From the Guidelines
Lemborexant can be considered a safer alternative to clonazepam for patients with insomnia due to its lower risk of dependence and tolerance. According to the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines, benzodiazepines like clonazepam are advised against for the treatment of chronic insomnia disorder due to their widely known harms and adverse effects, including risk for dependency and diversion, falls and cognitive impairment in older patients, hypoventilation in patients with respiratory conditions, and neuromuscular diseases 1. Lemborexant, a dual orexin receptor antagonist, is specifically approved for insomnia and has a more targeted mechanism of action, blocking orexin signaling to regulate wakefulness. This is in contrast to clonazepam, which enhances GABA activity, causing broader CNS depression.
- Key differences between lemborexant and clonazepam include:
- Mechanism of action: Lemborexant blocks orexin signaling, while clonazepam enhances GABA activity
- Risk of dependence and tolerance: Lemborexant has a lower risk compared to clonazepam
- Potential for next-day impairment: Lemborexant is less likely to cause next-day impairment at recommended doses
- When considering lemborexant as an alternative to clonazepam, it is essential to:
- Prescribe lemborexant at the recommended dose of 5-10 mg taken once nightly immediately before bedtime
- Gradually switch patients from clonazepam to lemborexant under medical supervision to avoid withdrawal symptoms
- Advise patients not to take lemborexant with alcohol or other CNS depressants and to plan for 7-8 hours of sleep after taking it to avoid morning drowsiness. The guidelines emphasize the importance of using nonbenzodiazepine agents, like lemborexant, at the lowest effective dose and for the shortest possible duration, and counseling patients on potential risks 1.
From the Research
Lemborexant as an Alternative to Clonazepam for Insomnia
- Lemborexant is a dual orexin receptor antagonist that has been approved for the treatment of sleep onset and/or maintenance insomnia 2.
- Studies have shown that lemborexant is effective in improving sleep onset latency, wake after sleep onset, and sleep efficiency in patients with insomnia 3, 4.
- Lemborexant has been compared to other pharmacotherapies for insomnia, including suvorexant, and has been found to have a similar efficacy and safety profile 2.
- A study that evaluated the efficacy and safety of transitioning to lemborexant from other insomnia treatments, including z-drugs and suvorexant, found that direct transition to lemborexant may be a valid treatment option for patients with insomnia who are dissatisfied with current treatment 5.
- Long-term studies have shown that lemborexant is effective and safe for up to 12 months of continuous treatment, with no evidence of rebound insomnia or withdrawal 6.
Comparison to Clonazepam
- Clonazepam is a benzodiazepine that is commonly used to treat insomnia, but it can have significant side effects, including dependence and withdrawal 2.
- Lemborexant, on the other hand, has been found to have a lower risk of dependence and withdrawal, and is generally well-tolerated 3, 4.
- A study that compared the efficacy and safety of lemborexant to placebo found that lemborexant was superior to placebo in decreasing sleep onset latency and wake after sleep onset, with a similar safety profile to suvorexant 3.
Key Findings
- Lemborexant is an effective treatment for insomnia, with improvements in sleep onset latency, wake after sleep onset, and sleep efficiency 3, 4.
- Lemborexant has a similar efficacy and safety profile to suvorexant, and may be a valid alternative for patients who are dissatisfied with current treatment 2, 5.
- Long-term studies have shown that lemborexant is effective and safe for up to 12 months of continuous treatment, with no evidence of rebound insomnia or withdrawal 6.