Treatment of Multiple System Atrophy in Patients with REM Sleep Behavior Disorder

Clinical Scenario

REM sleep behavior disorder (RBD) is a recognised feature of multiple system atrophy, characterised by the loss of normal muscle atonia during REM sleep and the emergence of abnormal motor behaviours — often as enactment of dreams. Identifying and addressing RBD in this population is a distinct clinical priority.

Treatment Approach

A specific pharmacological intervention taken at bedtime is established as the first-line approach for RBD in the context of multiple system atrophy. The choice of agent is guided by the need to avoid worsening other features that commonly accompany this condition.

First-line therapy involves a bedtime agent selected for its favourable tolerability profile in this specific patient group — the complete regimen, including considerations for combination or escalation, is detailed in the full protocol.

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References

DOI: 10.1212/cont.0000000000001598

RBD is characterized by the loss of muscle atonia during REM sleep with abnormal behaviors (often as dream enactment), which is common in patients with multiple system atrophy.

Melatonin or clonazepam at bedtime is a useful treatment for RBD, although the latter may aggravate nocturnal stridor, sleep apnea, and daytime ataxia.

Hence, melatonin is the first-line therapy, but it can be combined with clonazepam if needed.

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