Melatonin is a supplement that is most often used for insomnia. I see patients take this supplement on a daily and it is also a frequent recommendation of many providers. Here are a few melatonin clinical pearls that I would recommend you pay attention to when you see a patient taking it.
My first recommendation is to ensure that melatonin isn’t part of the prescribing cascade. Many times I have seen short-term orders for medications like prednisone that can cause insomnia. This adverse effect from prednisone leads to a new prescription or self-initiated use of melatonin. Other common medications that can cause insomnia include methylphenidate, amphetamine salts, modafinil, pseudoephedrine, and bupropion.
Another very common issue I see with melatonin is that it is often used with other medications used to treat insomnia. I’ve seen Z-drugs, trazodone, mirtazapine, and others used in combination with melatonin. One thing that you can do to help reduce polypharmacy is to ensure that we assess the efficacy of each medication. Pick one sedating agent at a time and if something isn’t successful, make sure it gets discontinued.
While melatonin is well-tolerated in most patients, the risk for adverse effects is going to increase as the dose increases. Many patients will grab a bottle of melatonin at a pharmacy and not think twice about what the actual dose is. I’m an advocate for trying to minimize the dose whenever possible. If you know a patient has started at 5 or 10 mg, they may be able to benefit from lower dosages. It would be worthwhile to consider a reduction in the dosing at some point to identify the minimum effective dose.
I’ll admit that it is a lot easier to take a pill than to focus on sleep hygiene, but it shouldn’t be disregarded. Having a fixed schedule and bedtime routine can significantly improve the ability of patients to fall asleep and stay asleep. Here’s a good link about sleep hygiene strategies.
While adverse effects are rare at lower over-the-counter dosages, there are two that I specifically look out for. The first one is pretty obvious; you have to monitor for excessive sedation that may impact functioning the next day. The other adverse effect that is very unique to melatonin is hyperprolactinemia. I especially lookout for this risk if patients are taking dopamine blocking agents that can have additive effects on increasing hyperprolactinemia risk.
Hopefully a few of these melatonin clinical pearls will help you better take care of your patients with insomnia!