Medications to Stop Before PSG for REM Sleep Behavior Disorder Diagnosis

Medications That Should Be Discontinued

Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and other antidepressants should be discontinued before polysomnography (PSG) when evaluating for REM sleep behavior disorder (RBD), as these medications can induce or exacerbate RBD symptoms and affect diagnostic accuracy, according to the American Academy of Sleep Medicine 1, 2
Tricyclic Antidepressants (TCAs) such as clomipramine and amitriptyline have been shown to induce or worsen RBD symptoms, as noted by the American Geriatrics Society 2

Medication discontinuation should be done under medical supervision, as abrupt cessation can lead to withdrawal symptoms, as recommended by the American Academy of Sleep Medicine 1
The American Academy of Sleep Medicine recommends discussing medication changes with the prescribing provider before stopping antidepressants 1

Drug-induced/exacerbated RBD (5-HT RBD) is characterized by dream enactment and elevated REM sleep motor tone after starting or increasing serotonergic medications, according to the American Academy of Sleep Medicine 1
Polysomnographic diagnosis of RBD requires evidence of REM sleep without atonia (RSWA) or excessive transient muscle activity in REM sleep, as stated by the American Academy of Sleep Medicine 3, 4

In patients who cannot safely discontinue antidepressants, the clinician should note this limitation when interpreting PSG results, as advised by the American Academy of Sleep Medicine 1
If RBD symptoms persist after discontinuing the suspected causative medication, the patient should be diagnosed with either isolated RBD or secondary RBD (if there is a clear underlying disorder), according to the American Academy of Sleep Medicine 1
For patients who still require antidepressant therapy, switching to an agent with a lower serotonergic profile (such as bupropion) may be considered, as suggested by the American Academy of Sleep Medicine 1

Environmental safety measures should be implemented regardless of pharmacologic treatment, as recommended by the American Academy of Sleep Medicine 6

Not distinguishing between drug-induced RBD and idiopathic or secondary RBD, which have different prognostic implications, as noted by the American Academy of Sleep Medicine 1