Ramelteon is a selective MT1/MT2 melatonin receptor agonist indicated for the treatment of insomnia characterized by difficulty falling asleep. As a non-benzodiazepine hypnotic, its unique mechanism of action requires special attention to administration regimens, dose adjustments, and individualized medication for special populations in clinical practice.

How to Use Ramelteon

Standard Dosage

Recommended Adult Dosage: 8mg, taken orally within 30 minutes before bedtime.

Administration Timing: It must be taken strictly before going to bed, and preparations for sleep should be made immediately after taking the medication.

Precautions

The maximum daily dose should not exceed 8mg; excessive doses provide no additional benefits and may increase the risk of adverse reactions.

After taking the medication, avoid engaging in activities that require high alertness (such as driving or operating machinery).

Dose Adjustment of Ramelteon

Adjustment Due to Drug Interactions

Absolutely Contraindicated Concomitant Use: Fluvoxamine (a strong CYP1A2 inhibitor): Concomitant use can increase the plasma concentration of ramelteon by 190 times and must be strictly avoided.

Rifampicin (a strong CYP inducer): Reduces ramelteon exposure by 80%, which may significantly weaken its therapeutic effect.

Concomitant Use Requiring Caution: Ketoconazole (a CYP3A4 inhibitor): Increases ramelteon AUC by 84%; monitoring for adverse reactions is recommended.

Fluconazole (a CYP2C9 inhibitor): Increases AUC by 150%; dose reduction or adjustment of administration intervals is required.

Donepezil/Doxepin: Increase ramelteon exposure by 100% and 66%, respectively; close observation is necessary when used concomitantly.

Patients with Hepatic Impairment

Mild Hepatic Impairment (Child-Pugh Class A): No dose adjustment is needed, but vigilance for adverse reactions is required.

Moderate Hepatic Impairment (Child-Pugh Class B): Exposure increases by more than 10 times; treatment should start at 4mg with careful titration.

Severe Hepatic Impairment (Child-Pugh Class C): Use is contraindicated.

Patients with Renal Impairment

No dose adjustment is required for patients with mild to end-stage renal disease (including those undergoing hemodialysis), as the drug is mainly metabolized in the liver.

Ramelteon Use in Special Populations

Elderly Patients

For patients aged ≥65 years, there is no significant difference in pharmacodynamics compared with young adults, but plasma concentrations may increase by 97%; attention should be paid to adverse reactions such as drowsiness and dizziness.

For patients aged over 75 years, an initial dose of 4mg is recommended, with adjustments based on tolerability.

Lactating Women

Ramelteon and its metabolites are excreted in rat milk; human data are lacking. It is recommended to suspend breastfeeding during medication use or interrupt breastfeeding for at least 25 hours (5 half-lives) after taking the medication.

Patients with Respiratory Diseases

COPD Patients: A single dose of 16mg did not show respiratory depression, but long-term data are lacking, so careful evaluation is required.

Sleep Apnea: Use is contraindicated in patients with moderate to severe sleep apnea; mild cases require use under doctor supervision.