We have read the article with interest published by Esaki et al.,1 and we take this opportunity to explain other therapeutic alternatives to clonazepam, also used in our extensive experience managing REM behavior disorder (RBD). We studied 23 patients (20 men) diagnosed with RBD, based on clinical and polysomnographic features, treated over the last 22 years.
We analyzed medical history (previous hyposmia-anosmia in 3 patients), sex, type of drug, doses and scale scores before and after treatment regarding symptoms, and sleep quality. Mean RBD onset symptoms age was 64.7 years old. Mean lag time between RBD onset and diagnosis and between RBD onset and start treatment were 4.8 and 10.5 years respectively. Frequent comorbidities were sleep apnea (12), Parkinson disease (10), cognitive and psychiatric disorders (8), Willis-Ekbom disease (3), and hypersomnia (1).
We used mostly monotherapy in each patient, as described below, changing or adding other medications if they presented side effects or were not effective (no reduction, regarding clinical anamnesis, in more than 50% of typical episodes): Gabapentin: 14 patients (300–800 mg, effective in 12, changed in 2); Pregabalin: 3 patients (75–150 mg, effective in 2, changed in 1); Melatonin (sustained-release): 5 patients (2 mg, effective in 4, mostly associated); and Benzodiazepines: 1 patient (0.5–2 mg, effective)
Based on this data, we think that gabapentin, pregabalin, and sustained-release melatonin could be better alternatives to clonazepam (first-choice treatment2,4,6–8) to manage RBD because they have excellent pharmacokinetics, low pharmacological tolerance, and less side effects.3–8
Moreover, they have not often previously been reported in the literature reviewed,2–8 so we recommend consider them for the RBD treatment, although other well-known drugs like benzodiazepines, melatonin (immediate-release) and ramelteon1 could be also useful1–8 and analyze them with further studies without our limitations (randomized, double-blind, more patients and prospective design).
DISCLOSURE STATEMENT
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
CITATION
Escribá J, Hoyo B. Alternatives to clonazepam in REM behavior disorder treatment. J Clin Sleep Med 2016;12(8):1193.
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