy regimen supplied here.	No trial-specific funding conclusion.	Review scope does not prove that no study exists.

What works and what does not

Approach	What the cited evidence supports	Limits
Sodium oxybate, pitolisant, modafinil, solriamfetol	AASM strong adult recommendations (AASM 2021).	No universal first-line ranking; individual contraindications and preferences matter.
Armodafinil, dextroamphetamine, methylphenidate	AASM conditional adult recommendations (AASM 2021).	Conditional is a recommendation label, not a moderate-certainty grade.
Naps / sleep timing	May support selected patients (behavioral review).	Small varied studies; not guaranteed sleep-attack control or a medication substitute.
L-carnitine	Small primary dozing-time signal (original crossover trial).	Other measured symptoms not significantly improved; not established routine treatment.
Vitamin D	Lower levels associated with NT1 cases (case-control study).	Study did not test supplementation or cause; nutritional deficiency care is a separate question.
Melatonin	Narcolepsy efficacy not established by the cited sources (general melatonin information).	General sleep or safety findings do not establish narcolepsy benefit.
Omega-3	Narcolepsy efficacy not established in this review.	No omega-3 narcolepsy efficacy trial is evaluated here.

Risks and side effects

The linked 2017 sodium-oxybate label is archived; XYWAV is a distinct mixed-salt product with a current label. Oxybate is Schedule III, while illicit GHB is Schedule I. Oxybate warnings include CNS depression, respiratory depression and abuse/misuse; alcohol and sedative-hypnotics are contraindicated combinations. REMS requires certified prescribers/pharmacies and patient enrollment. At 9 g/night, the older review reported nausea RR 7.74 (95% CI 3.2–19.2), vomiting RR 11.8 (1.6–89.4) and dizziness RR 4.3 (1.1–16.4); these short-term relative risks are not absolute or long-term event rates (archived sodium-oxybate label; XYWAV label; Alshaikh 2012).

WAKIX can prolong QT. Its label advises avoiding known QT prolongation, relevant arrhythmia/torsades risk factors and other QT-prolonging drugs. It can reduce hormonal contraceptive effectiveness; use nonhormonal contraception during treatment and for at least 21 days after stopping (WAKIX label).

Medicine risks differ. Modafinil and armodafinil labels warn about serious skin/hypersensitivity and psychiatric reactions, and cardiovascular monitoring; armodafinil trials showed small average blood-pressure/pulse increases. SUNOSI can increase blood pressure and heart rate and requires hypertension control before treatment and monitoring. Headache, nausea and sleep disturbance are among reported adverse reactions; their rates cannot be compared directly across separate trials (modafinil label; armodafinil label; SUNOSI label).

Important interactions

Drug/supplement	Interacting agent	Mechanism / effect	Severity
Oxybate products	Alcohol	CNS/respiratory depression.	Contraindicated (XYWAV label; archived sodium-oxybate label).
Oxybate products	Sedative-hypnotics and other CNS depressants	Alcohol/sedative-hypnotics are contraindicated. Other CNS depressants, including opioids, can increase respiratory depression, profound sedation, hypotension and death risk.	Prescriber must manage any required combination; dose reduction/discontinuation or temporary oxybate interruption may be needed (XYWAV label).
Oxybate products	Divalproex sodium	Increases GHB exposure; labelled dose reduction needed	Prescriber-directed adjustment; when adding divalproex to stable XYWAV, initial XYWAV reduction of at least 20% (Current prescribing information)
Pitolisant	Centrally acting H1 antihistamines	May reduce pitolisant effectiveness	Avoid combination per WAKIX label (Current prescribing information)
Solriamfetol	MAO inhibitors, including use within the past 14 days	Risk of hypertensive reaction	Contraindicated (Current prescribing information)
Solriamfetol	Other BP/heart-rate-raising or dopaminergic drugs	Potential cardiovascular or pharmacodynamic interaction; combinations not adequately evaluated	Prescriber caution and monitoring (Current prescribing information)
Pitolisant	Hormonal contraceptives	Enzyme induction reduces contraceptive efficacy	Use non-hormonal contraception during treatment and for at least 21 days after stopping (WAKIX prescribing information)
Pitolisant	QT-prolonging drugs	Additive QT risk.	Avoid combination per label (WAKIX label).
Pitolisant	Strong CYP2D6 inhibitors / strong CYP3A4 inducers	CYP2D6 inhibitors increase exposure about 2.2-fold; CYP3A4 inducers reduce exposure about 50%.	Label-directed dose adjustment and monitoring (WAKIX label).
Modafinil / armodafinil	Hormonal contraceptives	Can reduce hormonal contraceptive effectiveness.	US labels advise alternative or additional contraception during treatment and for one month after stopping; follow local product advice (modafinil label; armodafinil label).
L-carnitine	Anticoagulants (warfarin)	Oral levocarnitine label reports increased INR with warfarin; monitor INR after initiation or dose changes (Primary source)	Monitor INR with prescriber oversight (Primary source)
Vitamin D	Thiazide diuretics	Reduced urinary calcium excretion combined with increased calcium absorption may cause hypercalcemia.	Review with the prescriber, especially in older adults, kidney impairment or hyperparathyroidism (NIH ODS).
Melatonin	Sedating medicines and sedating herbs	Can increase drowsiness; the NHS lists benzodiazepines, opioids and some sleeping medicines.	Check the exact medicines with a pharmacist/prescriber; avoid combining sedating herbal remedies (NHS interaction guidance).

Who should avoid

• Oxybate must not be combined with alcohol or sedative-hypnotics. A history of misuse requires assessment and careful monitoring; it is not itself a blanket contraindication in the cited labeling (XYWAV label; archived sodium-oxybate label).
• Pregnancy and breastfeeding decisions need medicine-specific review with the treating team. The small L-carnitine pregnancy case reports do not establish safety. Modafinil/armodafinil and SUNOSI labels describe limited human pregnancy data and nonhuman risk information; NCCIH notes limited melatonin pregnancy/lactation research (L-carnitine review; modafinil label; armodafinil label; SUNOSI label; NCCIH).
• Succinic semialdehyde dehydrogenase deficiency is a contraindication to XYWAV and to the archived sodium-oxybate product label (XYWAV label; 2017 sodium-oxybate label).
• Pitolisant requires nonhormonal contraception during treatment and for at least 21 days after stopping. Modafinil/armodafinil US labels advise alternative or additional contraception during treatment and for one month afterward (WAKIX; modafinil; armodafinil).
• Known QT prolongation and relevant arrhythmia/torsades risk factors call for avoiding WAKIX under its label. SUNOSI requires blood-pressure control and monitoring; modafinil/armodafinil need their own cardiovascular assessment. Close supervision does not cancel a product’s avoidance or contraindication instructions (WAKIX; SUNOSI; modafinil; armodafinil).
• Do not replace prescribed care with supplements on the basis of the studies cited here. Nutritional deficiency treatment and narcolepsy symptom treatment answer separate clinical questions (vitamin D study; L-carnitine trial).

Prescribing information and study doses

Treatment	Adult label / studied regimen	Important limits
Sodium-oxybate oral solution / XYWAV mixed salts	The archived 2017 sodium-oxybate label and current adult XYWAV narcolepsy label start 4.5 g/night, titrating to 6–9 g in two doses 2.5–4 hours apart.	Formulation-specific instructions, food timing, comorbidities and interacting medicines require the current product label and prescriber. These instructions do not cover every oxybate formulation (archived sodium-oxybate label; XYWAV label).
Pitolisant	Adult WAKIX: 8.9 mg each morning in week 1, 17.8 mg week 2, with up to 35.6 mg from week 3.	Genotype, renal/hepatic function and interactions can require lower doses; response may take up to 8 weeks (WAKIX label).
Modafinil / armodafinil	US adult narcolepsy labels:modafinil 200 mg each morning; armodafinil 150–250 mg each morning.	Severe hepatic impairment and individual factors may require adjustment. Modafinil 400 mg did not consistently add benefit over 200 mg (modafinil label; armodafinil label).
Solriamfetol	US adult narcolepsy label: 75 mg once daily on awakening, up to 150 mg with increases no more often than every 3 days.	Renal function may require lower doses. Control hypertension first; MAOI use or use within 14 days is contraindicated (SUNOSI label).
L-carnitine	510 mg/day, as 170 mg capsules: two in the morning and one in the evening, eight weeks per treatment in the small crossover trial.	Descriptive study regimen, not a validated routine narcolepsy recommendation (Miyagawa 2013).
Vitamin D	The cited case-control study tested blood levels, not supplementation.	No narcolepsy treatment dose can be derived from it; deficiency management requires separate assessment (Carlander 2011; NIH ODS).
Melatonin / omega-3	This review supplies no validated narcolepsy regimen.	Its cited evidence does not establish routine symptom treatment. General melatonin safety is a separate issue (NCCIH).

Animal and in-vitro evidence

Animal and cell studies may inform mechanisms and regulatory safety warnings, but cannot directly establish human narcolepsy treatment benefit. Human efficacy results, observational associations and product-label precautions are kept distinct in this article (mechanistic background; product prescribing information).

Funding and source roles

Follow the money

Research funding at a glance

Funding & backers→Source & study→Claim & limits

9 disclosure entries. The counts below summarize independence tiers explicitly assigned in this article. They count disclosures, not studies, funding amounts or evidence quality.

No single explicit tier could be mapped. This graphic does not assign a new tier or infer independence.

Consult this article’s source and funding notes for named funders, countries, relationships and exceptions where available. Institutional backing, researcher interests and trial sponsorship are separate questions. Public funding alone does not establish independence; commercial ties alone do not prove a claim false. This overview is not a new financial audit.

• AASM guideline: funded by AASM. Rowley/Trotti were board members and Hashmi an AASM employee. Maski disclosed NINDS/Jazz support and company consulting/CME roles, and abstained from oxybate, solriamfetol and pitolisant development/voting. Watson disclosed Harmony/Jazz consulting; Trotti disclosed AASM Foundation/NINDS support. Indexed abstract and disclosures were read; full outcome-level GRADE tables were unavailable (AASM guideline and disclosures).
• Sodium-oxybate review: Saudi public science-program support and no financial conflicts declared. All six underlying trials privately industry-funded, with short follow-up and incomplete randomization/allocation reporting. Review funding is distinct from trial sponsorship (Alshaikh 2012).
• Pitolisant: Bioprojet trials; Harmony post-hoc analysis, writing/statistical support and publication charges. Four Harmony employees, a Bioprojet cofounder and paid advisory/speaker ties are disclosed. AASM’s recommendation is a clinical synthesis, not sponsor-independent replication (Meskill 2022; AASM).
• Vitamin D case-control study: no funding/support reported and no competing interests declared. This describes the authors’ disclosure, not complete clearance of every financial or procurement relationship (Carlander 2011).
• L-carnitine review: CNPq grant 126739/2020-0; one analysed 28-person RCT plus three pregnancy case reports. The original RCT reported Japanese government grants and Takeda Science, SENSHIN and Kowa Life Science foundation support; three authors were employees of the clinical-coordination company SSI. Capsules/placebo came from Otsuka Pharmaceutical, but purchase/donation terms were not established. Authors reported no funder role (Salles 2022; Miyagawa 2013).
• Foundation provenance: Takeda Science Foundation describes a Takeda Pharmaceutical endowment; SENSHIN describes its Yoshitomi Pharmaceutical origins; Kowa says it established Kowa Life Science Foundation. These company origins warrant disclosure, but do not establish direct control of this trial or its conclusions. The exact 2013 allocation and procurement terms remain unknown (Takeda foundation; SENSHIN history; Kowa).
• Behavioral review: authors declared no financial, proprietary or professional competing interests; funding not stated. UPenn hosts the copy. Small heterogeneous designs prevented a formal evidence-level assessment. Rauf’s mechanism review reports no specific funding/no conflicts, but has internal selection/date/reference inconsistencies and is background only (Marín Agudelo 2014; Rauf 2025).

Frequently asked questions

Is narcolepsy curable?
The 2017 NINDS educational booklet describes a chronic disorder without a cure; the cited medicine labels treat symptoms. That dated booklet does not verify every current investigational therapy or approval (NINDS, 2017; XYWAV; WAKIX; SUNOSI).

Can supplements replace prescribed narcolepsy treatment?
The cited supplement findings do not justify replacement. AASM supports several adult prescription options with strong or conditional recommendations; recommendation strength should not be relabeled as high/moderate certainty (L-carnitine trial; vitamin D study; AASM guideline).

Does low vitamin D cause narcolepsy?
The case-control study cannot establish cause. Its association persisted after BMI adjustment but sun exposure/diet were unmeasured, reverse causation was possible, and supplementation was not tested (Carlander 2011).

Is oxybate the same substance as GHB?
Sodium oxybate is the pharmaceutical sodium salt of GHB. The cited labels distinguish Schedule III oxybate from Schedule I illicit GHB, with boxed warnings and restricted REMS distribution. Mixed-salt XYWAV is a separate formulation (archived sodium-oxybate label; XYWAV label).

Do scheduled naps help?
They may help selected patients’ alertness, but studies used different schedules and sleep-attack reduction was not consistent. Use an individualized adjunct plan; naps do not guarantee safe driving or replace clinical care (behavioral review; NINDS education, 2017).

How should industry-funded trials be interpreted?
Randomization and blinding reduce some biases, while sponsorship, missing methods/data, selective analysis and short follow-up still matter. The sodium-oxybate review and pitolisant analysis disclose industry-funded trials. AASM’s conflict-managed guideline synthesis is useful but does not independently reproduce their results (Alshaikh 2012; Meskill 2022; AASM).

Sources and funding notes

• Salles 2022 — CNPq-funded review, one small RCT plus three case reports. Miyagawa 2013 original RCT — Japanese government and foundation support, SSI employees, Otsuka capsules/placebo with unknown procurement terms.
• Rauf 2025 — no specific funding/no conflicts reported; narrative background with internal selection/date/reference inconsistencies. NINDS 2017 educational booklet — dated government background for symptoms, types and testing, not current prescribing updates.
• Carlander 2011 — 51-case/55-control French case-control study; no support/conflicts reported; BMI-adjusted association, no causal or treatment inference.
• Maski / AASM 2021 — AASM-funded clinical guideline. Indexed abstract and complete indexed disclosures read; full outcome-level GRADE tables unavailable. Author company/governance ties and Maski abstentions disclosed.
• Alshaikh 2012 — full relevant main sections/disclosures read; review partly Saudi public-funded, all six RCTs privately industry-funded. Short follow-up and dose-reporting inconsistencies limit pooled interpretation.
• Meskill 2022 full original — post-hoc analysis of two short Bioprojet trials, funded by Harmony with employee/cofounder/paid roles and writing/statistical/publication support.
• Marín Agudelo 2014 review, UPenn-hosted — relevant methods, consensus, study-result discussion, conclusion and disclosure sections read; individual underlying behavioral trial papers not separately recovered. No formal evidence grading; funding not stated.
• FDA-hosted sodium-oxybate label, 2017 — archived product highlights. Current product-specific sources: XYWAV, WAKIX, SUNOSI, modafinil, armodafinil and CARNITOR. Labels support their own instructions/warnings, not supplement efficacy. NIH ODS vitamin D, NCCIH melatonin and NHS melatonin interactions provide general nutrient/safety guidance.

Last reviewed: October 3, 2026.

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