Dr. Nishi Bhopal reviews dual orexin receptor antagonists (DORAs)—suvorexant, lemborexant, and daridorexant—explaining how they reduce wake drive by blocking OX1R/OX2R and how this differs from GABAergic hypnotics. She covers dosing timing, food effects, differing half-lives, CYP3A4 interactions, and key adverse effects including sleep paralysis, hypnagogic hallucinations, vivid dreams, next-day sleepiness, and complex sleep behaviors. She argues clinicians are often disappointed when DORAs are expected to fix non-target problems such as circadian disruption, sleep apnea, substance-related sleep fragmentation, or lifestyle-driven hyperarousal, emphasizing accurate insomnia diagnosis using circadian rhythm, sleep drive, and hyperarousal drivers. She highlights best-fit populations (older adults, COMISA, and substance use disorders), discusses longer-term safety data up to 12 months, recommends CBT-I and intermittent dosing to reduce conditioned sleep anxiety, and provides a practical monitoring protocol and medication-selection nuances.
Have a patient who needs more than education? My clinical practice, Pacific Integrative Psychiatry, accepts referrals for insomnia and mental health care in California.
Referring a patient for the sleep programme? Effortless Sleep for clinicians has the referral details.
Not a clinician? The Effortless Sleep Program™ is the patient version of this work, available online, nationwide.
