Is it safe to prescribe Quviviq (daridorexant) 50 mg daily to an elderly patient and discontinue zopiclone (nonbenzodiazepine hypnotic agent) 5 mg?

Switching from Zopiclone to Quviviq (Daridorexant) 50 mg in an Elderly Woman

Yes, you can prescribe Quviviq (daridorexant) 50 mg daily to an elderly woman and discontinue zopiclone 5 mg, as daridorexant has demonstrated superior safety and efficacy in older adults compared to benzodiazepine receptor agonists like zopiclone, with no dose reduction required for age alone. 1, 2

Why Daridorexant 50 mg is Appropriate for Elderly Patients

Evidence Supporting Full Dose in Older Adults

• Daridorexant 50 mg does not require dose reduction based on age alone, as demonstrated in phase III trials where older adults (≥65 years) showed comparable safety and efficacy to younger patients 1
• In older adults specifically, daridorexant 50 mg reduced wake after sleep onset by 19.6 minutes and latency to persistent sleep by 14.9 minutes at month 3, with increased total sleep time of 59.9 minutes 1
• Critically, daridorexant 50 mg was the only dose that significantly improved daytime functioning in older adults, as measured by IDSIQ scores, while the 25 mg dose failed to improve daytime functioning in this age group 1
• The safety profile in older adults was favorable, with no increased risk of falls compared to placebo and no cases of complex sleep behaviors, narcolepsy, or cataplexy 1

Advantages Over Zopiclone in the Elderly

• Zopiclone and other benzodiazepine receptor agonists (BzRAs) are explicitly identified as potentially inappropriate medications in older adults by the American Geriatrics Society Beers Criteria due to risks of cognitive impairment, falls, fractures, and motor vehicle accidents 3
• BzRAs cause increased sensitivity in older adults, leading to delirium, dependence, and withdrawal syndromes 3
• The 2021 Mayo Clinic guidelines specifically recommend deprescribing benzodiazepine-like GABA receptor hypnotics (including zopiclone/eszopiclone) in elderly patients due to sedation, cognitive impairment, unsafe mobility with injurious falls, and habituation 3

Safe Discontinuation Protocol for Zopiclone

Tapering Approach

• Zopiclone should be tapered gradually rather than stopped abruptly to avoid withdrawal symptoms including rebound insomnia, similar to benzodiazepines 3
• Medications acting on the central nervous system need cautious discontinuation as they are most often associated with adverse drug withdrawal events 3
• Stop medications one at a time when making multiple changes 3

Practical Tapering Strategy

• Consider reducing zopiclone 5 mg to 3.75 mg for 1-2 weeks, then to 1.875 mg for another 1-2 weeks before complete discontinuation
• Start daridorexant 50 mg once zopiclone is fully discontinued rather than overlapping, to avoid additive CNS depression and to clearly assess daridorexant's efficacy 3
• Alternatively, if insomnia is severe, you may start daridorexant 50 mg while simultaneously beginning the zopiclone taper, but monitor closely for excessive sedation

Key Clinical Advantages of This Switch

Long-Term Safety Profile

• Daridorexant has been studied for up to 12 months with no new safety signals, no withdrawal symptoms, and no rebound insomnia upon discontinuation 4
• No next-morning residual sleepiness was observed even at the 50 mg dose in elderly patients 1, 4
• The overall incidence of adverse events with daridorexant (35-40%) was comparable to placebo across all age groups 4

Sustained Efficacy Without Tolerance

• Improvements in both sleep parameters and daytime functioning were maintained throughout 12 months of treatment without evidence of tolerance development 4
• Unlike BzRAs, daridorexant has no short-term usage restrictions and is appropriate for chronic use 3

Critical Monitoring Points

During the Transition Period

• Monitor for zopiclone withdrawal symptoms: anxiety, tremor, rebound insomnia, and in severe cases, seizures (though rare at 5 mg dose) 3
• Assess for adequate sleep time (allowing 7-8 hours in bed) to maximize daridorexant effectiveness 3
• Avoid alcohol and other CNS depressants during the transition and while on daridorexant 3

Contraindications and Cautions

• Ensure the patient does not have severe hepatic impairment (though no specific dose adjustment is mentioned for daridorexant in elderly with normal hepatic function) 1
• Screen for narcolepsy, as orexin antagonists are contraindicated in this condition 1
• Evaluate for compromised respiratory function (COPD, sleep apnea), as caution is advised with all sedative-hypnotics 3

Common Pitfalls to Avoid

• Do not reduce daridorexant to 25 mg simply because the patient is elderly—this dose fails to improve daytime functioning in older adults and provides suboptimal benefit 1
• Do not abruptly stop zopiclone without tapering, as this increases risk of withdrawal and rebound insomnia 3
• Do not combine daridorexant with benzodiazepines or other sedative-hypnotics, as this increases sedation risk 5
• Do not assume normal renal function based on serum creatinine alone in elderly patients with reduced muscle mass—calculate creatinine clearance if there are concerns about drug accumulation 6