Ramelteon, sold under the brand name Rozerem among others, is a melatonin agonistmedication which is used in the treatment of insomnia.[3][5] It is indicated specifically for the treatment of insomnia characterized by difficulties with sleep onset.[3] It reduces the time taken to fall asleep, but the degree of clinical benefit is small.[6] The medication is approved for long-term use.[3] Ramelteon is taken by mouth.[3]
Ramelteon is approved in the United States but was not approved in the European Union owing to concerns that it lacked effectiveness.[8] The Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) noted that ramelteon had only been found to improve sleep onset and not other sleep outcomes, only one of three clinical trials actually found that it improved sleep onset, and that the improvement in sleep onset was too small to be clinically meaningful.[8] The CHMP also noted that the long-term effectiveness of ramelteon had not been demonstrated.[8]
The American Academy of Sleep Medicine's 2017 clinical practice guidelines recommended the use of ramelteon in the treatment of sleep-onset insomnia.[13] It rated the recommendation as weak and the quality of evidence as very low but concluded that the potential benefits outweighed the potential harms.[13] The guidelines found that ramelteon reduces sleep latency by 9minutes (95% CITooltip confidence interval 6–12minutes) but does not improve sleep quality.[13] In contrast to ramelteon, the guidelines did not recommend the use of melatonin.[13]
A systematic review, published in 2014, concluded "ramelteon was found to be beneficial in preventing delirium in medically ill individuals when compared to placebo."[17] A 2022 systematic review and meta-analysis found that the combination of ramelteon and the orexin receptor antagonistsuvorexant may reduce the incidence of delirium in adults hospitalized patients whereas suvorexant alone was ineffective.[18]
Bipolar disorder
Ramelteon has received attention in psychiatry as a possible add-on treatment for mania in bipolar disorder.[19] However, to date, the scarce available evidence fails to support the clinical utility of ramelteon and other melatonin receptor agonists such as melatonin for mania.[19]
Ramelteon is not recommended for use in people with severe sleep apnea.[3]
Adverse effects
Side effects of ramelteon include somnolence (3% vs. 2% for placebo), fatigue (3% vs. 2% for placebo), dizziness (4% vs. 3% for placebo), nausea (3% vs. 2% for placebo), and exacerbated insomnia (3% vs. 2% for placebo).[3] Overall, side effects occurred in 6% with ramelteon and 2% with placebo in clinical trials.[3] Side effects leading to discontinuation occurred in 1% or fewer people.[3] Rarely, anaphylactic reactions, abnormal thinking, and worsening of depression or suicidal thinking in patients with pre-existing depression may occur with ramelteon.[3] Ramelteon has been found to slightly increase prolactin levels in women (+34% vs. –4% with placebo) but not in men and to decrease free testosterone levels (by 3–6% in younger men and by 13–18% in older men).[3][20][21]
Increased incidence of liver and testicular tumors have been observed with ramelteon in rodents but only at doses equivalent to at least 20 times greater than the recommended dose in humans.[3]
Overdose
Ramelteon has been assessed at doses of up to 64 mg in clinical studies.[3]
A drug interaction study showed that there were no clinically meaningful effects or an increase in adverse events when ramelteon and the SSRI Prozac (fluoxetine) were coadministered. When coadministered with ramelteon, fluvoxamine (strong CYP1A2 inhibitor) increased AUC approximately 190-fold, and the Cmax increased approximately 70-fold, compared to ramelteon administered alone. Ramelteon and fluvoxamine should not be coadministered.[3]
Ramelteon should be administered with caution in patients taking other CYP1A2 inhibitors, strong CYP3A4 inhibitors such as ketoconazole, and strong CYP2C9 inhibitors such as fluconazole.[3]
Efficacy may be reduced when ramelteon is used in combination with potent CYP enzyme inducers such as rifampin, since ramelteon concentrations may be decreased.[medical citation needed]
Pharmacology
Pharmacodynamics
Ramelteon is a melatonin receptor agonist with both high affinity for melatonin MT1 and MT2 receptors and selectivity over the non-human MT3 receptor. Ramelteon demonstrates full agonist activity in vitro in cells expressing human MT1 or MT2 receptors, and high selectivity for human MT1 and MT2 receptors compared to the non-human MT3 receptor.[22] The affinity of ramelteon for the MT1 and MT2 receptors is 3 to 16 times higher than that of melatonin.[8] Ramelteon has 8-fold higher affinity for the MT1 receptor over the MT2 receptor.[8] The binding profile of ramelteon distinguishes it from melatonin, tasimelteon, and agomelatine.[8][23] Remelteon has a clinically irrelevant affinity for the serotonin 5-HT1A receptor (Ki = 5.6 μM).[24]
The major metabolite of ramelteon, M-II, is active and has approximately one-tenth and one-fifth the binding affinity of the parent molecule for the human MT1 and MT2 receptors, respectively, and is 17- to 25-fold less potent than ramelteon in in vitro functional assays. Although the potency of M-II at MT1 and MT2 receptors is lower than the parent drug, M-II circulates at higher concentrations than the parent producing 20- to 100-fold greater mean systemic exposure when compared to ramelteon. M-II has weak affinity for the serotonin 5-HT2B receptor, but no appreciable affinity for other receptors or enzymes. Similar to ramelteon, M-II does not interfere with the activity of a number of endogenous enzymes.[medical citation needed]
The activity of ramelteon at the MT1 and MT2 receptors in the suprachiasmatic nucleus of the hypothalamus is believed to contribute to its sleep-promoting properties, as these receptors, acted upon by endogenous melatonin, are thought to be involved in the maintenance of the circadian rhythm underlying the normal sleep–wake cycle.
Pharmacokinetics
Absorption
The total absorption of ramelteon is 84% while its oralbioavailability is 1.8%.[3] The low bioavailability of ramelteon is due to extensive first-pass metabolism.[3] Ramelteon has a higher lipophilicity than melatonin and thus permeates more easily into tissue.[24] The absorption of ramelteon is rapid, with peak levels being reached after approximately 0.75 hours (range 0.5–1.5 hours).[3] Food increases peak concentrations of ramelteon by 22% and overall exposure by 31% and delays the time to peak levels by approximately 0.75 hours.[3] The pharmacokinetics of ramelteon are linear across a dose range of 4 to 64 mg.[3] There is substantial interindividual variability in the peak concentrations and area-under-the-curve levels of ramelteon which is consistent with high first-pass metabolism.[3]
Ramelteon is excreted 84% in urine and 4% in feces.[3] Less than 0.1% of drug is excreted as unchanged ramelteon.[3]Elimination of ramelteon is essentially complete by 96 hours following a single dose.[3]
The elimination half-life of ramelteon is 1 to 2.6 hours while the half-life of M-II, the major active metabolite of ramelteon, is 2 to 5 hours.[3][7] The half-lives of ramelteon and M-II are substantially longer than that of melatonin, which has a half-life in the range of 20 to 45 minutes.[7] Levels of ramelteon and its metabolites at or below the limit of detectability within 24 hours following a dose.[3]
Special populations
Peak levels of ramelteon and overall exposure are about 86% and 97% higher, respectively, in elderly adults compared to younger adults.[3] Conversely, peak levels of M-II are 13% and overall exposure 30% higher in elderly adults than in younger adults.[3] The elimination half-life of ramelteon is 2.6 hours in elderly adults.[3]
History
Ramelteon was first described in the medical literature in 2002.[9] It was approved for use in the United States in July 2005.[10]
Ramelteon, along with other melatonin receptor agonists like melatonin, has been repurposed in clinical trials as an adjunctive treatment for acute manic episodes in subjects with bipolar disorder.[19] Nonetheless, meta-analytic evidence is based on very few trials and does not allow supporting the use of melatonin receptor agonists as adjunctive options for mania in clinical practice, although the small sample size do not allow ruling out their beneficial effect.[19]
^Karim A, Tolbert D, Cao C (February 2006). "Disposition kinetics and tolerance of escalating single doses of ramelteon, a high-affinity MT1 and MT2 melatonin receptor agonist indicated for treatment of insomnia". Journal of Clinical Pharmacology. 46 (2): 140–148. doi:10.1177/0091270005283461. PMID16432265. S2CID38171735.
^ abcdeKuriyama A, Honda M, Hayashino Y (April 2014). "Ramelteon for the treatment of insomnia in adults: a systematic review and meta-analysis". Sleep Medicine. 15 (4): 385–392. doi:10.1016/j.sleep.2013.11.788. PMID24656909.
^ abUchikawa O, Fukatsu K, Tokunoh R, Kawada M, Matsumoto K, Imai Y, et al. (September 2002). "Synthesis of a novel series of tricyclic indan derivatives as melatonin receptor agonists". Journal of Medicinal Chemistry. 45 (19): 4222–4239. doi:10.1021/jm0201159. PMID12213063.
^Wang-Weigand S, McCue M, Ogrinc F, Mini L (May 2009). "Effects of ramelteon 8 mg on objective sleep latency in adults with chronic insomnia on nights 1 and 2: pooled analysis". Current Medical Research and Opinion. 25 (5): 1209–1213. doi:10.1185/03007990902858527. PMID19327100. S2CID72050626.
^Tian Y, Qin Z, Han Y (March 2022). "Suvorexant with or without ramelteon to prevent delirium: a systematic review and meta-analysis". Psychogeriatrics. 22 (2): 259–268. doi:10.1111/psyg.12792. PMID34881812. S2CID245076331.
^ abcdBartoli F, Cavaleri D, Bachi B, Moretti F, Riboldi I, Crocamo C, et al. (November 2021). "Repurposed drugs as adjunctive treatments for mania and bipolar depression: A meta-review and critical appraisal of meta-analyses of randomized placebo-controlled trials". Journal of Psychiatric Research. 143: 230–238. doi:10.1016/j.jpsychires.2021.09.018. PMID34509090. S2CID237485915.
^Richardson G, Wang-Weigand S (March 2009). "Effects of long-term exposure to ramelteon, a melatonin receptor agonist, on endocrine function in adults with chronic insomnia". Human Psychopharmacology. 24 (2): 103–111. doi:10.1002/hup.993. PMID19090503. S2CID23831933.
^Richardson GS, Zammit G, Wang-Weigand S, Zhang J (April 2009). "Safety and subjective sleep effects of ramelteon administration in adults and older adults with chronic primary insomnia: a 1-year, open-label study". The Journal of Clinical Psychiatry. 70 (4): 467–476. doi:10.4088/jcp.07m03834. PMID19284927.
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