Medications That Can Worsen REM Behavior Disorder
Among the medications listed, duloxetine and bupropion (Wellbutrin) are most likely to worsen REM behavior disorder, while methylphenidate (Concerta) may also potentially exacerbate symptoms. 1, 2, 3
Antidepressants and RBD
High Risk Medications
Duloxetine (SNRI): Case reports have documented duloxetine-induced RBD with violent dreams and increased muscle activity during REM sleep 1. As a serotonin-norepinephrine reuptake inhibitor, it can significantly disrupt normal REM sleep patterns.
Bupropion (Wellbutrin): As an antidepressant that affects both norepinephrine and dopamine, it falls into the category of medications that can increase REM sleep muscle tone and potentially trigger or worsen RBD 2, 3.
Mechanism of Action
Antidepressants increase REM sleep muscle tone (REM sleep without atonia) even in patients without diagnosed RBD 3. This effect appears to be medication-related rather than due to the underlying depression, as studies show elevated muscle activity specifically in antidepressant-treated patients compared to untreated psychiatric controls 3.
Stimulants and RBD
- Methylphenidate (Concerta): As a stimulant medication, it can potentially disrupt normal sleep architecture and exacerbate REM sleep abnormalities, though specific evidence for RBD exacerbation is more limited than for antidepressants 4.
Medications Less Likely to Worsen RBD
- Simvastatin: No evidence in the literature suggests that statins worsen RBD.
- Lisinopril: ACE inhibitors have not been associated with RBD exacerbation.
- Naltrexone: No documented association with RBD worsening.
- Varenicline (Chantix): No clear evidence linking it to RBD exacerbation.
Clinical Implications
Monitoring and Management
Recognize the association: When patients on antidepressants (particularly duloxetine or bupropion) develop new or worsening dream enactment behaviors, consider medication-induced RBD 1, 3.
Consider alternative treatments: For patients with RBD who require antidepressant therapy, consider medications with lower risk of RBD exacerbation.
Implement safety measures: For patients who must remain on these medications, implement sleep environment safety modifications to prevent injury 4:
- Remove dangerous objects from the bedroom
- Consider padding around the bed
- Separate sleeping arrangements from bed partners if necessary
Treatment Options for RBD
If medication-induced RBD is suspected:
First-line treatment: Melatonin (3-12 mg at bedtime) is suggested as first-line therapy with few side effects (Level B recommendation) 4, 5.
Second-line treatment: Clonazepam (0.25-2.0 mg at bedtime) is effective but should be used with caution, particularly in patients with cognitive issues, gait disorders, or sleep apnea 4.
Medication adjustment: Consider discontinuation or dose reduction of the offending medication if clinically appropriate, as RBD symptoms may gradually improve after discontinuation 1.
Important Caveats
Antidepressant-associated RBD may not be solely a medication side effect but could potentially be an early signal of an underlying neurodegenerative process 6.
Patients with antidepressant-associated RBD still show markers of prodromal neurodegeneration, though they have a lower risk of developing neurodegenerative disease than those with idiopathic RBD 6.
Neither melatonin nor clonazepam completely eliminates dream enactment behaviors, so a moderate target dosage that reduces attack frequency while avoiding adverse effects is the most reasonable strategy 5.