Hi.  I’m Dr. Christopher Mote, and this is another ARK Clinical Pearl. 

I want to talk to you about one of the more common problems in HPA axis dysfunction, and that is poor sleep. People who don’t sleep don’t restore their HPA axis dysfunction. 

When we look at sleep disturbances, there are three very common reasons for those sleep disturbances, and we’ve discovered two already.  Today I want to share with you the third of those three, and that is low melatonin. Whether you’re testing melatonin or you’re going to treat with melatonin without the benefit of a test, we need to think about whether the melatonin is due to a timing issue or an output issue. 

So if you’re going to test and you see a low bedtime melatonin, that tells you you have one of those two, but it really doesn’t tell whether the patient’s melatonin is coming up later and perhaps staying up later, or if it’s coming up appropriately but it’s just the output is not sufficient. You can certainly do further testing, but at that point I recommend that you go ahead and you do a trial of melatonin. 

So there’s a couple of ways to do that as well. You can do sublingual melatonin, typically between one and three milligrams under the tongue at bedtime, and then you can do p.o. melatonin, and swallow three to nine milligrams of melatonin. Oftentimes we do both.  If a patient has trouble getting to sleep as a result of low melatonin at bedtime, we’ll do a sublingual, and if they’re waking up later, we’ll also do an oral dose to work two or three hours later.

You get into trouble when you get too much melatonin. You’re not gonna hurt the patient but you can cause vivid and disturbing dream states, and that’s not always appreciated by the patient. The other is that you can have elevated morning levels, which leave patients really groggy in the morning. So whether you’re testing and treating or you’re just treating with melatonin, keep that in mind. The disturbing dream states, excessive fogginess and fatigue first thing in the morning are both signs of excess melatonin.