I’ve just heard of melatonin replacement therapy, a reader wrote last week to Ask The Savvy Insomniac, and I’m wondering if I should look into it. I’m 61. I never used to have problems with insomnia but now I wake up a lot at night. Over-the-counter melatonin does nothing for me. Is the melatonin used in replacement therapy somehow different?
A Bit of Background
The hormone melatonin is a major player in the sleep system. Secreted by the pineal gland, it helps create strong biological rhythms that regularly put people to sleep and keep us sleeping through the night.
But often melatonin rhythms grow weaker with age. This occurs for three reasons, says Rüdiger Hardeland in a recent review paper on melatonin in aging and disease:
- degeneration of neurons in the SCN (a.k.a. the body clock)
- deterioration of neurons connected to the pineal gland
- calcification of the pineal gland.
Any of these factors may result in insufficient production of internal melatonin, resulting in insomnia at the beginning or in the middle of the night.
Melatonin Replacement Therapy
It’s worth consideration if melatonin deficiency is your problem. In the US, two options for replacement therapy exist:
- over-the-counter melatonin supplements, and
- the prescription drug Rozerem, or ramelteon.
When caused by melatonin deficiency, trouble falling asleep at the beginning of the night responds well to treatment with melatonin supplements, Hardeland says. Over-the-counter melatonin, which is chemically identical to the melatonin produced in your body, may be effective even at low doses (e.g., 0.5 mg) and is the better option for people with sleep onset problems. If taking it close to bedtime doesn’t work, try taking it earlier in the evening. (See my blog on sleepy night owls.)
Replacement Therapy for Trouble Staying Asleep
But at low doses, OTC melatonin supplements are not going to help people who experience frequent wake-ups. The half-life of melatonin is just 20 to 45 minutes. It doesn’t have enough staying power to keep you sleeping through the night.
Higher dosages of melatonin—50 or 100 mg—have been proposed as a therapy for sleep maintenance insomniacs but have yet to be tested, Hardeland says, adding, however, that 300 mg of melatonin administered to ALS patients for up to 2 years was found to be safe.
If sleep maintenance is the issue, ramelteon, a drug more powerful than natural melatonin, is the better option, according to Hardeland. But it may not work for everyone. Trials of ramelteon have shown the improvements it produces in sleep maintenance to be modest. In a recent study of melatonin in elderly patients, the effects of the drug on sleep maintenance were “highly variable.”
A perfect solution for sleep maintenance insomnia caused by melatonin deficiency has yet to be invented. (Circadin, a time-release formulation of melatonin, is available by prescription in Europe. But with this drug, too, effects on sleep maintenance have been modest.)
If you’re a baby boomer or older, though, and your insomnia has developed with age, melatonin deficiency could be part of the problem. Replacement therapy is worth checking out.