From the Guidelines
REM behavior disorder (RBD) is typically treated with clonazepam as the first-line medication, usually starting at 0.25-1.0 mg taken at bedtime, as recommended by the American Academy of Sleep Medicine clinical practice guideline 1.
Treatment Options
- Clonazepam is a long-acting benzodiazepine that promotes GABAergic inhibition, reducing dream enactment with minimal reduction in REM sleep motor tone on PSG.
- Melatonin is an effective alternative, binding to the M1 and M2 receptors, suppressing REM sleep motor tone, and renormalizing other circadian features of REM sleep, starting at 3 mg and potentially increasing to 15 mg before bed 1.
- Pramipexole, a dopaminergic agonist, may be considered for treatment of RBD, although its mechanism of efficacy is uncertain and efficacy studies have shown contradictory results 1.
Safety Measures
- Removing dangerous objects from the bedroom, padding hard surfaces around the bed, and considering separate sleeping arrangements if bed partner injuries occur are essential safety measures 1.
- Regular neurological follow-up is recommended even when symptoms are well-controlled, as RBD can sometimes be an early sign of neurodegenerative disorders like Parkinson's disease 1.
Combination Therapy
- Combination therapy using clonazepam and melatonin is common in clinical practice if response to monotherapy is inadequate, although there is a paucity of data examining combination therapies 1.
Important Considerations
- Clonazepam should be used with caution in patients with dementia, gait disorders, or concomitant OSA, and its use should be monitored carefully over time as RBD appears to be a precursor to neurodegenerative disorders with dementia in some patients 1.
- Melatonin is considered a dietary supplement and is available over the counter in the United States and Canada, but its bioavailability and content may be less consistent across formulations 1.
From the Research
Treatment Options for REM Behavior Disorder
- Melatonin and clonazepam are the most commonly used treatments for REM sleep behavior disorder (RBD) 2, 3, 4.
- Melatonin has been shown to be effective in reducing RBD symptoms and injuries, with a response rate of 32.9% in one study 3.
- Clonazepam has also been found to be effective, with a response rate of 66.7% in one study 3.
- However, a critical review of the pharmacological treatment of RBD found that the evidence for the use of these treatments is limited, and more randomized placebo-controlled trials are needed 3.
Melatonin Treatment
- Melatonin has been found to be effective in treating isolated RBD, with symptoms improving over the first 4 weeks of treatment and remaining stable over a mean follow-up of 4.2 years 5.
- The effective dose of melatonin for RBD treatment is typically 2-6 mg, taken at the same time every night, around 10-11 pm 5, 6.
- Melatonin treatment has been found to be well-tolerated, with few side effects reported 5, 6.
Clonazepam Treatment
- Clonazepam is often considered the first-line treatment for RBD, but it may have more side effects than melatonin, particularly in older adults 2, 4.
- The effective dose of clonazepam for RBD treatment is typically 0.5-1.0 mg, taken at bedtime 2, 4.
- Clonazepam treatment has been found to be effective in reducing RBD symptoms and injuries, but it may not be suitable for all patients, particularly those with cognitive impairment or obstructive sleep apnea 2, 4.
Other Treatment Considerations
- Anticholinesterase inhibitors and dopaminergic agents are not recommended for RBD treatment, as they may worsen symptoms 4.
- Monoamine oxidase inhibitors, tricyclic antidepressants, serotonergic synaptic reuptake inhibitors, and noradrenergic antagonists may also induce or aggravate RBD symptoms and should be avoided in patients with RBD 4.