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Arnold V, Ancoli-Israel S, Dang-Vu TT, Mishima K, Pinner K, Malhotra M, Moline M. Efficacy of Lemborexant in Adults ≥ 65 Years of Age with Insomnia Disorder. Neurol Ther 2024; 13:1081-1098. [PMID: 38748321 PMCID: PMC11263438 DOI: 10.1007/s40120-024-00622-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/09/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Pharmacologic treatments are available to treat insomnia, a common and burdensome sleep disorder, but may be contraindicated in older adults who are prone to side effects from sleep-promoting drugs. These analyses of sleep diary data from Study E2006-G000-303 (Study 303) investigated the benefits of lemborexant 5 mg (LEM5) and 10 mg (LEM10) in the subgroup age ≥ 65 years with insomnia. METHOD Study 303, a 12-month, double-blind study of LEM5 and LEM10 in adults (age ≥ 18 years) with insomnia disorder (sleep onset and/or maintenance difficulties) assessed subject-reported (subjective) sleep-onset latency (sSOL), sleep efficiency (sSE), wake after sleep onset (sWASO), and total sleep time (sTST). Morning sleepiness/alertness, insomnia severity (Insomnia Severity Index [ISI]), fatigue (Fatigue Severity Scale [FSS]), perceptions of sleep-related medication effects (Patient Global Impression-Insomnia [PGI-I] questionnaire), and safety were also evaluated. RESULTS In this subgroup of older adults (≥ 65 years; n = 262), there were significantly larger changes from baseline for sSOL, sSE, sTST, and sWASO with LEM5 and LEM10 versus placebo through month 6 (except sWASO month 1), indicating improvement; these improvements were sustained through month 12. Subject-reported increases in morning alertness were significantly greater with one or both LEM doses versus placebo through month 6 and sustained through month 12. There were significantly larger ISI total and daytime functioning score decreases (improvement) from baseline with LEM versus placebo at months 1, 3, and 6 (total score: both doses; daytime functioning: LEM5 month 1 and both doses months 3 and 6) and decreases from baseline FSS at months 1 and 3 (LEM5) and month 6 (both doses), sustained to month 12. Compared with placebo, more subjects reported that LEM (both doses) positively impacted ability to sleep, time to fall asleep, and TST through month 6, sustained to month 12, with no rebound after drug withdrawal. LEM was well tolerated to month 12; mild somnolence was the most common treatment-emergent adverse event. CONCLUSIONS Improvements in subject-reported efficacy in LEM-treated adults age ≥ 65 years with insomnia were observed as early as the first week of treatment and sustained through end of month 12. LEM was well tolerated. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov identifier NCT02952820: E2006-G000-303; Study 303; SUNRISE-2 (First posted: October 2016); EudraCT 2015-001463-39 (First posted: November 2016).
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Affiliation(s)
| | | | - Thien Thanh Dang-Vu
- Department of Health, Kinesiology and Applied Physiology, Concordia University, Montreal, QC, Canada
- Centre de Recherche de l'Institut Universitaire de Gériatrie de Montréal (CRIUGM), Le Centre intégré universitaire de santé et de services sociaux (CIUSSS) Centre-Sud-de-l'île-de-Montréal, Montreal, QC, Canada
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Akita, Japan
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Zhang M, Chen T, Lu X, Lan X, Chen Z, Lu S. G protein-coupled receptors (GPCRs): advances in structures, mechanisms, and drug discovery. Signal Transduct Target Ther 2024; 9:88. [PMID: 38594257 PMCID: PMC11004190 DOI: 10.1038/s41392-024-01803-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/19/2024] [Accepted: 03/13/2024] [Indexed: 04/11/2024] Open
Abstract
G protein-coupled receptors (GPCRs), the largest family of human membrane proteins and an important class of drug targets, play a role in maintaining numerous physiological processes. Agonist or antagonist, orthosteric effects or allosteric effects, and biased signaling or balanced signaling, characterize the complexity of GPCR dynamic features. In this study, we first review the structural advancements, activation mechanisms, and functional diversity of GPCRs. We then focus on GPCR drug discovery by revealing the detailed drug-target interactions and the underlying mechanisms of orthosteric drugs approved by the US Food and Drug Administration in the past five years. Particularly, an up-to-date analysis is performed on available GPCR structures complexed with synthetic small-molecule allosteric modulators to elucidate key receptor-ligand interactions and allosteric mechanisms. Finally, we highlight how the widespread GPCR-druggable allosteric sites can guide structure- or mechanism-based drug design and propose prospects of designing bitopic ligands for the future therapeutic potential of targeting this receptor family.
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Affiliation(s)
- Mingyang Zhang
- Key Laboratory of Protection, Development and Utilization of Medicinal Resources in Liupanshan Area, Ministry of Education, Peptide & Protein Drug Research Center, School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
- Medicinal Chemistry and Bioinformatics Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Ting Chen
- Department of Cardiology, Changzheng Hospital, Affiliated to Naval Medical University, Shanghai, 200003, China
| | - Xun Lu
- Medicinal Chemistry and Bioinformatics Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Xiaobing Lan
- Key Laboratory of Protection, Development and Utilization of Medicinal Resources in Liupanshan Area, Ministry of Education, Peptide & Protein Drug Research Center, School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Ziqiang Chen
- Department of Orthopedics, Changhai Hospital, Affiliated to Naval Medical University, Shanghai, 200433, China.
| | - Shaoyong Lu
- Key Laboratory of Protection, Development and Utilization of Medicinal Resources in Liupanshan Area, Ministry of Education, Peptide & Protein Drug Research Center, School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China.
- Medicinal Chemistry and Bioinformatics Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Konno Y, Kamigaso S, Toki H, Terasaka S, Hikichi H, Endo H, Yamaguchi J, Mizuno‐Yasuhira A. Preclinical metabolism and the disposition of vornorexant/TS-142, a novel dual orexin 1/2 receptor antagonist for the treatment of insomnia. Pharmacol Res Perspect 2024; 12:e1183. [PMID: 38491717 PMCID: PMC10943176 DOI: 10.1002/prp2.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 03/18/2024] Open
Abstract
We investigated the metabolism and disposition of vornorexant, a novel dual orexin receptor antagonist, in rats and dogs, and clarified in vitro metabolite profiles in humans. Furthermore, we investigated the pharmacokinetics of active metabolites in rats and dogs and their CNS distribution in rats to elucidate its contribution to drug efficacy. [14 C]vornorexant was rapidly and mostly absorbed after the oral administration in rats and dogs. The drug-derived radioactivity, including metabolites, was distributed to major organs such as the liver, kidneys in rats, and was almost eliminated within 24 h post-dose in both species. Metabolite profiling revealed that main clearance mechanism of vornorexant was metabolism via multiple pathways by oxidation. The major circulating components were the cleaved metabolites (M10, M12) in rats, and the unchanged form in dogs, followed by M1, and then M3. Incubation with human hepatocytes resulted in formation of metabolites, including M1, M3, M10, and M12. The metabolic pathways were similar in all tested species. Resulting from the PK and CNS distribution of active metabolites (M1 and M3) with weaker pharmacological activity, the concentration of the unchanged form was higher than that of active metabolites in rat CSF and dog plasma, suggesting that the unchanged form mainly contributed to the drug efficacy. These findings demonstrate that vornorexant is absorbed immediately after administration, and vornorexant and its metabolites are rapidly and completely eliminated in rats and dogs. Thus, vornorexant may have favorable pharmacokinetic profiles as a hypnotic drug to provide rapid onset of action and minimal next-day residual effects in humans.
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Affiliation(s)
- Yoshihiro Konno
- Drug Safety and Pharmacokinetics, Research CenterTaisho Pharmaceutical Co., Ltd.SaitamaJapan
| | - Shunsuke Kamigaso
- Drug Safety and Pharmacokinetics, Research CenterTaisho Pharmaceutical Co., Ltd.SaitamaJapan
| | - Hidetoh Toki
- Drug Safety and Pharmacokinetics, Research CenterTaisho Pharmaceutical Co., Ltd.SaitamaJapan
| | - Shuichi Terasaka
- Drug Safety and Pharmacokinetics, Research CenterTaisho Pharmaceutical Co., Ltd.SaitamaJapan
| | - Hirohiko Hikichi
- Pharmacology, Research CenterTaisho Pharmaceutical Co., Ltd.SaitamaJapan
| | - Hiromi Endo
- Drug Safety and Pharmacokinetics, Research CenterTaisho Pharmaceutical Co., Ltd.SaitamaJapan
| | - Jun‐Ichi Yamaguchi
- Drug Safety and Pharmacokinetics, Research CenterTaisho Pharmaceutical Co., Ltd.SaitamaJapan
| | - Akiko Mizuno‐Yasuhira
- Drug Safety and Pharmacokinetics, Research CenterTaisho Pharmaceutical Co., Ltd.SaitamaJapan
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Tachibana M, Kanahara N, Oda Y, Hasegawa T, Kimura A, Iyo M. A retrospective clinical practice study comparing the usefulness of dual-orexin receptor antagonists and a melatonin receptor agonist in patients switching from long-term benzodiazepine receptor agonists. J Clin Sleep Med 2024; 20:603-613. [PMID: 38063235 PMCID: PMC10985311 DOI: 10.5664/jcsm.10946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 04/04/2024]
Abstract
STUDY OBJECTIVES Although novel hypnotics have recently emerged, there are currently no data comparing the clinical potency of benzodiazepine receptor agonists (BZRAs) and novel hypnotics, or the effectiveness of different methods of switching between them. This study examined how novel hypnotics might help reduce BZRA use in real-world practice. METHODS 289 patients with psychiatric disorders who took BZRAs for over 1 year before switching to either of 2 dual-orexin receptor antagonists (DORAs; suvorexant [SUV] or lemborexant [LEM]) or a melatonin receptor agonist (ramelteon [RMT]) were enrolled. We collected data on BZRAs at baseline and 3 months after commencement of SUV/LEM/RMT. RESULTS Significant reductions in BZRAs were observed for all 3 agents: -4.10, -2.80, and -1.65 mg in diazepam-equivalent doses in the SUV, LEM, and RMT groups, respectively. Dose reduction was significantly greater in the DORA than the RMT group (F = 15.053, P < .001). Within the DORA group, dose reduction was significantly greater in patients taking SUV than those taking LEM (F = 4.337, P = .043). The switching success rate did not differ among the switching methods for any of the hypnotics. CONCLUSIONS The reduction rate of BZRAs achieved by the switch fell into their equivalent-potency range estimated from clinical trials. The results suggest that DORAs can replace approximately 1 tablet of a BZRA. The difference in dose reduction between DORAs and RMT reflected the greater sleeping potency of the DORAs, whereas that between SUV and LEM might have reflected patient backgrounds: patients taking LEM may have been more strongly dependent on BZRAs. CITATION Tachibana M, Kanahara N, Oda Y, Hasegawa T, Kimura A, Iyo M. A retrospective clinical practice study comparing the usefulness of dual-orexin receptor antagonists and a melatonin receptor agonist in patients switching from long-term benzodiazepine receptor agonists. J Clin Sleep Med. 2024;20(4):603-613.
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Affiliation(s)
- Masumi Tachibana
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
- Safety and Health Organization, Chiba University, Chiba, Japan
| | - Nobuhisa Kanahara
- Division of Medical Treatment and Rehabilitation, Chiba University Center for Forensic Mental Health, Chiba, Japan
| | - Yasunori Oda
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tadashi Hasegawa
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
- Chiba University Hospital Palliative Care Center, Chiba, Japan
| | - Atsushi Kimura
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
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Fuller MC, Carlson SF, Grant C, Berry V, Ivancich M, Cornett EM, Kaye AM, Viswanath O, Urits I, Shekoohi S, Kaye AD. A Comprehensive Review of Lemborexant to Treat Insomnia. PSYCHOPHARMACOLOGY BULLETIN 2024; 54:43-64. [PMID: 38449475 PMCID: PMC10913865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Purpose of Review This is a comprehensive review of the literature regarding Lemborexant for the treatment of insomnia. It covers the background and management of insomnia and then reviews the body of existing evidence evaluating the use of Lemborexant for this purpose. Recent Findings Insomnia leads to significant decreased in quality of life and economic burden due to decreased workplace performance and increased health care costs. Insomnia manifests as a single common pathway of hyperarousal due to a highly complex network of interactions between activation of the sympathetic system and the endocrine system. Lemborexant is a dual orexin 1/2 antagonist that blocks cortical arousal and promotes sleep state transition. Lemborexant was approved by the FDA in 2019 for use in insomnia. It belongs to a class of orexin neuropeptide inhibitors that is growing in popular clinical application. Summary Insomnia is a crippling disorder of the sleep wake cycle that drives significant morbidity and mortality in the United States. It carries a high societal and economic toll due to direct and indirect effects to the healthcare system. Lemborexant is a new addition to the orexin antagonist class of drugs that already includes Almorexant and Suvorexant that has superior pharmacokinetic properties. While Lemborexant does have a mild side effect profile, its clinical safety and efficacy make it a promising insomnia drug of the future.
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Affiliation(s)
- Mitchell C Fuller
- Fuller, MD, Dartmouth School of Medicine, Department of Anesthesiology, Hanover, NH
| | - Samuel F Carlson
- Carlson, MD, University of Iowa, Department of Surgery, Iowa City, IA
| | - Chris Grant
- Grant, MD, University of California, Irvine, Department of Internal Medicine, Irvine, CA
| | - Vince Berry
- Berry, MD, University of Chicago, Department of Anesthesiology, Chicago, IL
| | - Marko Ivancich
- Ivancich, MD, Cape Fear Valley Health, Department of Psychiatry, Fayetteville, NC
| | - Elyse M Cornett
- Cornett, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport LA
| | - Adam M Kaye
- Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA
| | - Omar Viswanath
- Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport LA; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Valley Anesthesiology and Pain Consultants-Envision Physician Services, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Ivan Urits
- Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport LA
| | - Sahar Shekoohi
- Shekoohi, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport LA
| | - Alan D Kaye
- Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport LA
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Kim WJ, Kim HS. Emerging and upcoming therapies in insomnia. Transl Clin Pharmacol 2024; 32:1-17. [PMID: 38586124 PMCID: PMC10990727 DOI: 10.12793/tcp.2024.32.e5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 04/09/2024] Open
Abstract
Insomnia, commonly treated with benzodiazepine (BZD) receptor agonists, presents challenges due to associated serious side effects such as abuse and dependence. To address these concerns, many researches have been conducted to develop and advance both pharmacological and non-pharmacological interventions. Dual orexin receptor antagonists (DORAs), which include suvorexant, daridorexant and lemborexant, have recently been approved by United States Food and Drug Administration (US FDA) as a novel pharmacotherapeutic alternative. Unlike BZD receptor agonists that act as positive allosteric modulators of the gamma-aminobutyric acid type A subunit alpha 1 receptor, DORAs function by binding to both orexin receptor types 1 and 2, and inhibiting the action of the wake-promoting orexin neuropeptide. These drugs induce normal sleep without sleep stage change, do not impair attention and memory performance, and facilitate easier awakening. However, more real-world safety information is needed. Selective orexin-2 receptor antagonists (2-SORAs) is under clinical developments. This review provides an overview of the mechanism of action in relation to insomnia, pharmacokinetics, efficacy and safety information of DORAs and SORA. According to insomnia management guidelines, the first-line treatment for chronic insomnia is cognitive behavioral therapy for insomnia (CBT-I). Although it has proven effective in improving sleep-related quality of life, it has several restrictions limitations due to a face-to-face format. Recently, prescription digital therapy such as Somryst® was approved by US FDA. Somryst®, a smartphone app-based CBT-I, demonstrated meaningful responses in patients. However, digital limitations may impact scalability. Overall, these developments offer promising alternatives for insomnia treatment, emphasizing safety, efficacy, and accessibility.
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Affiliation(s)
- Woo-Ju Kim
- Inje University College of Medicine, Busan, Korea
| | - Ho-Sook Kim
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, Busan, Korea
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Watanabe K, Misaka S, Kanno-Nozaki K, Chiyoda T, Suzuki Y, Sato A, Suto T, Kuroda J, Shimomura K, Miura I, Yabe H. Effect of lemborexant on pharmacokinetics of clozapine: A potential drug-drug interaction mediated by time-dependent inhibition of CYP3A4. Br J Clin Pharmacol 2024; 90:354-359. [PMID: 37596710 DOI: 10.1111/bcp.15889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/02/2023] [Accepted: 08/09/2023] [Indexed: 08/20/2023] Open
Abstract
Clozapine (CLZ) is extensively used for treatment-resistant schizophrenia (TRS) with caution to avoid serious adverse events such as agranulocytosis and drug-drug interactions (DDIs). In the current report, we present a case of a 35-year-old male non-smoking TRS patient whose steady-state plasma trough concentrations (Ctrough ) of CLZ and its active metabolite, N-desmethylclozapine (NDMC), were significantly increased after initiating oral administration of lemborexant (LEM), a dual orexin receptor antagonist, for the treatment of insomnia. The patient experienced oversedation with sleepiness and fatigue while maintaining high levels of Ctrough of CLZ. The increased concentrations of CLZ returned to normal ranges after the discontinuation of LEM dosing, implying a pharmacokinetic DDI between CLZ and LEM. To gain insight into possible mechanisms, we performed in vitro assays of CYP1A2- and CYP3A4-mediated CLZ metabolism by measuring the formations of NDMC and clozapine N-oxide (CNO). In accordance with previous studies, the incubation of CLZ with each enzyme resulted in the production of both metabolites. LEM had only a weak inhibitory effect on CYP1A2- and CYP3A4-mediated CLZ metabolism. However, the preincubation of LEM with CYP3A4 in the presence of NADPH showed a significant enhancement of inhibitory effects on CLZ metabolism with IC50 values for the formations of CNO and NDMC of 2.8 μM and 4.1 μM, respectively, suggesting that LEM exerts as a potent time-dependent inhibitor for CYP3A4. Taken together, the results of the current study indicate that co-medication of CLZ with LEM may lead to increase in exposure to CLZ and risks of CLZ-related adverse events.
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Affiliation(s)
- Kenya Watanabe
- Department of Pharmacy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Shingen Misaka
- Department of Pharmacy, Fukushima Medical University Hospital, Fukushima, Japan
- Department of Bioregulation and Pharmacological Medicine, School of Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Keiko Kanno-Nozaki
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takaaki Chiyoda
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuhei Suzuki
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Akiko Sato
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takahiro Suto
- Department of Pharmacy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Junko Kuroda
- Department of Pharmacy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Kenju Shimomura
- Department of Bioregulation and Pharmacological Medicine, School of Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Itaru Miura
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
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Rawal S, Brimhall D, Aluri J, Cheng JY, Hall N, Moline M. Lemborexant levels in breast milk after single doses in healthy, lactating women. Br J Clin Pharmacol 2024; 90:158-163. [PMID: 37565541 DOI: 10.1111/bcp.15880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/29/2023] [Accepted: 08/05/2023] [Indexed: 08/12/2023] Open
Abstract
AIMS The aim of this study is to determine the cumulative amount of lemborexant (a competitive dual orexin receptor antagonist approved to treat adults with insomnia) excreted in human breast milk and the relative infant dose (RID) as a proportion of daily maternal dose. METHODS E2006-A001-010 was a single-centre, open-label study that enrolled lactating women (≥18 years) who breastfed for ≥5 weeks postpartum. After overnight fasting, subjects received a single 10-mg oral dose of lemborexant. Using a standardized electric pump, milk was sampled before and ≤240 h (10 days) after dosing; combined and total volume were recorded. The cumulative total amount of lemborexant excreted, fraction of dose excreted, daily infant dose and RID were calculated. Lemborexant concentration in human milk was assessed by liquid chromatography with tandem mass spectrometry. RESULTS Eight subjects completed the study. The mean cumulative total amount of lemborexant reached 0.0174 mg (coefficient of variation [CV] 54.5%; 0.174% of lemborexant 10 mg administered) in breast milk at 240 h (10 days); ~70% of excreted lemborexant accumulated in the first 24 h. For an infant weighing 6 kg, the daily infant dose was 0.00290 mg kg-1 (CV 54.5%) and the RID was 1.96% (CV 63.1%) of daily maternal dose. Mild treatment-emergent adverse events were reported in 4 subjects; these all resolved by end of study. CONCLUSION Trace quantities of lemborexant were found in human breast milk. Lemborexant was well tolerated by healthy lactating women.
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Muehlan C, Roch C, Vaillant C, Dingemanse J. The orexin story and orexin receptor antagonists for the treatment of insomnia. J Sleep Res 2023; 32:e13902. [PMID: 37086045 DOI: 10.1111/jsr.13902] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 04/23/2023]
Abstract
Insomnia is present in up to one third of the adult population worldwide, and it can present independently or with other medical conditions such as mental, metabolic, or cardiovascular diseases, which highlights the importance of treating this multifaceted disorder. Insomnia is associated with an abnormal state of hyperarousal (increased somatic, cognitive, and cortical activation) and orexin has been identified as a key promotor of arousal and vigilance. The current standards of care for the treatment of insomnia recommend non-pharmacological interventions (cognitive behavioural therapy) as first-line treatment and, if behavioural interventions are not effective or available, pharmacotherapy. In contrast to most sleep medications used for decades (benzodiazepines and 'Z-drugs'), the new orexin receptor antagonists do not modulate the activity of γ-aminobutyric acid receptors, the main inhibitory mechanism of the central nervous system. Instead, they temporarily block the orexin pathway, causing a different pattern of effects, e.g., less morning or next-day effects, motor dyscoordination, and cognitive impairment. The pharmacokinetic/pharmacodynamic properties of these drugs are the basis of the different characteristics explained in the package inserts, including the recommended starting dose. Orexin receptor antagonists seem to be devoid of any dependence and tolerance-inducing effects, rendering them a viable option for longer-term treatment. Safety studies did not show exacerbation of existing respiratory problems, but more real-world safety and pharmacovigilance experience is needed. This review provides an overview of the orexin history, the mechanism of action, the relation to insomnia, and key features of available drugs mediating orexin signalling.
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Poulie CM, Chan CB, Parka A, Lettorp M, Vos J, Raaschou A, Pottie E, Bundgaard MS, Sørensen LME, Cecchi CR, Märcher-Rørsted E, Bach A, Herth MM, Decker A, Jensen AA, Elfving B, Kretschmann AC, Stove CP, Kohlmeier KA, Cornett C, Janfelt C, Kornum BR, Kristensen JL. In Vitro and In Vivo Evaluation of Pellotine: A Hypnotic Lophophora Alkaloid. ACS Pharmacol Transl Sci 2023; 6:1492-1507. [PMID: 37854625 PMCID: PMC10580395 DOI: 10.1021/acsptsci.3c00142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Indexed: 10/20/2023]
Abstract
Quality of life is often reduced in patients with sleep-wake disorders. Insomnia is commonly treated with benzodiazepines, despite their well-known side effects. Pellotine (1), a Lophophora alkaloid, has been reported to have short-acting sleep-inducing properties in humans. In this study, we set out to evaluate various in vitro and in vivo properties of 1. We demonstrate that 1 undergoes slow metabolism; e.g. in mouse liver microsomes 65% remained, and in human liver microsomes virtually no metabolism was observed after 4 h. In mouse liver microsomes, two phase I metabolites were identified: 7-desmethylpellotine and pellotine-N-oxide. In mice, the two diastereomers of pellotine-O-glucuronide were additionally identified as phase II metabolites. Furthermore, we demonstrated by DESI-MSI that 1 readily enters the central nervous system of rodents. Furthermore, radioligand-displacement assays showed that 1 is selective for the serotonergic system and in particular the serotonin (5-HT)1D, 5-HT6, and 5-HT7 receptors, where it binds with affinities in the nanomolar range (117, 170, and 394 nM, respectively). Additionally, 1 was functionally characterized at 5-HT6 and 5-HT7, where it was found to be an agonist at the former (EC50 = 94 nM, Emax = 32%) and an inverse agonist at the latter (EC50 = 291 nM, Emax = -98.6). Finally, we demonstrated that 1 dose-dependently decreases locomotion in mice, inhibits REM sleep, and promotes sleep fragmentation. Thus, we suggest that pellotine itself, and not an active metabolite, is responsible for the hypnotic effects and that these effects are possibly mediated through modulation of serotonergic receptors.
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Affiliation(s)
- Christian
B. M. Poulie
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
| | - Camilla B. Chan
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
| | - Aleksandra Parka
- Department
of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, C Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Magnus Lettorp
- Department
of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, C Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Josephine Vos
- Department
of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, C Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Amanda Raaschou
- Department
of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, C Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Eline Pottie
- Laboratory
of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical
Sciences, Ghent University, Campus Heymans, Ottergemsesteenweg
460, B-9000 Ghent, Belgium
| | - Mikkel S. Bundgaard
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
| | - Louis M. E. Sørensen
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
| | - Claudia R. Cecchi
- Translational
Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N Aarhus, Denmark
| | - Emil Märcher-Rørsted
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
| | - Anders Bach
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
| | - Matthias M. Herth
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
- Department
of Clinical Physiology, Nuclear Medicine
& PET, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Ann Decker
- Center for
Drug Discovery, RTI International, Research Triangle Park, North Carolina 27709, United States
| | - Anders A. Jensen
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
| | - Betina Elfving
- Translational
Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N Aarhus, Denmark
| | - Andreas C. Kretschmann
- Department
of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, C Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Christophe P. Stove
- Laboratory
of Toxicology, Department of Bioanalysis, Faculty of Pharmaceutical
Sciences, Ghent University, Campus Heymans, Ottergemsesteenweg
460, B-9000 Ghent, Belgium
| | - Kristi A. Kohlmeier
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
| | - Claus Cornett
- Department
of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, C Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Christian Janfelt
- Department
of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, C Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Birgitte R. Kornum
- Department
of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, C Universitetsparken 2, 2100 Copenhagen, Denmark
| | - Jesper L. Kristensen
- Department
of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Jagtvej 160, 2100 Copenhagen, Denmark
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11
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Beran K, Hermans E, Holm R, Sepassi K, Dressman J. Projection of Target Drug Particle Size in Oral Formulations Using the Refined Developability Classification System (rDCS). Pharmaceutics 2023; 15:1909. [PMID: 37514095 PMCID: PMC10385664 DOI: 10.3390/pharmaceutics15071909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Dissolution limitations to oral absorption can occur if the time required for dissolution is longer than the transit time across the small intestine and/or if dissolution is slower than the drug's permeation through the gut wall. These limitations most often occur for poorly soluble drugs. A standard method for overcoming dissolution issues is to reduce the particle size of the (solid) drug. Building on the refined Developability Classification System (rDCS), this work establishes a novel set of equations with which the appropriate degree of particle size reduction needed to mitigate dissolution limitations to absorption can be calculated. According to the type of data available, the appropriate equation(s) for each situation can be applied. Three case examples are used to illustrate implementation of the equations: voriconazole, lemborexant and istradefylline. Although for voriconazole (rDCS Class I) target radius (rtarget) estimates indicate that particle size reduction is unnecessary, for lemborexant (rDCS Class I) a radius of ≤20 µm would be required to improve absorption. For istradefylline (rDCS Class IIb) the rtarget was approximately 12 µm. Results are commensurate with literature information for these three drugs, signaling that the equations are suitable for application to a wide variety of drug substances.
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Affiliation(s)
- Kristian Beran
- Fraunhofer Institute of Translational Medicine and Pharmacology, 60596 Frankfurt am Main, Germany
- Janssen Research & Development, Pharmaceutical & Material Sciences, 2340 Beerse, Belgium
| | - Eline Hermans
- Janssen Research & Development, Pharmaceutical & Material Sciences, 2340 Beerse, Belgium
| | - René Holm
- Department of Physics, Chemistry and Pharmacy, University of Southern Denmark, 5230 Odense, Denmark
| | - Kia Sepassi
- Janssen Research & Development, Discovery Pharmaceutics, La Jolla, CA 92121, USA
| | - Jennifer Dressman
- Fraunhofer Institute of Translational Medicine and Pharmacology, 60596 Frankfurt am Main, Germany
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12
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Moline M, Asakura S, Beuckman C, Landry I, Setnik B, Ashworth J, Henningfield JE. The abuse potential of lemborexant, a dual orexin receptor antagonist, according to the 8 factors of the Controlled Substances Act. Psychopharmacology (Berl) 2023; 240:699-711. [PMID: 36749354 PMCID: PMC10006052 DOI: 10.1007/s00213-023-06320-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/17/2023] [Indexed: 02/08/2023]
Abstract
RATIONALE Lemborexant (LEM) is a dual orexin receptor antagonist (DORA) approved in multiple countries including the USA, Japan, Canada, Australia, and several Asian countries for the treatment of insomnia in adults. As a compound with central nervous system activity, it is important to understand the abuse potential of LEM with respect to public health. OBJECTIVES This review discusses data for LEM relevant to each of the 8 factors of the United States Controlled Substances Act. RESULTS LEM did not demonstrate abuse potential in nonclinical testing and was associated with a low incidence of abuse-related adverse events in clinical study participants with insomnia disorder. Similar to other DORAs that have been evaluated (eg., almorexant, suvorexant (SUV), and daridorexant), LEM and the positive controls (zolpidem and SUV) also showed drug liking in a phase 1 abuse potential study that enrolled subjects who used sedatives recreationally. However, internet surveillance of SUV and the FDA Adverse Events Reporting System suggests that drugs in the DORA class display very low abuse-related risks in the community. Additionally, as described in FDA-approved labeling, it does not carry physical dependence and withdrawal risks. CONCLUSIONS LEM, similar to most other prescription insomnia medications, was placed into Schedule IV. However, LEM and other drugs in the DORA class may have a lower potential for abuse as suggested by real-world postmarketing data from federal surveys and internet surveillance, and thus may have lower risks to public health than Schedule IV benzodiazepines and nonbenzodiazepine hypnotics that potentiate GABA signaling.
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Affiliation(s)
- Margaret Moline
- Eisai Inc., 200 Metro Boulevard, Nutley, Jersey, NJ, 07110, USA.
| | | | | | | | - Beatrice Setnik
- Altasciences, Laval, Quebec, Canada and the Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | | | - Jack E Henningfield
- Pinney Associates, Inc., Bethesda, MD, USA.,The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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Saito J, Ishii M, Sandaiji N, Yamaguchi K, Suzuki T, Yakuwa N, Yamatani A, Tachibana Y, Sago H, Murashima A. Lemborexant levels in maternal serum, cord blood, and breast milk during pregnancy and lactation: A case report. PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2023; 2:e62. [PMID: 38868416 PMCID: PMC11114320 DOI: 10.1002/pcn5.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 06/14/2024]
Affiliation(s)
- Jumpei Saito
- Department of PharmacyNational Center for Child Health and DevelopmentTokyoJapan
| | - Mariko Ishii
- Department of PharmacyNational Center for Child Health and DevelopmentTokyoJapan
| | - Noriko Sandaiji
- Department of PharmacyNational Center for Child Health and DevelopmentTokyoJapan
| | - Koshi Yamaguchi
- Division of Maternal Medicine, Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Tomo Suzuki
- Division of Obstetrics, Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Naho Yakuwa
- Japan Drug Information Institute in PregnancyNational Center for Child Health and DevelopmentTokyoJapan
| | - Akimasa Yamatani
- Department of PharmacyNational Center for Child Health and DevelopmentTokyoJapan
| | - Yoshiyuki Tachibana
- Department of Psychosocial Medicine, Division of Infant and Toddler Mental HealthNational Center for Child Health and DevelopmentTokyoJapan
| | - Haruhiko Sago
- Division of Obstetrics, Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
- Division of Obstetrics, Center for Maternal‐Fetal, Neonatal and Reproductive MedicineNational Center for Child Health and DevelopmentTokyoJapan
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14
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Mogavero MP, Silvani A, Lanza G, DelRosso LM, Ferini-Strambi L, Ferri R. Targeting Orexin Receptors for the Treatment of Insomnia: From Physiological Mechanisms to Current Clinical Evidence and Recommendations. Nat Sci Sleep 2023; 15:17-38. [PMID: 36713640 PMCID: PMC9879039 DOI: 10.2147/nss.s201994] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/08/2023] [Indexed: 01/23/2023] Open
Abstract
After a detailed description of orexins and their roles in sleep and other medical disorders, we discuss here the current clinical evidence on the effects of dual (DORAs) or selective (SORAs) orexin receptor antagonists on insomnia with the aim to provide recommendations for their further assessment in a context of personalized and precision medicine. In the last decade, many trials have been conducted with orexin receptor antagonists, which represent an innovative and valid therapeutic option based on the multiple mechanisms of action of orexins on different biological circuits, both centrally and peripherally, and their role in a wide range of medical conditions which are often associated with insomnia. A very interesting aspect of this new category of drugs is that they have limited abuse liability and their discontinuation does not seem associated with significant rebound effects. Further studies on the efficacy of DORAs are required, especially on children and adolescents and in particular conditions, such as menopause. Which DORA is most suitable for each patient, based on comorbidities and/or concomitant treatments, should be the focus of further careful research. On the contrary, studies on SORAs, some of which seem to be appropriate also in insomnia in patients with psychiatric diseases, are still at an early stage and, therefore, do not allow to draw definite conclusions.
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Affiliation(s)
- Maria P Mogavero
- Vita-Salute San Raffaele University, Milan, Italy.,Sleep Disorders Center, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Silvani
- PRISM Lab, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Lanza
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy.,Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Lourdes M DelRosso
- Pulmonary and Sleep Medicine, University of California San Francisco-Fresno, Fresno, CA, USA
| | - Luigi Ferini-Strambi
- Vita-Salute San Raffaele University, Milan, Italy.,Sleep Disorders Center, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy
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15
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Dash A, Pinner K, Inoue Y, Hayashida K, Lim SC, Yun CH, Lan TH, Huang CL, Yardley J, Kubota N, Moline M. Efficacy and safety of lemborexant over 12 months in Asian adults with insomnia disorder. Sleep Med X 2022; 4:100044. [PMID: 35402894 PMCID: PMC8987601 DOI: 10.1016/j.sleepx.2022.100044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 11/30/2022] Open
Abstract
Study objectives Lemborexant (LEM) is a dual orexin receptor antagonist approved for treating adults with insomnia. We analyzed the efficacy (subjective sleep outcomes) and safety of LEM over 12 months in the subgroup of Asian subjects from Study E2006-G000-303 (Study 303). Methods Study 303 was a 12-month, randomized, placebo-controlled (first 6 months), double-blind, parallel-group, phase 3 study of adults with insomnia disorder. During the 6-month Period 1, subjects were randomized (1:1:1) to placebo, LEM 5 mg (LEM5), or LEM 10 mg (LEM10); LEM subjects continued treatment in the following 6-month Period 2. Outcome measures included subject-reported (subjective) sleep onset latency (sSOL), sleep efficiency (sSE), wake after sleep onset (sWASO), total sleep time (sTST), Insomnia Severity Index (ISI), and Patient Global Impression–Insomnia version (PGI-I). Treatment-emergent adverse events (TEAEs) were assessed. Results Overall, 178 Asian subjects (Japanese, n = 161; Chinese, n = 4; other Asian, n = 13) were included. Greater decreases in sSOL and sWASO and increases in sSE and sTST from baseline were observed with LEM vs placebo at 6 months; LEM benefits were sustained through 12 months. Greater decreases in ISI total score were seen with LEM vs placebo at 6 months; improvements from baseline with LEM continued through 12 months. For each PGI-I item, LEM-treated subjects had more positive medication effects than placebo-treated subjects at 6 months; these effects were maintained with LEM in Period 2. TEAEs were generally mild to moderate. Conclusions LEM improved subjective sleep parameters and was well-tolerated in Asian subjects with insomnia disorder over 12 months. Clinical trial registration ClinicalTrials.gov, NCT02952820; ClinicalTrialsRegister.eu, EudraCT Number 2015-001463-39. Lemborexant improved subjective sleep measures and provided positive medication effects over 6 months versus placebo. Benefits of lemborexant were sustained over 12 months. Few (∼3%) lemborexant-treated Asian subjects discontinued treatment because of adverse events. Lemborexant can potentially treat Asian persons with insomnia effectively, with fewer side effects than other medications.
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16
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Molecular basis for anti-insomnia drug design from structure of lemborexant-bound orexin 2 receptor. Structure 2022; 30:1582-1589.e4. [DOI: 10.1016/j.str.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/24/2022] [Accepted: 10/28/2022] [Indexed: 11/23/2022]
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17
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Abstract
PURPOSE OF REVIEW We review recent evidence on the use of orexin receptor antagonists (ORAs) for treating insomnia. We evaluate studies on five dual ORAs and one selective ORA. RECENT FINDINGS Research on suvorexant in recent years gradually focus on comorbid insomnia, while lemborexant and daridorexant were still being validated in primary insomnia. Almorexant is now mainly used as a commercial specific inhibitor of the orexin system in animal studies due to safety issues. Although filorexant has also shown a certain sleep-promoting effect, there are few clinical or experimental studies on sleep-related aspects of filorexant in recent years. As for selective ORAs, orexin receptor 2 antagonist seltorexant still has not yet reached phase 3. High-quality clinical trials in insomnia populations are needed which directly compare authorized ORAs and investigate non-approved ORAs, the use of ORAs in comorbid insomnia, and the orexin signaling system pathophysiology in insomnia.
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Affiliation(s)
- Xin Wu
- Department of Neurosurgery & Brain, Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, Suzhou, 215006, China.,Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, 215200, China
| | - Tao Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain, Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, Suzhou, 215006, China
| | - Zhong Wang
- Department of Neurosurgery & Brain, Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, Suzhou, 215006, China.
| | - Gang Chen
- Department of Neurosurgery & Brain, Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Jiangsu Province, Suzhou, 215006, China
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18
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Okino K, Suzuki H, Kondo S, Tomioka H, Tokumasu T, Yamada H, Iwanami A, Inamoto A. Effectiveness of change from suvorexant to lemborexant drug in the treatment of sleep disorders. Psychogeriatrics 2022; 22:595-604. [PMID: 35689366 DOI: 10.1111/psyg.12858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/28/2022] [Accepted: 05/19/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study aimed to examine the effects of a change in medication from suvorexant to lemborexant among patients with insomnia. METHODS Patients with chronic insomnia who had persistent insomnia for 3 months or longer and who had been taking suvorexant for 3 months or longer were selected. The participants were divided into two groups: the 'modified' group and the 'non-modified' group. Four sub-types of insomnia (i.e., difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, and non-restorative sleep) were investigated. Logistic regression was used to investigate improvements in both the groups after 12 weeks. RESULTS Among the 77 participants, 43 and 34 patients were in the modified drug group and the non-modified drug group, respectively. Comparing sleep disorders between the two groups, we found significant improvement after 12 weeks in the modified drug group in terms of difficulty initiating sleep, compared with the non-modified drug group (odds ratio = 0.036, P = 0.008, 95% CI = 0.003-0.415). However, no significant differences were found between the two groups in terms of difficulty maintaining sleep, early-morning awakening, and non-restorative sleep. CONCLUSIONS Sleep disorders can be treated by alleviating difficulties in initiating sleep by changing from suvorexant to lemborexant. In addition, it was confirmed that the drug change caused no serious side effects and that it was highly safe and tolerated.
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Affiliation(s)
- Kazumaro Okino
- Mental Care Center, Showa University Northern Yokohama Hospital, Yokohama-shi, Japan.,Department of Neuropsychiatry, Showa University School of Medicine, Shinagawa-ku, Japan
| | - Hirohisa Suzuki
- Department of Neuropsychiatry, Showa University School of Medicine, Shinagawa-ku, Japan.,Neuropsychiatry, Showa University Karasuyama Hospital, Setagaya-ku, Japan
| | | | - Hiroi Tomioka
- Mental Care Center, Showa University Northern Yokohama Hospital, Yokohama-shi, Japan.,Department of Neuropsychiatry, Showa University School of Medicine, Shinagawa-ku, Japan
| | - Takahiro Tokumasu
- Mental Care Center, Showa University Northern Yokohama Hospital, Yokohama-shi, Japan.,Department of Neuropsychiatry, Showa University School of Medicine, Shinagawa-ku, Japan
| | - Hiroki Yamada
- Mental Care Center, Showa University Northern Yokohama Hospital, Yokohama-shi, Japan.,Department of Neuropsychiatry, Showa University School of Medicine, Shinagawa-ku, Japan
| | - Akira Iwanami
- Department of Neuropsychiatry, Showa University School of Medicine, Shinagawa-ku, Japan.,Neuropsychiatry, Showa University Karasuyama Hospital, Setagaya-ku, Japan
| | - Atsuko Inamoto
- Mental Care Center, Showa University Northern Yokohama Hospital, Yokohama-shi, Japan.,Department of Neuropsychiatry, Showa University School of Medicine, Shinagawa-ku, Japan
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19
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Landry I, Hall N, Aluri J, Filippov G, Setnik B, Dayal S, Reyderman L, Moline M. Effect of alcohol coadministration on the pharmacodynamics, pharmacokinetics, and safety of lemborexant: A randomized, placebo-controlled crossover study. J Psychopharmacol 2022; 36:745-755. [PMID: 35634694 PMCID: PMC9150140 DOI: 10.1177/02698811221080459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lemborexant is a dual orexin receptor antagonist approved to treat insomnia in adults in several countries including the USA, Canada, and Japan. AIMS This study was conducted to investigate effects of lemborexant and alcohol coadministration on postural stability, cognitive performance, and the pharmacokinetics, safety, and tolerability of lemborexant. METHODS This was a Phase 1, double-blind, placebo-controlled, four-period crossover study in 32 healthy adults. Individuals were randomized into one of four treatment sequences to receive single doses of placebo, lemborexant 10 mg (LEM10), alcohol (males, 0.7 g/kg; females, 0.6 g/kg), and LEM10 plus alcohol, each separated by a 14-day washout. Postural stability (body sway) was measured by ataxiameter and a cognitive performance assessment battery evaluated four domains of attention and memory. RESULTS Pharmacodynamic outcomes were analyzed for the 18 participants who completed all four treatments. Change from baseline in body sway showed no significant differences between lemborexant plus alcohol versus alcohol alone. Compared with alcohol alone, coadministration of lemborexant with alcohol showed additive negative effects on cognitive performance domains, corresponding approximately with peak plasma lemborexant concentrations (median = 1.5 h). Cognitive performance was also impaired with lemborexant alone at 0.5 and 2 h in this experimental paradigm with morning dosing. Alcohol increased plasma lemborexant exposure by 70% based on area under the curve to 72 h, and increased peak plasma lemborexant concentrations by 35%. The most commonly reported treatment-emergent adverse event was somnolence. CONCLUSION Coadministration of lemborexant with alcohol showed additive negative effects on cognitive measures, but not on postural stability, compared with alcohol alone. Lemborexant exposure was increased with alcohol. Lemborexant alone or with alcohol was well tolerated. Patients are advised not to consume alcohol with lemborexant.
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Affiliation(s)
| | | | | | | | - Beatrice Setnik
- Syneos Health, Raleigh, NC, USA,Department of Toxicology & Pharmacology, University of Toronto, Toronto, ON, Canada
| | | | | | - Margaret Moline
- Eisai Inc., Nutley, NJ, USA,Margaret Moline, Clinical Research, Eisai Inc., 200 Metro Blvd, Nutley, NJ 07110, USA.
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20
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Kishi T, Nishida M, Koebis M, Taninaga T, Muramoto K, Kubota N, Moline M, Sakuma K, Okuya M, Nomura I, Iwata N. Evidence-based insomnia treatment strategy using novel orexin antagonists: A review. Neuropsychopharmacol Rep 2021; 41:450-458. [PMID: 34553844 PMCID: PMC8698673 DOI: 10.1002/npr2.12205] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/09/2021] [Accepted: 08/22/2021] [Indexed: 11/20/2022] Open
Abstract
Most conventional insomnia medications are gamma‐aminobutylic acid receptor agonists. However, physical dependence is a concern and one of the major limiting factors for long‐term treatment. The dual orexin receptor antagonists, suvorexant and lemborexant, were recently approved for treating chronic insomnia, giving a novel pharmacotherapeutic option. Because there are no comparative studies on these drugs, a network meta‐analysis was conducted, which is suitable for comparing interventions. According to this analysis, 5‐ and 10‐mg lemborexant were superior to 20‐mg suvorexant because of the greater improvement in initiating sleep after 1‐week administration. Furthermore, 5‐mg lemborexant (not 10 mg) and suvorexant were similarly well tolerated, without requiring discontinuation due to adverse events. We also overviewed the pharmacological and pharmacokinetic properties of lemborexant and suvorexant that may support these clinical outcomes. When compared to suvorexant, lemborexant quickly binds to the orexin receptors. The time to reach the maximum concentration after multiple administrations is shorter for lemborexant than for suvorexant. Considering these results, we recommend 5‐mg lemborexant as an initial treatment for insomnia, followed by 10‐mg lemborexant or suvorexant. A network meta‐analysis of the dual orexin receptor antagonists, suvorexant, and lemborexant, showed that 5‐ and 10‐mg lemborexant were superior to 20‐mg suvorexant, with greater improvement in sleep onset after 1 week of treatment. In addition, 5‐mg (but not 10‐mg) lemborexant and suvorexant were similarly well tolerated. We have overviewed the pharmacological and pharmacokinetic properties of lemborexant and suvorexant that may support these clinical results, and recommended 5‐mg lemborexant as initial treatment for insomnia, followed by 10‐mg lemborexant or suvorexant.
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Affiliation(s)
- Taro Kishi
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | | | | | | | | | | | | | - Kenji Sakuma
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Makoto Okuya
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Ikuo Nomura
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.,Department of Psychiatry, The Moriyama General Mental Hospital, Nagoya, Aichi, Japan
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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21
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Landry I, Aluri J, Hall N, Filippov G, Dayal S, Moline M, Reyderman L. Effects of Lemborexant on the Pharmacokinetics of Oral Contraceptives: Results From a Phase 1 Drug-Drug Interaction Study in Healthy Females. Clin Pharmacol Drug Dev 2021; 10:1089-1098. [PMID: 34107159 PMCID: PMC8453935 DOI: 10.1002/cpdd.953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/17/2021] [Indexed: 11/06/2022]
Abstract
Lemborexant is a dual orexin receptor antagonist approved in multiple countries including the United States, Canada, and Japan for the treatment of insomnia in adults. As women of childbearing potential may be prescribed insomnia drugs, a drug‐drug interaction study was conducted. This single‐center, open‐label, fixed‐sequence study examined potential drug‐drug interactions between lemborexant and an oral contraceptive (OC) in healthy females (18–44 years, n = 20). The purpose of this study was to determine the effect of lemborexant 10 mg (at steady state) on the pharmacokinetics of a single dose of OC (0.03 mg ethinyl estradiol and 1.5 mg norethindrone acetate), assess the effect of a single dose of OC on lemborexant pharmacokinetics, and evaluate safety and tolerability of lemborexant and OC coadministration. Ethinyl estradiol maximum plasma drug concentration was not altered by lemborexant coadministration; area under the curve from zero time to the last quantifiable concentration was slightly increased, by 13%. No clinically relevant effects on norethindrone acetate pharmacokinetics were observed. Coadministration of OC with lemborexant had no clinically relevant effect on the steady‐state pharmacokinetics of lemborexant. Adverse events were consistent with the known safety profile. These results support the conclusion that lemborexant and OC can be coadministered without dose adjustment.
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Affiliation(s)
| | | | - Nancy Hall
- Eisai Inc., Woodcliff Lake, New Jersey, USA
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Waters K. Review of the Efficacy and Safety of Lemborexant, a Dual Receptor Orexin Antagonist (DORA), in the Treatment of Adults With Insomnia Disorder. Ann Pharmacother 2021; 56:213-221. [PMID: 34078141 DOI: 10.1177/10600280211008492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To provide an overview of the efficacy and safety of lemborexant in the treatment of insomnia disorder by assessing the currently available literature. DATA SOURCES A literature search of PubMed was performed (2010 to March 2021) using the following search terms: lemborexant, sleep, orexin. STUDY SELECTION AND DATA EXTRACTION All relevant English-language studies were reviewed and considered, with a focus on phase 3 trials. DATA SYNTHESIS The efficacy and safety of lemborexant in the treatment of insomnia disorder in adults was demonstrated in 2 phase 3 trials. Lemborexant significantly reduced latency to persistent sleep compared with placebo. The first study also demonstrated a significant reduction compared with the active control zolpidem ER. Somnolence and headache were relatively common, but the marked adverse effects associated with other medications commonly used to treat insomnia, such as cognitive and psychomotor impairment and complex sleep-related behaviors, were not observed. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Although nonpharmacological therapy is considered first-line treatment for insomnia disorder, pharmacological treatment is most commonly utilized. Lemborexant is a viable pharmacological treatment option for patients who are unable to tolerate the adverse effects associated with the most commonly prescribed medications for insomnia, such as benzodiazepines and sedative-hypnotics (Z drugs). This is especially true for geriatric patients, who may be more sensitive to these adverse effects. CONCLUSION Lemborexant can be recommended to treat insomnia disorder when pharmacological treatment is warranted. It has demonstrated efficacy in clinical trials and is likely better tolerated than most currently available treatment options.
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Abstract
INTRODUCTION Insomnia is a complex sleep disorder that compromises quality of life and affects approximately 10% of the general population. Insomnia, defined as trouble initiating or maintaining sleep associated with impaired daytime function or distress, is treated using a comprehensive approach comprised of cognitive behavioral therapy and pharmacotherapy. Lemborexant, a dual orexin receptor antagonist, is a new pharmacotherapeutic option recently approved for the treatment of insomnia. AREAS COVERED Here, the authors describe lemborexant, assess its efficacy and safety profile in clinical trials, and evaluate its role in the current insomnia treatment landscape. EXPERT OPINION Lemborexant may offer an improved treatment option compared with other pharmacotherapies for insomnia because it is effective both over the long term and over a wide range of outcome measures. Importantly, lemborexant improves latency to sleep onset and sleep maintenance and is able to help people who experience early morning awakenings. Safety data reveal that lemborexant has minimal residual effects on morning alertness or next day function, and that patients are able to respond to an external auditory stimulus in the middle of the night. In conclusion, lemborexant represents a new, effective, and well-tolerated medication for patients with insomnia.
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Affiliation(s)
- Gary Zammit
- Clinilabs Drug Development Corporation, New York, NY, USA
| | - Andrew Krystal
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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24
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Dayal S, Aluri J, Hall N, Filippov G, Moline M, Reyderman L, Landry I. Effect of hepatic impairment on pharmacokinetics, safety, and tolerability of lemborexant. Pharmacol Res Perspect 2021; 9:e00758. [PMID: 33822479 PMCID: PMC8023329 DOI: 10.1002/prp2.758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/19/2021] [Accepted: 02/24/2021] [Indexed: 12/25/2022] Open
Abstract
Lemborexant, a dual orexin receptor antagonist, is approved in the United States, Japan, and Canada for the treatment of insomnia in adults. This phase I, multicenter, open‐label, parallel‐group study assessed the impact of mild or moderate hepatic impairment (HI) on lemborexant pharmacokinetics and metabolism. The pharmacokinetics, tolerability, and safety of lemborexant were evaluated in subjects with mild (Child–Pugh class A) or moderate (Child–Pugh class B) HI and healthy age‐, sex‐, and body mass index (BMI)‐matched control subjects (n = 8 subjects/group). Subjects received a single oral dose of lemborexant 10 mg (LEM10). Blood samples were collected up to 312 hours post dosing for lemborexant pharmacokinetics assessments. Median time to maximum plasma concentration was similar across all groups. Compared with healthy subjects, exposure measures (maximum plasma concentration [Cmax] and area under the curve extrapolated to infinity [AUC0‐inf]) increased by ~58% (Cmax) and ~25% (AUC0‐inf) in subjects with mild HI and ~22% (Cmax) and ~54% (AUC0‐inf) in subjects with moderate HI. Clearance decreased by 20% and 35% in subjects with mild and moderate HI, respectively, versus healthy subjects. Lemborexant unbound fraction was similar in all groups (range: 0.060–0.065). All treatment‐emergent adverse events (TEAEs) were mild in severity; no serious TEAEs occurred. In conclusion, following a single LEM10 dose, lemborexant exposure was similar in subjects with mild HI and increased in subjects with moderate HI versus healthy subjects. No dose adjustment is required in subjects with mild HI. Dosing in subjects with moderate HI should be restricted to 5 mg. Lemborexant was well tolerated in all groups.
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Ueno T, Miyajima Y, Landry I, Lalovic B, Schuck E. Physiologically-based pharmacokinetic modeling to predict drug interactions of lemborexant with CYP3A inhibitors. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:455-466. [PMID: 33704920 PMCID: PMC8129715 DOI: 10.1002/psp4.12606] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/29/2021] [Accepted: 02/19/2021] [Indexed: 12/29/2022]
Abstract
Lemborexant, a recently approved dual orexin receptor antagonist for treatment of adults with insomnia, is eliminated primarily by cytochrome P450 (CYP)3A metabolism. The recommended dose of lemborexant is 5 mg once per night, with a maximum recommended dose of 10 mg once daily. A physiologically-based pharmacokinetic (PBPK) model for lemborexant was developed and applied to integrate data obtained from in vivo drug-drug interaction (DDI) assessments, and to further explore lemborexant interaction with CYP3A inhibitors and inducers. The model predictions were in good agreement with observed pharmacokinetic data and with DDI results from clinical studies with CYP3A inhibitors, itraconazole and fluconazole. The model further predicted that DDI effects of weak CYP3A inhibitors (fluoxetine and ranitidine) are weak, and effects of moderate inhibitors (erythromycin and verapamil) are moderate. Based on the PBPK simulations and clinical efficacy and safety data, the maximum daily recommended lemborexant dose when administered with weak CYP3A inhibitors is 5 mg; co-administration of moderate and strong inhibitors should be avoided except in countries where 2.5 mg has been approved.
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Landry I, Aluri J, Hall N, Filippov G, Dayal S, Moline M, Reyderman L. Effect of severe renal impairment on pharmacokinetics, safety, and tolerability of lemborexant. Pharmacol Res Perspect 2021; 9:e00734. [PMID: 33689224 PMCID: PMC7945683 DOI: 10.1002/prp2.734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/24/2021] [Indexed: 12/19/2022] Open
Abstract
The primary aim of this study was to examine the effect of severe renal impairment (SRI) on the pharmacokinetics of lemborexant, a dual orexin receptor antagonist indicated for the treatment of insomnia. A phase 1 multicenter, single‐dose, open‐label, parallel‐group study was conducted in subjects with SRI not requiring dialysis (estimated glomerular filtration rate 15–29 ml/min/1.73 m2; n = 8) compared with demographically matched healthy subjects with normal renal function (n = 8). Plasma levels of lemborexant and its metabolites were measured over 240 h following a single oral 10‐mg dose administered in the morning. Relative to subjects with normal renal function, lemborexant maximum plasma concentration (Cmax) was similar, whereas area under the plasma concentration–time curve from zero to time of last quantifiable concentration (AUC(0‐t)) and AUC from zero to infinity (AUC(0‐inf)) were about 1.5‐fold higher in subjects with SRI. The geometric mean ratios (90% confidence interval) were 104.8 (77.4–142.0), 150.5 (113.2–200.3), and 149.8 (113.1–198.6) for Cmax, AUC(0‐t), and AUC(0‐inf), respectively. In both groups, the median lemborexant time to Cmax (tmax) was 1 h, and the mean unbound fraction of lemborexant was ~7%. For the M4, M9, and M10 metabolites, Cmax was reduced ~20% and exposure (AUC(0‐t) and AUC(0‐inf)) was ~1.4‐ to 1.5‐fold higher in subjects with SRI versus healthy subjects; tmax was delayed ~1.5–2 h for M4 and M10. All treatment‐emergent adverse events were mild or moderate. Lemborexant pharmacokinetics were not sufficiently altered to warrant a dose adjustment for subjects with renal impairment.
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Landry I, Aluri J, Nakai K, Hall N, Miyajima Y, Ueno T, Dayal S, Filippov G, Lalovic B, Moline M, Reyderman L. Evaluation of the CYP3A and CYP2B6 Drug-Drug Interaction Potential of Lemborexant. Clin Pharmacol Drug Dev 2021; 10:681-690. [PMID: 33455055 PMCID: PMC8248323 DOI: 10.1002/cpdd.915] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/21/2020] [Indexed: 12/31/2022]
Abstract
Lemborexant is approved for treating insomnia and is under investigation for treating irregular sleep‐wake rhythm disorder. Based on in vitro drug‐drug interaction (DDI) characteristics, phase 1, open‐label DDI studies were conducted to evaluate lemborexant's cytochrome P450 3A (CYP3A) and CYP2B6 interaction potential. Interactions between lemborexant 10 mg and strong and moderate CYP3A inhibitors (itraconazole and fluconazole), a strong CYP3A inducer (rifampin), and CYP3A (midazolam) and CYP2B6 substrates (bupropion) were evaluated. Coadministration of lemborexant with itraconazole or fluconazole resulted in 1.4‐ to 1.6‐fold and 3.7‐ to 4‐fold increases in lemborexant maximum observed concentration (Cmax) and area under the concentration‐time curve from zero time extrapolated to infinity (AUC0‐inf), respectively. Coadministration of lemborexant with rifampin resulted in >90% decreases in lemborexant Cmax and AUC0‐inf. Midazolam exposure was not affected. Coadministration of lemborexant with bupropion resulted in 49.9% and 45.5% decreases in S‐bupropion Cmax and AUC0‐inf, respectively.Comparison of estimated exposures for patients in phase 3 trials who were/were not receiving concomitant weak CYP3A inhibitors substantiated the DDI pharmacokinetic findings. Lemborexant was generally well tolerated in the phase 1 studies. In summary, lemborexant does not affect the pharmacokinetics of CYP3A substrates and has potential to induce CYP2B6. Consistent with in vitro findings, moderate and strong CYP3A inhibitors and inducers affected the pharmacokinetics of lemborexant; hence, patients taking lemborexant 5 or 10 mg should avoid coadministration with moderate and strong CYP3A inhibitors and inducers.
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Affiliation(s)
| | | | | | - Nancy Hall
- Eisai Inc., Woodcliff Lake, New Jersey, USA
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Rosenberg R, Citrome L, Drake CL. Advances in the Treatment of Chronic Insomnia: A Narrative Review of New Nonpharmacologic and Pharmacologic Therapies. Neuropsychiatr Dis Treat 2021; 17:2549-2566. [PMID: 34393484 PMCID: PMC8354724 DOI: 10.2147/ndt.s297504] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic insomnia disorder, which affects 6-10% of the population, is diagnostically characterized by ongoing difficulties with initiating or maintaining sleep occurring at least three times per week, persisting for at least 3 months, and associated with daytime impairment. While chronic insomnia is often considered a condition primarily related to impaired sleep, the disorder can also adversely affect domains of physical and mental health, quality of life, and daytime function, which highlights the importance of treating the multidimensional sleep disorder. Owing to misperceptions about the safety and effectiveness of treatment options, many individuals with insomnia may not seek professional treatment, and alternatively use ineffective home remedies or over-the-counter medications to improve sleep. Some physicians may even believe that insomnia is remediated by simply having the patient "get more sleep". Unfortunately, treatment of insomnia is not always that simple. The disorder's complex underlying pathophysiology warrants consideration of different nonpharmacologic and pharmacologic treatment options. Indeed, recent insights gained from research into the pathophysiology of insomnia have facilitated development of newer treatment approaches with more efficacious outcomes. This narrative review provides a summary of the diagnostic criteria and pathophysiology of insomnia and its subtypes. Further, this review emphasizes new and emerging nonpharmacologic and pharmacologic treatments for chronic insomnia, including recent enhancements in approaches to cognitive behavioral therapy for insomnia (CBT-I) and the new dual orexin receptor antagonist (DORA) pharmacologics. These advances in treatment have expanded the treatment options and are likely to result in improved outcomes in patients with chronic insomnia.
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Affiliation(s)
| | - Leslie Citrome
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, NY, USA
| | - Christopher L Drake
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
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Abstract
Pediatric insomnia can affect physical and mental health and cause cognitive deficits, social deficits and decrease quality of life. There are no Food and Drug Administration approved medications approved for pediatric insomnia. Pharmacologic interventions derive mostly from adult data or pediatric case reports. This review focuses on Food and Drug Administration approved prescription drugs (in adults), over-the-counter drugs, and off-label pediatric insomnia drugs. This review helps the clinician learn general principles, practice guidelines, and pharmacologic considerations for medication selection in the pediatric population. Pharmacologic management should be considered in combination with behavior therapy, which is proven to have long-lasting outcomes.
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Affiliation(s)
- Vijayabharathi Ekambaram
- Department of Psychiatry, Touro University, Touro University Medical Group, 1805 North California Street, Suite 201, Stockton, CA 95204, USA.
| | - Judith Owens
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Lalovic B, Majid O, Aluri J, Landry I, Moline M, Hussein Z. Population Pharmacokinetics and Exposure-Response Analyses for the Most Frequent Adverse Events Following Treatment With Lemborexant, an Orexin Receptor Antagonist, in Subjects With Insomnia Disorder. J Clin Pharmacol 2020; 60:1642-1654. [PMID: 32666570 PMCID: PMC7689791 DOI: 10.1002/jcph.1683] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/03/2020] [Indexed: 01/04/2023]
Abstract
Lemborexant is a novel orexin receptor antagonist approved in the United States and Japan for the treatment of insomnia. This article describes the population pharmacokinetics (PK) of lemborexant and the relationship of its daily steady-state exposure (Cav,ss ) to the probability of most frequent treatment-emergent adverse events (TEAEs). The 12 230-observation, 1892-subject PK data set included data from 12 clinical studies with predominantly female subjects (66%) ranging in age from 18 to 88 years and from 37 to 168 kg in body weight. The 1664-subject exposure-response data set included data from 3 late-stage studies. Lemborexant pharmacokinetics were described by a 3-compartment model with combined first- and zero-order absorption with lag time and linear elimination. Oral clearance decreased with increasing body mass index (exponent, -0.428), increasing alkaline phosphatase levels (exponent, -0.118), and was 26% lower in the elderly (≥65 years). Across the adverse event analysis, the frequency of subjects experiencing TEAEs during active treatment ranged from approximately 3% to 8%, in the range estimated for placebo. With and without adjustment for age, lemborexant exposure (Cav,ss ) was not a clinically meaningful linear predictor of the probability of specific TEAEs: somnolence, nasopharyngitis, flu/influenza, urinary tract infection, upper respiratory tract infection, or headache. Given the small effect sizes of covariates of the PK model and a low degree of association of lemborexant TEAEs and exposure over the range of phase 3 (therapeutic) 5- and 10-mg doses, lemborexant can be safely administered without the need for dose adjustment.
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Landry I, Aluri J, Hall N, Kumar D, Dayal S, Moline M, Reyderman L. Effect of gastric acid-reducing agents on the pharmacokinetics and efficacy of lemborexant. Pharmacol Res Perspect 2020; 8:e00678. [PMID: 33135390 PMCID: PMC7604696 DOI: 10.1002/prp2.678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
Lemborexant is a dual orexin receptor antagonist approved for treating insomnia. As the solubility of lemborexant is pH-sensitive, the impact of the gastric acid-reducing agent (ARA), famotidine, on lemborexant pharmacokinetics was evaluated in a Phase 1 study. Additionally, post hoc analysis of data from Phase 3 studies examined the potential effect of concomitant ARAs on patient-reported/subjective sleep onset latency (sSOL) in subjects with insomnia. Coadministration of lemborexant 10 mg with famotidine decreased the maximum observed concentration by 27% and delayed time of maximum observed concentration by 0.5 hours. Famotidine did not affect overall lemborexant exposure based on comparison of area under the concentration curves. Concomitant ARA use in the Phase 3 studies did not impact the effect of lemborexant on sSOL; the change from baseline during the last 7 nights of 1 month of treatment with lemborexant 10 mg was -17.1 minutes with vs -17.9 minutes without ARAs. Collectively, these results indicate that lemborexant can be coadministered with ARAs.
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