What is the treatment for Rapid Eye Movement (REM) sleep behavioral disorder?

From the Guidelines

The primary treatment for REM sleep behavioral disorder (RBD) is clonazepam, typically starting at 0.25-1.0 mg taken at bedtime, which may be increased if needed, as recommended by the American Academy of Sleep Medicine clinical practice guideline 1. The treatment of RBD involves a combination of medication and safety measures to prevent injury to the patient and their bed partner.

• Clonazepam is a long-acting benzodiazepine that promotes GABAergic inhibition and has been the most commonly prescribed medication for RBD since its efficacy was described in the original 1986 report characterizing RBD 1.
• Melatonin is an effective alternative, usually at doses of 3-15 mg before sleep, which binds to the M1 and M2 receptors, suppressing REM sleep motor tone and renormalizing other circadian features of REM sleep 1.
• Other options for patients who don't respond to clonazepam include pramipexole (0.125-2.0 mg), rivastigmine (4.6-9.5 mg patch), or combination therapy using clonazepam and melatonin 1. Beyond medication, safety measures are essential:
• Removing dangerous objects from the bedroom, such as loaded firearms and handguns, which can be discharged during a dream enactment episode 1.
• Padding the floor beside the bed and considering separate sleeping arrangements if a bed partner is at risk of injury 1.
• Treating underlying conditions like sleep apnea may also help reduce RBD symptoms 1. Since RBD can be an early sign of neurodegenerative disorders like Parkinson's disease, regular neurological follow-up is important for monitoring 1. Patients should avoid alcohol and certain antidepressants (particularly SSRIs and SNRIs) as these can worsen symptoms 1.

From the Research

Treatment Options for REM Sleep Behavior Disorder

The treatment for Rapid Eye Movement (REM) sleep behavioral disorder is primarily focused on preventing injury and managing symptoms. According to 2, the approach to managing RBD is twofold: symptomatic treatment to prevent injury and prognostic counseling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders.

Symptomatic Treatment

Symptomatic treatment for RBD includes:

• Melatonin: dosed 3-12 mg at bedtime, considered as the first-line therapy 2, 3, 4
• Clonazepam: 0.25-2.0 mg at bedtime, considered as an alternative to melatonin 2, 3, 5
• Other alternative therapies with anecdotal efficacy include temazepam, lorazepam, zolpidem, zopiclone, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate 2

Efficacy of Treatment Options

Studies have shown that:

• Melatonin and clonazepam are equally effective in reducing RBD behaviors and injuries 3
• Melatonin-treated patients reported less frequent adverse effects than those treated with clonazepam 3
• Clonazepam improved RWA and RBD symptom improvement tended to be better after clonazepam than PR melatonin 6
• Melatonin can be considered as a possible sole or add-on therapy in select patients with RBD 4

Considerations for Treatment

When choosing a treatment option, consider:

• The patient's medical history and coexisting neurologic disorders 5, 4
• The risk of falls, cognitive impairment, and obstructive sleep apnea 5
• The potential for adverse effects, such as morning headaches, morning sleepiness, and delusions/hallucinations 4