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Bjorness TE, Greene RW. Orexin-mediated motivated arousal and reward seeking. Peptides 2024; 180:171280. [PMID: 39159833 DOI: 10.1016/j.peptides.2024.171280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 08/03/2024] [Accepted: 08/05/2024] [Indexed: 08/21/2024]
Abstract
The neuromodulator orexin has been identified as a key factor for motivated arousal including recent evidence that sleep deprivation-induced enhancement of reward behavior is modulated by orexin. While orexin is not necessary for either reward or arousal behavior, orexin neurons' broad projections, ability to sense the internal state of the animal, and high plasticity of signaling in response to natural rewards and drugs of abuse may underlie heightened drug seeking, particularly in a subset of highly motivated reward seekers. As such, orexin receptor antagonists have gained deserved attention for putative use in addiction treatments. Ongoing and future clinical trials are expected to identify individuals most likely to benefit from orexin receptor antagonist treatment to promote abstinence, such as those with concurrent sleep disorders or high craving, while attention to methodological considerations will aid interpretation of the numerous preclinical studies investigating disparate aspects of the role of orexin in reward and arousal.
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Affiliation(s)
- Theresa E Bjorness
- Research Service, VA North Texas Health Care System, Dallas, TX 75126, USA; Departments of Psychiatry University of Texas Southwestern Medical Center, Dallas, TX 75390-9111, USA.
| | - Robert W Greene
- Departments of Psychiatry University of Texas Southwestern Medical Center, Dallas, TX 75390-9111, USA; Department of Neuroscience, Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX 75390-9111, USA; International Institute for Integrative Sleep Medicine, University of Tsukuba, Tsukuba 305-8577, Japan
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2
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Mohammadkhani A, Mitchell C, James MH, Borgland SL, Dayas CV. Contribution of hypothalamic orexin (hypocretin) circuits to pathologies of motivation. Br J Pharmacol 2024. [PMID: 39317446 DOI: 10.1111/bph.17325] [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: 07/30/2023] [Revised: 06/17/2024] [Accepted: 06/28/2024] [Indexed: 09/26/2024] Open
Abstract
The orexin (also known as hypocretin) system, consisting of neuropeptides orexin-A and orexin-B, was discovered over 25 years ago and was immediately identified as a central regulator of sleep and wakefulness. These peptides interact with two G-protein coupled receptors, orexin 1 (OX1) and orexin 2 (OX2) receptors which are capable of coupling to all heterotrimeric G-protein subfamilies, but primarily transduce increases in calcium signalling. Orexin neurons are regulated by a variety of transmitter systems and environmental stimuli that signal reward availability, including food and drug related cues. Orexin neurons are also activated by anticipation, stress, cues predicting motivationally relevant information, including those predicting drugs of abuse, and engage neuromodulatory systems, including dopamine neurons of the ventral tegmental area (VTA) to respond to these signals. As such, orexin neurons have been characterized as motivational activators that coordinate a range of functions, including feeding and arousal, that allow the individual to respond to motivationally relevant information, critical for survival. This review focuses on the role of orexins in appetitive motivation and highlights a role for these neuropeptides in pathologies characterized by inappropriately high levels of motivated arousal (overeating, anxiety and substance use disorders) versus those in which motivation is impaired (depression).
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Affiliation(s)
- Aida Mohammadkhani
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute, The University of Calgary, Calgary, Alberta, Canada
| | - Caitlin Mitchell
- School of Biomedical Sciences and Pharmacy, University of Newcastle, University Drive, Callaghan, New South Wales, Australia
- The Hunter Medical Research, New Lambton Heights, New South Wales, Australia
| | - Morgan H James
- Department of Psychiatry and Brain Health Institute, Robert Wood Johnson Medical School, Rutgers University, Piscataway, New Jersey, USA
| | - Stephanie L Borgland
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute, The University of Calgary, Calgary, Alberta, Canada
| | - Christopher V Dayas
- School of Biomedical Sciences and Pharmacy, University of Newcastle, University Drive, Callaghan, New South Wales, Australia
- The Hunter Medical Research, New Lambton Heights, New South Wales, Australia
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Kishi T, Koebis M, Sugawara M, Kawatsu Y, Taninaga T, Iwata N. Orexin receptor antagonists in the treatment of insomnia associated with psychiatric disorders: a systematic review. Transl Psychiatry 2024; 14:374. [PMID: 39277609 PMCID: PMC11401906 DOI: 10.1038/s41398-024-03087-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 09/02/2024] [Accepted: 09/02/2024] [Indexed: 09/17/2024] Open
Abstract
Insomnia is highly comorbid in patients with psychiatric disorders, including depression, bipolar disorder, and substance use disorders, and should be treated as an independent condition. Dual orexin receptor antagonists (DORAs) have been investigated as a treatment for chronic insomnia. The objective of this systematic review was to examine evidence for two DORAs, lemborexant and suvorexant, as treatments for insomnia comorbid with a psychiatric disorder. We searched PubMed, Cochrane, and Embase from their inception until January and April 2023, and included studies examining suvorexant and lemborexant for treating insomnia comorbid with psychiatric disorders. We also manually searched clinical trial registries ( https://clinicaltrials.gov and https://www.umin.ac.jp/ctr ). Randomized clinical trials and observational/cohort studies were included. We identified 18 studies from PubMed, Cochrane, and Embase and three studies from clinicaltrials.gov and UMIN. Of the 21 reports, four were completed/terminated randomized clinical trials, eight were ongoing clinical trials, and nine were observational studies. We identified evidence for switching from benzodiazepine receptor agonists to a DORA, or using a DORA as add-on therapy and, therefore, discuss this topic as well. Two studies examined switching to or adding on a DORA in patients being treated with a benzodiazepine receptor agonist. DORAs may be as effective and safe for treating psychiatric comorbid insomnia (for most psychiatric conditions) as they are for treating primary insomnia. However, the evidence is limited to a few small studies. Further investigation of DORAs for the treatment of comorbid insomnia in those with coexisting psychiatric conditions is warranted.
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Affiliation(s)
- Taro Kishi
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
| | | | | | - Yuka Kawatsu
- Medical Headquarters, Eisai Co, Ltd, Tokyo, Japan
| | | | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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Pertynska-Marczewska M, Pertynski T. Non-hormonal pharmacological interventions for managing vasomotor symptoms-how can we help: 2024 landscape. Eur J Obstet Gynecol Reprod Biol 2024; 302:141-148. [PMID: 39270577 DOI: 10.1016/j.ejogrb.2024.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Revised: 09/06/2024] [Accepted: 09/09/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Vasomotor symptoms (VMS) affect 70% of menopausal women and are considered as hallmark symptoms of the menopausal transition experienced by over three quarters of women and severely by 25% of women. Estrogen withdrawal alone is not fully responsible for the onset of the menopausal vasomotor symptoms and the mechanism of altered thermoregulation appears to be centrally mediated with alterations in hypothalamic neurotransmitters playing a key part. The loss of thermoregulatory control coexists with the altered Kisspeptin- Neurokinin B-Dynorphin-expressing (KNDy) neurons of the arcuate nucleus signaling triggered by menopause. OBJECTIVE Aim of the review was to explore evidence-based non-hormonal pharmacological interventions for treating vasomotor symptoms. METHODS Comprehensive overview of relevant literature. CONCLUSIONS In the population where, hormonal options are contraindicated or not preferred by the patient, it is essential to explore evidence-based non-hormonal pharmacological interventions for treating vasomotor symptoms. The 2024 landscape of available treatments has expanded yet again, arming the providers with an even wider range of possibilities to help their patients. Fezolinetant, is the first NK3R antagonist developed for the purpose of treating hot flashes in menopausal women. NK3R antagonists provide a safe and effective treatment option for managing menopausal women with VMS.
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Luyet PP, McCall WV, Bassetti CLA, Braunstein G, Laurent J, Olivieri A, Hedner J. Dose-response of daridorexant in insomnia disorder: An analysis of Phase 2 and 3 studies. Sleep Med 2024; 121:315-325. [PMID: 39047305 DOI: 10.1016/j.sleep.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/12/2024] [Accepted: 07/14/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE Daridorexant is approved for the treatment of insomnia at two dose levels (25 and 50 mg). Dose-efficacy and -safety response relationships were evaluated using Phase 2 and 3 data. METHODS Data (N = 2153) from one Phase 2 (daridorexant 5, 10, 25, 50 mg, placebo once daily for 1 month) and two Phase 3 studies (daridorexant 10 and 25 or 25 and 50 mg, placebo once daily for 3 months) were pooled. Dose-response analyses at 1 month of double-blind treatment were performed using a linear regression and a two-stage meta-analysis approach. Efficacy endpoints were polysomnography-derived wake after sleep onset, latency to persistent sleep (LPS), self-reported total sleep time and the Insomnia Daytime Symptoms and Impacts Questionnaire total score (only Phase 3 data for the latter). Safety endpoints were the incidence of total adverse events (AEs) and AEs corresponding to somnolence/fatigue. RESULTS Dose-responses for all efficacy endpoints were significant in the observed dose range (both statistical approaches, p < 0.01). All dose-response relationships were linear except for LPS (two-stage meta-analysis) which showed a change in slope above 10 mg without reaching a plateau. No significant dose-response was observed for any AE (both approaches, p > 0.05). The incidence of AEs corresponding to somnolence/fatigue was low at all doses and, without linear assumption (two-stage meta-analysis) there was no dose-dependency (p = 0.369). CONCLUSIONS The data support the use of 50 mg as the preferred daridorexant dose in patients with insomnia disorder to provide the greatest opportunity for efficacy with no increased risk for AEs, including somnolence/fatigue, compared to lower doses.
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Affiliation(s)
| | - William V McCall
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, 997 St Sebastian Way, Augusta, GA, 30912, USA.
| | - Claudio L A Bassetti
- Claudio Bassetti: Department of Neurology, Inselspital, University of Bern, Bern, Switzerland.
| | - Guy Braunstein
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland.
| | - Johann Laurent
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland.
| | - Antonio Olivieri
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland.
| | - Jan Hedner
- Center for Sleep and Vigilance Disorders, Institute of Medicine University of Gothenburg, Gothenburg, Sweden.
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Saito T, Nojiri S, Naito R, Kasai T. Rehospitalisation risk by hypnotics class in older patients with heart failure: a cohort study utilizing administrative claims data in Japan. Open Heart 2024; 11:e002889. [PMID: 39214535 PMCID: PMC11367327 DOI: 10.1136/openhrt-2024-002889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Studies comparing the safety of orexin receptor antagonists and other hypnotic types for older patients with heart failure (HF) remain lacking. This study aimed to compare orexin receptor antagonists (suvorexant) with benzodiazepines or Z-drugs for sleep treatment and investigate the risk of acute HF-related rehospitalisation in older patients with HF. METHODS This study used a cohort design to analyse data from an administrative claims database from April 2008 to December 2020. The study population was determined based on inclusion and exclusion criteria from a cohort of 1 159 937 patients aged ≥65 years, selected through random sampling. The follow-up period was censored based on multiple criteria, including outcome occurrences and hypnotic classification changes. Kaplan-Meier survival analysis and Cox proportional hazards models were conducted for risk assessment. RESULTS The analysis included 1858 patients, aged ≥65 years and experiencing their first HF-related hospitalisation. These patients were categorised based on the initially prescribed hypnotic classification, including suvorexant, benzodiazepines and Z-drugs in 490, 606 and 762 patients, respectively. The average age and SD were similar across all hypnotic classes at 82.7±7.6 years. Kaplan-Meier curves indicated a higher trend of rehospitalisation risk for benzodiazepines and Z-drugs than for suvorexant. The adjusted HRs were 2.77 (95% CI 1.17 to 6.52) for benzodiazepines and 2.98 (95% CI 1.33 to 6.68) for Z-drugs. CONCLUSIONS Suvorexant administration for sleep treatment in older patients with HF shows a potentially reduced risk of acute HF-related rehospitalisation compared with benzodiazepines and Z-drugs. The results of this study provide valuable information for selecting hypnotics in older patients with HF having concurrent sleep disorders.
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Affiliation(s)
- Tomoyuki Saito
- Medical Technology Innovation Center, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Shuko Nojiri
- Medical Technology Innovation Center, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Ryo Naito
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Sleep and Sleep-Disordered Breathing Center, Juntendo University Hospital, Bunkyo-ku, Tokyo, Japan
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Uchiyama M, Mishima K, Yagi T, Yoshihara T, Eto T, Muehlan C, Togo O, Inoue Y. Pharmacokinetics, safety, and efficacy of daridorexant in Japanese subjects: Results from phase 1 and 2 studies. J Sleep Res 2024:e14302. [PMID: 39118245 DOI: 10.1111/jsr.14302] [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: 04/17/2024] [Revised: 06/25/2024] [Accepted: 07/22/2024] [Indexed: 08/10/2024]
Abstract
Daridorexant is a dual orexin receptor antagonist for the treatment of insomnia. We report results from the first two randomised, double-blind clinical studies of daridorexant in Japanese subjects. In the Phase 1 study, daridorexant (10, 25, 50 mg) or placebo were administered in the morning for 4 days in 24 young (mean age 26.9 years) and 24 older (mean age 69.7 years) healthy Japanese adults. Daridorexant reached a peak plasma concentration within 1.0 h across every dose and age group. For all doses, the mean plasma concentration of daridorexant showed a similar change between the age groups. Exposure parameters increased dose-dependently with minimal/no accumulation upon repeated dosing. The terminal half-life was ~8 h. In the Phase 2, four-period, four-way crossover study, 47 Japanese subjects (mean age 50.4 years) with insomnia disorder were randomised to receive four treatments (daridorexant 10, 25, 50 mg, placebo) during four treatment periods, each consisting of two treatment nights (5-12 day washout between treatment periods). Subjects continued their fourth treatment for 12 further days. A statistically significant dose-response relationship (multiple-comparison procedure-modelling, p < 0.0001) was found in the reduction of polysomnography-measured wake after sleep onset (WASO; primary endpoint) and latency to persistent sleep (secondary endpoint) from baseline to days 1/2. Statistically significant dose-response relationships were also observed for secondary subjective endpoints from baseline to days 1/2 (sWASO, latency to sleep onset). All daridorexant doses were well tolerated, with no treatment discontinuations and no next-morning residual effects. These results supported further investigation of daridorexant in Japanese patients with insomnia disorder.
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Affiliation(s)
- Makoto Uchiyama
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
- Tokyo Adachi Hospital, Tokyo, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Tomoko Yagi
- Kurume University School of Medicine, Fukuoka, Japan
| | - Tatsuya Yoshihara
- SOUSEIKAI Fukuoka Mirai Hospital Clinical Research Center, Fukuoka, Japan
| | | | - Clemens Muehlan
- Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Osamu Togo
- Data Management & Biometry, Nxera Pharma Japan Co., Ltd, Tokyo, Japan
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Pan G, Ni L, Yan H, Yao L. Association between the use of orexin receptor antagonists and falls or fractures: A meta-analysis. J Psychiatr Res 2024; 176:393-402. [PMID: 38944018 DOI: 10.1016/j.jpsychires.2024.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024]
Abstract
Evidence indicates that the use of sedative-hypnotics, including benzodiazepines and z-drugs, is linked to an increased risk of falls and fractures. Nonetheless, the potential exacerbation of this risk by orexin receptor antagonists, which are novel therapeutic agents for treating insomnia, remains uncertain despite their escalating prevalence in clinical practice. We systematically searched four electronic databases from inception to April 17, 2024. In addition, we performed a quality assessment; calculated pooled odds ratios (ORs) to assess the relationship between the use of orexin receptor antagonists and the occurrence of falls or fractures; evaluated heterogeneity across the included studies; and conducted sensitivity analyses. The meta-analysis encompassed eight papers, comprising a total of 46,636 subjects. These papers included 5 case-control studies and 3 randomized controlled trials (RCTs), collectively encompassing ten studies. Analysis of the included case-control studies (pooled adjusted OR = 0.75, 95% confidence interval [CI] = 0.00-1.50, I2 = 66.2%, k = 3) and RCTs (OR = 0.68, 95% CI = 0.31-1.50, I2 = 45.9%, k = 5) indicated that the use of orexin receptor antagonists did not elevate the risk of falls. Similarly, analysis of the included case-control studies revealed no significant increase in the risk of fractures associated with the use of orexin receptor antagonists (pooled adjusted OR = 1.01, 95% CI = 0.82-1.20, I2 = 40.1%, k = 2). This meta-analysis suggests that the use of orexin receptor antagonists for treating insomnia does not escalate the risk of falls or fractures, although the data for lemborexant and daridorexant are limited.
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Affiliation(s)
- Guobiao Pan
- Department of Orthopedics, Hangzhou Third Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China
| | - Lingzhi Ni
- Department of Orthopedics, Hangzhou Third Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310000, Zhejiang, China
| | - Haohao Yan
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Lan Yao
- Department of Medical Oncology Ward 3, Hangzhou Cancer Hospital, Hangzhou, 310002, Zhejiang, China.
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Cheung JMY, Scott H, Muench A, Grunstein RR, Krystal AD, Riemann D, Perlis M. Comparative short-term safety and efficacy of hypnotics: A quantitative risk-benefit analysis. J Sleep Res 2024; 33:e14088. [PMID: 38016812 DOI: 10.1111/jsr.14088] [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: 03/01/2023] [Revised: 07/12/2023] [Accepted: 10/17/2023] [Indexed: 11/30/2023]
Abstract
Several professional societies have provided recommendations for prescribing medications for insomnia. None has provided an integrative analysis that concurrently quantifies safety and efficacy (e.g., risk-benefit ratios). This represents an important gap for informing clinician decision-making. Accordingly, the aim of the present review is to provide such an analysis for five classes of sleep-promoting medications. Adverse event data values were extracted from the most recent FDA-approved package inserts and converted to an integer before being placebo-adjusted and standardized as a rate per 1000 (AEr). Efficacy data, pre-to-post self-reported data for active and placebo conditions were acquired from pivotal trials identified in "white papers" and systematic reviews/meta-analyses. Weighted effect sizes were calculated for subjective sleep latency, wake time after sleep onset and total sleep time, and then were averaged by medication class for each sleep continuity variable. Overall efficacy was represented by a single variable, SWT (sleep latency + wake time after sleep onset + total sleep time). Risk-benefit was represented using a simple ratio value. For safety, it was found that melatonin receptor agonists had the lowest adverse event rate (AEr = 43.1), and non-benzodiazepine benzodiazepine receptor agonists had the highest rate (AEr = 255.0). For efficacy, it was found that the pre-to-post placebo adjusted effect sizes were largest for benzodiazepines (effect size = 1.94) and smallest for melatonin receptor agonists (effect size = 0.109). For risk-benefit, histamine antagonist had the most favourable profile (risk-benefit = 69.5), while melatonin receptor agonist had the least favourable profile (risk-benefit = 395.7). Overall, the combined metric for risk-benefit suggests that treatment with a histamine antagonist is optimal and potentially represents the best first-line therapy for the medical management of insomnia.
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Affiliation(s)
- Janet M Y Cheung
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown Campus, Sydney, New South Wales, Australia
| | - Hannah Scott
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Alexandria Muench
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ronald R Grunstein
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Macquarie University, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew D Krystal
- Department of Psychiatry, University of California, San Francisco, California, San Francisco, USA
| | - Dieter Riemann
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine University of Freiburg, Freiburg, Germany
| | - Michael Perlis
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kolla BP, Mansukhani MP, Chakravorty S, Frank JA, Coombes BJ. Prevalence and associations of multiple hypnotic prescriptions in a clinical sample. J Clin Sleep Med 2024; 20:793-800. [PMID: 38189358 PMCID: PMC11063698 DOI: 10.5664/jcsm.10988] [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: 06/23/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/09/2024]
Abstract
STUDY OBJECTIVES We examined the prevalence of multiple hypnotic prescriptions and its association with clinical and demographic characteristics from the electronic health record (EHR) in the Mayo Clinic Biobank. METHODS Adult participants enrolled in the Mayo Clinic Biobank with an EHR number of ≥ 1 year were included (n = 52,940). Clinical and demographic characteristics were compared between participants who were and were not prescribed any hypnotic approved for insomnia by the US Food and Drug Administration and/or trazodone and in those prescribed a single vs multiple (≥ 2) hypnotics. A phenotype-based, phenome-wide association study (PheWAS) examining associations between hypnotic prescriptions and diagnoses across the EHR was performed adjusting for demographic and other confounders. RESULTS A total of 17,662 (33%) participants were prescribed at least 1 hypnotic and 5,331 (10%) received ≥ 2 hypnotics. Participants who were prescribed a hypnotic were more likely to be older, female, White, with a longer EHR, and a greater number of diagnostic codes (all P < .001). Those with multiple hypnotic prescriptions were more likely to be younger, female, with a longer EHR, and a greater number of diagnostic codes (all P < .001) compared with those prescribed a single hypnotic. The PheWAS revealed that participants with multiple hypnotic prescriptions had higher rates of mood disorders, anxiety disorders, suicidal ideation, restless legs syndrome, and chronic pain (all P < 1 e-10). CONCLUSIONS Receiving multiple hypnotic prescriptions is common and associated with a greater prevalence of psychiatric, chronic pain, and sleep-related movement disorders. Future studies should examine potential genetic associations with multiple hypnotic prescriptions to personalize treatments for chronic insomnia. CITATION Kolla BP, Mansukhani MP, Chakravorty S, Frank JA, Coombes BJ. Prevalence and associations of multiple hypnotic prescriptions in a clinical sample. J Clin Sleep Med. 2024;20(5):793-800.
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Affiliation(s)
- Bhanu Prakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
- Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Jacob A. Frank
- Department of Quantitative Health Sciences, Division of Computational Biology, Mayo Clinic, Rochester, Minnesota
| | - Brandon J. Coombes
- Department of Quantitative Health Sciences, Division of Computational Biology, Mayo Clinic, Rochester, Minnesota
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11
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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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12
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Na HJ, Jeon N, Staatz CE, Han N, Baek IH. Clinical safety and narcolepsy-like symptoms of dual orexin receptor antagonists in patients with insomnia: a systematic review and meta-analysis. Sleep 2024; 47:zsad293. [PMID: 37950346 DOI: 10.1093/sleep/zsad293] [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: 08/17/2023] [Revised: 11/02/2023] [Indexed: 11/12/2023] Open
Abstract
STUDY OBJECTIVES Dual orexin receptor antagonists (DORAs) are emerging treatments for insomnia. This meta-analysis study aimed to assess the safety of FDA-approved DORAs (suvorexant, lemborexant, and daridorexant), focusing on narcolepsy-like symptoms associated with these drugs. METHODS Five prominent databases were searched to identify randomized controlled trials (RCTs) on this topic. Primary safety outcomes included treatment-emergent adverse events (TEAEs), treatment-related TEAEs, TEAEs leading to discontinuation, and serious TEAEs. Excessive daytime sleepiness (EDS), sleep paralysis, and hallucinations were categorized as adverse events (AEs)-related narcolepsy-like symptoms. RESULTS Eleven RCTs with 7703 patients were included. DORAs were associated with a higher risk of TEAEs (risk ratio [RR], 1.09; 95% confidence interval [CI], 1.03 to 1.15) and treatment-related TEAEs (RR, 1.69; 95% CI: 1.49 to 1.92) when compared to placebo. The DORA group exhibited a significantly higher risk of EDS (RR, 2.15; 95% CI: 1.02 to 4.52) and sleep paralysis (RR, 3.40; 95% CI: 1.18 to 9.80) compared to the placebo group. CONCLUSION This meta-analysis achieved a comparative evaluation of the clinical safety and tolerability of FDA-approved DORAs for primary insomnia, specifically focusing on AEs-related narcolepsy-like symptoms. This study contributes to understanding the safety profile of FDA-approved DORAs for treating insomnia.
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Affiliation(s)
- Hyun-Jin Na
- College of Pharmacy, Kyungsung University, Busan, Republic of Korea
| | - Nakyung Jeon
- College of Pharmacy and Research Institute for Drug Development, Pusan National University, Busan, Republic of Korea
| | - Christine E Staatz
- School of Pharmacy, University of Queensland, Pharmacy Australia Centre of Excellence, Brisbane, QLD, Australia
| | - Nayoung Han
- College of Pharmacy, Jeju National University, Jeju, Republic of Korea
| | - In-Hwan Baek
- College of Pharmacy, Kyungsung University, Busan, Republic of Korea
- School of Pharmacy, University of Queensland, Pharmacy Australia Centre of Excellence, Brisbane, QLD, Australia
- Functional Food and Drug Convergence Research Center, Industry-Academic Cooperation Foundation, Kyungsung University, Busan, Republic of Korea
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13
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Kron JOZJ, Keenan RJ, Hoyer D, Jacobson LH. Orexin Receptor Antagonism: Normalizing Sleep Architecture in Old Age and Disease. Annu Rev Pharmacol Toxicol 2024; 64:359-386. [PMID: 37708433 DOI: 10.1146/annurev-pharmtox-040323-031929] [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] [Indexed: 09/16/2023]
Abstract
Sleep is essential for human well-being, yet the quality and quantity of sleep reduce as age advances. Older persons (>65 years old) are more at risk of disorders accompanied and/or exacerbated by poor sleep. Furthermore, evidence supports a bidirectional relationship between disrupted sleep and Alzheimer's disease (AD) or related dementias. Orexin/hypocretin neuropeptides stabilize wakefulness, and several orexin receptor antagonists (ORAs) are approved for the treatment of insomnia in adults. Dysregulation of the orexin system occurs in aging and AD, positioning ORAs as advantageous for these populations. Indeed, several clinical studies indicate that ORAs are efficacious hypnotics in older persons and dementia patients and, as in adults, are generally well tolerated. ORAs are likely to be more effective when administered early in sleep/wake dysregulation to reestablish good sleep/wake-related behaviors and reduce the accumulation of dementia-associated proteinopathic substrates. Improving sleep in aging and dementia represents a tremendous opportunity to benefit patients, caregivers, and health systems.
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Affiliation(s)
- Jarrah O-Z J Kron
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia;
| | - Ryan J Keenan
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia;
- Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Daniel Hoyer
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia;
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia;
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
| | - Laura H Jacobson
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia;
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia;
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14
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Dong P, Dai W, Su M, Wang S, Ma Y, Zhao T, Zheng F, Sun P. The potential role of the orexin system in premenstrual syndrome. Front Endocrinol (Lausanne) 2024; 14:1266806. [PMID: 38292774 PMCID: PMC10824941 DOI: 10.3389/fendo.2023.1266806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/29/2023] [Indexed: 02/01/2024] Open
Abstract
Premenstrual syndrome (PMS) occurs recurrently during the luteal phase of a woman's menstrual cycle and disappears after menstruation ends. It is characterized by abnormal changes in both the body and mood, and in certain cases, severe disruptions in daily life and even suicidal tendencies. Current drugs for treating PMS, such as selective serotonin reuptake inhibitors, do not yield satisfactory results. Orexin, a neuropeptide produced in the lateral hypothalamus, is garnering attention in the treatment of neurological disorders and is believed to modulate the symptoms of PMS. This paper reviews the advancements in research on sleep disturbances, mood changes, and cognitive impairment caused by PMS, and suggests potential pathways for orexin to address these symptoms. Furthermore, it delves into the role of orexin in the molecular mechanisms underlying PMS. Orexin regulates steroid hormones, and the cyclic fluctuations of estrogen and progesterone play a crucial role in the pathogenesis of PMS. Additionally, orexin also modulates the gamma-aminobutyric acid (GABA) system and the inflammatory response involved in coordinating the mechanism of PMS. Unraveling the role of orexin in the pathogenesis of PMS will not only aid in understanding the etiology of PMS but also hold implications for orexin as a novel target for treating PMS.
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Affiliation(s)
- Ping Dong
- School of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Weibo Dai
- Department of Pharmacy, Zhongshan Hospital of Traditional Chinese Medicine, Zhong Shan, China
| | - Mengyue Su
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Shukun Wang
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yuexiang Ma
- School of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tingting Zhao
- College of Foreign Languages, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Feng Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Peng Sun
- Innovation Research Institute of Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
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15
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Winkelman JW, Wipper B, Zackon J, Hoeppner BB. Lack of Efficacy of Suvorexant in People with Insomnia and Poorly Controlled Type 2 Diabetes. Nat Sci Sleep 2023; 15:1117-1128. [PMID: 38152441 PMCID: PMC10752032 DOI: 10.2147/nss.s434058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023] Open
Abstract
Objective/Background Sleep disturbance is a common and underappreciated feature of diabetes and sleep may contribute to glycemic control in people with type 2 diabetes (T2D). We conducted a 3-month trial to examine the efficacy of suvorexant in improving sleep and health outcomes in people with suboptimally controlled T2D and insomnia. Participants/Methods This parallel, double-blind, randomized placebo-controlled trial was conducted using the sequential parallel comparison design (SPCD). Sixty-nine people with poorly controlled T2D (HbA1c ≥ 6.5) were randomized to placebo and/or suvorexant (10-20 mg). The primary outcome was subjective total sleep time (sTST), and secondary outcomes were Insomnia Severity Index (ISI) score and wake time after sleep onset (WASO). Exploratory outcomes included sleep efficiency, hemoglobin A1c (HbA1c), and C-reactive protein (CRP). Exploratory analyses were conducted on relationships between sleep and diabetes outcomes. Results There were no significant improvements in sTST (p = 0.27), ISI (p = 0.86), or WASO (p = 0.94) among participants taking suvorexant compared to placebo. There were also no significant changes in any of the exploratory endpoints. Improvements in sleep were associated with improvements in both objective (ie, HbA1c) and subjective (ie, Diabetes Distress Scale) measures of diabetes, as well as reductions in depressive symptoms, independent of treatment assignment. Conclusion The study did not find evidence that suvorexant is efficacious for insomnia in people with poorly controlled T2D. The associations of improved sleep with improvements in both diabetes-related metrics and depressive symptoms across groups highlight the importance of identifying and treating sleeping difficulties in this population. CT Registration # Nct03818581.
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Grants
- research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, NJ, USA
- this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, NJ, USA
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Affiliation(s)
- John W Winkelman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Jordana Zackon
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Bettina B Hoeppner
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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16
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Zhou M, Liu R, Tang J, Tang S. Effects of new hypnotic drugs on cognition: A systematic review and network meta-analysis. Sleep Med X 2023; 6:100094. [PMID: 38149178 PMCID: PMC10749902 DOI: 10.1016/j.sleepx.2023.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 12/28/2023] Open
Abstract
Background Insomnia is a common disease, and the application of various types of sleeping pills for cognitive impairment is controversial, especially as different doses can lead to different effects. Therefore, it is necessary to evaluate the cognitive impairment caused by different sleeping pills to provide a theoretical basis for guiding clinicians in the selection of medication regimens. Objective To evaluate whether various different doses (low, medium and high) of anti-insomnia drugs, such as the dual-orexin receptor antagonist (DORA), zopiclone, eszopiclone and zolpidem, induce cognitive impairment. Methods The PubMed, Embase, Scopus, Cochrane Library, and Google Scholar databases were searched from inception to September 20th, 2022 for keywords in randomized controlled trials (RCTs) to evaluate the therapeutic effects of DORA, eszopiclone, zopiclone and zolpidem on sleep and cognitive function. The primary outcomes were indicators related to cognitive characteristics, including scores on the Digit Symbol Substitution Test (DSST) and daytime alertness. The secondary outcomes were the indicators associated with sleep and adverse events. Continuous variables were expressed as the standard mean difference (SMD). Data were obtained through GetData 2.26 and analyzed by Stata v.15.0. Results A total of 8702 subjects were included in 29 studies. Eszopiclonehigh significantly increased the daytime alertness score (SMD = 3.00, 95 % CI: 1.86 to 4.13) compared with the placebo, and eszopiclonehigh significantly increased the daytime alertness score (SMD = 4.21, 95 % CI: 1.65 to 6.77; SMD = 3.95, 95 % CI: 1.38 to 6.51; SMD = 3.26, 95 % CI: 0.38 to 6.15; and SMD = 3.23, 95 % CI: 0.34 to 6.11) compared with zolpidemlow, zolpidemhigh, DORAlow, and eszopiclonemid, respectively. Compared with the placebo, zopiclone, zolpidemmid, and eszopiclonehigh, DORA significantly increased the TST (SMD = 2.39, 95 % CI: 1.11 to 3.67; SMD = 6.00, 95 % CI: 2.73 to 9.27; SMD = 1.89, 95 % CI: 0.90 to 2.88; and SMD = 1.70, 95 % CI: 0.42 to 2.99, respectively). Conclusion We recommend DORA as the best intervention for insomnia because it was highly effective in inducing and maintaining sleep without impairing cognition. Although zolpidem had a more pronounced effect on sleep maintenance, this drug is better for short-term use. Eszopiclone and zopiclone improved sleep, but their cognitive effects have yet to be verified.
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Affiliation(s)
- Mengzhen Zhou
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
| | - Rujia Liu
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
- Yuhuangding Hospital, No, 20, Yuhuangding East Road, Zhifu District, Yantai, Shandong, PR China
| | - Jiyou Tang
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, PR China
| | - Shi Tang
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
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17
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Krystal AD. Insomnia medications: History, characteristics, and guidelines for optimal use in clinical practice. J Sleep Res 2023; 32:e14084. [PMID: 37940337 DOI: 10.1111/jsr.14084] [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: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 11/10/2023]
Abstract
This article reviews the history of insomnia pharmacotherapy, documenting the evolution that has occurred over time in the increasing availability of medications with novel mechanisms of action that more specifically target the neural systems that modulate sleep/wake function. This evolution provides an increasing capacity to improve the effectiveness of insomnia pharmacotherapy by allowing the selection of medications that specifically target the particular type of sleep difficulty present in each patient. As a result, they can achieve a therapeutic effect with fewer effects on aspects of brain function other than those needed to achieve benefit, thereby minimising adverse effects. The accumulated evidence-base is such that it can serve as the basis for a personalised insomnia pharmacotherapy paradigm. Here we outline a set of best-practice recommendations for how to carry out optimised personalised insomnia pharmacotherapy based on that evidence base in the hope that it will improve the treatment delivered to the many individuals suffering from insomnia.
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Affiliation(s)
- Andrew D Krystal
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
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18
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Bliwise DL, Wang TC, Svetnik V, Zammit G, Tao P, Lines C, Herring WJ. Phase advance of bedtimes in Alzheimer's disease. Sleep 2023; 46:zsad191. [PMID: 37540589 DOI: 10.1093/sleep/zsad191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023] Open
Affiliation(s)
- Donald L Bliwise
- Sleep Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Ting-Chuan Wang
- Merck Research Laboratories, Merck & Co., Inc., Rahway, NJ, USA
| | | | - Gary Zammit
- Clinilabs Drug Development Corporation, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peining Tao
- Merck Research Laboratories, Merck & Co., Inc., Rahway, NJ, USA
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19
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Jang SR, Moline M. Commentary on Yue et al. Efficacy and tolerability of pharmacological treatments for insomnia in adults: A systematic review and network meta-analysis. Sleep Med Rev 2023; 71:101816. [PMID: 37487343 DOI: 10.1016/j.smrv.2023.101816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/21/2023] [Indexed: 07/26/2023]
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20
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Morishita C, Tamada Y, Shimura A, Ishibashi Y, Higashiyama M, Masuya J, Higashi S, Inoue T, Fujimura Y. Identification of the simultaneous use of multiple hypnotics as a risk factor for falls in hospitalized patients by a matched case-control study. PLoS One 2023; 18:e0291607. [PMID: 37725607 PMCID: PMC10508619 DOI: 10.1371/journal.pone.0291607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 09/03/2023] [Indexed: 09/21/2023] Open
Abstract
AIM The risk of falls owing to simultaneous use of multiple hypnotics has not been clarified. The aim of this study was to assess the association between the simultaneous use of 2 hypnotics and the occurrence of falls in hospitalized patients. METHODS A matched case-control study was conducted at Tokyo Medical University Hospital in Tokyo, Japan, utilizing data from medical records. Cases were 434 hospitalized patients who experienced falls during their hospital stay between January 2016 and December 2016, and controls were 434 hospitalized patients without falls, individually matched by age, sex, and clinical department. The outcome was the occurrence of an in-hospital fall. The associations between the use of 1 hypnotic and falls, and between the use of 2 hypnotics and falls were assessed by conditional logistic regression analyses. The main multivariable conditional logistic regression model was adjusted for potential risk factors, including the use of other classes of psychotropics (antipsychotics, antidepressants, and anxiolytics), in addition to patient characteristics. RESULTS The main multivariable conditional logistic regression analyses showed that the simultaneous use of 2 hypnotics (odds ratio [OR] = 2.986; 95% confidence interval [CI], 1.041-8.567), but not the use of a single hypnotic (OR = 1.252; 95% CI, 0.843-1.859), was significantly associated with an increased OR of falls. CONCLUSION The simultaneous use of 2 hypnotics is a risk factor for falls among hospitalized patients, whereas the use of a single hypnotic may not.
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Affiliation(s)
- Chihiro Morishita
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yu Tamada
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
- Department of Psychiatry, Tokyo Medical University Hachioji Medical Center, Hachioji-shi, Tokyo, Japan
- Department of Psychiatry, Toranomon Hospital Kajigaya, Kawasaki-shi, Kanagawa, Japan
| | - Akiyoshi Shimura
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yoshiki Ishibashi
- Department of Preventive Medicine and Public Health, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan
| | - Motoki Higashiyama
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Jiro Masuya
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Shinji Higashi
- Department of Psychiatry, Tokyo Medical University Ibaraki Medical Center, Inashiki-gun, Ibaraki, Japan
| | - Takeshi Inoue
- Department of Psychiatry, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yota Fujimura
- Department of Psychiatry, Tokyo Medical University Hachioji Medical Center, Hachioji-shi, Tokyo, Japan
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21
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Morishita C, Masuya J, Ishii Y, Seki T, Deguchi A, Iwata Y, Tamada Y, Fujimura Y, Honyashiki M, Harada K, Taguri M, Inoue T. Association between psychotropics use and occurrence of falls in hospitalized patients: A matched case-control study. PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2023; 2:e133. [PMID: 38867824 PMCID: PMC11114364 DOI: 10.1002/pcn5.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/20/2023] [Accepted: 07/29/2023] [Indexed: 06/14/2024]
Abstract
Aim Understanding the appropriate prescription of psychotropics for hospitalized patients in terms of preventing falls is an important issue. The aim of this study was to assess the associations between the occurrence of falls and the use of various individual psychotropics in hospitalized patients. Methods A retrospective matched case-control study was conducted on adult patients admitted to every department of Tokyo Medical University Hospital, with the outcome being in-hospital falls. A total of 447 hospitalized patients who had had in-hospital falls at some point in their hospitalization between January 2016 and December 2016 were included as cases. A total of 447 hospitalized patients who did not have in-hospital falls, and were individually matched to the cases by sex, age, and clinical department, were included as controls. All data were extracted from electronic medical records. Conditional logistic regression analyses were conducted to assess the association between the exposure to 16 psychotropic medications and the occurrence of in-hospital falls. The multivariable logistic regression model adjusted sex, age, clinical department, body mass index, fall risk score on the fall risk assessment measure, and use of psychotropic medications. Results The multivariable conditional logistic regression model showed a significant association between the use of risperidone (odds ratio [OR] = 3.730; 95% confidence interval [CI] = 1.229-11.325) and flunitrazepam (OR = 4.120; 95% CI = 1.105-15.364) and an increased OR of falls among hospitalized patients. Conclusion The use of risperidone and flunitrazepam were identified as risk factors for falls among hospitalized patients.
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Affiliation(s)
| | - Jiro Masuya
- Department of PsychiatryTokyo Medical UniversityTokyoJapan
| | | | - Tomoteru Seki
- Department of PsychiatryTokyo Medical UniversityTokyoJapan
| | - Ayaka Deguchi
- Department of PsychiatryTokyo Medical UniversityTokyoJapan
| | - Yoshio Iwata
- Department of PsychiatryTokyo Medical UniversityTokyoJapan
| | - Yu Tamada
- Department of PsychiatryTokyo Medical University Hachioji Medical CenterTokyoJapan
| | - Yota Fujimura
- Department of PsychiatryTokyo Medical University Hachioji Medical CenterTokyoJapan
| | | | - Kazuharu Harada
- Department of Health Data ScienceTokyo Medical UniversityTokyoJapan
| | - Masataka Taguri
- Department of Health Data ScienceTokyo Medical UniversityTokyoJapan
| | - Takeshi Inoue
- Department of PsychiatryTokyo Medical UniversityTokyoJapan
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22
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Wong AK, Wang D, Marco D, Le B, Philip J. Prevalence, Severity, and Predictors of Insomnia in Advanced Colorectal Cancer. J Pain Symptom Manage 2023; 66:e335-e342. [PMID: 37295563 DOI: 10.1016/j.jpainsymman.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
CONTEXT Insomnia is an under-recognized and undertreated symptom in palliative care and advanced cancer cohorts. Insomnia in an advanced colorectal cancer cohort is yet to be investigated despite colorectal cancer being the third commonest cancer worldwide and one with a high symptom burden. OBJECTIVES To examine the prevalence of insomnia and its associations in a large advanced colorectal cancer cohort. METHODS A consecutive cohort study of 18,302 patients with colorectal cancer seen by palliative care services across various settings (inpatient, outpatient, and ambulatory) was conducted from an Australia-wide database (2013-2019). The Symptom Assessment Score (SAS) was used to assess the severity of insomnia. Clinically significant insomnia was defined as SAS score ≥3/10, and used to compare associations with other symptoms and functional scores from validated questionnaires. RESULTS The prevalence of any insomnia was 50.5%, and clinically significant insomnia 35.6%, particularly affecting people who were younger (<45-years-old), more mobile (AKPS score ≥70), or physically capable (RUG-ADL score ≤5). Outpatients and patients living at home had higher prevalence of insomnia. Nausea, anorexia and psychological distress were the commonest concurrent symptoms in patients with clinically significant insomnia. CONCLUSIONS To our knowledge, this study was the first to investigate the prevalence and associations of insomnia in an advanced colorectal cancer cohort. Our findings demonstrate several groups at greater risk of suffering from insomnia (younger, greater physical capacity, living at home, and those with greater psychological distress). This may guide earlier recognition and management of insomnia to improve overall quality of life in this population.
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Affiliation(s)
- Aaron K Wong
- Parkville Integrated Palliative Care Service (A.K.W., D.W., B.L., J.P.), The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Eastern Hill Campus, (A.K.W., D.M., J.P.), University of Melbourne, Fitzroy, Victoria, Australia.
| | - Dorothy Wang
- Parkville Integrated Palliative Care Service (A.K.W., D.W., B.L., J.P.), The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - David Marco
- Department of Medicine, Eastern Hill Campus, (A.K.W., D.M., J.P.), University of Melbourne, Fitzroy, Victoria, Australia; Centre for Palliative Care, St Vincent's Hospital Melbourne (D.M.), Fitzroy, Victoria, Australia
| | - Brian Le
- Parkville Integrated Palliative Care Service (A.K.W., D.W., B.L., J.P.), The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jennifer Philip
- Parkville Integrated Palliative Care Service (A.K.W., D.W., B.L., J.P.), The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Eastern Hill Campus, (A.K.W., D.M., J.P.), University of Melbourne, Fitzroy, Victoria, Australia; Palliative Care Service (J.P.), St Vincent's Hospital, Fitzroy, Victoria, Australia
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23
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Golebiowski R, Mansukhani MP, Kolla BP. Are clinical trials for insomnia recruiting real-world patients? J Clin Sleep Med 2023; 19:1553-1555. [PMID: 37185063 PMCID: PMC10394364 DOI: 10.5664/jcsm.10640] [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: 04/14/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Abstract
Recent Phase III trials of hypnotic medications that have led to Food and Drug Administration approval have severely restrictive eligibility criteria. One hundred patients referred for insomnia who received a hypnotic medication at a large tertiary referral center were identified. Data were extracted to evaluate whether these patients would be eligible to be included in any of the recent Phase III trials. Of the 100 patients identified, only 3 were eligible. Most were excluded because of a prior or concurrent trial of cognitive behavioral therapy for insomnia. If this criterion were set aside, only 12% would have been eligible to participate. The remaining top reasons for exclusion were medical comorbidities, daytime napping, and sleep apnea. These findings question the generalizability of the regulatory studies and suggest that future trials should enroll patients with less-restrictive criteria to help determine the effectiveness of these medications in real-world settings. CITATION Golebiowski R, Mansukhani MP, Kolla BP. Are clinical trials for insomnia recruiting real-world patients? J Clin Sleep Med. 2023;19(8):1553-1555.
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Affiliation(s)
| | | | - Bhanu Prakash Kolla
- Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
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24
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Di Marco T, Scammell TE, Meinel M, Seboek Kinter D, Datta AN, Zammit G, Dauvilliers Y. Number, Duration, and Distribution of Wake Bouts in Patients with Insomnia Disorder: Effect of Daridorexant and Zolpidem. CNS Drugs 2023; 37:639-653. [PMID: 37477771 PMCID: PMC10374812 DOI: 10.1007/s40263-023-01020-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Daridorexant, a dual orexin receptor antagonist approved in early 2022, reduces wake after sleep onset without reducing the number of awakenings in patients with insomnia. The objective of this post hoc analysis was to explore the effect of daridorexant on the number, duration, and distribution of night-time wake bouts, and their correlation with daytime functioning. METHODS Adults with insomnia disorder were randomized 1:1:1:1:1:1 to placebo, zolpidem 10 mg, or daridorexant 5, 10, 25, or 50 mg in a phase II dose-finding study, and 1:1:1 to placebo or daridorexant 25 or 50 mg in a pivotal phase III study. We analyzed polysomnography data for daridorexant 25 and 50 mg, zolpidem 10 mg, and placebo groups. Polysomnography was conducted at baseline, then on Days 1/2, 15/16, and 28/29 in the phase II study, and Months 1 and 3 in the phase III study. The number, duration, and distribution of wake bouts (≥ 0.5 min) were assessed. RESULTS Data from 1111 patients (phase II study: daridorexant 50 mg [n = 61], zolpidem 10 mg [n = 60], placebo [n = 60]; phase III study: daridorexant 25 mg [n = 310], daridorexant 50 mg [n = 310], placebo [n = 310]) were analyzed. Long wake bouts were defined as > 6 min. Compared with placebo, daridorexant 50 mg reduced overall wake time (p < 0.05; all time points, both studies), the odds of experiencing long wake bouts (p < 0.001; Months 1 and 3, phase III study), and the cumulative duration of long wake bouts (p < 0.01; all time points, both studies). Reductions in long wake bouts were sustained through the second half of the night and correlated with improvements in daytime functioning. An increase in the cumulative duration of short wake bouts was observed with daridorexant 50 mg (p < 0.01 vs placebo, Months 1 and 3, phase III study); this was uncorrelated with daytime functioning. CONCLUSION Daridorexant reduced the number and duration of longer wake bouts throughout the night compared with placebo, corresponding with improved daytime functioning. CLINICAL TRIALS Clinicaltrials.gov NCT02839200 (registered July 20, 2016), NCT03545191 (registered June 4, 2018).
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Affiliation(s)
- Tobias Di Marco
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland.
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4031, Basel, Switzerland.
| | - Thomas E Scammell
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael Meinel
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Dalma Seboek Kinter
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Alexandre N Datta
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4031, Basel, Switzerland
- Pediatric Neurology and Developmental Medicine Department, University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Gary Zammit
- Clinilabs Drug Development Corporation, New York, NY, USA
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases, Narcolepsy-Rare hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, Institute for Neurosciences of Montpellier INM, Univ Montpellier, INSERM, Montpellier, France
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Abstract
OBJECTIVE To update the evidence-based Nonhormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society. METHODS An advisory panel of clinicians and research experts in women's health were selected to review and evaluate the literature published since the Nonhormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society. Topics were divided into five sections for ease of review: lifestyle; mind-body techniques; prescription therapies; dietary supplements; and acupuncture, other treatments, and technologies. The panel assessed the most current and available literature to determine whether to recommend or not recommend use based on these levels of evidence: Level I, good and consistent scientific evidence; Level II, limited or inconsistent scientific evidence, and Level III, consensus and expert opinion. RESULTS Evidence-based review of the literature resulted in several nonhormone options for the treatment of vasomotor symptoms. Recommended: Cognitive-behavioral therapy, clinical hypnosis, selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors, gabapentin, fezolinetant (Level I); oxybutynin (Levels I-II); weight loss, stellate ganglion block (Levels II-III). Not recommended: Paced respiration (Level I); supplements/herbal remedies (Levels I-II); cooling techniques, avoiding triggers, exercise, yoga, mindfulness-based intervention, relaxation, suvorexant, soy foods and soy extracts, soy metabolite equol, cannabinoids, acupuncture, calibration of neural oscillations (Level II); chiropractic interventions, clonidine; (Levels I-III); dietary modification and pregabalin (Level III). CONCLUSION Hormone therapy remains the most effective treatment for vasomotor symptoms and should be considered in menopausal women within 10 years of their final menstrual periods. For women who are not good candidates for hormone therapy because of contraindications (eg, estrogen-dependent cancers or cardiovascular disease) or personal preference, it is important for healthcare professionals to be well informed about nonhormone treatment options for reducing vasomotor symptoms that are supported by the evidence.
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Sarathi Chakraborty D, Choudhury S, Lahiry S. Daridorexant, a Recently Approved Dual Orexin Receptor Antagonists (DORA) in Treatment of Insomnia. Sleep Sci 2023; 16:256-264. [PMID: 37425970 PMCID: PMC10325868 DOI: 10.1055/s-0043-1770805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Insomnia is one of the major challenges in medical science nowadays as it leads to great socio-economic burden by impairing daytime function as well as the development of exhaustion, depression, and memory disturbance in affected individuals. Several important classes of drugs have been tried, including the BZDs and non-BZD hypnotics. Available drugs to combat this disease have the limitations of abuse potential, tolerance, and cognitive impairment. In some instances, withdrawal symptoms have been observed upon the abrupt cessation of those drugs. The Orexin system has been very recently targeted as a therapeutic option to overcome those limitations. Treatment of insomnia with Daridorexant as a Dual Orexin Receptor Antagonist (DORA) has been evaluated in several preclinical and clinical studies. Available information obtained from those studies has shown a promising future for this drug in the management of insomnia. Beyond its effectiveness in insomnia, it has been successfully used in patients suffering from obstructive sleep apnoea, chronic obstructed airway disease (COAD), Alzheimer's disease (AD), hypertension, and cardiovascular disorders. Larger studies need to address the safety issues as well as obtain robust pharmacovigilance information to safeguard the risk-benefit aspect of this drug in insomniac adults.
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Affiliation(s)
| | | | - Sandeep Lahiry
- Independent Research Scholar, Barasat, Kolkata, West Bengal, India
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27
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Luo F, Deng JY, Sun X, Zhen J, Luo XD. Anterior cingulate cortex orexin signaling mediates early-life stress-induced social impairment in females. Proc Natl Acad Sci U S A 2023; 120:e2220353120. [PMID: 37155875 PMCID: PMC10193930 DOI: 10.1073/pnas.2220353120] [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: 12/02/2022] [Accepted: 03/30/2023] [Indexed: 05/10/2023] Open
Abstract
Early-life stress has long-term impacts on the structure and function of the anterior cingulate cortex (ACC), and raises the risk of adult neuropsychiatric disorders including social dysfunction. The underlying neural mechanisms, however, are still uncertain. Here, we show that, in female mice, maternal separation (MS) during the first three postnatal weeks results in social impairment accompanied with hypoactivity in pyramidal neurons (PNs) of the ACC. Activation of ACC PNs ameliorates MS-induced social impairment. Neuropeptide Hcrt, which encodes hypocretin (orexin), is the top down-regulated gene in the ACC of MS females. Activating ACC orexin terminals enhances the activity of ACC PNs and rescues the diminished sociability observed in MS females via an orexin receptor 2 (OxR2)-dependent mechanism. Our results suggest orexin signaling in the ACC is critical in mediating early-life stress-induced social impairment in females.
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Affiliation(s)
- Fei Luo
- Center for Neuropsychiatric Diseases, Institute of Life Science, Nanchang University, Nanchang330031, China
- Department of Psychiatry, Yichun First municipal People’s Hospital, YiChun336000, China
| | - Jun-yang Deng
- Department of Psychiatry, Yichun First municipal People’s Hospital, YiChun336000, China
| | - Xuan Sun
- Center for Neuropsychiatric Diseases, Institute of Life Science, Nanchang University, Nanchang330031, China
| | - Jian Zhen
- Center for Neuropsychiatric Diseases, Institute of Life Science, Nanchang University, Nanchang330031, China
| | - Xiao-dan Luo
- Department of Psychiatry, Yichun First municipal People’s Hospital, YiChun336000, China
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28
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Xue T, Wu X, Li J, Chen S, Wang Z, Tan X, Wang Z, Zhang J. Different doses of dual orexin receptor antagonists in primary insomnia: a Bayesian network analysis. Front Pharmacol 2023; 14:1175372. [PMID: 37261282 PMCID: PMC10228643 DOI: 10.3389/fphar.2023.1175372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/05/2023] [Indexed: 06/02/2023] Open
Abstract
Background: Systematic comparisons of the doses of the Food and Drug Administration (FDA)-approved dual orexin receptor antagonists (DORAs) for people with insomnia are limited. Methods: PubMed, Embase, Cochrane Library, and Clinicaltrials. gov were systematically searched to identify relevant studies published before 31 October 2022. We assessed the certainty of evidence using the confidence in network meta-analysis (CINeMA) framework. Results: We pooled 7257 participants from 9 randomized controlled trials (RCTs). Moderate to high certainty evidence demonstrated suvorexant (20 and 40 mg) and daridorexant (10 and 50 mg) as the most effective in latency to persistent sleep (LPS) reduction. Lemborexant at 5 and 10 mg was the most effective in subjective sleep onset time (sTSO) reduction. For wake time after sleep onset (WASO), all drugs except daridorexant 5 mg were more effective than placebo. Lemborexant 5 mg was among the best in subjective WASO (sWASO) (moderate to high certainty) and had the highest surface under the curve ranking area (SUCRA) values for sWASO (100%). For total sleep time (TST), suvorexant and daridorexant, except the respective minimum doses, were more effective than placebo, while suvorexant 40 mg and lemborexant 10 mg may have been the most effective for subjective TST (sTST) (low to very low certainty). Suvorexant 40 mg (RR 1.09), suvorexant 80 mg (RR 1.65), and daridorexant 25 mg (RR 1.16) showed a higher safety risk than placebo. Conclusion: Suvorexant 20 mg, lemborexant 5 mg, lemborexant 10 mg, and daridorexant 50 mg represent suitable approaches for insomnia. Clinical Trial Registration: clinicaltrials.gov, PROSPERO (CRD42022362655).
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Affiliation(s)
- Tao Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Wu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
- Department of Neurosurgery, Suzhou Ninth People’s Hospital, Suzhou, China
| | - Jiaxuan Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Shujun Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xin Tan
- Department of Neurology, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu Province, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing, China
- Beijing Key Laboratory of Neurostimulation, Beijing, China
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29
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Rocha RB, Bomtempo FF, Nager GB, Cenci GI, Telles JPM. Dual orexin receptor antagonists for the treatment of insomnia: systematic review and network meta-analysis. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:475-483. [PMID: 37257468 DOI: 10.1055/s-0043-1768667] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Several randomized clinical trials (RCTs) have shown that dual orexin receptor antagonists (DORAs) are effective in the treatment of chronic insomnia. However, the superiority of one particular DORA over the others remains unclear. OBJECTIVE To perform a network meta-analysis to evaluate the efficacy of different DORAs in patients with chronic insomnia. METHODS The Medline, Embase, and Cochrane Central databases were searched for RCTs that compared DORA with placebo in patients ≥ 18 years of age with a diagnosis of insomnia disorder. We pooled outcomes for wake time after sleep onset (WASO), latency to persistent sleep (LPS), total sleep time (TST), and adverse events (AEs). RESULTS We included 10 RCTs with 7,806 patients, 4,849 of whom received DORAs as the intervention. Overall, we found that DORAs were associated with the improvement of all analyzed efficacy outcomes. Concerning TST, an apparent dose-dependent pattern was noticed, with higher doses relating to a longer TST. Lemborexant 10mg provided the largest reduction in WASO (at month 1) in minutes (standardized mean difference [SMD] = -25.40; 95% confidence interval [95%CI] = -40.02--10.78), followed by suvorexant 20/15mg (SMD = -25.29; 95%CI = -36.42--14.15), which also appeared to provide the largest decrease in long-term WASO (SMD = -23.70; 95%CI = -35.89--11.51). The most frequent AEs were somnolence, nasopharyngitis, and headache, with rates of up to 14.8%. CONCLUSION Our results suggest that DORAs are associated with greater efficacy when compared with placebo in the treatment of insomnia, a complex 24-hour sleep disorder. Additionally, dosing might play an important role in the management of chronic insomnia.
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Affiliation(s)
| | | | - Gabriela Borges Nager
- Universidade Federal do Estado do Rio de Janeiro, Faculdade de Medicina, Rio de Janeiro RJ, Brazil
| | | | - João Paulo Mota Telles
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
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30
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Watson NF, Bertisch SM, Morin CM, Pelayo R, Winkelman JW, Zee PC, Krystal AD. Do Insomnia Treatments Improve Daytime Function? J Clin Med 2023; 12:jcm12093089. [PMID: 37176529 PMCID: PMC10179344 DOI: 10.3390/jcm12093089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/05/2023] [Accepted: 04/08/2023] [Indexed: 05/15/2023] Open
Abstract
A scientific advisory panel of seven U.S. and Canadian sleep experts performed a clinical appraisal by comparing general medical opinion, assessed via a survey of practicing clinicians, regarding insomnia treatment, with the available scientific evidence. This clinical appraisal focuses on the specific statement, "Treatments for insomnia have uniformly been shown to significantly improve the associated daytime impairment seen with insomnia." The advisory panel reviewed and discussed the available body of evidence within the published medical literature to determine what discrepancies may exist between the currently published evidence base and general medical opinion. The advisory panels' evaluation of this statement was also compared with the results of a national survey of primary care physicians, psychiatrists, nurse practitioners, physician assistants, and sleep specialists in the United States. Contrary to general medical opinion, the expert advisory panel concluded that the medical literature did not support the statement. This gap highlights the need to educate the general medical community regarding insomnia treatment efficacy in pursuit of improved treatment outcomes.
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Affiliation(s)
- Nathaniel F Watson
- Department of Neurology, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Suzanne M Bertisch
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02130, USA
| | - Charles M Morin
- Department of Psychology, Cervo/Brain Research Centre, Laval University, Québec City, QC G1J 2G3, Canada
| | - Rafael Pelayo
- Department of Psychiatry and Behavioral Sciences, Stanford University Sleep Medicine Center, Redwood City, CA 94063, USA
| | - John W Winkelman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Phyllis C Zee
- Department of Neurology, Center for Circadian and Sleep Medicine, Northwestern University, Evanston, IL 60209, USA
| | - Andrew D Krystal
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, San Francisco, CA 94103, USA
- Department of Neurology, UCSF Weill Institute for Neurosciences, San Francisco, CA 94103, USA
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Lalovic B, Savant Landry I, Moline M, Reyderman L, Hussein Z. Exposure-Response Analyses of Polysomnography and Subjective Sleep Efficacy End Points From the Phase 3 Trials of Lemborexant, a Dual Orexin Receptor Antagonist for the Treatment of Insomnia. J Clin Pharmacol 2023; 63:498-511. [PMID: 36524428 DOI: 10.1002/jcph.2192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
This report describes polysomnography and sleep diary exposure-response analyses from Study E2006-G000-304 (Study 304), a 1-month trial of 5- or 10-mg lemborexant, zolpidem, or placebo; and Study E2006-G000-303 (Study 303), a 6-month trial of 5- or 10-mg lemborexant or placebo. Studies 304 and 303 included 1006 (86%) and 956 (68%) (female) participants, respectively; >40% were ≥65 years, with individual lemborexant exposures derived from a previously described pharmacokinetic model. Linear mixed-effects analyses of polysomnography: latency to persistent sleep (LPS), sleep efficiency (SE), and wake after sleep onset (WASO) quantified the change from baseline given lemborexant exposure, time, and covariates, guided by consensus recommendations regarding clinical significance. A small impact of sex, body weight, and race was predicted for LPS and SE, irrespective of treatment. Effect of age on LPS was small; baseline SE was estimated to be 8% higher for a 50-year-old versus an 80-year-old, decreasing to 6% by 1 month. Baseline WASO was 13 minutes longer for Black versus White subjects, corresponding to a 5-minute lower change from baseline at the end of the study. For subjective end points, the statistically significant covariate effects for age, sex, and race were not deemed therapeutically relevant, likely reflecting physiologic sleep pattern changes across age and study subgroups. Both polysomnography and subjective analyses indicated clinically meaningful differences from baseline for both lemborexant treatments, with effects being greater for 10-mg versus 5-mg lemborexant, while indicating that covariate-specific lemborexant dose adjustments are not warranted.
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32
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Watson NF, Benca RM, Krystal AD, McCall WV, Neubauer DN. Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia. J Clin Med 2023; 12:jcm12072493. [PMID: 37048577 PMCID: PMC10095217 DOI: 10.3390/jcm12072493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
Determining the most effective insomnia medication for patients may require therapeutic trials of different medications. In addition, medication side effects, interactions with co-administered medications, and declining therapeutic efficacy can necessitate switching between different insomnia medications or deprescribing altogether. Currently, little guidance exists regarding the safest and most effective way to transition from one medication to another. Thus, we developed evidence-based guidelines to inform clinicians regarding best practices when deprescribing or transitioning between insomnia medications. Five U.S.-based sleep experts reviewed the literature involving insomnia medication deprescribing, tapering, and switching and rated the quality of evidence. They used this evidence to generate recommendations through discussion and consensus. When switching or discontinuing insomnia medications, we recommend benzodiazepine hypnotic drugs be tapered while additional CBT-I is provided. For Z-drugs zolpidem and eszopiclone (and not zaleplon), especially when prescribed at supratherapeutic doses, tapering is recommended with a 1–2-day delay in administration of the next insomnia therapy when applicable. There is no need to taper DORAs, doxepin, and ramelteon. Lastly, off-label antidepressants and antipsychotics used to treat insomnia should be gradually reduced when discontinuing. In general, offering individuals a rationale for deprescribing or switching and involving them in the decision-making process can facilitate the change and enhance treatment success.
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33
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Pan B, Ge L, Lai H, Hou L, Tian C, Wang Q, Yang K, Lu Y, Zhu H, Li M, Wang D, Li X, Zhang Y, Gao Y, Liu M, Ding G, Tian J, Yang K. The Comparative Effectiveness and Safety of Insomnia Drugs: A Systematic Review and Network Meta-Analysis of 153 Randomized Trials. Drugs 2023; 83:587-619. [PMID: 36947394 DOI: 10.1007/s40265-023-01859-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Pharmacological treatment is common in practice and widely used for the management of insomnia. However, evidence comparing the relative effectiveness, safety, and certainty of evidence among drug classes and individual drugs for insomnia are still lacking. This study aimed to determine the relative effectiveness, safety, and tolerability of drugs for insomnia. METHODS In this systematic review and network meta-analysis we systematically searched PubMed, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and ClinicalTrials.gov, from inception to January 10, 2022 to identify randomized controlled trials that compared insomnia drugs with placebo or an active comparator in adults with insomnia. We conducted random-effects frequentist network meta-analyses to summarize the evidence, and used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty, categorize interventionsand present the findings. RESULTS A total of 148 articles met our eligibility criteria; these included 153 trials which enrolled 46,412 participants and assessed 36 individual drugs from eight drug classes. Compared with placebo, both subjectively and objectively measured total sleep time were significantly improved with non-benzodiazepine (subjective: mean difference [MD] 25.07, 95% confidence interval [CI] 15.49-34.64, low certainty; objective: MD 22.34, 95% CI 7.64-37.05, high certainty), antidepressants (subjective: MD 54.40, 95% CI 34.96-75.83, low certainty; objective: MD 35.64, 95% CI 13.05-58.24, high certainty), and orexin receptor antagonists (subjective: MD 21.62, 95% CI 0.84-42.40, high certainty; objective: MD 31.81, 95% CI 2.66-60.95, high certainty); of which doxepin, almorexant, suvorexant, and lemborexant were among the relatively effective drugs with relatively good tolerability and lower risks of any adverse events (AEs). Both subjectively and objectively measured sleep onset latency were significantly shortened with non-benzodiazepines (subjective: MD - 10.12, 95% CI - 13.84 to - 6.40, moderate certainty; objective: MD - 12.11, 95% CI - 19.31 to - 4.90, moderate certainty) and melatonin receptor agonists (subjective: MD - 7.73, 95% CI - 15.21 to - 0.26, high certainty; objective: MD - 7.04, 95% CI - 12.12 to - 1.95, moderate certainty); in particular, zopiclone was among the most effective drugs with a lower risk of any AEs but worse tolerability. Non-benzodiazepines could significantly decrease both subjective and objective measured wake time after sleep onset (subjective: MD - 16.67, 95% CI - 21.79 to - 11.56, moderate certainty; objective: MD - 13.92, 95% CI - 22.71 to - 5.14, moderate certainty). CONCLUSIONS Non-benzodiazepines probably improve total sleep time, sleep onset latency, and wake time after sleep onset. Other insomnia drug classes and individual drugs also showed potential benefits in improving insomnia symptoms. However, the choice of insomnia drugs should be based on the phenotype of insomnia presented, as well as each drug's safety and tolerability. Protocol registration PROSPERO (CRD42019138790).
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Affiliation(s)
- Bei Pan
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Long Ge
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China.
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China.
| | - Honghao Lai
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Liangying Hou
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Chen Tian
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Qi Wang
- Department of Epidemiology, School of Public Health, Shandong University, Jinan, China
| | - Kelu Yang
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven-University of Leuven, Leuven, Belgium
| | - Yao Lu
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Hongfei Zhu
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Mengting Li
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Deren Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiuxia Li
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Yuqing Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ya Gao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ming Liu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Guowu Ding
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China.
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, No. 199 Donggang West Road, Chengguan District, Lanzhou, 730000, China.
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China.
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Inoue Y, Nishida M, Kubota N, Koebis M, Taninaga T, Muramoto K, Ishikawa K, Moline M. Comparison of the treatment effectiveness between lemborexant and zolpidem tartrate extended-release for insomnia disorder subtypes defined based on polysomnographic findings. J Clin Sleep Med 2023; 19:519-528. [PMID: 36472134 PMCID: PMC9978424 DOI: 10.5664/jcsm.10378] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVES Patients with chronic insomnia may respond differently to therapeutic modalities. This study examined differences in response of individuals with 2 insomnia phenotypes-short sleep duration (I-SSD; < 6 hours) and normal sleep duration (I-NSD; ≥ 6 hours) determined by polysomnography-to treatment with lemborexant and zolpidem tartrate extended-release 6.25 mg (zolpidem ER), compared with placebo. METHODS Study E2006-G000-304 (Study 304; SUNRISE-1; NCT02783729) was a global, randomized, double-blind, placebo, and active comparator-controlled, parallel-group study comparing lemborexant 5 and 10 mg in individuals aged ≥ 55 years with insomnia disorder. In this analysis, changes in subjective (self-reported) variables based on sleep diaries and objective variables based on polysomnographs were assessed after 1-month administration of study drugs. Data from participants with I-SSD and I-NSD were compared. RESULTS In the I-SSD subgroup, both lemborexant doses provided significant benefit for sleep-onset latency (SOL), total sleep time (TST), and wake after sleep onset (WASO) vs placebo; zolpidem ER also provided significant benefit for TST and WASO, but not SOL, on both measures vs placebo. In the I-NSD subgroup, lemborexant and zolpidem ER provided significant benefit for TST and WASO vs placebo objectively but not subjectively; both doses of lemborexant provided significant benefit for SOL vs placebo subjectively, but not objectively. CONCLUSIONS Both drugs, but lemborexant more consistently, showed subjective and objective benefits compared with placebo in participants with insomnia with objective short sleep duration. However, neither lemborexant nor zolpidem provided consistent benefits for participants with normal sleep duration on sleep-onset and sleep maintenance variables. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Study of the Efficacy and Safety of Lemborexant in Subjects 55 Years and Older With Insomnia Disorder (SUNRISE 1); URL: https://clinicaltrials.gov/ct2/show/record/NCT02783729; Identifier: NCT02783729. CITATION Inoue Y, Nishida M, Kubota N, et al. Comparison of the treatment effectiveness between lemborexant and zolpidem tartrate extended-release for insomnia disorder subtypes defined based on polysomnographic findings. J Clin Sleep Med. 2023;19(3):519-528.
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Affiliation(s)
- Yuichi Inoue
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
- Japan Somnology Center, Institute of Neuropsychiatry, Tokyo, Japan
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Treiber A, Delahaye S, Weigel A, Aeänismaa P, Gatfield J, Seeland S. The Metabolism of the Dual Orexin Receptor Antagonist Daridorexant. Xenobiotica 2023:1-11. [PMID: 36809238 DOI: 10.1080/00498254.2023.2183159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Daridorexant is a dual orexin receptor antagonist developed for the treatment of insomnia disorder and has shown improvement in sleep outcomes and daytime functioning. The present work describes its biotransformation pathways in vitro and in vivo and provides a cross-species comparison between the animal species used in preclinical safety assessments and man.Daridorexant clearance is driven by metabolism along seven distinct pathways. Metabolic profiles were characterized by downstream products while primary metabolic products were of minor importance. The metabolic pattern differed between rodent species, with the rat reflecting the human pattern better than the mouse.In rodents, daridorexant is mostly excreted via the bile after extensive metabolism while urinary excretion was negligible in the rat. Only traces of parent drug were detected in urine, bile or faeces.Daridorexant has three major metabolites which are well covered in these preclinical safety species. All of them retain some residual affinity towards orexin receptors. However, none of these is considered to contribute to the pharmacological effect of daridorexant as their active concentrations in human brain are too low.
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Affiliation(s)
| | | | - Aude Weigel
- Department of Non-clinical Pharmacokinetics and Metabolism and
| | - Päivi Aeänismaa
- Department of Non-clinical Pharmacokinetics and Metabolism and
| | - John Gatfield
- Department of Biology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Swen Seeland
- Department of Non-clinical Pharmacokinetics and Metabolism and
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Jiang F, Li H, Chen Y, Lu H, Ni J, Chen G. Daridorexant for the treatment of insomnia disorder: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2023; 102:e32754. [PMID: 36800596 PMCID: PMC9936001 DOI: 10.1097/md.0000000000032754] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Daridorexant is a novel dual orexin receptor antagonist that has shown efficacy as a treatment for insomnia in multiple randomized clinical trials. However, the efficacy and safety of daridorexant for treatment of insomnia disorder has not been characterized comprehensively in the literature. Therefore, we performed a meta-analysis of available studies. We performed a meta-analysis to systematically evaluate the efficacy and safety of daridorexant for treatment of insomnia disorder. METHODS MEDLINE, Embase, Cochrane Library, and Clinicaltrials.gov for randomized controlled trials were systematically searched up to February 2022. Relative risk and standard mean difference were used to evaluate clinical outcomes. RESULTS We pooled 2271 patients from 4 randomized clinical trials, and evaluated efficacy endpoints. We found that 50 mg of daridorexant was superior to placebo for 4 efficacy outcomes including wake time after sleep onset, latency to persistent sleep, subjective total sleep time, and Insomnia Daytime Symptoms and Impacts Questionnaire domain score (P < .05). In addition, there were no significant differences (P > .05) in adverse events between daridorexant and placebo. CONCLUSIONS Different dosages of daridorexant were tested for treatment of insomnia; however, 5 and 10 mg are not available because of issues of suboptimal effectiveness. Daridorexant showed better efficacy and safety for treatment of insomnia disorder at doses of 25 and 50 mg.
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Affiliation(s)
- Feiyu Jiang
- Brain and Nerve Research Laboratory, Institute of Stroke Research, Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hang Li
- Brain and Nerve Research Laboratory, Institute of Stroke Research, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yanting Chen
- Brain and Nerve Research Laboratory, Institute of Stroke Research, Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haifeng Lu
- Brain and Nerve Research Laboratory, Institute of Stroke Research, Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jianqiang Ni
- Brain and Nerve Research Laboratory, Institute of Stroke Research, Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
- * Correspondence: Jianqiang Ni, Brain and Nerve Research Laboratory, Institute of Stroke Research, Department of Neurology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, China (e-mail: )
| | - Gang Chen
- Brain and Nerve Research Laboratory, Institute of Stroke Research, Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Zhou M, Tang S. Effect of a dual orexin receptor antagonist on Alzheimer's disease: Sleep disorders and cognition. Front Med (Lausanne) 2023; 9:984227. [PMID: 36816725 PMCID: PMC9929354 DOI: 10.3389/fmed.2022.984227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/18/2022] [Indexed: 02/04/2023] Open
Abstract
Orexin is a neuropeptide produced by the lateral hypothalamus that plays an important role in regulating the sleep-wake cycle. The overexpression of the orexinergic system may be related to the pathology of sleep/wakefulness disorders in Alzheimer's disease (AD). In AD patients, the increase in cerebrospinal fluid orexin levels is associated with parallel sleep deterioration. Dual orexin receptor antagonist (DORA) can not only treat the sleep-wakefulness disorder of AD but also improve the performance of patients with cognitive behavior disorder. It is critical to clarify the role of the orexin system in AD, study its relationship with cognitive decline in AD, and evaluate the safety and efficacy of DORA.
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Affiliation(s)
- Mengzhen Zhou
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Shi Tang
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China,*Correspondence: Shi Tang
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Zhou M, Tang J, Li S, Li Y, Zhao M. Orexin dual receptor antagonists, zolpidem, zopiclone, eszopiclone, and cognitive research: A comprehensive dose-response meta-analysis. Front Hum Neurosci 2023; 16:1029554. [PMID: 36699960 PMCID: PMC9869688 DOI: 10.3389/fnhum.2022.1029554] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/31/2022] [Indexed: 01/11/2023] Open
Abstract
Background About one-third of adults have trouble sleeping, ranging from occasional difficulty to chronic insomnia, along with difficulty maintaining sleep. Many studies reported that the long-term use of hypnotics can cause brain dysfunction and damage cognition. Objective The objective of the study is to evaluate whether low, medium, and high doses of orexin dual receptor antagonists (DORA), zopiclone (ZOP), eszopiclone (ESZ), and zolpidem (ZST) can impair cognition. Methods From the beginning through September 20, 2022, PubMed, Embase, Scopus, the Cochrane Library, and Google Scholar were searched. Randomized controlled trials (RCTs) assessing the therapeutic effects of DORA, eszopiclone, and zopiclone for sleep and cognitive function were included. The primary outcomes were indices related to the cognitive profile, including memory, alertness, execution and control function, and attention and orientation. The secondary outcomes were indices related to sleep and adverse events. The standard mean difference (SMD) was generated for continuous variables. Certain data were captured from figures by GetData 2.26 and analyzed using RStudio 4.2. Results Finally, a total of 8,702 subjects were included in 29 studies. Compared with the placebo, the DSST (Digit Symbol Substitution Test) scores of low, medium, and high doses of DORA were SMD = 0.77; 95% CI: 0.33-1.20; SMD = 1.58; 95% CI: 1.11-2.05; and SMD = 0.85; 95% CI: 0.33-1.36, respectively. The DSST scores of zolpidem at low, medium, and high doses were SMD = -0.39; 95% CI: 0.85-0.07; SMD = -0.88, 95% CI: -2.34-0.58; and SMD = -0.12, 95% CI: -0.85-0.60, respectively. Zopiclone's DSST scale score was SMD = -0.18; 95% CI: -0.54-0.18. In addition, the total sleep time (TST) of low, medium, and high doses of DORA was SMD = 0.28, 95% CI: -0.15-0.70; SMD = 1.36, 95% CI: 0.87-1.86; and SMD = 2.59, 95% CI: 1.89-3.30, respectively. The TST of zolpidem with low, medium, and high doses was SMD = 1.01, 95% CI: 0.18-1.83; SMD = 1.94, 95% CI: 0.46-3.43; and SMD = 1.71, 95% CI: 0.86-2.56, respectively. The TST of low, medium, and high doses of eszopiclone was relatively SMD = 2.03, 95% CI: -0.21-4.27; SMD = 2.38, 95% CI: 1.35-3.42; and SMD = 1.71, 95% CI: 0.60-2.82. Zopiclone's TST was SMD = 2.47, 95% CI: 1.36-3.58. Conclusion We recommend DORA as the best intervention for insomnia because it is highly effective in inducing and maintaining sleep without impairing cognition. Although zolpidem has a more pronounced effect on maintaining sleep, it is best to reduce its use because of its side effects. Eszopiclone and zopiclone improved sleep quality, but their safety in cognition remains to be verified.
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Affiliation(s)
- Mengzhen Zhou
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Jiyou Tang
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China,*Correspondence: Jiyou Tang
| | - Shasha Li
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Yaran Li
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Mengke Zhao
- Stem Cell Clinical Research Center, National Joint Engineering Laboratory, Regenerative Medicine Center, The First Affiliated Hospital of Dalian Medical University, Dalian Innovation Institute of Stem Cell and Precision Medicine, Dalian, Liaoning, China
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Orexin Receptor Antagonists in the Treatment of Depression: A Leading Article Summarising Pre-clinical and Clinical Studies. CNS Drugs 2023; 37:1-12. [PMID: 36436175 DOI: 10.1007/s40263-022-00974-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 11/28/2022]
Abstract
The orexin (hypocretin) system comprises two neuropeptides (orexin-A and orexin-B) and two G-protein coupled receptors (the orexin type 1 and the orexin type 2 receptor). The system regulates several biological functions including appetite, the sleep-wake cycle, the stress response, and motivation and reward processing. Dysfunction of the orexin system has been implicated in the pathophysiology of depression in human and animal studies, although the exact nature of this dysfunction remains unclear. Orexin receptor antagonists (ORAs) are a class of compounds developed for the treatment of insomnia and have demonstrated efficacy in this area. Three dual orexin receptor antagonists (DORAs) have received licences for treatment of primary insomnia and some ORAs have since been investigated as potential treatments for major depressive disorder (MDD). In this leading article, we summarise the existing literature on use of ORAs in depression, in pre-clinical and clinical studies. In rodent models of depression, investigated ORAs have included the DORA almorexant and TCS1102, the selective orexin 1 receptor antagonists SB334867 and SB674042 and the selective orexin 2 receptor antagonists LSN2424100, MK-1064 and TCS-OX2-29. These pre-clinical studies suggest a possible antidepressant effect of systemic DORA treatment, however the evidence from selective ORAs is conflicting. To date, four published RCTs (one with the DORA filorexant and three with the selective orexin 2 receptor antagonist seltorexant), have compared an ORA with placebo in the treatment of MDD. Only one of these demonstrated a statistically significant difference relative to placebo.
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Tao P, Svetnik V, Bliwise DL, Zammit G, Lines C, Herring WJ. Comparison of polysomnography in people with Alzheimer's disease and insomnia versus non-demented elderly people with insomnia. Sleep Med 2023; 101:515-521. [PMID: 36529106 DOI: 10.1016/j.sleep.2022.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/16/2022] [Accepted: 11/27/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND We used baseline polysomnography (PSG) data obtained during the clinical program development for suvorexant to compare the PSG profiles of people with Alzheimer's disease and insomnia (ADI) versus age-matched elderly individuals with insomnia (EI). METHODS Sleep laboratory baseline PSG data from participants age 55-80 years from 2 trials in people with insomnia and a trial in people with ADI were included. ADI participants had dementia of mild-to-moderate severity. Diagnostic criteria for insomnia, exclusion for other sleep problems, PSG recording procedures, and endpoint derivations were similar across the trials. All participants underwent a night of in-laboratory PSG prior to the baseline night to allow for screening/adaptation. Participants in the EI and ADI groups were compared with regard to sleep architecture, sleep micro-structure, and quantitative EEG power spectral endpoints. The analysis was performed on a post hoc basis using propensity score matching to compare sleep parameters separately in women and men while accounting for age group and total sleep time. RESULTS A total of 837 EI and 239 ADI participants were included, with the majority in each population (∼65%) being women. Compared to EI, those with ADI had a lower percentage of time spent in slow wave sleep (and a corresponding higher percentage of time spent in the lighter N1 sleep), a lower number of spindles per minute of N2 sleep, and lower absolute EEG power during NREM sleep, particularly in the lower-frequency bands. Trends for lower REM sleep percentage in ADI did not reach statistical significance. CONCLUSIONS Our findings in this large data set, in which the influence of sleep problems was effectively subtracted out (since both groups had insomnia), provide strong confirmatory support of results from previous smaller studies in indicating that AD of mild-to-moderate severity is associated with less slow wave sleep, spindles, and lower-frequency EEG power. TRIAL REGISTRATION ClinicalTrials.gov, numbers NCT01097616, NCT01097629, NCT02750306.
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Affiliation(s)
| | | | - Donald L Bliwise
- Sleep Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Gary Zammit
- Clinilabs Drug Development Corporation, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Yoshioka R, Yamamoto S, Nakatani E. Effectiveness of suvorexant versus benzodiazepine receptor agonist sleep drugs in reducing the risk of hip fracture: Findings from a regional population-based cohort study. PLoS One 2023; 18:e0284726. [PMID: 37093840 PMCID: PMC10124872 DOI: 10.1371/journal.pone.0284726] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/05/2023] [Indexed: 04/25/2023] Open
Abstract
Sleep drugs are often necessary to treat insomnia in older patients. Benzodiazepine receptor agonists (BZRAs) are primarily used for insomnia in these patients, but there are concerns regarding their association with delirium and bone fractures. Among sleep drugs, orexin receptor antagonists such as suvorexant have a lower risk of delirium than BZRAs, but their effectiveness in preventing hip fractures is unknown. Hip fracture is a life-threatening trauma in advanced-age patients and a social problem. Therefore, we investigated the relationship between suvorexant and hip fracture. The Shizuoka Kokuho Database was used to compare the time to hip fracture in patients who had been newly taking suvorexant and other sleep drugs such as benzodiazepines since November 2014. A proportional hazards model for hip fracture as an outcome was used to estimate the hazard ratio. Propensity scores were estimated using a logistic regression model, and the confounding factors were age, sex, several comorbidities, and each oral medication. The suvorexant group comprised 6860 patients (110 with hip fracture), and the BZRA group (benzodiazepines and Z-drugs) comprised 50,203 patients (1487 with hip fracture). In the matched cohort (6855:6855 patients), 259 and 249 patients in the suvorexant and BZRA group developed hip fractures during the observational period, respectively. The hazard ratio of the suvorexant group compared with the BZRA group was 1.48 (95% confidence interval, 1.20-1.82). In the subgroup analysis, patients in the suvorexant group had a higher risk of hip fracture if they were aged >75 years, had no diabetes, had no neurological disease, had no renal failure, had liver disease, had hypertension, were not taking alpha 1 blockers, and were not taking oral steroids. Among people in the Japanese regional population who use sleep drugs, patients taking suvorexant can be at higher risk of hip fracture than patients taking BZRAs.
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Affiliation(s)
- Ryozo Yoshioka
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
- Department of Emergency Medicine, Shizuoka General Hospital, Aoi-ku, Shizuoka, Japan
| | - Seiichiro Yamamoto
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Eiji Nakatani
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
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Takaesu Y, Suzuki M, Moline M, Pinner K, Inabe K, Nishi Y, Kuriyama K. Effect of discontinuation of lemborexant following long-term treatment of insomnia disorder: Secondary analysis of a randomized clinical trial. Clin Transl Sci 2022; 16:581-592. [PMID: 36564964 PMCID: PMC10087073 DOI: 10.1111/cts.13470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/09/2022] [Accepted: 12/16/2022] [Indexed: 12/25/2022] Open
Abstract
Discontinuing long-term pharmacotherapy for insomnia can result in rebound insomnia or withdrawal symptoms and suboptimal treatment. Post hoc analyses evaluated rebound insomnia and withdrawal symptoms among the subset of subjects from a phase III, 12-month, global, multicenter, randomized, double-blind, parallel-group study who completed 12 or 6 months of active treatment and follow-up period. Study E2006-G000-303 (Study 303) included adults (N = 655) with subjective sleep-onset latency ≥30 min and/or subjective wake-after-sleep onset ≥60 min at least three times weekly during the 4 weeks before enrollment. Subjects were randomized 1:1:1 to lemborexant 5 mg (LEM5) or 10 mg (LEM10) or placebo for 6 months. Thereafter, for an additional 6 months, LEM5- and LEM10-treated subjects continued lemborexant and the placebo group was rerandomized 1:1 to LEM5 or LEM10. Month 12 was followed by abrupt discontinuation and a 2-week end-of-study follow-up. Using daily electronic sleep diaries, patients reported (subjective) sleep end points (sleep-onset latency, wake-after-sleep onset, sleep efficiency, and total sleep time). Withdrawal symptoms were assessed using the Tyrer Benzodiazepine Withdrawal Symptoms Questionnaire (T-BWSQ). Sleep outcome improvements with lemborexant at month 12 were generally maintained throughout the 2-week off-treatment period wherein <20% of subjects experienced significant worsening of insomnia symptoms versus screening. There was no evidence of withdrawal symptoms by T-BWSQ following lemborexant discontinuation. This analysis demonstrates rebound insomnia is unlikely to occur with lemborexant, and its effectiveness is maintained after abrupt discontinuation without placebo replacement following 6-12 months of treatment.
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Affiliation(s)
- Yoshikazu Takaesu
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masahiro Suzuki
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | | | | | | | | | - Kenichi Kuriyama
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
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Abstract
Sleep health is an important factor across several physical and mental health disorders, and a growing scientific consensus has identified sleep as a critical component of opioid use disorder (OUD), both in the active disease state and during OUD recovery. The goal of this narrative review is to collate the literature on sleep, opioid use, and OUD as a means of identifying therapeutic targets to improve OUD treatment outcomes. Sleep disturbance is common and often severe in persons with OUD, especially during opioid withdrawal, but also in persons on opioid maintenance therapies. There is ample evidence that sleep disturbances including reduced total sleep time, disrupted sleep continuity, and poor sleep quality often accompany negative OUD treatment outcomes. Sleep disturbances are bidirectionally associated with several other factors related to negative treatment outcomes, including chronic stress, stress reactivity, low positive affect, high negative affect, chronic pain, and drug craving. This constellation of outcome variables represents a more comprehensive appraisal of the quality of life and quality of recovery than is typically assessed in OUD clinical trials. To date, there are very few clinical trials or experimental studies aimed at improving sleep health in OUD patients, either as a means of improving stress, affect, and craving outcomes, or as a potential mechanistic target to reduce opioid withdrawal and drug use behaviors. As such, the direct impact of sleep improvement in OUD patients is largely unknown, yet mechanistic and clinical research suggests that therapeutic interventions that target sleep are a promising avenue to improve OUD treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Parrino L, Halasz P, Szucs A, Thomas RJ, Azzi N, Rausa F, Pizzarotti S, Zilioli A, Misirocchi F, Mutti C. Sleep medicine: Practice, challenges and new frontiers. Front Neurol 2022; 13:966659. [PMID: 36313516 PMCID: PMC9616008 DOI: 10.3389/fneur.2022.966659] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Sleep medicine is an ambitious cross-disciplinary challenge, requiring the mutual integration between complementary specialists in order to build a solid framework. Although knowledge in the sleep field is growing impressively thanks to technical and brain imaging support and through detailed clinic-epidemiologic observations, several topics are still dominated by outdated paradigms. In this review we explore the main novelties and gaps in the field of sleep medicine, assess the commonest sleep disturbances, provide advices for routine clinical practice and offer alternative insights and perspectives on the future of sleep research.
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Affiliation(s)
- Liborio Parrino
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- *Correspondence: Liborio Parrino
| | - Peter Halasz
- Szentagothai János School of Ph.D Studies, Clinical Neurosciences, Semmelweis University, Budapest, Hungary
| | - Anna Szucs
- Department of Behavioral Sciences, National Institute of Clinical Neurosciences, Semmelweis University, Budapest, Hungary
| | - Robert J. Thomas
- Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Nicoletta Azzi
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
| | - Francesco Rausa
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Silvia Pizzarotti
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
| | - Alessandro Zilioli
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Francesco Misirocchi
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Carlotta Mutti
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
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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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Ikeda S, Azuma MK, Fujimoto K, Shibahara H, Inoue S, Moline M, Ishii M, Mishima K. Cost-effectiveness analysis of lemborexant for treating insomnia in Japan: a model-based projection, incorporating the risk of falls, motor vehicle collisions, and workplace accidents. Psychol Med 2022; 52:2822-2834. [PMID: 35506334 PMCID: PMC9647554 DOI: 10.1017/s0033291722000356] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 01/21/2022] [Accepted: 01/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Lemborexant has demonstrated statistically significant improvements in sleep onset and sleep maintenance compared with placebo and zolpidem tartrate extended release, measured both objectively using polysomnography and subjectively using sleep diaries, in the phase 3 clinical trial SUNRISE 1. This study evaluated the cost-effectiveness of lemborexant compared with suvorexant, zolpidem immediate release (IR), and untreated insomnia. METHODS A decision-tree model was developed for falls, motor vehicle collisions, and workplace accidents associated with insomnia and insomnia treatments from a Japanese healthcare perspective and with a 6-month time horizon. The model extracted subjective sleep onset latency treatment responses and disutility values for non-responders from SUNRISE 1. Cost-effectiveness was assessed using incremental cost per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were conducted to evaluate the impact of parameter uncertainty on the results. RESULTS In the base-case analysis, the mean estimated QALYs for lemborexant, suvorexant, zolpidem-IR, and untreated insomnia were 0.4220, 0.4204, 0.4113, and 0.4163, and expected medical costs were JPY 34 034, JPY 38 371, JPY 38 139, and JPY 15 383, respectively. Lemborexant saved JPY 4337 and JPY 4105 compared with suvorexant or zolpidem-IR, respectively, while conferring QALY benefits. The incremental cost-effectiveness ratio (ICER) of lemborexant compared with that of untreated insomnia was JPY 3 220 975 /QALY. Lemborexant was dominant over suvorexant and zolpidem-IR and was cost-effective when compared with untreated insomnia. Sensitivity analyses supported the results' robustness. CONCLUSIONS In a Japanese clinical practice setting, lemborexant may represent a better investment for treating insomnia in the healthcare system in Japan.
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Affiliation(s)
- Shunya Ikeda
- Department of Public Health, School of Medicine, International University of Health and Welfare, Narita, Japan
| | | | | | - Hidetoshi Shibahara
- CRECON Medical Assessment Inc., Tokyo, Japan
- Graduate School of Health and Welfare, International University of Health and Welfare, Tokyo, Japan
| | | | | | | | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
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Dos Santos JBR, da Silva MRR. Daridorexant for the treatment of insomnia disorder: findings and implications. Eur J Clin Pharmacol 2022; 78:1749-1761. [PMID: 36098753 DOI: 10.1007/s00228-022-03381-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 09/03/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The involvement of the orexin system in the physiopathology of insomnia has been rapidly increasing in understanding. In this sense, daridorexant was the third orexin receptor antagonist approved by the FDA in January 2022. This review aims to summarize the chemistry, pharmacodynamics, pharmacokinetics, efficacy, safety, and tolerability profile of daridorexant for the treatment of insomnia disorder. METHODS We performed a review of daridorexant for the treatment of insomnia disorder. The search was carried out in Medline via PubMed, Embase, and clinical trials, up to March 2022. RESULTS Daridorexant 25 and 50 mg had more significant improvement for the wake after sleep onset (WASO), latency to persistent sleep (LPS), and subjective total sleep time (sTST) than placebo. In addition, daridorexant 50 mg was better for Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ) than placebo. The most common adverse events were nasopharyngitis and headache. CONCLUSION Daridorexant was efficacious and safe. Studies that evaluate the long-term safety and compare daridorexant with benzodiazepines, benzodiazepine receptor agonists, sedative antidepressants, and other orexin receptor antagonists are required.
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Affiliation(s)
- Jéssica Barreto Ribeiro Dos Santos
- Health Technology Assessment and Economy Group, Center for Exact, Natural and Health Sciences, Federal University of Espírito Santo, Alto Universitário S/N, Guararema, Alegre, Espírito Santo, 29500-000, Brazil
| | - Michael Ruberson Ribeiro da Silva
- Health Technology Assessment and Economy Group, Center for Exact, Natural and Health Sciences, Federal University of Espírito Santo, Alto Universitário S/N, Guararema, Alegre, Espírito Santo, 29500-000, Brazil.
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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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Uemura SI, Imanishi A, Terui Y, Park I, Satake M, Han G, Shioya T, Kanbayashi T, Nishino S. Residual effects of low dose of suvorexant, zolpidem, and ramelteon in healthy elderly subjects: A randomized double‐blind study. Neuropsychopharmacol Rep 2022; 42:288-298. [PMID: 35748642 PMCID: PMC9515713 DOI: 10.1002/npr2.12262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/27/2022] [Accepted: 05/01/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Methods Result Conclusion
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Affiliation(s)
- Sachiko Ito Uemura
- Department of Physical Therapy Akita University Graduate School of Health Sciences Akita Japan
| | - Aya Imanishi
- Department of Psychiatry Akita University Graduate School of Medicine Akita Japan
| | - Yoshino Terui
- Department of Physical Therapy Akita University Graduate School of Health Sciences Akita Japan
| | - Insung Park
- International Institute for Integrative Sleep Medicine (WPI‐IIIS) University of Tsukuba Tsukuba Japan
| | - Masahiro Satake
- Department of Physical Therapy Akita University Graduate School of Health Sciences Akita Japan
| | - GoEun Han
- International Institute for Integrative Sleep Medicine (WPI‐IIIS) University of Tsukuba Tsukuba Japan
| | | | - Takashi Kanbayashi
- International Institute for Integrative Sleep Medicine (WPI‐IIIS) University of Tsukuba Tsukuba Japan
- Ibaraki Prefectural Medical Center of Psychiatry Kasama Japan
| | - Seiji Nishino
- Sleep & Circadian Neurobiology Laboratory, Stanford Sleep Research Center Stanford University School of Medicine Palo Alto California USA
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Dujardin S, Pijpers A, Pevernagie D. Prescription Drugs Used in Insomnia. Sleep Med Clin 2022; 17:315-328. [PMID: 36150797 DOI: 10.1016/j.jsmc.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In insomnia, the subjective aspects of the sleep complaint are paramount in the diagnostic criteria. Epidemiologic studies increasingly point to a link between insomnia and somatic morbidity and mortality, but until now, only in the subgroup of objectively poor sleepers. Although pharmacologic treatment might offer some benefits to this subgroup of insomnia patients, to date, there is no evidence that hypnotics can ameliorate their health risks. Further unraveling of the neurobiology and genetics of sleep regulation and the pathophysiology of insomnia will help the development of drugs that not only improve subjective sleep complaints but also objective health outcomes.
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Affiliation(s)
- Sylvie Dujardin
- Sleep Medicine Center Kempenhaeghe, PO Box 61, Heeze 5590 AB, the Netherlands
| | - Angelique Pijpers
- Sleep Medicine Center Kempenhaeghe, PO Box 61, Heeze 5590 AB, the Netherlands
| | - Dirk Pevernagie
- Sleep Medicine Center Kempenhaeghe, PO Box 61, Heeze 5590 AB, the Netherlands; Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, Ghent 9000, Belgium.
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