Prescribing Pattern of Hypnotic Medications in Patients Initiating Treatment at Japanese Hospitals: A Nationwide, Retrospective, Longitudinal, Observational Study Using a Claims Database

Digital cognitive-behavioural therapy application compared with zolpidem for the treatment of insomnia: protocol for an exploratory randomised controlled trial

INTRODUCTION

Insomnia is a common health problem and cognitive-behavioural therapy (CBT) is recommended as a treatment. As there is a critical shortage of CBT-trained therapists, we developed a digital CBT application (IIIP MED: Sleepy Med) as Software as a Medical Device for insomnia. This paper describes the study protocol for an exploratory randomised controlled trial (RCT) to evaluate effectiveness and safety of our developed digital CBT (dCBT) for 5 weeks compared with zolpidem tartrate for patients with insomnia disorder.

METHODS AND ANALYSIS

This proposed multicentre exploratory RCT will be conducted at the outpatient clinic of Chiba University Hospital, Akita University Hospital and Yoyogi Sleep Disorder Center, Japan. The study population comprises two parallel groups (dCBT and zolpidem) consisting of 15 participants each (n=30 in total) diagnosed with insomnia disorder who remain symptomatic at 4 weeks after sleep hygiene education. We will evaluate the effectiveness at baseline, week 5 (post-intervention) and week 10 (follow-up). The primary outcome will be the change of subjective sleep onset latency at week 5 from baseline. Secondary outcomes include sleep-related outcomes, such as objective sleep onset latency measured by mobile electroencephalography, functional improvement during the daytime and quality of life.

ETHICS AND DISSEMINATION

Ethics approval was granted by the Institutional Review Board of Chiba University Hospital (K2023001). All participants will be required to provide written informed consent. Results will be published in international journals.

TRIAL REGISTRATION NUMBER

jRCT2032230353.

Safety and Efficacy of Lemborexant in Insomnia Patients: Results of a Postmarketing Observational Study of Dayvigo® Tablets

BACKGROUND AND OBJECTIVE

A prospective, postmarketing observational study was conducted to evaluate the safety and efficacy of lemborexant (LEM) tablets in daily clinical practice in Japan. No other studies of a similar size have been conducted since the marketing approval of LEM, making this the first report of its kind.

METHODS

Insomnia patients (n = 550) administered LEM (5-10 mg daily) for the first time were enrolled. Adverse events were collected for target events (somnolence, parasomnia, narcolepsy and associated conditions, suicidal ideation and suicidal behavior). Overall improvement of insomnia symptoms was assessed by the investigator based on the patient's complaint. Subjective sleep onset latency (sSOL) and subjective total sleep time (sTST) were investigated as sleep parameters.

RESULTS

A case report form was obtained from 539 patients. The incidence of adverse drug reactions (ADRs) was 7.65% for somnolence, 1.76% for nightmares, 0.59% for abnormal dreams, and 0.20% for sleep paralysis. No serious ADRs or ADRs related to suicidal ideation or suicidal behavior were observed. The efficacy rate at the final evaluation was 80.83%. Decreased sSOL and increased sTST were observed as assessed starting from Week 8 of treatment.

CONCLUSION

Based on the results of this study, the safety result was consistent with the safety profile described in the current package insert. Efficacy results also indicated that LEM is clinically useful.

Treatment Failure and Long-Term Prescription Risk for Guideline-Recommended Hypnotics in Japan

Importance

Although insomnia guidelines recommend the use of several individual hypnotics, the most useful hypnotic for treating insomnia in a clinical setting remains unclear.

Objective

To determine which guideline-recommended hypnotics have lower risks of monotherapy failure and which hypnotics have a higher risk of long-term prescription for insomnia treatment.

Design, Setting, and Participants

This retrospective observational cohort study used data from the Japan Medical Data Center Claims Database from April 1, 2005, to March 31, 2021. Participants included adults whose first prescribed pharmaceutical treatment for insomnia was guideline-recommended hypnotic monotherapy. Data were analyzed from December 24, 2022, to September 26, 2023.

Exposures

Suvorexant, ramelteon, eszopiclone, zolpidem, and triazolam monotherapy.

Main Outcomes and Measures

The primary outcome was monotherapy failure, defined as a change in hypnotic or having an additional hypnotic prescribed for insomnia within 6 months of the first prescription of a guideline-recommended hypnotic monotherapy. The secondary outcome was monotherapy discontinuation, defined as no prescription of any hypnotic for 2 consecutive months within 6 months after prescribing a guideline-recommended hypnotic in patients for whom monotherapy did not fail. Monotherapy failure and discontinuation were compared using Cox proportional hazards and logistic regression models, respectively.

Results

The study included 239 568 adults (median age, 45 [IQR, 34-55] years; 50.2% women) whose first prescription for insomnia was guideline-recommended hypnotic monotherapy. During the 6-month follow-up period, 24 778 patients (10.3%) experienced failure of monotherapy with a guideline-recommended hypnotic. In comparison with eszopiclone, there were more cases of monotherapy failure for ramelteon (adjusted hazard ratio [AHR], 1.23 [95% CI], 1.17-1.30; P < .001), fewer cases for zolpidem (AHR, 0.84 [95% CI, 0.81-0.87]; P < .001) and triazolam (AHR, 0.82 [95% CI, 0.78-0.87]; P < .001), and no significant difference between suvorexant and eszopiclone. Among those without monotherapy failure, monotherapy was discontinued in 84.6% of patients, with more discontinuations for ramelteon (adjusted odds ratio [AOR], 1.31 [95% CI, 1.24-1.40]; P < .001) and suvorexant (AOR, 1.20 [95% CI, 1.15-1.26]; P < .001) than for eszopiclone and no significant difference between zolpidem or triazolam and eszopiclone.

Conclusions and Relevance

Due to uncontrolled confounding factors in this cohort study, no conclusions regarding the pharmacologic properties of guideline-recommended hypnotics can be drawn based on these results. Further studies accounting for confounding factors, including diagnoses of chronic vs acute insomnia disorder, insomnia and psychiatric symptom severity, and physician attitudes toward hypnotic prescription, are needed.

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

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.

Descriptive Study of Patients Treated in a Psychosomatic Internal Medicine Declared by Japanese Family Medicine Clinic

Background

Psychosomatic internal medicine (PSIM) assesses psychosocial factors and provides holistic consideration. In Japan, PSIM physicians seem to be recognized as providers of mental health services, but family medicine did not so. When family physicians confront with psychological problems, high dropout rate is reported so it is needed to reveal factors related to dropouts, The purpose of this study is to describe characteristics of patients, treatment dropouts and its related factors in PSIM practice by family physician.

Methods

This cross-sectional study used data from the medical records of the Kitaibaraki Center of Family Medicine located in Kitaibaraki City, Ibaraki, Japan. The study included all new patients who made an appointment and visited the PSIM in this clinic from January 2020 to December 2022.Chief complaints and diagnoses were coded based on the International Classification of Primary Care, version 2 (ICPC-2).

Results

In total, 377 new patients were included in this study. The mean age was 39.9 ± 20.2 years. We found that 69.2% of patients who visited the clinic had a psychological chief complaint and 84.1% of primary diagnoses consisted of a psychological problem. One hundred sixty-five patients (43.8%) were still receiving treatment 6 months after the initial visit. Of the patients who ended treatment within 6 months after the initial visit, 84 patients (39.2%) dropped out. In multivariate analysis, the dropouts were less likely to occur patients with primary diagnosis of psychological problem (odds ratio (OR): 0.35, 95% confidence interval (CI): 0.19 - 0.67).

Conclusions

Patients who visited a PSIM wanted consultation about psychological problems. Patients with a diagnosis of a psychological problem at the initial visit were less likely to drop out.

Hypnotic prescription trends and patterns for the treatment of insomnia in Japan: analysis of a nationwide Japanese claims database

BACKGROUND

There is limited consensus regarding the optimal treatment of insomnia. The recent introduction of orexin receptor antagonists (ORA) has increased the available treatment options. However, the prescribing patterns of hypnotics in Japan have not been comprehensively assessed. We performed analyses of a claims database to investigate the real-world use of hypnotics for treating insomnia in Japan.

METHODS

Data were retrieved for outpatients (aged ≥ 20 to < 75 years old) prescribed ≥ 1 hypnotic for a diagnosis of insomnia between April 1^st, 2009 and March 31^st, 2020, with ≥ 12 months of continuous enrolment in the JMDC Claims Database. Patients were classified as new or long-term users of hypnotics. Long-term use was defined as prescription of the same mechanism of action (MOA) for ≥ 180 days. We analyzed the trends (2010-2019) and patterns (2018-2019) in hypnotics prescriptions.

RESULTS

We analyzed data for 130,177 new and 91,215 long-term users (2010-2019). Most new users were prescribed one MOA per year (97.1%-97.9%). In 2010, GABA_A-receptor agonists (benzodiazepines [BZD] or z-drugs) were prescribed to 94.0% of new users. Prescriptions for BZD declined from 54.8% of patients in 2010 to 30.5% in 2019, whereas z-drug prescriptions remained stable (~ 40%). Prescriptions for melatonin receptor agonist increased slightly (3.2% to 6.3%). Prescriptions for ORA increased over this time from 0% to 20.2%. Prescriptions for BZD alone among long-term users decreased steadily from 68.3% in 2010 to 49.7% in 2019. Prescriptions for ORA were lower among long-term users (0% in 2010, 4.3% in 2019) relative to new users. Using data from 2018-2019, multiple (≥ 2) MOAs were prescribed to a higher proportion of long-term (18.2%) than new (2.8%) users. The distribution of MOAs according to psychiatric comorbidities, segmented by age or sex, revealed higher proportions of BZD prescriptions in elderly (new and long-term users) and male (new users) patients in all comorbidity segments.

CONCLUSION

Prescriptions for hypnotics among new and long-term users in Japan showed distinct patterns and trends. Further understanding of the treatment options for insomnia with accumulating evidence for the risk-benefit balance might be beneficial for physicians prescribing hypnotics in real-world settings.

Factors Associated with Prescriptions for an Orexin Receptor Antagonist Among Japanese Patients with Insomnia: Analysis of a Nationwide Japanese Claims Database

BACKGROUND

Few studies have examined the prescribing patterns of orexin receptor antagonists (ORAs) in the real-world clinical setting in Japan.

OBJECTIVE

We sought to analyze the factors associated with ORA prescriptions for patients with insomnia in Japan.

METHODS

Outpatients (aged ≥ 20 to < 75 years old) prescribed one or more hypnotic for insomnia between April 1, 2018 and March 31, 2020 with continuous enrollment for ≥ 12 months were extracted from the JMDC Claims Database. We performed multivariable logistic regression to identify factors (patient demographics and psychiatric comorbidities) associated with ORA prescription in new or non-new users of hypnotics (patients without or with hypnotics prescription history, respectively).

RESULTS

Of 58,907 new users, 11,589 (19.7%) were prescribed ORA at the index date. Male sex (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.12-1.22) and presence of bipolar disorders (OR 1.36, 95% CI 1.20-1.55) were associated with greater odds of ORA prescription. Among 88,611 non-new users, 15,504 (17.5%) were prescribed ORA at the index date. Younger age and several psychiatric comorbidities, such as neurocognitive disorders (OR 1.64, 95% CI 1.15-2.35), substance use disorders (OR 1.19, 95% CI 1.05-1.35), bipolar disorders (OR 1.14, 95% CI 1.07-1.22), schizophrenia spectrum disorders (OR 1.07, 95% CI 1.01-1.14), and anxiety disorders (OR 1.05, 95% CI 1.00-1.10), were associated with greater odds of ORA prescription.

CONCLUSION

This is the first study to determine the factors associated with ORA prescriptions in Japan. Our findings could help guide appropriate insomnia treatment using ORAs.

Physicians' attitudes toward hypnotics for insomnia: A questionnaire-based study

INTRODUCTION

Benzodiazepines and non-benzodiazepines are still widely prescribed despite safety concerns and the introduction of novel hypnotics (orexin receptor antagonists [ORA] and melatonin receptor agonists [MRA]), which may be influenced by physicians' attitudes toward hypnotics.

METHODS

A questionnaire survey was administered to 962 physicians between October 2021 and February 2022, investigating frequently prescribed hypnotics and the reasons for their selection.

RESULTS

ORA were the most frequently prescribed at 84.3%, followed by non-benzodiazepines (75.4%), MRA (57.1%), and benzodiazepines (54.3%). Compared to non-frequent prescribers of hypnotics, a logistic regression analysis showed that frequent ORA prescribers were more concerned with efficacy (odds ratio [OR]: 1.60, 95% confidence interval [CI]: 1.01-2.54, p = 0.044) and safety (OR: 4.52, 95% CI: 2.99-6.84, p < 0.001), frequent MRA prescribers were more concerned with safety (OR: 2.48, 95% CI: 1.77-3.46, p < 0.001), frequent non-benzodiazepine prescribers were more concerned with efficacy (OR: 4.19, 95% CI: 2.91-6.04, p < 0.001), and frequent benzodiazepine prescribers were more concerned with efficacy (OR: 4.19, 95% CI: 2.91-6.04, p < 0.001) but less concerned with safety (OR: 0.25, 95% CI: 0.16-0.39, p < 0.001).

DISCUSSION

This study suggested that physicians believed ORA to be an effective and safe hypnotic and were compelled to prescribe benzodiazepine and non-benzodiazepine frequently, choosing efficacy over safety.

Attitudes and Difficulties Associated with Benzodiazepine Discontinuation

Long-term use of benzodiazepine receptor agonists (BZDs) may depend on clinicians' BZD discontinuation strategies. We aimed to explore differences in strategies and difficulties with BZD discontinuation between psychiatrists and non-psychiatrists and to identify factors related to difficulties with BZD discontinuation. Japanese physicians affiliated with the Japan Primary Care Association, All Japan Hospital Association, and Japanese Association of Neuro-Psychiatric Clinics were surveyed on the following items: age group, specialty (psychiatric or otherwise), preferred time to start BZD reduction after improvement in symptoms, methods used to discontinue, difficulties regarding BZD discontinuation, and reasons for the difficulties. We obtained 962 responses from physicians (390 from non-psychiatrists and 572 from psychiatrists), of which 94.0% reported difficulty discontinuing BZDs. Non-psychiatrists had more difficulty with BZD discontinuation strategies, while psychiatrists had more difficulty with symptom recurrence/relapse and withdrawal symptoms. Psychiatrists used more candidate strategies in BZD reduction than non-psychiatrists but initiated BZD discontinuation after symptom improvement. Logistic regression analysis showed that psychosocial therapy was associated with less difficulty in BZD discontinuation (odds ratio, 0.438; 95% confidence interval, 0.204-0.942; p = 0.035). Educating physicians about psychosocial therapy may alleviate physicians' difficulty in discontinuing BZDs and reduce long-term BZD prescriptions.

Hazardous use of benzodiazepine receptor agonists in psychiatric clinics in China: electronic prescription database study

BACKGROUND

Benzodiazepine receptor agonists (BZRAs) are commonly used clinically and data on their hazardous use from large populations of psychiatric patients is limited.

AIMS

To assess the current status of hazardous BZRA use and related factors in Chinese out-patient psychiatric settings.

METHOD

The study included out-patients with at least one BZRA prescription from five psychiatric settings in east, central and west China in 2018. Demographic and prescription information were extracted from the electronic prescription database. We defined the co-occurrence of overdose and long-term use as hazardous use, and patients whose recorded diagnoses did not meet any indications approved by the Chinese Food and Drug Administration as over-indication users. Additionally, 200 hazardous users were randomly selected for follow-up interview to confirm the actual situation.

RESULTS

Among 720 054 out-patients, 164 450 (22.8%) had at least one BZRA prescription; 55.9% of patients were prescribed over-indication and 3% were defined as hazardous users. Multilevel multivariate regression analysis with hospital as a random effect showed that factors associated with hazardous use were older age (18-64 years: β = 0.018; 95% CI 0.013-0.023; >65 years: β = 0.015; 95% CI 0.010-0.021), male (β = 0.005, 95% CI 0.003-0.007), over-indication (β = 0.013, 95% CI 0.012-0.015), more out-patient visits (β = 0.006, 95% CI 0.006-0.006) and more visits to different doctors (β = 0.007, 95% CI 0.007-0.008); 98.5% of hazardous users (197/200) could not be contacted.

CONCLUSIONS

BZRAs are commonly used and there is a relatively large proportion of over-indication users among Chinese psychiatric out-patients. However, only a small proportion of hazardous users were detected. The study highlights how to use prescription data to support improvements in clinical practice.

Analysis of regional differences in the amount of hypnotic and anxiolytic prescriptions in Japan using nationwide claims data

BACKGROUND

In Japan, there has been no investigation of regional differences in the number or amount of prescriptions of anxiolytics or hypnotics. Attributes related to the high amount of prescriptions for these drugs are unknown. We investigated recent trends and regional differences in the amount of prescriptions of hypnotics and anxiolytics in Japan and identified factors associated with these regional differences.

METHODS

The National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open data from 2015 to 2018 were used. We calculated diazepam-equivalent doses (mg) for each drug and the total amount of prescriptions per capita for hypnotics and anxiolytics by sex and age. In addition, we calculated the standardized claim ratio (SCR) of the amount of prescriptions by prefecture. We investigated factors associated with regional differences in the SCRs of hypnotics and anxiolytics using the prefectures' medical, socioeconomic, and physical characteristics by an ecological study using a linear mixed-effects model.

RESULTS

The amount of prescriptions of hypnotics and anxiolytics, specifically, the amount of prescriptions of benzodiazepine receptor agonists (BZRAs), decreased in many of the adult age groups from 2015 to 2018. The regression analysis revealed that the number of medical clinics per capita, the number of public assistance recipients per capita, the proportion of persons whose HbA1c ≥ 6.5%, and the proportion of persons whose BMI ≥25 kg/m2 were positively and significantly associated with the SCR of hypnosis. In contrast, the number of public assistance recipients per capita and the proportion of persons whose BMI ≥25 kg/m2 were positively and significantly associated with the SCR of anxiolytics.

CONCLUSIONS

Factors associated with prescription amount of hypnotics and anxiolytics were revealed in this study, and a further study is needed for investigating causal relationships between the prescriptions amount and the associated factors using individual data.

Trends in Prescriptions for Insomnia in a Province in China Between 2015 and 2019

BACKGROUND

The inappropriate use of pharmacological treatments for insomnia may increase patients' risk of serious adverse events. However, few epidemiological studies on the use of medications for insomnia in China have been conducted to date.

OBJECTIVE

We aimed to investigate the current pharmacological treatments for insomnia and guide the rational use of drugs.

METHODS

The prescription data of outpatients with insomnia between 2015 and 2019 in Zhejiang province were extracted from the Hospital Prescription Analysis Cooperative Project of China and evaluated. The demographic characteristics of insomnia and the proportion and prescription trends of different drugs were analyzed along with multidrug combinations for insomnia.

RESULTS

The number of patients with insomnia who were prescribed medications for insomnia increased from 2,385 in 2015 to 3,919 in 2019, with an increase of 64.32%, whereas the mean age of these patients decreased from 64.07 years to 60.94 years. There were nearly 1.42 times as many female patients prescribed medications for insomnia as male patients, and female patients tended to be younger than male patients. Benzodiazepines (53.99%) were the most common type of medicine for insomnia. The incidence of benzodiazepine usage decreased significantly yearly (P < 0.01), whereas the incidences of non-benzodiazepine receptor agonist (nBZRA) and antidepressant usage increased (P < 0.05). The most common benzodiazepine, nBZRA, antidepressant, and antipsychotic were estazolam, zolpidem, trazodone, and olanzapine, respectively. A total of 13.97% of outpatients with insomnia were prescribed multiple drugs for insomnia, even though nearly half of the drug combinations had similar pharmacological mechanisms.

CONCLUSIONS

Benzodiazepines remained the most common medication for insomnia, but the prescription rates of nBZRAs and antidepressants increased. Attention should be paid to multidrug combinations for insomnia, which may lead to an increased risk of serious adverse effects.

Trends in the Prescription of Benzodiazepine Receptor Agonists from 2009 to 2020: A Retrospective Study Using Electronic Healthcare Record Data of a University Hospital in Japan

In recent years, the prescription trends of benzodiazepine receptor agonists (BZRAs) have not been investigated in Japan despite the publication of guidelines that promote cautious use of BZRAs. The prescription trend of BZRAs was assessed using the electronic healthcare records data of a University Hospital in Japan. The data from April 2009 to March 2021 were used. The following three types of outcomes were set: the proportion of patients who were prescribed with BZRAs within those prescribed hypnotics or anxiolytics; the mean number of the types of prescribed BZRAs, and the mean average daily doses of BZRAs. The same analysis was conducted for benzodiazepines (BZDs) and non-benzodiazepines (Z-drugs). As a result, we found that the proportions of patients prescribed BZRAs within those prescribed hypnotics or anxiolytics began to decrease, particularly from 2015 for patients aged <75 years and those aged ≥75 years. Further, the degree of decrease was larger in patients aged ≥75 years. The proportion for BZDs decreased particularly in the study period, and the proportion for Z-drugs also began to decrease approximately from 2016 in patients aged ≥75 years. The results suggest a possibility that guidelines affected the decreased prescriptions of BZRAs.