Is Dayvigo (Lemborexant) recommended for a patient with insomnia and mild obstructive sleep apnea (OSA) who is on a Continuous Positive Airway Pressure (CPAP) machine?

Dayvigo (Lemborexant) in Insomnia with Mild OSA on CPAP

Dayvigo can be used in patients with insomnia and mild obstructive sleep apnea who are on CPAP therapy, as lemborexant has demonstrated respiratory safety without worsening apnea-hypopnea index or oxygen saturation in dedicated OSA trials. 1, 2

Respiratory Safety Profile

The key consideration for using any insomnia medication in OSA patients is respiratory depression risk. Lemborexant specifically addresses this concern:

• Lemborexant 10 mg showed no significant differences versus placebo in apnea-hypopnea index (mean difference -0.03 on day 1 and -0.06 on day 8) or oxygen saturation during sleep in patients with mild OSA 2

• No worsening of oxygen desaturation parameters occurred, including percentage of sleep time with oxygen saturation <80%, <85%, or <90% 2

• The American Academy of Sleep Medicine notes that lemborexant has demonstrated respiratory safety in dedicated OSA trials 1

Clinical Algorithm for Prescribing

When considering Dayvigo for this patient population, follow this approach:

1. Confirm OSA Treatment Status

• Verify the patient is adherent with CPAP therapy, as CPAP remains the gold standard for moderate-to-severe OSA and should be used for the entirety of sleep periods 3
• The VA/DOD guidelines strongly recommend educational, behavioral, and supportive interventions to improve PAP adherence in patients with OSA and concurrent insomnia 3

2. Assess OSA Severity

• Mild OSA (AHI 5-15 events/hour) on CPAP is the appropriate population based on the respiratory safety data 2
• Confirm OSA diagnosis was established with polysomnography or home sleep apnea testing 1

3. Evaluate for Contraindications

• Screen for mechanical upper airway obstruction, untreated pneumothorax, or recent upper airway surgery 4
• Assess for severe temporomandibular joint disorders or significant pulmonary disease requiring special consideration 4

4. Initiate and Monitor

• Start at appropriate dosing as indicated for insomnia treatment 1
• Monitor for respiratory effects, though the safety profile is favorable 1, 2
• Continue CPAP therapy throughout treatment, as the combination addresses both conditions 3

Important Clinical Context

The coexistence of insomnia and OSA is common and requires addressing both conditions. The VA/DOD guidelines specifically recognize that patients with OSA and concurrent insomnia are at high risk for poor PAP adherence 3. Rather than choosing between treating insomnia or OSA, this patient requires:

• Continued CPAP use as the primary OSA treatment 3
• Lemborexant as safe adjunctive therapy for insomnia that does not compromise respiratory function 2

The treatment-emergent adverse event incidence with lemborexant was low and similar to placebo in the OSA population studied 2.

Common Pitfalls to Avoid

• Do not discontinue CPAP when starting insomnia medication. The guidelines strongly recommend PAP therapy continuation even if used <4 hours/night 3

• Do not assume all insomnia medications are safe in OSA. Some pharmacologic treatments cause respiratory depression, making lemborexant's demonstrated safety profile particularly valuable 2

• Do not neglect CPAP adherence interventions. Educational, behavioral, and supportive interventions should be offered to patients with OSA and insomnia to improve PAP adherence 3