0801 Melatonin Induced Autoimmune Hepatitis in the Setting of the Management of REM Sleep Behavior Disorder

Abstract

Abstract Introduction Melatonin is a neurohormone that serves a key role in human circadian physiology. It is widely used in the United States as an over-the-counter (OTC) sleep aid for managing insomnia, circadian rhythm disorders, and parasomnias. The US Food and Drug do not regulate it as a dietary supplement. However, insufficient data currently exist about formulations and overall safety for long-term usage. While serious adverse events with melatonin are rare, we describe a patient in whom clinical, laboratory, and biopsy features of autoimmune-mediated hepatitis developed in temporal association with time-release melatonin (MLTR) therapy for the treatment of dream enactment behaviors in the setting of REM-sleep behavior disorder (RBD). Report of Cases: A 78-year-old female was referred to our clinic to manage disruptive dream enactment in the setting of RBD. The patient had been previously treated with Clonazepam, Diazepam, and Temazepam but remained refractory. Management with MLTR at 5 mg achieved clinical improvement and titration over a month up to 10 and 15 mg fully controlled dream enactment. Unfortunately, during this time, the patient developed swollen and erythematous joints and abdominal pain. Liver biopsy demonstrated lymphoplasmacytic infiltrate with rosette formation consistent with autoimmune hepatitis consistent with idiosyncratic drug-induced hepatitis associated with elevated liver function enzymes [AST 184 (H) (NL <39U/L), ALT 395 (H) (NL<56 U/L), Bilirubin, Direct= 0.3 (H) (NL<=0.2 mg/dL)]. Melatonin was discontinued achieving complete resolution of symptoms and normalization of liver function indicating its causal association with hepatitis. Conclusion This unusual report of melatonin-induced autoimmune hepatitis is uncommon but points to intriguing immunostimulatory effects of melatonin. Our case highlights an important and sometimes overlooked attribute of melatonin that prescribers and patients must recognize. While melatonin is often viewed as a safe dietary supplement, its use, particularly among people with autoimmune disorders, should be documented and monitored with care. Support (If Any)