Ramelteon for Treatment of Insomnia in Cirrhosis
Condition: Cirrhosis
MeSH terms: Liver Cirrhosis; Fibrosis
Intervention: Ramelteon Pill
Intervention description: Patients with compensated cirrhosis and insomnia will be provided ramelteon
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 10.0
Sex: All
Minimum age: 21 Years
Maximum age: 65 Years
Healthy volunteers: No
Keywords: sleep

Summary:

      To study the effect of ramelteon, a melatonin receptor agonist, on sleep quality, duration
      and cognitive function in cirrhotics with insomnia.

      Patients with cirrhosis have difficulties with their sleep quality, which adversely affects
      their health-related quality of life. It is assumed the sleep disturbances are related to
      hepatic encephalopathy (HE) in these patients. However, several recent reports have indicated
      that this is not a perfect concordance and that cognition is not related to sleep
      disturbance. The mechanism for this change is not clear, although there is evidence of
      melatonin-delayed phase in these patients as well as difficulties with the excretion pattern
      of cortisol. Ghrelin is an orexigenic hormone produced by the stomach which stimulates the
      appetite and also has a profound effect on sleep. Our group has demonstrated a substantial
      alteration in ghrelin secretion in cirrhosis that correlates with poor slow-wave sleep. In
      healthy individuals, ghrelin injection encourages slow-wave sleep while sleep deprivation
      increases ghrelin levels. The role of ghrelin in the sleep disturbances of cirrhosis has not
      been determined. Prior studies have also lacked the use of overnight polysomnography as a
      tool and have relied on either actigraphy or questionnaires. There is a need for detailed
      mechanistic and therapeutic approaches to analyzing sleep disturbances in cirrhosis.

      Also the therapy of sleep disturbance in cirrhosis is largely empirical. Prior studies have
      evaluated hydroxyzine which runs the risk of precipitating HE. Ramelteon is a melatonin
      analog that is FDA-approved for use in insomnia and will potentially be useful to restore the
      sleep-wake cycle in cirrhosis-associated sleep disturbance.

      The investigators aim to study the impact of the FDA-approved ramelteon on the sleep quality
      (using questionnaires and sleep diaries) on these patients with cirrhosis.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Child class A cirrhosis proven by biopsy, radiology or endoscopic evidence of varices
             - Able to give informed consent

        Exclusion Criteria:

          -  Patient unwilling to start therapy

          -  Allergic reactions to ramelteon in the past

          -  Obstructive sleep apnea

          -  Periodic limb movement disorder

          -  Moderate to severe depression

          -  Unable to give informed consent

          -  Night shift workers

          -  Inter-continental travel within the last 4 weeks

          -  Renal insufficiency on dialysis

          -  Current alcohol or illicit drug use

          -  Diabetes Mellitus using insulin therapy

          -  Use of chronic hypnotic medications more than once per week or more than 5-6 times per
             month