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Ozone M, Hirota S, Ariyoshi Y, Hayashida K, Ikegami A, Habukawa M, Ohshima H, Harada D, Hiejima H, Kotorii N, Murotani K, Taninaga T, Uchimura N. Efficacy and Safety of Transitioning to Lemborexant from Z-drug, Suvorexant, and Ramelteon in Japanese Insomnia Patients: An Open-label, Multicenter Study. Adv Ther 2024; 41:1728-1745. [PMID: 38460107 PMCID: PMC10960898 DOI: 10.1007/s12325-024-02811-2] [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: 08/21/2023] [Accepted: 02/02/2024] [Indexed: 03/11/2024]
Abstract
INTRODUCTION For patients with chronic insomnia, conventional therapy may not always provide satisfactory efficacy and safety. Thus, switching to an alternative therapeutic agent can be explored. However, there is a lack of prospective studies evaluating the effectiveness of such changes. This prospective, non-randomized, open-label, interventional, multicenter study assessed whether Japanese patients with chronic insomnia dissatisfied with treatment could transition directly to lemborexant (LEM) from four cohorts-non-benzodiazepine sedative-hypnotic (zolpidem, zopiclone, or eszopiclone) monotherapy, dual orexin receptor antagonist (suvorexant) monotherapy, suvorexant + benzodiazepine receptor agonists (BZRAs), and melatonin receptor agonist (ramelteon) combination. We evaluated whether transitioning to LEM improved patient satisfaction based on efficacy and safety. METHODS The primary endpoint was the proportion of successful transitions to LEM at 2 weeks (titration phase end), defined as the proportion of patients on LEM by the end of the 2-week titration phase who were willing to continue on LEM during the maintenance phase (Weeks 2-14). Patient satisfaction and safety (the incidence of treatment-emergent adverse events [TEAEs]) were assessed at 14 weeks (end of titration and maintenance phases). RESULTS Among the 90 patients enrolled, 95.6% (95% confidence interval: 89.0-98.8%) successfully transitioned to LEM at 2 weeks. The proportions of patients who successfully continued on LEM were 97.8% and 82.2% at the end of the titration and maintenance phases (Weeks 2 and 14), respectively. The overall incidence of TEAEs was 47.8%; no serious TEAEs occurred. In all cohorts, the proportions of patients with positive responses were higher than the proportions with negative responses on the three scales of the Patient Global Impression-Insomnia version. During the maintenance phase, Insomnia Severity Index scores generally improved at Weeks 2, 6, and 14 of LEM transition. CONCLUSIONS Direct transition to LEM may be a valid treatment option for patients with insomnia who are dissatisfied with current treatment. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT04742699.
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Affiliation(s)
- Motohiro Ozone
- Department of Neuropsychiatry, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, Japan.
| | | | | | | | | | - Mitsunari Habukawa
- Department of Neuropsychiatry, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, Japan
| | - Hayato Ohshima
- Department of Neuropsychiatry, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, Japan
| | | | - Hiroshi Hiejima
- Department of Neuropsychiatry, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, Japan
| | | | | | | | - Naohisa Uchimura
- Department of Neuropsychiatry, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, Japan
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Murayama T, Ito Y, Narita K, Ishida T, Hinotsu S, Fujita M. The effect of lemborexant on insomnia in patients with psychiatric disorders: Detailed evaluation using the Athens Insomnia Scale. PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2024; 3:e165. [PMID: 38868465 PMCID: PMC11114419 DOI: 10.1002/pcn5.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 06/14/2024]
Abstract
Aim Chronic insomnia disorder is common and associated with reduced quality of life. Benzodiazepine hypnotics are commonly prescribed for insomnia, but have potential side effects such as concentration impairment, somnolence, and dependence. Lemborexant (LEM) is an orexin receptor antagonist considered to have fewer side effects than benzodiazepine hypnotics. This study evaluated the effect of LEM on sleep in detail and examined whether benzodiazepine hypnotics can be gradually tapered by adding LEM. Methods We retrospectively examined the effectiveness of LEM in 28 outpatients with insomnia. Insomnia symptoms were assessed using the Athens Insomnia Scale (AIS) before and after LEM administration. We also attempted to taper benzodiazepine hypnotics and assessed benzodiazepine dose using diazepam equivalents for some patients taking benzodiazepine hypnotics. Wilcoxon's signed-rank test was used for statistical analysis. Results The mean AIS score was significantly improved after LEM treatment (8.7 ± 5.2 vs. 3.8 ± 3.3; P < 0.01). Among the AIS subitems, significant improvement was observed for six items: sleep induction, awakenings during the night, sleep quality, well-being, functioning capacity, and sleepiness during the day. The mean benzodiazepine dose was significantly lower after LEM treatment (4.6 ± 5.0 mg vs. 2.1 ± 3.3 mg; P < 0.01). Conclusions This study indicated the potential of LEM for improving insomnia and reducing benzodiazepine dose.
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Affiliation(s)
- Tomonori Murayama
- Department of PsychiatryAsahikawa Keisenkai HospitalHokkaidoJapan
- Department of PsychiatryKushiro Red Cross HospitalHokkaidoJapan
| | - Yuji Ito
- Department of PsychiatryKushiro Red Cross HospitalHokkaidoJapan
| | - Kenji Narita
- Department of PsychiatryKushiro Red Cross HospitalHokkaidoJapan
- Graduate school of MedicineSapporo Medical UniversityHokkaidoJapan
| | - Tetsuro Ishida
- Department of PsychiatryJapan Health Care UniversityHokkaidoJapan
| | - Shiro Hinotsu
- Department of Biostatistics and Data ManagementSapporo Medical UniversityHokkaidoJapan
| | - Masahiko Fujita
- Wellness Boyo Hospital Otaru Sleep Disorders ClinicHokkaidoJapan
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Horikoshi S, Miura I, Suzuki Y, Kobayashi Y, Hirata Y, Goto M, Ichinose M, Yamamoto S, Kanno-Nozaki K, Watanabe K, Yabe H. Switching to lemborexant for the management of insomnia in mental disorders: the SLIM study. J Clin Sleep Med 2023; 19:1753-1758. [PMID: 37243798 PMCID: PMC10545988 DOI: 10.5664/jcsm.10668] [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: 11/20/2022] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023]
Abstract
STUDY OBJECTIVES We conducted a retrospective study to investigate the efficacy and safety of switching from other hypnotics, including benzodiazepines and Z-drugs, suvorexant, ramelteon, mirtazapine, trazodone, and antipsychotics, to lemborexant, a dual orexin receptor antagonist, for 3 months. METHODS Clinical data obtained from the medical records of 61 patients treated at the Horikoshi Psychosomatic Clinic between December 2020 and February 2022 were analyzed, including the Athens Insomnia Scale, Epworth Sleepiness Scale, and Perceived Deficits Questionnaire-5. The primary outcome was the mean change in Athens Insomnia Scale score after 3 months. Secondary outcomes were the mean changes in the Epworth Sleepiness Scale and Perceived Deficits Questionnaire-5 scores over 3 months. We also compared pre- and post-diazepam equivalents. RESULTS The mean Athens Insomnia Scale score decreased over 3 months after switching to lemborexant (1 mo: -2.98 ± 5.19, P < .001; 2 mo: -3.20 ± 5.64, P < .001; 3 mo: -3.38 ± 5.61, P < .001). Mean Epworth Sleepiness Scale score did not change from baseline to 1 month (-0.49 ± 3.41, P = 0.27), 2 months (0.082 ± 4.62, P = .89), or 3 months (-0.64 ± 4.80, P = .30). Mean Perceived Deficits Questionnaire-5 score did improve from baseline to 1 month (-1.17 ± 2.47, P = .004), 2 months (-1.05 ± 2.97, P = .029), and 3 months (-1.24 ± 3.06, P = .013). There was also a reduction in the total diazepam equivalent (baseline vs 3 mo: 14.0 ± 20.2 vs 11.3 ± 20.6, P < .001). CONCLUSIONS Our study showed that, by switching to lemborexant from other hypnotics, the risks associated with benzodiazepines and Z-drugs may be reduced. CITATION Horikoshi S, Miura I, Suzuki Y, et al. Switching to lemborexant for the management of insomnia in mental disorders: the SLIM study. J Clin Sleep Med. 2023;19(10):1753-1758.
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Affiliation(s)
- Sho Horikoshi
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Neuropsychiatry, Horikoshi Psychosomatic Clinic, Fukushima, Japan
| | - Itaru Miura
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuhei Suzuki
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuri Kobayashi
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yoichiro Hirata
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masayuki Goto
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mizue Ichinose
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shinnosuke Yamamoto
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Keiko Kanno-Nozaki
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kenya Watanabe
- Department of Pharmacy, Fukushima Medical University School, Fukushima, Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
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Takaesu Y, Sakurai H, Aoki Y, Takeshima M, Ie K, Matsui K, Utsumi T, Shimura A, Okajima I, Kotorii N, Yamashita H, Suzuki M, Kuriyama K, Shimizu E, Mishima K, Watanabe K, Inada K. Treatment strategy for insomnia disorder: Japanese expert consensus. Front Psychiatry 2023; 14:1168100. [PMID: 37229388 PMCID: PMC10203548 DOI: 10.3389/fpsyt.2023.1168100] [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: 02/17/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
Purpose There is a lack of evidence regarding answers for clinical questions about treating insomnia disorder. This study aimed to answer the following clinical questions: (1) how to use each hypnotic and non-pharmacological treatment differently depending on clinical situations and (2) how to reduce or stop benzodiazepine hypnotics using alternative pharmacological and non-pharmacological treatments. Methods Experts were asked to evaluate treatment choices based on 10 clinical questions about insomnia disorder using a nine-point Likert scale (1 = "disagree" to 9 = "agree"). The responses of 196 experts were collected, and the answers were categorized into first-, second-, and third-line recommendations. Results The primary pharmacological treatment, lemborexant (7.3 ± 2.0), was categorized as a first-line recommendation for sleep initiation insomnia, and lemborexant (7.3 ± 1.8) and suvorexant (6.8 ± 1.8) were categorized as the first-line recommendations for sleep maintenance insomnia. Regarding non-pharmacological treatments for primary treatment, sleep hygiene education was categorized as the first-line recommendation for both sleep initiation (8.4 ± 1.1) and maintenance insomnia (8.1 ± 1.5), while multicomponent cognitive behavioral therapy for insomnia was categorized as the second-line treatment for both sleep initiation (5.6 ± 2.3) and maintenance insomnia (5.7 ± 2.4). When reducing or discontinuing benzodiazepine hypnotics by switching to other medications, lemborexant (7.5 ± 1.8) and suvorexant (6.9 ± 1.9) were categorized as first-line recommendations. Conclusion Expert consensus indicates that orexin receptor antagonists and sleep hygiene education are recommended as first-line treatments in most clinical situations to treat insomnia disorder.
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Affiliation(s)
- Yoshikazu Takaesu
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
- Department of Neuropsychiatry, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Hitoshi Sakurai
- Department of Neuropsychiatry, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Yumi Aoki
- Department of Neuropsychiatry, Faculty of Medicine, Kyorin University, Tokyo, Japan
- Psychiatric and Mental Health Nursing, St. Luke’s International University, Tokyo, Japan
| | - Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Kenya Ie
- Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
- Division of General Internal Medicine, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
| | - Kentaro Matsui
- Department of Clinical Laboratory, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Tomohiro Utsumi
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Psychiatry, The Jikei University School of Medicine, Tokyo, Japan
| | - Akiyoshi Shimura
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Isa Okajima
- Department of Psychological Counseling, Faculty of Humanities, Tokyo Kasei University, Tokyo, Japan
| | - Nozomu Kotorii
- Kotorii Isahaya Hospital, Nagasaki, Japan
- Department of Psychiatry, School of Medicine, Kurume University, Fukuoka, 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
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Eiji Shimizu
- Research Center for Child Mental Development, Chiba University, Chiba, Japan
- Department of Cognitive Behavioral Physiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Ken Inada
- Department of Psychiatry, School of Medicine, Kitasato University, Tokyo, Japan
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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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Baldwin DS. Clinical management of withdrawal from benzodiazepine anxiolytic and hypnotic medications. Addiction 2022; 117:1472-1482. [PMID: 34542216 DOI: 10.1111/add.15695] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/22/2021] [Indexed: 11/30/2022]
Abstract
Benzodiazepines continue to be prescribed widely in the management of patients with insomnia or anxiety disorders, despite the availability and acceptability of alternative pharmacological and psychological treatments. Many patients will experience adverse effects during treatment and considerable distress when the dosage is reduced and stopped. Management of benzodiazepine withdrawal includes measures to prevent the development of dependence, careful attention to underlying medical conditions, medication consolidation and gradual dosage reduction, accompanying psychological interventions, occasional prescription of concomitant medication, and relapse prevention with on-going support to address psychosocial stressors. There are needs for easier patient access to services with refined expertise and for further research to optimise strategies for preventing dependence and facilitating withdrawal.
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Affiliation(s)
- David S Baldwin
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.,Mood and Anxiety Disorders Service, Southern Health NHS Foundation Trust, Southampton, UK
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Berger AA, Sottosanti ER, Winnick A, Keefe J, Gilbert E, Hasoon J, Thase ME, Kaye AD, Viswanath O, Urits I. Suvorexant in the Treatment of Difficulty Falling and Staying Asleep (Insomnia). PSYCHOPHARMACOLOGY BULLETIN 2022; 52:68-90. [PMID: 35342199 PMCID: PMC8896749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Purpose of Review Insomnia affects more than 10% of the population and causes significant discomfort and disability. Suvorexant is an orexin receptor antagonist that specifically targets the wake-sleep cycle. This review summarizes recent and seminal evidence in the biological and physiological evidence of insomnia, the mechanism of action of suvorexant in treating insomnia, and clinical evidence regarding its use. Recent Findings There is no single clear diagnosis for insomnia, and thus prevalence is not entirely clear, but it is estimated to affect 10%-30% of the adult population. Comorbidities include obesity, diabetes, and various psychiatric conditions, and insomnia likely has a contributing role in these conditions. Insomnia, by definition, impacts sleep quality and also wakefulness, including academic success and work efficiency. Insomnia is likely related to genetic susceptibility and a triggering event, leading to hyper-arousal states and functional brain disturbances. This leads to hyperactivity of the hypothalamic-pituitary-adrenal axis, over-secretion of corticotropin-releasing factor, and aberrancy in neurotransmitter release. Though several pharmacological options exist for the treatment of insomnia, there is equivocal data regarding their efficacy or limits to their use due to side effects and contraindications. Suvorexant is a novel dual orexin receptor antagonist, which is shown to improve sleep by reducing arousals. Unlike classical therapeutics, suvorexant does not alter the sleep profile; it prolongs the time spent in each sleep state. Though it may cause some somnolence, it is milder than reported with other drugs. Summary Multiple clinical studies support the use of suvorexant in insomnia. In primary insomnia, suvorexant is effective (over placebo), as measured by polysomnography and reported by patients, in both attaining and maintaining sleep. Similar, albeit to a smaller degree, results were found in secondary insomnia. Suvorexant carries two significant advantages over existing therapies; it has a much better safety profile in approved doses, and it preserves natural sleep architecture, thus promoting more restful sleep and recovery. Unfortunately, data exists mostly for suvorexant versus placebo, and head-to-head trials with common hypnotics are needed to assess the true efficacy of suvorexant over the alternatives. And while tolerance is less likely to develop, close monitoring of post-marketing data is required to evaluate for long term adverse events and efficacy.
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Campbell R, Chabot I, Rousseau B, Bridge D, Nicol G, Meier G. Understanding the unmet needs in insomnia treatment: a systematic literature review of real-world evidence. Int J Neurosci 2021:1-15. [PMID: 34668828 DOI: 10.1080/00207454.2021.1995383] [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: 10/20/2022]
Abstract
STUDY OBJECTIVE The objective of this study was to define and characterize the unmet needs in the pharmacological management of insomnia. METHODS A systematic literature review was conducted to identify relevant literature reporting real-world evidence in insomnia, published from January 2009 to April 2020. Pharmacological treatments - both prescription (benzodiazepines, 'Z-drugs' and suvorexant) and off-label (antidepressants, antipsychotics, and antihistamines) - were considered. RESULTS Overall, 108 publications describing the humanistic (n = 59) and economic burden (n = 20) of insomnia, off-label treatment patterns (n = 28) and factors influencing treatment adherence or persistence (n = 8) were identified. A high prevalence of comorbid conditions was reported in patients with insomnia resulting in significantly lower health-related QoL compared to those with insomnia or a comorbidity alone. Current treatment options were associated with adverse events, including reduced sleep quality and next-day somnolence. An increased risk of accidents/injuries was also associated with insomnia and its treatment. Furthermore, safety concerns and perceived lack of efficacy for approved treatments have led to frequent off-label prescribing, despite a lack of clinical evidence of risk/benefit ratios. Safety concerns associated with benzodiazepines include risk of dependence, leading to prolonged treatment persistence and exacerbated adverse events, making them unsuitable for use in patients with chronic insomnia. Finally, the substantial economic burden of insomnia was evident, with reduced work productivity demonstrated in patients with insomnia compared to the general population. CONCLUSIONS This review highlights a clear unmet need for insomnia therapies that improve sleep quality without resulting in next-day impairment and/or dependence.
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Affiliation(s)
- Renee Campbell
- Formerly at Global Value and Access, Eisai, New York, USA
| | - Isabelle Chabot
- Faculty of Pharmacy, University of Montreal, Montreal, Canada
| | - Ben Rousseau
- Adelphi Values PROVE, Adelphi Mill, Bollington, UK
| | - Daisy Bridge
- Adelphi Values PROVE, Adelphi Mill, Bollington, UK
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Han Y, Yuan K, Zheng Y, Lu L. Orexin Receptor Antagonists as Emerging Treatments for Psychiatric Disorders. Neurosci Bull 2020; 36:432-448. [PMID: 31782044 PMCID: PMC7142186 DOI: 10.1007/s12264-019-00447-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022] Open
Abstract
Orexins comprise two neuropeptides produced by orexin neurons in the lateral hypothalamus and are released by extensive projections of these neurons throughout the central nervous system. Orexins bind and activate their associated G protein-coupled orexin type 1 receptors (OX1Rs) and OX2Rs and act on numerous physiological processes, such as sleep-wake regulation, feeding, reward, emotion, and motivation. Research on the development of orexin receptor antagonists has dramatically increased with the approval of suvorexant for the treatment of primary insomnia. In the present review, we discuss recent findings on the involvement of the orexin system in the pathophysiology of psychiatric disorders, including sleep disorders, depression, anxiety, and drug addiction. We discuss the actions of orexin receptor antagonists, including selective OX1R antagonists (SORA1s), selective OX2R antagonists (SORA2s), and dual OX1/2R antagonists (DORAs), in the treatment of these disorders based on both preclinical and clinical evidence. SORA2s and DORAs have more pronounced efficacy in the treatment of sleep disorders, whereas SORA1s may be promising for the treatment of anxiety and drug addiction. We also discuss potential challenges and opportunities for the application of orexin receptor antagonists to clinical interventions.
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Affiliation(s)
- Ying Han
- National Institute of Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, 100191, China
| | - Kai Yuan
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, 100191, China
- Peking-Tsinghua Center for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, 100871, China
| | - Yongbo Zheng
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, 100191, China
| | - Lin Lu
- National Institute of Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, 100191, China.
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, 100191, China.
- Peking-Tsinghua Center for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, 100871, China.
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Campbell EJ, Norman A, Bonomo Y, Lawrence AJ. Suvorexant to treat alcohol use disorder and comorbid insomnia: Plan for a phase II trial. Brain Res 2019; 1728:146597. [PMID: 31837287 DOI: 10.1016/j.brainres.2019.146597] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 11/16/2022]
Abstract
Alcohol use disorder (AUD) is a complex neuropsychiatric disease state in which currently approved pharmacotherapeutics are of relatively low effect at a population level. One reason for this may be that current pharmacotherapeutics focus on the reward pathway in relapse prevention, rather than addressing AUD from a holistic perspective. Importantly, one often overlooked symptom of AUD is sleep disruption. In recent years, an efficient, relatively low risk and economic strategy that has proven successful in other disorders is the repositioning or repurposing of drugs approved for the treatment of other indications. Suvorexant, a dual orexin receptor antagonist, has been licensed for the treatment of insomnia in the USA, Australia and Japan. The orexin system also plays a role in the emotional dysregulation that occurs during withdrawal from alcohol use and in alcohol-seeking behaviours. These two factors prompted the planning of a clinical trial into the use of suvorexant to treat insomnia in alcohol dependent individuals during and 24 weeks post-acute alcohol withdrawal. In this review we outline the comorbid nature of AUD and sleep disruptions. We then highlight the role of the orexin system in both sleep-wake regulation and AUD. Finally, we discuss our plan for a Phase II double blind placebo controlled trial examining the effectiveness of suvorexant for the treatment of comorbid insomnia and AUD.
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Affiliation(s)
- Erin J Campbell
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Victoria 3010, Australia
| | - Amanda Norman
- St Vincent's Hospital Melbourne, Department of Addiction Medicine, The University of Melbourne, Victoria 3010, Australia
| | - Yvonne Bonomo
- St Vincent's Hospital Melbourne, Department of Addiction Medicine, The University of Melbourne, Victoria 3010, Australia
| | - Andrew J Lawrence
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Victoria 3010, Australia.
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Sano H, Asai Y, Miyazaki M, Iwakura M, Maeda Y, Hara M. Safety profile and clinical course of patients with insomnia administered suvorexant by initial treatment status in a post-marketing survey. Expert Opin Drug Saf 2019; 18:1109-1118. [PMID: 31478753 DOI: 10.1080/14740338.2019.1657091] [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: 10/26/2022]
Abstract
Objectives: Suvorexant is a dual orexin receptor antagonist used for treating insomnia. The authors elucidated the safety profiles and clinical course of insomnia therapy with suvorexant under different initial treatment status seen in daily routine practice. Methods: Subgroup analysis of a post-marketing survey (PMS; 2015-2017) divided patients based on their initial treatment status with suvorexant into 'hypnotic-naïve (Group N)', 'switching from a prior sleep medication (Group S),' 'add-on therapy (Group A),' and 'others (Group O).' Results: Among 3248 patients analyzed in the PMS, the number of patients in Groups N, S, A, and O was 1946 (59.9%), 703 (21.6%), 536 (16.5%), and 63 (1.9%), respectively. The incidence of insomnia-related adverse drug reactions (ADRs) in Group S (5.3%) tended to be higher than that in Groups N (0.46%) and A (1.5%). Discontinuation rate due to an inadequate effect at 6 months in Group S (14.9%) tended to be higher than that in Groups N (9.6%) and A (10.4%). Conclusion: The results suggest that initiating suvorexant treatment after switching from other insomnia medication must require careful monitoring of insomnia-related ADRs, which might be due to abrupt discontinuation of the prior insomnia medication use.
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Affiliation(s)
- Hideki Sano
- CNS Medical Information, Medical Affairs, MSD K.K ., Tokyo , Japan
| | - Yuko Asai
- Pharmacovigilance, MSD K.K ., Tokyo , Japan
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