Does Belsomra (suvorexant) worsen Restless Leg Syndrome (RLS)?

Does Belsomra (Suvorexant) Worsen Restless Leg Syndrome (RLS)?

Belsomra (suvorexant) should be avoided in patients with RLS as it may potentially worsen symptoms due to its antihistaminergic properties, which are known to exacerbate RLS.

Mechanism and Concerns

• The American Academy of Sleep Medicine specifically recommends addressing potential exacerbating factors for RLS, including antihistaminergic medications 1
• Belsomra (suvorexant) is an orexin receptor antagonist with antihistaminergic properties that could potentially worsen RLS symptoms 1
• Medications with antihistaminergic effects are known to exacerbate RLS and should be avoided in patients with this condition 1

Preferred Treatment Options for RLS

First-Line Treatments

• Alpha-2-delta ligands are strongly recommended as first-line therapy for RLS:
  • Gabapentin (strong recommendation, moderate certainty of evidence) 1
  • Gabapentin enacarbil (strong recommendation, moderate certainty of evidence) 1
  • Pregabalin (strong recommendation, moderate certainty of evidence) 1

Iron Therapy

• Iron supplementation should be considered if serum ferritin ≤75 ng/mL or transferrin saturation <20% 1
• Options include:
  • Oral ferrous sulfate (conditional recommendation, moderate certainty) 1
  • IV ferric carboxymaltose (strong recommendation, moderate certainty) 1

Medications to Avoid in RLS

• Antihistaminergic medications (including suvorexant) should be avoided as they can exacerbate RLS symptoms 1
• Serotonergic medications should be avoided as they may worsen RLS 1
• Antidopaminergic medications should be avoided as they can worsen RLS 1
• The American Academy of Sleep Medicine specifically recommends against several medications for RLS treatment, including:
  • Bupropion 1
  • Carbamazepine 1
  • Clonazepam 1
  • Valproic acid 1

Managing RLS Symptoms

• Non-pharmacological approaches that may help include:

  • Moderate exercise 2
  • Smoking cessation 2
  • Alcohol avoidance 2
  • Caffeine reduction or elimination 2
  • Discontinuation of offending medications (including antihistaminergic drugs like suvorexant) 2, 1

• For patients requiring medication for both sleep and RLS, consider:

  • Alpha-2-delta ligands (gabapentin, pregabalin) which can improve both sleep and RLS symptoms 1
  • Avoiding sleep medications with antihistaminergic properties 1

Conclusion

When treating patients with both insomnia and RLS, it's important to select medications that won't exacerbate RLS symptoms. Belsomra (suvorexant) should be avoided in these patients due to its antihistaminergic properties. Instead, consider alpha-2-delta ligands which can address both conditions without worsening RLS symptoms.