2011 Society of Behavioral Sleep Medicine 1
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1 Challenges in Measuring and Shifting the Central Circadian Clock in Humans Helen J Burgess, Ph.D. Professor, Department of Behavioral Sciences Director, Biological Rhythms Research Laboratory Rush University Medical Center Outline Measuring the central clock: questionnaires wrist actigraphy core body temperature melatonin Phase shifting the central clock: exogenous melatonin bright light The Central Circadian System Emens & Burgess, Sleep Med Clin Society of Behavioral Sleep Medicine 1
2 Morningness-Eveningness (Owl-Lark) Questionnaire Horne and Ostberg, Int J Chronobiol Munich ChronoType Questionnaire Roenneberg et al., J Biol Rhythms 2003 Questionnaires ~4 h range in DLMO around each chronotype score so do not use to time circadian treatments Owl Lark Questionnaire: MEQ score Benefits of Munich: Shorter Can estimate social jetlag Munich ChronoType questionnaire: MSFsc score Kantermann, Sung & Burgess, 2015 Journal of Biological Rhythms 2011 Society of Behavioral Sleep Medicine 2
3 Actigraphy More movement = wake Less movement = sleep Two commonly used circadian phase markers temperature (deg C) Tmin raw temperature (deg C) fitted temperature (deg C) salivary melatonin (pg/ml) melato onin (pg/ml) DLMO DLMOff :00 19:00 21:00 23:00 1:00 3:00 5:00 7:00 9:00 11:00 13:00 15:00 17:00 time Pills that are swallowed to monitor temperature have not been hugely successful Society of Behavioral Sleep Medicine 3
4 6-sulphatoxymelatonin (urinary melatonin metabolite) 2008 No NSAIDs for 72 h prior (replace with acetaminophen) No beta-blockers No caffeine or alcohol for 24 h prior Dim light! Concerns: - Sampling rate low (e.g. every 2 h) - Compliance to dim light outside of the lab Most useful for: -Field studies -Unclear on patient s circadian timing DLMO = Dim light melatonin onset temperature (deg C) Tmin raw temperature (deg C) fitted temperature (deg C) salivary melatonin (pg/ml) melato onin (pg/ml) DLMO DLMOff :00 19:00 21:00 23:00 1:00 3:00 5:00 7:00 9:00 11:00 13:00 15:00 17:00 time Put picture of front door In the lab 2011 Society of Behavioral Sleep Medicine 4
5 Melatonin in Plasma 2008 Benefits: - Stronger signal (melatonin 3x higher) Concerns: -In lab only -Some folks don t want an IV -Clogged IV lines, lost data -Assay more expensive Lab DLMOs versus Home DLMOs Healthy controls r=0.91, p<0.001 DSWPD r=0.93, p<0.001 Using in R01 and R34 currently Needs development for clinical practice. Burgess et al. SLEEP Burgess et al. J Sleep Res Society of Behavioral Sleep Medicine 5
6 Shifting the Central Circadian Clock The Central Circadian System iprgcs blue light Period ~24.2 h Emens & Burgess, Sleep Med Clin 2015 The Central Circadian Clock >70% humans have an endogenous circadian period >24 hours Most of us have a natural tendency to drift later Burgess & Eastman, JBR, Society of Behavioral Sleep Medicine 6
7 Two uses: 1. Soporific (3mg) 2. Phase shifting (0.5mg) Melatonin Phase Response Curve (0.5 mg) ase Shift (h) y Advance Ph Delay Advance 3 AFTERNOON 2 5 h before usual bedtime Burgess et al., Delay MORNING -3 Usual waking time Time Relative to Baseline DLMO (h) Average Clock Time (h) Contraindications for Melatonin FDA: dietary supplement driving, operating heavy machinery seeking to become pregnant, pregnant, nursing children except non-24 h disorder, neurodevelopmental disorders asthma blood thinners epilepsy impairs glucose tolerance? interactions with other medications 2011 Society of Behavioral Sleep Medicine 7
8 Melatonin purity? USP Verified Program for Dietary Supplements (nonprofit, voluntary testing) Rugby Melatonin Receptor Agonists Sleep Med Clinics Agomelatine melatonin agonist & serotonin antagonist for depression Tasimelteon for non-24 sleep wake disorder (free running) Ramelteon for insomnia Circadian for insomnia To date, melatonin appears to phase shift as effectively as melatonin agonists 2011 Society of Behavioral Sleep Medicine 8
9 Light Phase Response Curve Phase Shift (h) Delay Advance Symbol for DLMO Delay (move later) NIGHT Reduced sensitivity S L E E P Advance (move earlier) MORNING Hours Before and After the DLMO ~ 3500 lux for 2 h Contraindications for Bright Light Existing eye disease May induce migraines (33% of sufferers) Taking phototoxic medications May induce mania (1% of winter depressives) No adverse events in our clinical trials 2011 Society of Behavioral Sleep Medicine 9
10 Re-timer Luminette 2 Phase shifting during sleep? Cole et al continuous light Figueiro & Rea 2012 flashes Zeitzer et al flashes ~1-2% of light can pass through eyelids, can do without major sleep disruption 2011 Society of Behavioral Sleep Medicine 10
11 Acknowledgments Faculty John Burns, PhD Dingcai Cao, PhD Stephanie Crowley, PhD Charmane Eastman, PhD Jonathan Emens, PhD Ali Keshavarzian, PhD Kristen Knutson, PhD Leon Lack, PhD Jason Ong, PhD Garth Swanson, PhD Alyson Zalta, PhD Research Assistants Catherine Keefner Athanathios Kondilis Muneer Rizvydeen Zerbrina Valdespino-Hayden Lab Manager Thomas Molina Biostatisticians Louis Fogg, PhD Rajan Kumar, PhD Current NIH funding AA021762, AT Society of Behavioral Sleep Medicine 11
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