Daridorexant treatment for chronic insomnia: a real-world retrospective single-center study

Clinical practice guidelines for switching or deprescribing hypnotic medications for chronic insomnia: Results of European neuropsychopharmacology and sleep expert's consensus group

INTRODUCTION

Current guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as the first-line treatment for chronic insomnia. Pharmacological recommendations by European guidelines for the treatment of insomnia disorder include positive GABAergic modulators such as short and medium acting benzodiazepines and "Z-drugs" (eszopiclone, zaleplon, zolpidem, zopiclone), dual orexin receptor antagonists (DORAs; daridorexant), melatonin receptor agonists (melatonin 2 mg prolonged release - PR). Given the chronic nature of insomnia, the presence of non-responders to some treatments it is often necessary switching between various therapeutic approaches and medications. However, clear guidance regarding safe and effective protocols for switching these medications currently lacks in Europe.

METHOD

To address this gap, we used the RAND/UCLA Appropriateness to evaluate the appropriateness of procedures for switching medications prescribed for insomnia disorder. Following a systematic review of the literature conducted in accordance with the PRISMA guidelines, we then formulated some recommendations.

RESULTS

Twenty-one papers were selected.

CONCLUSIONS

Discontinuation of Hypnotic Benzodiazepines and Z-drugs should be gradual, with dose reductions of 10-25 % each week. Multi-component CBT-I, daridorexant, eszopiclone, and melatonin 2 mg PR were shown to facilitate the gradual discontinuation of hypnotic benzodiazepines/Z-drugs within a cross-tapered program, which can be delayed when necessary. Finally, daridorexant and melatonin 2 mg PR do not require special switching or deprescribing protocols. Several sedative-hypnotic dosage reduction algorithms are proposed in this work for clinical use in real world settings.

Evaluation and management of insomnia in the clinical practice in Italy: a 2023 update from the Insomnia Expert Consensus Group

BACKGROUND

Insomnia is the most reported sleep disorder in industrialized countries, affecting, in the chronic form, around 10% of the European population. In Italy, such a percentage seems to be even higher. Although insomnia can be an independent disorder, it is frequently described as comorbid condition and may precipitate, exacerbate, or prolong a broad range of physical and mental disorders. Evaluating and targeting insomnia in the Italian clinical practice should be a priority.

METHODS

The present expert opinions and recommendations represent an update from 2020 and insights from Insomnia Expert Consensus Group, based on systematic reviews according to PRISMA on available options in Italy from January 2020 to March 2023.

RESULTS

We evaluated 28 papers among international guidelines, expert opinions, systematic reviews, and meta-analysis produced during the last 26 months.

CONCLUSIONS

Our findings suggest that symptoms of insomnia must be assessed in the Italian clinical practice by evaluating nocturnal and daytime symptoms, comorbid conditions, and lifestyle. Cognitive behavioral therapy for insomnia should be the first option according to availability. The choice of the drug should be based on different factors including type of insomnia, age, comorbidities, and potential side effects. If the choice would be a Z-drug or a short-acting benzodiazepine (in subjects < 65 years old), the use should be in the short term (≤ 4 weeks). Indeed, eszopiclone, as a new option in Italy, may present a different profile and may be used for up to 6 months, also in the elderly. If the choice is melatonin, it should be used melatonin 2 mg prolonged release in adults ≥ 55 years for up to 13 weeks. A new dual orexin antagonist, daridorexant, is available in Italy; it has been shown to be effective in adults and elderly and it can be used for at least 3 months and up to 1 year.