From the Guidelines
The best medical therapy for REM behavior disorder (RBD) is typically clonazepam, starting at a low dose of 0.25-1.0 mg administered at bedtime, or melatonin, starting at a dose of 3 mg taken at bedtime, with the option to titrate up to 15 mg as needed, as recommended by the most recent guidelines from the American Academy of Sleep Medicine 1. This recommendation is based on the most recent and highest quality studies, which suggest that both clonazepam and melatonin are effective in reducing the symptoms of RBD, with clonazepam suppressing physical movements during REM sleep and melatonin renormalizing circadian features of REM sleep. Some key points to consider when treating RBD include:
- Clonazepam should be used with caution in patients with dementia, gait disorders, or concomitant OSA, and its use should be monitored carefully over time 1.
- Melatonin is an effective alternative, especially for patients who cannot tolerate clonazepam, and has the advantage of having few side effects 1.
- Combination therapy using clonazepam and melatonin may be considered if response to monotherapy is inadequate, although there is limited data on the effectiveness of combination therapies 1.
- Safety measures, such as removing dangerous objects from the bedroom and considering separate sleeping arrangements, are essential to prevent injuries, and regular follow-up is important to monitor medication effectiveness and side effects 1. It's also worth noting that RBD can sometimes be an early sign of neurodegenerative disorders like Parkinson's disease, so ongoing neurological evaluation may be warranted 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medical Therapies for REM Sleep Behavior Disorder
- Clonazepam has been the first-line therapy for many years, but it can be associated with adverse events, especially in the elderly or those with cognitive impairment 2.
- Alternative therapies to clonazepam have been explored, including zopiclone, which has been reported to be effective in a series of patients under long-term follow-up for RBD 2.
- Pramipexole is another possible alternative, but the evidence is inconclusive due to the lack of randomized controlled trials and challenges in interpreting polysomnography findings in RBD 3.
- Melatonin therapy has been shown to be beneficial for the management of RBD, with reductions in clinical behavioral outcomes and decrease in muscle tonicity during REM sleep 4, 5, 6.
- Melatonin has a favorable safety and tolerability profile over clonazepam, with limited potential for drug-drug interactions, making it a suitable option for elderly individuals with RBD receiving polypharmacy 4, 6.
Comparison of Therapies
- A study comparing clonazepam and melatonin treatment in isolated REM sleep behavior disorder found that melatonin impacted sleep architecture more than clonazepam, with significant increases in N3 stage and moderate reductions in N2 and REM sleep 5.
- Clonazepam moderately increased the percentage of both REM sleep and N2, while reducing N1 and wakefulness, but patients treated with both clonazepam and melatonin did not show major changes in sleep architecture 5.
Treatment Considerations
- The choice of therapy for RBD should be individualized, taking into account the patient's specific needs and medical history 2, 3, 4, 5, 6.
- Further research is needed to establish the evidence basis for melatonin and clonazepam as RBD therapies, as well as to explore other potential treatment options 3, 4, 6.