What is the recommended dose of melatonin (N-acetyl-5-methoxytryptamine) for a hospital patient (inpatient) with impaired sleep quality?

Melatonin Dosing for Hospitalized Patients with Sleep Disturbances

For hospitalized adult patients with impaired sleep quality, melatonin should be administered at 1-5 mg approximately 1-2 hours before bedtime, with elderly patients starting at lower doses of 1-2 mg.

Dosing Recommendations Based on Patient Population

Melatonin dosing should follow these guidelines:

• General adult inpatients: 1-5 mg taken 1-2 hours before bedtime 1
• Elderly patients: Start with lower doses (1-2 mg) and titrate as needed 1
• Patients with neurodevelopmental disorders: Consider extended-release formulations 1

Evidence for Melatonin Use in Hospital Settings

The American Academy of Sleep Medicine clinical practice guidelines do not strongly recommend melatonin for treating either sleep onset or sleep maintenance insomnia 2. In their analysis, melatonin (2 mg) showed only modest benefits:

• Mean reduction in sleep latency was 9 minutes greater compared to placebo
• Small improvement in quality of sleep
• Limited adverse effects

In the critical care setting, there is insufficient evidence to make a recommendation regarding melatonin use for improving sleep in critically ill adults 2. Small studies using doses of 3-10 mg showed non-significant improvements in sleep quality and quantity.

Administration Considerations

• Administer on an empty stomach to maximize effectiveness 2
• Timing is crucial - give 1-2 hours before the target bedtime (typically 10 pm to midnight) 1
• Avoid administration during daytime hours as it may cause drowsiness and disrupt circadian rhythm adaptation 3

Safety Profile

Melatonin has a favorable safety profile compared to other sleep medications:

• Few immediate side effects except drowsiness 4
• No short-term usage restrictions unlike benzodiazepine receptor agonists 2
• No evidence of withdrawal symptoms or rebound insomnia 2
• Minimal drug interactions, though caution is advised with:
  • Patients taking warfarin
  • Patients with epilepsy
  • Patients with hepatic impairment 1

Practical Considerations for Hospital Use

• Quality control of melatonin products is important - hospital formulary products should be preferred over patient's own supply 3
• Regular monitoring for efficacy and side effects is essential 1
• Consider discontinuing melatonin periodically to assess continued need 1
• Melatonin should be part of a broader approach to improving sleep in the hospital setting, including non-pharmacological interventions such as:
  • Reducing noise and light exposure
  • Maintaining consistent sleep-wake schedules when possible
  • Creating a comfortable sleep environment 2, 1

Common Pitfalls to Avoid

• Using doses above 5 mg does not appear to provide additional benefits 3
• Administering at incorrect times can disrupt circadian rhythms 3
• Relying solely on melatonin without addressing environmental factors affecting sleep in the hospital
• Continuing melatonin without periodic reassessment of its necessity

While melatonin is not FDA-approved for insomnia, its favorable safety profile and modest efficacy make it a reasonable option for hospitalized patients with sleep disturbances, particularly when compared to alternatives like benzodiazepines or sedating antidepressants that carry greater risks.