Efficacy and Tolerability of Ramelteon in Patients With Rapid Eye Movement (REM) Behavior Disorder and Parkinsonism

Efficacy and Tolerability of Ramelteon in Patients With REM Behavior Disorder and Parkinsonism: A Placebo Controlled, Double Blind, Randomized, Prospective Pilot Study

Parkinson's disease (PD) is the second most common neurodegenerative disorder of the elderly that affects a million patients in US. Sleep dysfunction impacts up to 90% of PD patients. PD patients experience a variety of sleep disorders including parasomnias, specifically REM behavior disorder (RBD) that can precede the onset of motor manifestations of PD. RBD has negative consequences on patients' and their bed partners' quality of life mainly due to its impact on the sleep quality and day time alertness. RBD also predisposes affected individuals and their bed partners to physical injuries.

There are no FDA approved treatments for RBD. Clonazepam is the most commonly used treatment but carries risks of daytime sedation, tolerance, and withdrawal symptoms. More recently, melatonin has been demonstrated to be effective in several small studies. Ramelteon, a selective melatonin receptor agonist with favorable safety profile, could potentially be effective for the treatment of RBD.

This pilot protocol will investigate safety and efficacy of ramelteon for the treatment of RBD in subjects with parkinsonism. We plan to recruit 20 subjects with RBD diagnosed based on the clinical interview and confirmed by the polysomnographic (PSG) data. The study is designed as a prospective randomized placebo controlled 12-week study. Primary outcome measure will be change in frequency of RBD events based on the daily sleep diaries. Secondary outcome measure will be change in the amount of tonic muscle activity based on the results of the baseline and final PSG. A number of other secondary and exploratory outcome measures will be collected

See above.

Inclusion Criteria:

• Diagnosis of parkinsonism (idiopathic PD, multiple systems atrophy, Lewy body dementia)
• RBD frequency of at least once per week based on the RBD screening clinical questionnaire
• PSG evidence of RBD
• Presence of bed partner/caregiver who sleeps in the same room as PD patient

Exclusion Criteria:

• Known hypersensitivity to ramelteon or related compounds, including melatonin and melatonin-related compounds.
• Use of hypnotics or other sedatives within a month prior to the study initiation
• Presence of active psychosis
• Use of neuroleptics, except for the atypical neuroleptics - specifically quetiapine (the dose should not exceed 50mg/day)
• Use of antidepressants unless the patient has been on a stable dose for at least three months
• Use of Venlafaxine (Effexor®)
• Presence of cognitive impairment, defined as the Mini Mental Status Examination (MMSE) score <24
• Presence of depression defined as the Beck Depression Inventory (BDI) score >14
• Significant sleep disordered breathing (defined as an apnea-hypopnea index>15 events/hr of sleep on screening PSG), significant periodic limb movement disorder (defined as a PLM index>10 events/hr of sleep with awakening on screening PSG)
• Travel through two time zones within a month prior to the study initiation