Lemborexant for Shift Workers: Not Recommended
Lemborexant should not be used for shift work-related insomnia because shift work disorder is a circadian rhythm sleep disorder, not a primary insomnia disorder, and lemborexant is not indicated for circadian misalignment. 1
Why Lemborexant Is Not Appropriate for Shift Workers
The Core Problem: Wrong Mechanism for Wrong Disorder
- Shift work disorder results from misalignment between the body's internal circadian clock and the required work schedule, making it fundamentally different from primary insomnia 1
- Lemborexant is a dual orexin receptor antagonist that blocks cortical arousal and promotes sleep state transition, but it does not address the underlying circadian disruption that drives shift work-related sleep problems 2
- Current American College of Physicians guidelines do not recommend dual orexin receptor antagonists like lemborexant for circadian rhythm sleep disorders such as shift work disorder 1
What Should Be Used Instead
First-line treatment should be cognitive behavioral therapy for insomnia (CBT-I) with specific adaptations for shift work schedules 1
For pharmacotherapy, melatonin is more appropriate because it has chronobiotic properties that can help realign circadian rhythms, directly addressing the root cause of shift work disorder 1
Additional evidence-based interventions include:
- Light therapy strategically timed to shift circadian phase 1
- Sleep hygiene specifically tailored to shift workers 1
- Strategic scheduling of sleep periods 1
- If a hypnotic is absolutely necessary, agents with shorter half-lives and established efficacy in circadian rhythm disorders would be preferred over lemborexant 1
Clinical Pitfalls to Avoid
The most common mistake is treating shift work disorder as if it were primary insomnia 1. While lemborexant is highly effective for primary insomnia—improving sleep onset latency, wake after sleep onset, and sleep efficiency 3—these benefits do not translate to circadian rhythm disorders where the fundamental problem is timing misalignment, not hyperarousal.
Lemborexant's efficacy data comes exclusively from studies of primary insomnia disorder, not shift work populations 4, 5, 3. Using it off-label for shift workers means prescribing without evidence of benefit for the specific pathophysiology involved.
When Lemborexant Works (But Not Here)
Lemborexant excels in primary insomnia by:
- Reducing sleep onset latency by 9-13 minutes 3
- Decreasing wake after sleep onset by 19-22 minutes 3
- Improving sleep efficiency by 6-7% 3
- Maintaining effectiveness for up to 12 months without tolerance 5
- Causing minimal next-day impairment 6
However, these benefits address hyperarousal-driven insomnia, not the circadian phase delay or advance problems inherent to shift work 1.