Medication Highlight: Dayvigo

For the treatment of insomnia, patients can cycle through multiple classes including benzodiazepines, Z-drugs (zolpidem, zopiclone), antipsychotics and antidepressants. We can add another agent to the mix - Dayvigo (lemborexant).


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Dayvigo, otherwise known as lemborexant, is the second agent in the class of dual orexin receptor antagonists (DORA) to be approved for insomnia in Canada (the first being Belsomra (suvorexant)). Dayvigo targets the orexin receptors OX1R and OX2R which are responsible for promoting wakefulness. By blocking these two receptors (with a higher affinity to OX2R), this prevents neurotransmitters Orexin A and Orexin B from binding, thus allowing sleep to proceed. The theoretical advantage of orexin receptor antagonists is less potential for physical dependence and rebound insomnia. However, the potential for psychological dependence and abuse is still present.


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The recommended dose of Dayvigo is 5 mg at bedtime (a few minutes before going to bed). The dose can be increased to 10 mg if needed. Most patients will be asleep for 7 hours. Note that if taken after a meal, its onset of action may be delayed.


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Hypnotics such as Dayvigo carry the usual set of adverse effects, the most common being somnolence and daytime drowsiness. The most serious but rare adverse effects include neuropsychiatric events such as anxiety, hallucinations and amensia. Unique adverse effects include sleep paralysis, cataplexy (sudden loss of muscle function in legs) and abnormal dreams.


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Similar to other Z-drugs, Dayvigo is a CYP3A4 substrate, so it is best to avoid moderate to strong CYP3A4 inhibitors. The dose should be reduced to 5 mg in the presence of weak CYP3A4 inhibitors. Likewise, strong CYP3A4 inducers such as rifampin should be avoided due to risk of ineffective treatment with Dayvigo.


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Dayvigo should be used in caution with other CNS depressants such as opioids, tricyclic antidepressants and benzodiazepines. Particuarly, alcohol is a CNS depressant which can also increase the AUC and Cmax exposure to Dayvigo, so patients should not combine the two agents.





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