Pilot Study of Melatonin and Epilepsy
Condition: Epilepsy
MeSH terms: Epilepsy
Study type: Interventional
Phase: Phase 2

Summary: 
      The prevalence of epilepsy is 1% in the USA. About 30% of epilepsy patients eventually become
      refractory to medical treatment. Co morbid conditions are becoming as important as seizure
      control as these affect overall wellbeing. Sleep related complaints are frequent in them
      including, frequent arousals, difficulty falling asleep and excessive daytime sleepiness.
      Polysomnography shows increased arousal index, sleep onset latency, and stage shifts and
      fragmented REM sleep. Poor sleep efficiency causes daytime fatigue, poor cognition and
      behavior and can worsen seizure control. Stabilizing sleep may improve seizure control.
      Melatonin is a naturally occurring hormone in the body involved in the regulation of
      circadian rhythm and exogenously given, has been shown to decrease sleep onset latency,
      arousals, and there-by increase sleep efficiency in healthy pediatric patients. Similar data
      does not exist in the patients with epilepsy. As sleep has important impact on epilepsy and
      overall functioning, it is important to study effect of melatonin in children with epilepsy.

      We propose a randomized double blind placebo controlled trial with a cross-over design. Our
      hypothesis is that, for patients with epilepsy, administration of melatonin 30 minutes before
      bedtime for four weeks may:

        -  Improve the quality of sleep;

        -  Improve daytime functioning in terms of cognition, behavior and quality of life;

        -  Decrease epileptic potential. We will use polysomnography, electroencephalogram,
           psychomotor vigilance task, seizure diary, and questionnaires to assess the effect of
           melatonin on these domains. This study may help to improve the care of children with
           epilepsy.
    

Detailed description: 
      Hypothesis 1: Melatonin treatment improves the quality of sleep in patients with epilepsy.

      Various studies evaluating sleep problems in patients with epilepsy using questionnaires have
      shown that 34-45% patients have sleep related problems [1-3]. Cortesi et al reported that
      children with seizures had higher sleep difficulties than their siblings and controls[4].
      Bedtime difficulties, sleep fragmentation, daytime sleepiness, snoring and parasomnia were
      reported as sleep problems in this population [2, 4]. Patients with refractory seizures and
      using multiple antiepileptic drugs(AED) showed worse problems[5]. On polysomnography (PSG)
      these patients show increased arousal index, increased sleep onset latency, fragmented or
      reduced REM sleep, increased stage shifts and increased Stage 1 sleep and decreased stage 2
      and slow wave sleep. [6-9] Melatonin has been shown to decrease sleep onset latency and
      increase total sleep time and subjectively improve sleep in healthy individuals.[10-15].
      Various studies using fast release and sustained release formulations have suggested
      improvement in sleep efficiency and decreased arousals as well.[16-18] In a randomized
      placebo controlled study by Gupta et al[19], Melatonin was shown to subjectively improve
      sleep in patients with epilepsy. Studies in children with neurodevelopmental delay and autism
      along with epilepsy have also reported similar findings.[17, 20-23] Rationale: There are
      significant sleep disturbances in children with epilepsy. Melatonin has been shown to improve
      sleep in this group of patients. However, all these studies report improvement based on
      parent report and only one study is placebo-controlled. Our study will assess this in
      randomized placebo controlled fashion and will provide both subjective and objective
      improvement in sleep with the primary outcome being improved sleep efficiency on PSG.

      Hypothesis 2: Melatonin improves daytime functioning in terms of cognition, behavior and
      quality of life in the patients with epilepsy.

      Poor sleep and epilepsy both have detrimental effect on cognition.[24-27] Melatonin by
      improving sleep may improve cognitive functioning in these patients.

      Some patients with epilepsy have poor behavior and psychiatric function.[28-30] Severity of
      these problems are related to the worsening of the sleep problems.[2, 4] Melatonin by
      improving sleep may improve the behavior in these patients.

      Epilepsy has negative effect on various aspects of the patients' life including social,
      behavioral, and academic [31, 32]. Questionnaires have been developed to assess the impact on
      overall quality of life of the patients [33, 34]. These tools are helpful to quickly and
      subjectively assess quality of life. Based on these studies, it has been shown that patients
      with refractory seizures have poor quality of life [33-37] and an improvement is seen if the
      seizure frequency is decreased.[38-41] There has been only one study reporting quality of
      life (QOL) after use of melatonin in patients with epilepsy. In this randomized placebo
      controlled study, significant improvement was seen in the cognitive, anxiety and behavior
      subscales of the QOLCE after use of melatonin.[42] To date, there are no studies reporting on
      the effect of melatonin on cognition or behavior in epilepsy patients.

      Rationale: Poor behavior, cognition and quality of life have been reported in children with
      epilepsy and sleep disturbances. By improving the quality of sleep, melatonin will improve
      all these domains. QOLCE has been validated and used in epilepsy patients and will assess the
      QOL in these patients. Vigilance is the component of cognition that is most consistently and
      drastically affected by sleep deprivation. PVT measures "vigilant attention" and has been
      used widely in adult patients to assess the effect of sleep deprivation on cognition. It has
      been described as a very sensitive measure to see both acute and chronic effects of sleep
      deprivation. BASC-PRS has been used to assess behavior in children and is found equally
      useful in epilepsy patients as child behavior check list (CBCL). It is a sensitive tool to
      compare changes over shorter time span.

      Hypothesis 3: Melatonin treatment decreases epileptic potential. Sleep deprivation has been
      known to induce seizures and epileptic discharges on EEG[43]. Seizures are also known to
      occur with change in the depth or rhythmicity of sleep.[43] Patients with epilepsy report
      sleep deprivation as a significant seizure precipitating factor [44, 45]. In a recent study,
      Haut et al reported that one hour of additional sleep on the preceding night decreased
      relative odds of a seizure on the subsequent day to 0.91[46]. In a study Oliveira reported
      that treatment of obstructive sleep apnea (OSA) decreased interictal epileptiform
      discharges.[47] The belief that fewer epileptiform discharges represent better seizure
      control is controversial. But a study suggested that decreasing epileptiform discharges on
      EEG improves behavior.[48] Studies investigating obstructive sleep apnea in patients with
      epilepsy have reported improvement in seizure control with treatment of OSA [49-54]. These
      suggest that stabilizing sleep has a beneficial effect on seizure control.

      Many studies that evaluated melatonin in epilepsy patients report overall improvement in
      seizure control[17, 21], while others report no worsening of seizure control after the use of
      melatonin[20, 22, 23]. Coppola et al reported inconclusive results with regards to seizure
      control after melatonin use[55]. However, these studies are not powered to account for
      variability in seizure occurrence reported with epilepsy patients.

      Rationale: There are no randomized controlled studies available to evaluate the effect of
      melatonin on seizure control in the children with epilepsy. This study will identify the
      effect of short term use of melatonin compared with placebo and will provide pilot data to
      evaluate this effect in a larger trial in future.
    

Intervention name(s): Melatonin; Placebos
Intervention type(s): Drug; Drug
Intervention description(s): Sustained release formula (Brand: Jigsaw); dosage will be 9mg for all subjects. Taken 30 minutes prior to bedtime for four weeks.; Placebo. Taken 30 minutes prior to bedtime for four weeks.
Other intervention name(s): natural supplement; Placebo
Intervention MeSH terms: Melatonin
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Treatment
Keywords: epilepsy; sleep; seizures; cognition