Clinical practice guidelines for CRSWDs

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A new clinical practice guideline published by the American Academy of Sleep Medicine provides clinicians with updated recommendations for the treatment of intrinsic circadian rhythm sleep-wake disorders (CRSWDs).

The guideline updates previously published practice parameters for the treatment of advanced sleep-wake phase disorder, delayed sleep-wake phase disorder, non-24-hour sleep-wake rhythm disorder, and irregular sleep-wake rhythm disorder. Developed by an expert task force and approved by the AASM board of directors, the guideline was based on a systematic literature review, assessment of the evidence using the GRADE methodology, and meta-analyses.

"This new clinical practice guideline promotes high quality, patient-centred care for people who have an intrinsic circadian rhythm sleep-wake disorder," said AASM president Dr Nathaniel Watson. "I expect this guideline will catalyse future research that will further our understanding of the treatment of these disorders."

Among the recommendations included in the guideline are: positive endorsement of strategically timed melatonin for select CRSWD patients; positive endorsement of light therapy with or without accompanying behavioral interventions for select CRSWD patients; and avoidance of melatonin and discrete sleep-promoting medications for select elderly CRSWD patients

Due to either insufficient or absent data, no recommendations were provided for other treatments such as prescribed sleep-wake scheduling or wakefulness-promoting medications.

It is important for clinicians to note that the new clinical guideline did not update the existing practice parameters for the two circadian rhythm sleep-wake disorders that are extrinsic: shift work disorder and jet lag disorder.

According to the AASM, circadian rhythm sleep-wake disorders are caused by alterations of the circadian time-keeping system, its entrainment mechanisms, or a misalignment of the endogenous circadian rhythm and the external environment. While intrinsic disorders are thought to exist predominantly due to innate phenomena, extrinsic disorders predominantly arise from environmental influences.

The AASM reports that the most common presenting symptoms of circadian rhythm sleep-wake disorders are difficulty initiating and maintaining sleep, and excessive sleepiness. Left untreated, these disorders can cause adverse health outcomes; impairments in social, occupational and educational performance; and safety concerns.

A systematic literature review and meta-analyses (where appropriate) were performed and the GRADE approach was used to update the previous American Academy of Sleep Medicine Practice Parameters on the treatment of intrinsic circadian rhythm sleep-wake disorders. Available data allowed for positive endorsement (at a second-tier degree of confidence) of strategically timed melatonin (for the treatment of DSWPD, blind adults with N24SWD, and children/ adolescents with ISWRD and comorbid neurological disorders), and light therapy with or without accompanying behavioral interventions (adults with ASWPD, children/adolescents with DSWPD, and elderly with dementia). Recommendations against the use of melatonin and discrete sleep-promoting medications are provided for demented elderly patients, at a second- and first-tier degree of confidence, respectively. No recommendations were provided for remaining treatments/ populations, due to either insufficient or absent data. Areas where further research is needed are discussed.

American Academy of Sleep Medicine material Journal of Clinical Sleep Medicine abstract

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