What are the risks of consuming alcohol while taking Dayvigo (Lemborexant) for insomnia, particularly in older adults or individuals with a history of substance abuse?

Dayvigo and Alcohol: Risks and Recommendations

Patients taking Dayvigo (lemborexant) should not consume alcohol due to additive negative effects on cognitive performance and increased drug exposure, with particular concern for older adults and those with substance abuse history. 1

Evidence of Harmful Interaction

Cognitive Impairment

• Coadministration of lemborexant 10 mg with alcohol showed additive negative effects on multiple cognitive performance domains including attention and memory, with impairment corresponding to peak plasma lemborexant concentrations (median 1.5 hours after dosing). 1
• The cognitive impairment from the combination was significantly worse than alcohol alone, though postural stability (body sway) showed no significant differences between lemborexant plus alcohol versus alcohol alone. 1

Increased Drug Exposure

• Alcohol increased plasma lemborexant exposure by 70% based on area under the curve and increased peak plasma concentrations by 35%, meaning patients experience substantially higher drug levels when combining these substances. 1
• This increased exposure amplifies the risk of adverse effects and prolonged sedation. 1

Special Risks in Vulnerable Populations

Older Adults (≥65 years)

• Older adults are particularly vulnerable to drug-alcohol interactions due to altered pharmacokinetics, with more than 75% using medications that may interact adversely with alcohol. 2
• Major adverse clinical outcomes of drug-alcohol interactions in the elderly include altered blood levels, sedation and delirium, and interference with medication effects. 2
• While lemborexant has demonstrated efficacy and tolerability in older adults without alcohol, the combination creates unacceptable risk. 3, 4

Individuals with Substance Abuse History

• Alcohol is explicitly not recommended for insomnia treatment due to its short duration of action, adverse effects on sleep, exacerbation of obstructive sleep apnea, and potential for abuse. 5
• Patients with substance abuse history face heightened risks of dependency and misuse when combining sedating medications with alcohol. 5
• The American Academy of Sleep Medicine guidelines emphasize educating patients about risks of abuse and misuse of sleep medications. 5

Clinical Recommendations

Absolute Contraindication

• Patients must be counseled not to consume alcohol with lemborexant at the time of prescribing. 1
• The FDA has issued warnings about additive effects on psychomotor performance with concomitant CNS depressants and/or alcohol use for all sedative/hypnotics. 5

Patient Education Points

• Explain that alcohol increases lemborexant blood levels by 70%, leading to excessive sedation and cognitive impairment. 1
• Warn about risks of impaired memory, attention, and next-day functioning when combining these substances. 1
• Emphasize that even moderate alcohol consumption (the study used 0.6-0.7 g/kg) creates significant interaction. 1

Monitoring Considerations

• Screen for alcohol use at baseline and follow-up visits, as patients may not volunteer this information. 2
• In older adults, be particularly vigilant about alcohol consumption patterns, as education about drug-alcohol interactions should be routine. 2
• For patients with substance abuse history, consider whether lemborexant is appropriate or if non-pharmacological approaches (CBT-I) should be prioritized. 6

Common Pitfalls to Avoid

• Do not assume patients understand the risks - explicit counseling is required as lemborexant was well-tolerated in studies, but only when alcohol was excluded. 1
• Do not underestimate "social drinking" - even single occasions of moderate alcohol consumption create clinically significant interactions. 1
• Do not overlook timing - the cognitive effects peak around 1.5 hours after lemborexant dosing, coinciding with typical bedtime alcohol consumption patterns. 1