Should Belsomra (suvorexant) for insomnia be taken every night or only as needed?

Suvorexant (Belsomra) for Insomnia: Nightly Use vs. As-Needed

Suvorexant (Belsomra) can be taken either nightly or intermittently (as needed) for insomnia, with the choice depending on the pattern and chronicity of the patient's insomnia symptoms. 1, 2

Dosing Recommendations

• Initial dosing: 10 mg once per night, taken within 30 minutes of going to bed 1
• Maximum dose: 20 mg once per night if 10 mg is well-tolerated but not effective 1
• Administration timing: Take only when able to get a full night's sleep (at least 7 hours) 1

Nightly vs. As-Needed Administration

When to Consider Nightly Use

• Chronic insomnia with consistent sleep difficulties
• Patients with persistent sleep maintenance problems
• When establishing a consistent sleep pattern is therapeutic goal

When to Consider As-Needed (Intermittent) Use

• Episodic insomnia triggered by specific factors
• Patients concerned about medication dependence
• When symptoms are not present every night

Evidence Supporting Flexible Dosing Schedules

The American Academy of Sleep Medicine clinical guideline explicitly states that "long-term administration may be nightly, intermittent (e.g., three nights per week), or as needed" 2. This recommendation acknowledges that both regular and intermittent dosing schedules are appropriate depending on the patient's specific insomnia pattern.

The FDA label for Belsomra states to "take no more than once per night" but does not mandate daily use 1. The instructions specify to take it "if needed," supporting the as-needed approach when appropriate.

Efficacy Considerations

Suvorexant has demonstrated efficacy for sleep maintenance insomnia with:

• Improved total sleep time (10-16 minutes longer than placebo) 2
• Reduced wake time after sleep onset (16-28 minutes less than placebo) 2

Safety and Practical Considerations

Advantages of As-Needed Use

• Minimizes risk of tolerance development
• Reduces overall medication exposure
• May decrease risk of side effects
• Potentially lower cost to patient

Advantages of Nightly Use

• More consistent sleep improvement
• May be better for establishing regular sleep patterns
• Avoids decision-making about when to take medication

Common Side Effects to Monitor

• Somnolence (most common side effect) 1
• Next-day drowsiness 1
• Potential impairment of driving skills 1

Important Precautions

• Avoid alcohol when taking suvorexant 1
• Do not take after consuming a meal (may delay onset of action) 1
• Use caution in obese patients and women (higher drug exposure) 1
• Avoid activities requiring mental alertness until feeling fully awake the next day 1

Clinical Decision Algorithm

1. Assess insomnia pattern:

   • If symptoms occur ≥4 nights per week consistently → Consider nightly use
   • If symptoms are episodic or <4 nights per week → Consider as-needed use

2. Evaluate patient preferences:

   • Concern about medication dependence → Favor as-needed use
   • Need for consistent sleep schedule → Favor nightly use

3. Consider comorbidities:

   • Presence of chronic conditions affecting sleep → May benefit from nightly use
   • Transient stressors causing insomnia → May benefit from as-needed use

4. Monitor effectiveness:

   • If as-needed use becomes frequent (>4 nights/week) → Consider switching to nightly use
   • If nightly use leads to daytime impairment → Consider switching to as-needed use

Unlike some traditional hypnotics, suvorexant has not shown significant rebound insomnia or withdrawal effects when discontinued after 3 or 12 months of nightly use 3, making it suitable for either dosing approach.