Thoughts?
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Matt seems to have a positive view of Dual Orexin Receptor Antagonists (DORAs) which includes suvorexant (Belsomra), the drug studied in this RCT, and doxepin, because he believes they do not disrupt and may in fact improve sleep architecture. He likes trazodone for the same reason, although it seems to act through a different unknown mechanism. I have found trazodone helpful but have not tried any of the DORAs.
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suvorexant (it turned out) isn’t covered by my insurance & is $300 for 30 pills, so I haven’t tried it either.
I think there was a study that suggested it’s protective against dementia, which isn’t surprising because sleep itself if protective.
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I found this shared by another member-
I’m just learning about DORA’s for the first time.
My husband takes ambien, so I just asked our doc to get him on one of these, asap. After watching Matt, I was under the impression these were new, so I’m shocked to see they’ve been available for a while and no one has talked to him about them!! Grrrrr.
FYI, on goodrx, I see one is over $400 per month, but two of them are $135, cash pay.
He started talking about them starting at 1:55
Unfortunately, suxvorexant is a controlled substance in the US. It is not available from India in tablet form, at least as far as I can find
You can buy it by the kilo, though. 
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IMO: For many of the elderly, sleep aids are necessary. No amount of sleep hygiene, CBT, is going to cure the problem. The problem is old age and loss of function. Many people, including me, will require long-term sleep supplements and/or medication. No amount of psycho BS, " cure the root cause," is going to cure it. The root cause is old age, and while rapamycin is very beneficial, it has had no effect one way or another on my sleep.
There are many reasons not to take doxylamine. IMO: Doxepin is a safer alternative, possibly peptides, but there are no long-term studies on sleep-inducing peptides that I could find.
Anticholinergic & central nervous system effects
First-generation antihistamines like doxylamine have strong anticholinergic activity. In older adults, this is linked to:Confusion, delirium, and worsening cognition
Hallucinations or agitation in vulnerable patients
Daytime sedation, slowed reaction time, and impaired balance
Large observational studies of chronic anticholinergic use (including first-gen antihistamines) show an increased risk of dementia that can persist many years after exposure
Participants 40 770 patients aged 65-99 with a diagnosis of dementia between April 2006 and July 2015, and 283 933 controls without dementia.
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As a sleep medication, DORAs are terrible — at least daridorexant. I used it for a few months and the effect eventually stopped completely, like hitting a wall. My body had gotten used to the medication, and without it I was left with strong hyperarousal for a long time. There are lots of bad experiences on Reddit. The drug isn’t very popular. It’s certainly a better option than benzos or Ambien, if it happens to work for you. The medication has to be taken on an empty stomach, otherwise you won’t notice any effect. Sometimes you don’t notice any effect even when you take it on an empty stomach. A strange medication.
That’s a great heads up, so thanks for sharing your experience.
My husband can’t take trazadone (it’s contraindicated with something else he takes), so I’ll hope this works for him.
Doc just called in Quviviq (daridorexant) for him to try. He only rx’d 10 because he said most patients don’t like how they feel on them. Also, he said he does not have one patient that likes bellsomra.
If this doesn’t work, I imagine he’ll try the other 2 options just to be sure.
The main problem for most people is that lemborexant is a controlled substance and expensive for most people.
"Lemborexant and controlled substance classification
Federal scheduling: The Drug Enforcement Administration (DEA) officially placed lemborexant in Schedule IV of the Controlled Substances Act through a final rule that became effective on March 3, 2021.
Schedules of Controlled Substances: Placement of Lemborexant in Schedule IV
“Federal Register :: Request Access”Abuse potential: While a clinical study found that lemborexant has an abuse potential similar to other Schedule IV sedatives like suvorexant and zolpidem, the risk of developing dependence and misuse is considered low. Some studies also suggest it may have a lower potential for abuse than benzodiazepines.
Prescription restrictions: As a controlled substance, lemborexant is subject to certain federal and state restrictions. These may include limits on the number of pills per prescription and restrictions on refills
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Doxepin is also one of the worst sleep medications I know; I don’t understand how it can help anyone sleep at all. In general, I would leave sleep medications as the very last option. The body gets used to them and their effect wears off sooner or later, and once you’ve learned to sleep with medication, sleeping without them becomes impossible. Maybe not everyone ends up like this, but I did, and getting out of that mess took a long time — I’m still trying to recover. I’ve tried practically every ‘sleep medication’ available in Europe. In the end, the only path to improvement has been meditation, though you shouldn’t expect any quick results; it requires regular practice.
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If your husband is used to taking Ambien, switching directly to daridorexant won’t work. I’d recommend starting with, for example, half an Ambien plus daridorexant, and then gradually tapering off the Ambien. If dependence has already developed, it’s impossible to sleep without it. Daridorexant works in a very different way. It has to be taken on an empty stomach, and you need to be in bed on time; falling asleep happens naturally, if it happens. If you miss the right time window, for example by watching TV or something similar, the medication won’t have any effect later. At least that’s how it is for me, and many others have reported the same. But at its best, the medication allows you to sleep in a very natural way and wake up feeling refreshed.”
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I took ambien for aprox 15 years… then switched to edibles… then switched to trazadone…then got off trazadone, too.
And to your point, yes, I went through a few months where I had many nights with less than 4 hours of sleep to break the cycle. I was a zombie.
In the meantime, for the husband, almost anything is worth a shot to get him off ambien… so DORAs it shall be!
@desertshores they are crazy expensive! At least we can get lemborexant and daridorexant for $135 per month, vs over $400 for belllsomra. Once we know which, if any, of these work for him, then I’ll try ordering from KnippeRX as David shared
@tj_long thanks, I’ll share your tips with him!
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Sorry for your sleep problems. Since meditation works for you, it is possibly just a psychological problem, not the problems old age and loss of function create.
When it comes to psych meds for sleep, they don’t work for everyone, just as particular antidepressants don’t work for everyone.
Both doxepin and quetiapine work for me. But doxepin is the safer of the two. Doxepin is a tricyclic antidepressant drug used to treat depression, anxiety, and insomnia.
Have you tried quetiapine? It is not an antidepressant. A 50 mg tablet, which I obtained from India, knocks me out all night. 50 mg of quetiapine is considered a low dose. It is a dose used for sleep. This dose is smaller than the doses used for therapeutic purposes.
“atypical antipsychotic medication used primarily to treat schizophrenia and bipolar disorder. It is available in both immediate-release and extended-release forms and works by rebalancing levels of dopamine and serotonin in the brain to improve mood, thinking, and behavior.”
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They are expensive. For me, daridorexant cost €300 per month. When the effect wore off, I first spent a few weeks getting about 2 hours of sleep per night, and eventually I went three days with 0 hours of sleep. I was close to psychosis and had to start diazepam, because nothing else, less harmful, had worked. I then tapered it off slowly once I got my mental state stabilized.
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Of course, I have tried quetiapine, it messes with my head, but for sleep it does absolutely nothing. It’s not really a sleep medication to begin with, just like most of the drugs that are used aren’t. Also, it makes my nose so blocked that it’s already hard to sleep because of that. The same thing happens with trazodone, it makes my nose congested.
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Just incase it’s helpful, I’ve shared this previously, but in addition to many things turning my sleep around, including rapa, the addition of LDN last year was a game changer. It doesn’t work for everyone but you’ll take this stuff out of my cold dead hands.
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tj_long, Yes. I agree. It was a big disappointment. So, I wonder what is the biological difference I have that makes it useless for me?