Would adding Lemborexant (Dayvigo) as needed (PRN) be appropriate for a 29-year-old male with insomnia, currently on Quetiapine (Seroquel) 25 milligrams (mg) daily and Mirtazapine 7.5 mg daily, for one night of poor sleep?

From the Guidelines

Adding Dayvigo (lemborexant) PRN for occasional nights of poor sleep could be an appropriate measure for this 29-year-old male already taking Seroquel (quetiapine) 25 mg daily and mirtazapine 7.5 mg daily.

Key Considerations

• Dayvigo is a dual orexin receptor antagonist approved specifically for insomnia and works through a different mechanism than his current medications 1.
• A typical starting dose would be 5 mg taken only on nights when needed, about 30 minutes before bedtime.
• The patient should ensure he has at least 7 hours available for sleep after taking it.
• Since he's already on two sedating medications, monitoring for excessive daytime sleepiness, cognitive impairment, or complex sleep behaviors would be important 1.

Mechanism and Rationale

• Dayvigo specifically targets the brain's wake-promoting orexin system, which complements his current regimen that works primarily through histamine, serotonin, and dopamine pathways.
• This targeted, as-needed approach may be more appropriate than increasing doses of his daily medications, considering the potential for increased side effects and the lack of evidence supporting long-term use of pharmacologic treatments for chronic insomnia disorder 1.

Clinical Guidelines and Evidence

• The American Academy of Sleep Medicine clinical practice guideline suggests the use of orexin receptor antagonists like suvorexant for sleep maintenance insomnia in adults 1.
• While there is limited direct evidence on the use of Dayvigo in this specific context, its mechanism and the clinical guidelines on orexin receptor antagonists support its potential use for occasional nights of poor sleep in patients already on other sedating medications.

From the Research

Treatment of Insomnia

The patient is currently taking seroquel 25 mg qday and mirtazapine 7.5 mg qday, but still experiences one night of poor sleep. Adding Dayvigo (lemborexant) PRN on the one night of poor sleep may be considered as an option.

Efficacy of Lemborexant

• Lemborexant has been shown to be effective in treating insomnia, with studies indicating that it can improve sleep onset latency, sleep efficiency, and total sleep time 2, 3, 4.
• A network meta-analysis found that lemborexant had the highest probability of being the best treatment for three out of four objectively measured insomnia efficacy outcomes, with a safety profile broadly similar to other insomnia treatments 3.
• Another study found that lemborexant was well tolerated in adults aged 65 years and older with insomnia disorder, with improvements in subject-reported efficacy observed as early as the first week of treatment and sustained through 12 months 4.

Considerations for Adding Dayvigo

• The patient is already taking mirtazapine, which has been shown to be effective in treating insomnia, particularly in low doses 5.
• Adding Dayvigo PRN on the one night of poor sleep may be considered as a rescue medication to help improve sleep quality on that night.
• However, it is essential to consider the potential risks of combining multiple sleep-promoting medications, including the risk of increased sedation and other adverse events.

Potential Interactions and Risks

• The patient is taking seroquel, which can increase the risk of sedation and other adverse events when combined with other sleep-promoting medications.
• The use of lemborexant in combination with other central nervous system depressants, including seroquel and mirtazapine, may increase the risk of adverse events, including somnolence and falls 3, 4.