From the Guidelines
Daridorexant should not be used as a first-line treatment in a patient with systemic lupus erythematosus (SLE) and Ehlers-Danlos syndrome (EDS) who experiences malignant cardiovascular syncope (vasovagal syncope). This recommendation is based on the potential risks associated with daridorexant, particularly its effects on blood pressure regulation and sedative properties, which could exacerbate existing cardiovascular instability in patients with EDS and worsen episodes of fainting or hypotension in those with malignant cardiovascular syncope 1.
Considerations for Treatment
When considering treatment options for insomnia in patients with SLE, EDS, and malignant cardiovascular syncope, the following factors should be taken into account:
- The potential for medication interactions, particularly in lupus patients who are often on multiple medications 1
- The risk of worsening cardiovascular instability due to the sedative effects of daridorexant
- The need for a thorough cardiovascular evaluation, including orthostatic vital signs and possibly tilt-table testing, before initiating treatment with daridorexant
Alternative Treatment Options
Alternative insomnia treatments that may be safer options for patients with SLE, EDS, and malignant cardiovascular syncope include:
- Cognitive behavioral therapy for insomnia (CBT-I)
- Sleep hygiene improvements
- Medications with less cardiovascular impact
Monitoring and Dosing
If daridorexant is considered, it is essential to start at the lowest possible dose (typically 25mg at night) and closely monitor the patient for worsening syncope, blood pressure changes, or other adverse effects 1.
Priority of Morbidity, Mortality, and Quality of Life
The primary concern in managing patients with SLE, EDS, and malignant cardiovascular syncope is to prioritize treatments that minimize morbidity, mortality, and improve quality of life. In this context, the potential risks associated with daridorexant outweigh its benefits, and alternative treatment options should be explored first.
From the Research
Daridorexant Use in Patients with SLE and EDS
- There are no direct studies on the use of daridorexant in patients with systemic lupus erythematosus (SLE) and Ehlers-Danlos syndrome (EDS) who experience malignant cardiovascular syncope (vasovagal syncope) 2, 3, 4, 5, 6.
- However, studies have shown that patients with EDS are at a higher risk of cardiovascular abnormalities, including mitral valve prolapse, tricuspid valve prolapse, and great vessel dilatation 2.
- Patients with SLE are also at risk of cardiovascular manifestations, including pericarditis, valvular disease, and myocarditis, as well as accelerated atherosclerosis 3, 4, 6.
- The use of daridorexant in patients with SLE and EDS may need to be carefully considered, taking into account the potential risks and benefits, as well as the patient's individual medical history and current health status.
Cardiovascular Risks in SLE and EDS
- Patients with SLE are at risk of developing conduction abnormalities, including complete heart block, which can lead to syncope 3, 4.
- EDS patients are also at risk of cardiovascular abnormalities, including mitral valve prolapse and great vessel dilatation, which can increase the risk of syncope 2.
- The combination of SLE and EDS may increase the risk of cardiovascular complications, including syncope, and therefore requires careful medical management.
Treatment Options for SLE and EDS
- Treatment options for SLE and EDS are varied and depend on the individual patient's needs and medical history 5, 6.
- Patients with SLE may require treatment with immunosuppressive medications, anticoagulants, and anti-inflammatory medications, while patients with EDS may require physical therapy, occupational therapy, and pain management medications 5.
- The use of daridorexant in patients with SLE and EDS would need to be carefully considered in the context of the patient's overall treatment plan.