Can Lemborexant Cause Nightmares?
Yes, lemborexant can cause nightmares, though this adverse effect occurs in only 2-5% of patients, particularly at the 10 mg dose. 1
Incidence and Dosing Relationship
- Nightmares are a recognized adverse effect of lemborexant, with higher rates observed at the 10 mg dose compared to the 5 mg dose 1
- The incidence of nightmares affects approximately 2-5% of patients, which is roughly similar to the rate seen with suvorexant 40 mg 1
- Somnolence is more common (occurring in about 10% of patients at 10 mg), while nightmares and headaches are less frequent side effects 1
Mechanism and Clinical Context
Lemborexant is a dual orexin receptor antagonist that works by blocking the wake-promoting orexin system. While the exact mechanism by which it causes nightmares is not fully elucidated, drugs affecting neurotransmitter systems can produce nightmares 2. The orexin system plays a role in REM sleep regulation, and alterations in REM sleep architecture may contribute to nightmare occurrence.
Related Parasomnia Concerns
Beyond nightmares, lemborexant carries additional parasomnia risks that clinicians should monitor:
- Sleep paralysis can occur with lemborexant use 1
- Hypnagogic/hypnopompic hallucinations have been reported 1
- Cataplexy-like symptoms may emerge 1
- Complex sleep behaviors are possible, though less common than with traditional sedative-hypnotics 1
Clinical Monitoring Recommendations
For patients with a history of sleep disorders or nightmare disorder, particular caution is warranted:
- Start with the 5 mg dose rather than 10 mg to minimize nightmare risk 1
- Monitor closely for emergence of nightmares, especially in the first few weeks of treatment 1
- Be aware that patients with psychiatric disorders have not been adequately studied in lemborexant trials, requiring heightened vigilance 1
- Watch for emergence of depression or suicidal ideation, which can occur with lemborexant 1
Risk-Benefit Consideration
Despite the nightmare risk, lemborexant demonstrates no tolerance to sedation or withdrawal effects on discontinuation 1, and shows minimal residual effects on morning alertness 3, 4. The overall safety profile may be favorable compared to benzodiazepines and Z-drugs, particularly in geriatric patients 4.
If nightmares develop, consider dose reduction to 5 mg or discontinuation if symptoms are distressing or impair quality of life, as nightmare disorder itself can cause significant morbidity including sleep avoidance, psychiatric distress, and impaired daytime function 2.