From the Guidelines
Advanced circadian rhythm treatment should prioritize a combination of light therapy, melatonin supplementation, and behavioral modifications to effectively manage intrinsic circadian rhythm sleep-wake disorders. When considering treatment options, it's essential to understand the role of light and melatonin in regulating the body's internal clock. According to the American Academy of Sleep Medicine clinical practice guideline 1, light therapy can be used to phase shift circadian timing, with evening light leading to phase delays and morning light leading to phase advances. The guideline also highlights the importance of timing melatonin supplementation, with afternoon or evening dosing shifting rhythms earlier and morning dosing shifting rhythms later 1. Key considerations for treatment include:
- Using a 10,000 lux light box for 20-30 minutes each morning to help regulate the body's internal clock
- Melatonin supplementation at doses of 0.5-5mg, taken 2-3 hours before the desired bedtime, to help phase shift the circadian rhythm
- Maintaining consistent sleep-wake times, even on weekends, to help synchronize the body's internal clock
- Practicing good sleep hygiene, such as avoiding screens 1-2 hours before bed, keeping the bedroom dark and cool, and limiting caffeine after noon
- Considering time-restricted eating to limit food intake to an 8-12 hour window during daylight hours, which can help synchronize the circadian rhythm. These treatments work by resetting the body's internal clock, which regulates hormone production, body temperature, and sleep-wake cycles through the suprachiasmatic nucleus in the hypothalamus, ultimately improving morbidity, mortality, and quality of life outcomes.
From the FDA Drug Label
1 INDICATIONS AND USAGE
1.1 Non-24-Hour Sleep-Wake Disorder (Non-24) Tasimelteon capsules are indicated for the treatment of Non-24 in adults.
- Tasimelteon is used for the treatment of Non-24-Hour Sleep-Wake Disorder (Non-24) in adults.
- This condition is related to advanced circadian rhythm disorders.
- Tasimelteon can be considered a treatment option for advanced circadian rhythm disorders, specifically Non-24 2.
From the Research
Advanced Circadian Rhythm Treatment
- The treatment of circadian rhythm sleep disorders (CRSD) may include light therapy, chronotherapy, and melatonin 3.
- Exogenous melatonin is increasingly being used in patients with insomnia or CRSD, but its effectiveness depends on the individual's circadian timing, typically assessed using the dim light melatonin onset (DLMO) 3.
- Knowing the patient's individual circadian timing by assessing DLMO can improve diagnosis and treatment of CRSD with melatonin as well as other therapies such as light or chronotherapy 3.
- Various tools used in the diagnosis of circadian rhythm sleep-wake disorders include sleep diaries and actigraphy monitoring, and therapeutic applications of strategically timed light therapy, melatonin, and other behavioral and pharmacological therapies 4.
- Management strategies towards each major human circadian sleep-wake rhythm disorder, including jet lag and shift work disorders, delayed and advanced sleep-wake phase rhythm disorders, non-24-h sleep-wake rhythm disorder, and irregular sleep-wake rhythm disorder, are summarized 4.
- Non-pharmacological interventions, such as sleep hygiene education, are generally preferred as the first-line approach to improve sleep-related symptoms in patients with circadian rhythm disorders 5, 6.
- Pharmacological agents, such as melatonin receptor agonists, can be effective in treating circadian rhythm sleep disorders, including free-running type CRSD 6.
- Light therapies, including evening light avoidance, can improve sleep quality, duration, and timing in patients with intrinsic circadian rhythm sleep disorders and neuro-psychiatric illness 7.
Treatment Options
- Melatonin and melatonin receptor agonists, such as ramelteon, can be effective in treating CRSD 3, 6.
- Light therapy, including strategically timed light exposure, can improve sleep quality and duration in patients with CRSD 4, 7.
- Chronotherapy, including sleep schedule adjustments, can be effective in treating CRSD 3, 4.
- Non-pharmacological interventions, such as sleep hygiene education, can improve sleep-related symptoms in patients with circadian rhythm disorders 5, 6.
Diagnosis and Assessment
- Dim light melatonin onset (DLMO) is a reliable measure of individual circadian timing and can improve diagnosis and treatment of CRSD 3.
- Sleep diaries and actigraphy monitoring are useful tools in the diagnosis of circadian rhythm sleep-wake disorders 4.
- Polysomnographic sleep-onset time does not reliably predict DLMO or circadian timing in patients with CRSD 3.