Treatment Adherence and Switching Treatments for Insomnia


Dr Paul Doghramji shares his approach to switching medications for the treatment of insomnia.

Paul Doghramji, MD, FAAFP: Most patients with insomnia don't want to take anything at all for their insomnia. But when they're forced to do so, you then must tell them how to take the medication properly. And for most patients, what we need to tell them is to take this medicine every single day. Because in fact, in some of the data that's come out with, let's say daridorexant, it seems like the medications benefit builds over time. With that in mind, I've been telling my patients, take this medicine every single day and try it out for a good month and a half, because the data with the daytime sleepiness and the total sleep time suggests that if you take the medicine over time, you may get increased improvement in benefit. In order to help them adhere to the medicine, giving them that information may be helpful. That, again, if you take this medicine on a nightly basis, you may get the best bang for your buck as opposed to trying to go to sleep, you don't fall asleep, then you take the medication, you're not sure whether you should take it or not. That isn’t a good way of doing it in general. But just looking at the clinical studies with these latest medications that I talked about, they were all nightly-used medication. And we should therefore recommend that patients that are taking these medications adhere to that which is nightly used. We think that's where they're going to get their best bang for their buck in treating their insomnia.

There are 2 to 3 instances where you want to switch medications. One of them is obviously when a patient is not getting the desired benefit. Maybe you've titrated the medication, you've given the medicine the best that you think that they can do and they're not doing well with it. That's one instance. The second one is obviously adverse effects. The patient doesn't like how they feel. Either during the night or during the day, they don't like how they feel. That's one. And the third thing, unfortunately, is also insurance or financial challenges. There are some instances where certain patients just can't afford the medicine, or their insurance won't pay for it. These are instances where you want to change the medication to something else.

If you're transitioning a patient from one medication to another, chances are if they're in the same mechanism of action medication. Like for example, if they're going from one Z-drug to another one, you can just go from one to the other and you're probably going to do well. But if you're transitioning to a different category of medication, let's say going from a Z-drug to a DORA, there's no clinical trials to guide us. But my recommendation would be 1 of 2 ways. One is to wean off the Z-drug completely and see where their sleep situation still lies. Do they still have just as much insomnia? Is it improved for whatever reason or is it worse? And depending on what happens, then you can go to the DORA. There are other instances, and I know some of my colleagues have done this, where they will put the both medications together while they wean off the Z-drug while they are also on the DORA. I tend not to do that. I tend to wean off the Z-drug and then go to the DORA. But I also want to tell the patient that the experience they're going to have with the DORA is probably not going to be the same experience that they had with the Z-drug. The Z-drugs tend to, for lack of a better way, knock you out, tranquilize you, whatever. Whereas the DORAs have more of a tendency to gradually put you to sleep and help you stay asleep. And that kind of an effect may improve over time. They're probably going to have a different experience. And I do counsel my patients that are on the DORAs specifically, daridorexant to take the medication for a good month and a half before they judge and see how well the medicine is working to help them get to sleep and stay asleep and how well they feel the next day.

Transcript Edited for Clarity

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