Ramelteon

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Ramelteon
Ramelteon skeletal formula.svg
Ramelteon ball-and-stick model.png
Clinical data
Trade namesRozerem, others
AHFS/Drugs.comMonograph
MedlinePlusa605038
License data
Routes of
administration		By mouth
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability1.8%
Protein binding~82%
MetabolismHepatic (CYP1A2-mediated)
Elimination half-life1–2.6 hours
ExcretionRenal (84%) and fecal (4%)
Identifiers
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.215.666 Edit this at Wikidata
Chemical and physical data
FormulaC16H21NO2
Molar mass259.349 g·mol−1
3D model (JSmol)
  

Ramelteon, sold under the brand name Rozerem among others, is a sleep agent medication that selectively binds to the MT1 and MT2 receptors in the suprachiasmatic nucleus (SCN), instead of binding to GABAA receptors, such as with drugs like zolpidem.

It appears to speed the onset of sleep and alter the total amount of sleep a person gets.[1] It is approved by the US Food and Drug Administration (FDA) for long-term use.[2]

Ramelteon does not show any appreciable binding to GABAA receptors, which are associated with anxiolytic, myorelaxant, and amnesic effects.[2]

Medical uses[]

Ramelteon is approved in the United States for the treatment of insomnia characterized by difficulty with sleep onset.[2]

A systematic review, published in 2014, concluded "ramelteon was found to be beneficial in preventing delirium in medically ill individuals when compared to placebo."[3]

Ramelteon has received attention in psychiatry as a possible add-on treatment for mania in bipolar disorder.[4] 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.[4]

Adverse effects[]

Ramelteon has not been shown to produce dependence and has shown no potential for abuse, and the withdrawal and rebound insomnia that is typical with GABA modulators is not present in ramelteon.[2]

Six percent of ramelteon-treated patients in clinical trials discontinued due to an adverse event, compared with two percent in the placebo arms. The most frequent adverse events leading to discontinuation were somnolence, dizziness, nausea, fatigue, headache, and insomnia. The United States official Prescribing Information warns of rare cases of anaphylactic reactions, abnormal thinking, worsening of depression or suicidal thinking in patients with pre-existing depression, and decreased testosterone and increased prolactin levels.[5] It also notes that ramelteon is not recommended for use in patients with severe sleep apnea.[5]

In mice treated with ramelteon for two years, increases in liver and testicular tumors were observed, but only at doses at least 20 times greater than the recommended human dose on a milligram/kilogram basis.[5]

Drug interactions[]

Ramelteon has been evaluated for potential drug interactions with the following medications and showed no significant effects: omeprazole, theophylline, dextromethorphan, and midazolam, digoxin and warfarin. There were no clinically meaningful effects when ramelteon was coadministered with any of these drugs.[medical citation needed]

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.[2]

Ramelteon has significant drug–drug interaction with the following drugs: amiodarone, ciprofloxacin, fluvoxamine, ticlopidine.

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.[2]

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]

Mechanism of action[]

Ramelteon is a melatonin receptor agonist with both high affinity for melatonin MT1 and MT2 receptors and selectivity over the 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 MT3 receptor.[6]

The activity of ramelteon at the MT1 and MT2 receptors 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. Ramelteon has no appreciable affinity for the GABA receptor complex or for receptors that bind neuropeptides, cytokines, serotonin, dopamine, noradrenaline, acetylcholine, and opioids. Ramelteon also does not interfere with the activity of a number of selected enzymes in a standard panel.[medical citation needed]

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 17–25-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 20–100-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]

History[]

Ramelteon was approved for use in the United States in July 2005.[7]

Research[]

Psychiatry[]

Ramelteon, together with other melatonin-receptor agonist melatonin, has been repurposed in clinical trials as an adjunctive treatment for acute manic episodes in subjects with bipolar disorder.[4] 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.[4]

See also[]

  • Discovery and development of melatonin receptor agonists

References[]

  1. ^ Neubauer DN (February 2008). "A review of ramelteon in the treatment of sleep disorders". Neuropsychiatric Disease and Treatment. 4 (1): 69–79. doi:10.2147/ndt.s483. PMC 2515902. PMID 18728808.
  2. ^ Jump up to: a b c d e f "Rozerem- ramelteon tablet, film coated". DailyMed. 28 December 2018. Retrieved 13 April 2020.
  3. ^ Chakraborti D, Tampi DJ, Tampi RR (March 2015). "Melatonin and melatonin agonist for delirium in the elderly patients". American Journal of Alzheimer's Disease and Other Dementias. 30 (2): 119–29. doi:10.1177/1533317514539379. PMID 24946785.
  4. ^ Jump up to: a b c d Bartoli F, Cavaleri D, Bachi B, Moretti F, Riboldi I, Crocamo C, Carrà G (September 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.
  5. ^ Jump up to: a b c "HIGHLIGHTS OF PRESCRIBING INFORMATION: ROZEREM (ramelteon) tablets, for oral use" (PDF). U.S. Food and Drug Administration. FDA. December 2018. Retrieved 2 July 2021.
  6. ^ Owen RT (April 2006). "Ramelteon: profile of a new sleep-promoting medication". Drugs of Today. 42 (4): 255–63. doi:10.1358/dot.2006.42.4.970842. PMID 16703122.
  7. ^ "Drug Approval Package: Rozerem (Ramelteon) NDA #021782". U.S. Food and Drug Administration (FDA). 20 October 2005. Retrieved 13 April 2020.

Further reading[]

External links[]

  • "Ramelteon". Drug Information Portal. U.S. National Library of Medicine.
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