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

The guideline, published in the Oct 15 issue of the Journal of Clinical Sleep Medicine, 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-centered care for people who have an intrinsic circadian rhythm sleep-wake disorder,” says AASM president Nathaniel Watson, MD, MSc, in a release. “I expect this guideline will catalyze 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
  • 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.