Is lemborexant (dual orexin receptor antagonist) effective for treating insomnia related to shift work?

Lemborexant is Not Recommended for Shift Work-Related Insomnia

Lemborexant is not recommended for treating insomnia related to shift work as it is not specifically indicated for circadian rhythm sleep disorders, and there is insufficient evidence supporting its use in this population.

Understanding Shift Work-Related Insomnia

• Shift work disorder is classified as a circadian rhythm sleep disorder, not a primary insomnia disorder, as it results from a misalignment between the body's internal clock and the required work schedule 1
• Approximately 33-50% of adults experience insomnia symptoms, with shift work being a consistent risk factor for developing sleep disturbances 1
• Shift work-related sleep problems differ from primary insomnia and require targeted interventions that address the underlying circadian disruption 1

Current Guidelines for Shift Work-Related Sleep Disorders

• Clinical guidelines from the American Academy of Sleep Medicine recognize shift work as a distinct risk factor for insomnia that requires specialized management approaches 1
• The American College of Physicians' guidelines for insomnia management do not specifically recommend dual orexin receptor antagonists like lemborexant for circadian rhythm sleep disorders such as shift work disorder 1
• Current evidence-based recommendations for shift work-related sleep problems focus on chronobiotic agents and behavioral interventions rather than traditional hypnotics 1

Evidence Regarding Lemborexant

• Lemborexant is a dual orexin receptor antagonist approved for treating insomnia disorder, but clinical trials have not specifically evaluated its efficacy for shift work-related insomnia 2, 3
• While lemborexant improves sleep onset latency and wake after sleep onset in primary insomnia patients, these studies were conducted in populations with traditional sleep schedules, not shift workers 2, 4
• Lemborexant has a half-life of 17-19 hours, which could potentially interfere with necessary wakefulness during irregular work schedules 5
• The most common adverse effect of lemborexant is somnolence (approximately 10%), which could be problematic for shift workers who need to maintain alertness during unconventional hours 5

Potential Concerns for Shift Workers

• Lemborexant's long half-life (17-19 hours) may cause residual daytime sleepiness that could interfere with a shift worker's ability to maintain alertness during work hours 5
• Although lemborexant shows minimal next-day residual effects in standard insomnia populations, these findings cannot be generalized to shift workers with disrupted circadian rhythms 6
• The timing of lemborexant administration (recommended at least 7 hours before planned awakening) may be difficult to implement consistently with rotating shift schedules 5

Recommended Approaches for Shift Work-Related Insomnia

• Cognitive behavioral therapy for insomnia (CBT-I) with specific adaptations for shift work schedules should be considered first-line treatment 1
• Melatonin may be more appropriate for shift work-related sleep problems due to its chronobiotic properties that can help realign circadian rhythms 1
• Non-pharmacological interventions including light therapy, sleep hygiene specifically tailored to shift workers, and strategic scheduling of sleep periods are recommended 1
• If pharmacotherapy is necessary, agents with shorter half-lives and established efficacy in circadian rhythm disorders would be more appropriate than lemborexant 1

Conclusion

While lemborexant is effective for primary insomnia disorder, its use for shift work-related insomnia is not supported by current evidence or guidelines. Treatment approaches should focus on addressing the underlying circadian disruption through behavioral interventions, chronobiotic agents, and if necessary, carefully selected short-acting hypnotics that won't interfere with necessary wakefulness during work hours.