II. Indications

III. Preparations

  1. Quviviq (Daridorexant) 25 to 50 mg orally at bedtime
  2. Belsomra (Suvorexant) 10 to 20 mg orally at bedtime
    1. Onset: 30 minutes
    2. Half-Life: 12 hours
  3. Dayvigo (Lemborexant) 5 to 10 mg orally at bedtime
    1. Onset: 15 to 20 minutes
    2. Half-Life: 17 to 19 hours

IV. Mechanism

  1. FDA Schedule IV Agent (as with other Nonbenzodiazepine Sedative-Hypnotic agents)
  2. Orexin (hypocretin) is a Neurotransmitter that promotes wakefulness (deficiency in Narcolepsy)
  3. Blocking orexin transiently allows for sleep

V. Efficacy

  1. Similar effectiveness to other standard agents used for Insomnia (e.g. Zolpidem)
  2. Compared with Placebo
    1. Reduce time to sleep onset by 5 to 10 minutes
    2. Increase sleep duration by 15 to 20 minutes (22 minutes for Belsomra)

VI. Adverse Effects

  1. Daytime Somnolence (including the next day)
  2. Sleep Paralysis or Leg weakness (transient, rare)

VII. Drug Interactions

  1. Metabolized by CYP3A4
  2. Moderate CYP3A4 Inhibitors (e.g. Verapamil)
    1. Start Belsomra at low dose (e.g. 5 mg)
  3. Strong CYP3A4 Inhibitors (e.g. Clarithromycin, Itraconazole)
    1. Avoid Belsomra with strong CYP3A4 Inhibitors

VIII. Disadvantages

  1. Expensive agents ($300/month or $15/dose)
  2. No benefit over Zolpidem (Ambien) which is $10/month at generic pricing

IX. References

  1. (2015) Presc Lett 22(2):10
  2. (2022) Presc Lett 29(6): 34

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Related Studies

Cost: Medications

belsomra (on 1/6/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
BELSOMRA 10 MG TABLET $9.82 each
BELSOMRA 15 MG TABLET $9.81 each
BELSOMRA 20 MG TABLET $9.81 each
BELSOMRA 5 MG TABLET $10.00 each