How would you dose your patients? What do you take into consideration?

patients who have difficulty in falling asleep and staying asleep. I would monitor by patient evaluation and physical exam.

Patients when suffering from insomnia, they feel poor attention and concentration during the day, they are tired and cranky ( edgy or snappy), if they have chronic pain it will be worsening.
once sleep improved there is drastic change in all those aspects and the change will be obvious to patients themselves.

Orexin antagonists are without a question the most physiologica wayt improve very promising lack of habituation is apromise of ongoing function without addiction.My problem is coverage which is absent in many insurances and the lack of possibilities for the Armed Forces to obtain coupons since only commercial insurance is allowed.

Thanks, All, for your wonderful contributions! How would you advise your patients on treatment with daridorexant?

treatment naive and refractory patient
by followup discussion on its impact during the day

As an ED physician I dont have any need or use for such meds but find them interesting- perhaps for personal use!

This would be appropriate for my patients who have failed multiple treatments for insomnia. Insurance coverage is important. Would monitor by history, sleep diary, daytime fatigue or excessive sleepiness.

Most of my patients that have trouble with insomnia - initiating and maintaining sleep - would be good for the ones whose primary issue is not sleep itself. The ones having anxiety need to have treatments aimed at that first. Shift workers might not be the best candidates and those who are pilots and air traffic controllers would not be candidates while on or nearing upcoming duties. This could be a big gamechanger though for many with insomnia - especially those that tend "to wake up easy and not get back to sleep" (a phrase we hear fairly often). It would be interesting to see if the somnolence is more of a factor for those that usually sleep for different lengths of time. Some people are fully refreshed at 5 hours - others need 8 hours. I would assess their somnolence / cognitive ability and response times with some variation of quick cognitive tests - including timed response. This would require a few visits or a little homework book to have a home. On those where appropriate and the patient is agreeable, the patient's boss or spouse could monitor to see if a new trial medicine was helping or not - would not enlighten them on what medication it was as that might influence their opinions.

Would definitely refer this patient to CBT ( cognitive behavioral therapy) as first line treatment for insomnia

Most patients with sleep maintenance difficulty are candidates. Screen for OSA before prescribing. These are the first choice for safety for patients with dementia.

Most of my patients would be a candidate for Quviviq since most of them have tried multiple medications. However, the problem is access and affordability. It seems to be less of an addiction potential. A daily sleep/wake diary and close follow up is a must to ensure medication compatibility .

Daridorexant would be helpful for patients who have failed or where Z-drugs have become ineffective since having tried a Z-drug is frequently required to get this approved. This clould also be a safer option than Z-drugs for elderly patients.

Daridorexant is a great option if cost to patients is reasonable-For this reason I would try other available medications first.
Best way to monitor is by assessing daytime fatigue and sleepiness.

I have a significant numbers of patients who have tried every possible option for their insomnia, so most of them would be ideal candidates for this medication. Standardized scales can be used for monitoring, but a thorough history at follow-up visits is often enough to be beneficial in evaluating treatment and daytime functioning.

Those that have circadian rhythm abnormalities, who have failed other treatments. I would monitor them through repeat follow ups as to their day-time tiredness and their degree of wakefulness on the medication.

Another useful option for insomnia that isn't a benzo or z-drug. Will still usually try a generic (e.g., Trazodone) first, though.

I'm looking forward to giving several of my patients a trial with Quviviq. Too often in my practice I have found myself between a rock and a hard place when it comes to treatments for sleep: inadequate sleep duration (eg zolpidem) or adequate sleep but poor daytime function (trazodone). The orexin antagonists emerged onto the scene with great promise pharmacodynamically speaking but thus far I've had occasional complaints of a hangover effect from Belsomra and Dayvigo. Quviviq's shorter half life and , more importantly, real data, give me cause to be optimistic that we may get the best of both here: adequate sleep duration without compromised daytime function.

This type of medication seems to work best in my patients who have not been on benzos and have difficulty falling asleep. Others with high anxiety levels or middle of the night awakening or early morning wakening do not seem to respond as well.

The dual orexin receptor antagonists offer a new mechanism of action in insomnia treatment. However, there are a number of problems that need to be managed in patients on these agents including needing to avoid benzodiazepines concurrently, which can be difficult especially if the patient is taking one during the day for daytime anxiety comorbidities. In addition, case reports of sleep paralysis and narcolepsy related to their use need to be monitored carefully. Nonetheless, to have another option available can only be of benefit to consider in certain select individuals.

seems to be an effective, and probably safer alternative to sedative/hypnotics, given the mechanism of action. My only hesitation is that I work in an inner-city mental health center where most patients are on Medicaid, medicare or uninsured; so copays, prior auth requirements may be barriers to easy access to them.

I would use this in patients who have failed or not found benefit to traditional first-line medications (trazodone, mirtazapine, doxepin.). I find that many patients struggle with sleep and finding a good medication to fit them - it is a blessing to have new options to offer, especially with less impact on next day functioning!
(Including many of the patients I see with anxiety and eating disorders!)

Its an interesteting concept, I would use it for treatment resistant insomnia patients

Any insomnia patient especially those with addiction potential and those that have sleep walking with other meds. Will evaluate by standard scales time time to sleep day time cognition etc.

I would use this medication for patients who have had prior tolerance issues with excessive sedation from older sleep meds, and those at fall risk from sedatives. Would also consider for those with frequent awakenings through the night. also would need to make sure medication is approved with patients insurance.

Depends on insurance coverage . Contraindicated in patients with narcolepsy. I tried belsomra in the post with some patients with marginal help.

This would be appropriate - IF the insurance companies would have it on formulary!!

Ostensibly, all patients with insomnia could potentially benefit from such a medication, since the paradigm of insomnia is homogeneous, that of excessive wakefulness. And with improved daytime functioning, this is especially appealing since it is not enough to sleep well, but also to be well rested for the day.

Patients that have difficulty with initial insomnia and difficulty staying asleep but that do not want to experience excessive daytime sedation.
Low side effect profile with recent FDA approval.
Scales that assess for excessive daytime sleepiness should allow for monitoring.