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SLEEP
MEDICINE

M aybe you have heard this from a family member or friend: mended as a first line therapy for treatment of chronic insomnia. How-
In addition to pharmacotherapy options, CBT-I is still recom-
“I don’t sleep at all. I just lie awake the whole night.” Though
this is typically a vast exaggeration, we’ve all encountered
this patient before. In a sleep medicine clinic, it seems to occur daily. ever, treatment is not always attainable. It typically consists of about
six sessions of provider-directed therapy, making it time-consuming
The bottom line is, most people know when they’re not getting adequate for the patient. It also requires immense self-discipline and commit-
sleep, and they feel the effects. Whether the ment from the patient. Finding a provider
cause is psychological, mental illness, be- who is educated in CBT-I can also be diffi-
havioral health, pain or something else en- cult. Lastly, it is not always covered by in-
tirely, it’s up to us to help the patient find surance, so six sessions can become cost
relief. prohibitive. However, a recent study uti-
Various medications have been used off- lizing nurses to direct sleep restriction
label for decades to help induce or maintain therapy over four sessions showed im-
sleep, sometimes with very undesirable side provement in insomnia compared to pro-
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effects. There are also a handful of FDA-ap- viding education on sleep hygiene alone.
proved sleep medications — mostly benzo- Though insomnia continues to be a
diazepine hypnotics — but they also have common problem for patients, the newer
risks of side effects, dependence and toler- treatment options all appear to be an im-
ance. However, the newest class of medica- provement. Traditional insomnia medica-
tions available, dual orexin antagonists tions and even off-label medications
(DORAs), seem to be showing more prom- certainly still have their place. They are still
ise. Cognitive behavioral therapy for insom- used frequently in our sleep medicine prac-
nia (CBT-I) has also been recommended as tice at University Health, which includes
a first-line treatment for chronic insomnia, our Sleep Lab where specialists use tech-
though there are many barriers to treat- nology to monitor you while you sleep. We
ment. There is new data showing that an ab- anticipate increased use of DORAs and
breviated form of CBT-I can be an effective the various forms of CBT-I as insurance
treatment, as well. coverage improves.
DORAs include lemborexant (Dayvigo), suvorexant (Belsomra) and
the newest addition: daridorexant (Quviviq). These medications prevent References:
wake-promotion by blocking the binding of neuropeptides, orexin A and 1. Neubauer, David N. “Pharmacotherapy For Insomnia in Adults.” Up-
orexin B. These medications had excellent efficacy compared against ToDate, 29 Jan. 2024. www.uptodate.com/contents/pharmacother-
placebo and zolpidem in clinical trials, but are more appealing since they apy-for-insomnia-in-adults?sectionName=Special+populations&to
appear to have fewer side effects. They are effective at improving sleep picRef=107235&anchor=H1357008358&source=see_link#H337
onset, duration and quality, with studies showing sustained effects at 12 9101117
months. There has been no evidence of respiratory depression with 2. Kyle SD, Siriwardena AN, Espie CA, et al. Clinical and cost-effec-
DORAs, and users experienced fewer falls while using DORAs compared tiveness of nurse-delivered sleep restriction therapy for insomnia in
to BZRAs. That makes them an ideal choice for geriatric patients or those primary care (HABIT): A pragmatic, superiority, open-label, ran-
with underlying sleep apnea or other respiratory conditions. These med- domized controlled trial. Lancet 2023; 402:975
ications also had no evidence of physical dependency and low abuse po-
tential. There were also no reports of complex sleep behaviors such as sleep Elise Vader is a physician assistant who received an undergrad-
walking/talking/eating or memory disturbance, which are sometimes seen uate degree in biology from Texas A&M University, College Sta-
with BZRAs. However, they do carry the same risk of next-day somno- tion and a master’s degree in Physician Assistant Studies from
lence as with other sleep medications, but to a lesser degree. Additionally, University of Texas Medical Branch, Galveston. She has been in practice
concomitant use with strong CYP3A inhibitors is not recommended. at University Health for nine years, providing care to patients in both pri-
Thus far, the biggest obstacle we’ve experienced with prescribing DORAs mary care and sleep medicine and has been certified to provide cognitive
has been poor insurance coverage. Few insurances include DORAs on behavioral therapy for insomnia.
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their formulary and prior authorizations are frequently denied.
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