Don’t lose sleep over it is a common phrase, yet many people seem unable to take this advice as occasional, short-term insomnia affects 30-50% of the population. In industrialized nations, chronic insomnia, with insomnia lasting 3 months or more, has a prevalence of 5-10%. Patients that have medical problems or psychiatric illness experience a greater rate of insomnia. All patients with insomnia are potentially affected by increased risk factors of impaired daytime functioning, substance abuse, mood disorders, chronic pain, as well as other medical diseases, including high blood pressure, dementia, and obesity being associated with insomnia. Given the tremendous burden insomnia places on individuals and society, treatment is a necessity. Both non-pharmacological, cognitive therapy, and pharmacological treatments are available. While cognitive therapy is considered the first choice of treatment, there are also a variety of pharmacological treatments that are used: Benzodiazepines, Non-benzodiazepines, Melatonin agonists, Heterocyclics, Anticonvulsants, and Orexin receptor antagonists.

What have you found to be the pros and cons of the various options?

References

• Sateia, M., Buysse, D., Krystal, A., Neubauer, D., and Heald, J., 2017. Clinical Practice Guideline: Insomnia. Journal of Clinical Sleep Medicine, Vol. 13, No. 2, 2017, p. 307-349. https://doi.org/10.5664/jcsm.6470

Don’t lose sleep over it is a common phrase, yet many people seem unable to take this advice as occasional, short-term insomnia affects 30-50% of the population. In industrialized nations, chronic insomnia, with insomnia lasting 3 months or more, has a prevalence of 5-10%. Patients that have medical problems or psychiatric illness experience a greater rate of insomnia. All patients with insomnia are potentially affected by increased risk factors of impaired daytime functioning, substance abuse, mood disorders, chronic pain, as well as other medical diseases, including high blood pressure, dementia, and obesity being associated with insomnia. Given the tremendous burden insomnia places on individuals and society, treatment is a necessity. Both non-pharmacological, cognitive therapy, and pharmacological treatments are available. While cognitive therapy is considered the first choice of treatment, there are also a variety of pharmacological treatments that are used: Benzodiazepines, Non-benzodiazepines, Melatonin agonists, Heterocyclics, Anticonvulsants, and Orexin receptor antagonists.

What have you found to be the pros and cons of the various options?

References

• Sateia, M., Buysse, D., Krystal, A., Neubauer, D., and Heald, J., 2017. Clinical Practice Guideline: Insomnia. Journal of Clinical Sleep Medicine, Vol. 13, No. 2, 2017, p. 307-349. https://doi.org/10.5664/jcsm.6470

Don’t lose sleep over it is a common phrase, yet many people seem unable to take this advice as occasional, short-term insomnia affects 30-50% of the population. In industrialized nations, chronic insomnia, with insomnia lasting 3 months or more, has a prevalence of 5-10%. Patients that have medical problems or psychiatric illness experience a greater rate of insomnia. All patients with insomnia are potentially affected by increased risk factors of impaired daytime functioning, substance abuse, mood disorders, chronic pain, as well as other medical diseases, including high blood pressure, dementia, and obesity being associated with insomnia. Given the tremendous burden insomnia places on individuals and society, treatment is a necessity. Both non-pharmacological, cognitive therapy, and pharmacological treatments are available. While cognitive therapy is considered the first choice of treatment, there are also a variety of pharmacological treatments that are used: Benzodiazepines, Non-benzodiazepines, Melatonin agonists, Heterocyclics, Anticonvulsants, and Orexin receptor antagonists.

What have you found to be the pros and cons of the various options?

References

• Sateia, M., Buysse, D., Krystal, A., Neubauer, D., and Heald, J., 2017. Clinical Practice Guideline: Insomnia. Journal of Clinical Sleep Medicine, Vol. 13, No. 2, 2017, p. 307-349. https://doi.org/10.5664/jcsm.6470

The insomnia treatment market is mostly made up of benzodiazepines and nonbenzodiazepines, which are gamma-aminobutyric acid (GABA) agonists. Recently, drugs targeting orexin receptors have made their way further into the insomnia medication landscape. These drugs belong to the Dual Orexin Receptor Antagonists (DORAs) class and bind orexin-A and orexin-B neuropeptides. DORAs are taken orally, with a bioavailability of approximately 80%, typically reaching peak blood plasma concentration about 2 h after ingestion.

DORAs inhibit wakefulness associated with the orexin signaling pathways, whereas GABA agonists lower the activity of neural cells in the brain and CNS and promote sleepiness. Side effects of GABA agonists include dizziness, dependence and, most commonly, somnolence. The DORA class is said to reduce the ‘hangover’ effect/excessive next-day sleepiness, which should lead to greater safety and tolerability. Targeting a system that's more specific for sleep may also reduce drug dependency.

What has been your experience with the efficacy and safety of DORAs compared to GABA agonists? For which types of patients with insomnia would you switch to DORAs e.g., patients with certain co-morbid conditions, etc.?