What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?

Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole.

Thanks,
Sam Morkous

Make sure the melatonin is ER as RBD occurs in the early morning hours.

If both are at their max doses, then, in addition to making sure the bedroom environment is safe, I recommend rivastigmine.

HA

In my experience, patients who develop Parkinson’s disease can develop REM sleep behaviors.

In those cases, I have mostly counted on primary treatment of Parkinson’s disease.

With that, I have used clonazepam and melatonin.

Some young sleepwalking patients that I am aware of who were not in treatmen...

I would first ask if the diagnosis is correct, assuming this is diagnosed from a sleep study and sleep medicine. My answer would be really specific depending on the comorbidity. I wouldn't use DA in an older person, nor gabapentin in a patient with kidney issues.

Ramelteon: From a pharmacological perspective, despite limited data and the absence of an extended‑release formulation, a trial of ramelteon is reasonable given its favorable safety profile, particularly in older adults. Worth trying in select patients.