Orexin antagonist

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An orexin receptor antagonist, or orexin antagonist, is a drug that inhibits the effect of orexin by acting as a receptor antagonist of one (selective orexin receptor antagonist or SORA) or both (dual orexin receptor antagonist or DORA) of the orexin receptors, OX1 and OX2. [1] Medical applications include treatment of sleep disorders such as insomnia. [2] [3]

Contents

Examples

Marketed

Under development

Not marketed

Medical uses

Insomnia

Orexin receptor antagonists dose-dependently improve sleep parameters including latency to persistent sleep (LPS), wake after sleep onset (WASO), sleep efficiency (SE), total sleep time (TST), and sleep quality (SQ). [22] [23] [24] [25] [26]

Orexin receptor antagonists are not currently used as first-line treatments for insomnia due to cost and concerns about possible misuse liability. [27]

Delirium

Suvorexant appears to be effective in the prevention of delirium. [9] [10]

Side effects

Side effects of orexin receptor antagonists include somnolence, daytime sleepiness and sedation, headache, abnormal dreams, fatigue, and dry mouth. [22] [23] [24] [26] [25]

Rates of somnolence or fatigue with orexin receptor antagonists in clinical trials were 7% (vs. 3% with placebo) for suvorexant 15 to 20 mg, [28] 7 to 10% (vs. 1.3% for placebo) for lemborexant 5 to 10 mg, [29] and 5 to 6% (vs. 4% with placebo) for daridorexant 25 to 50 mg. [30]

Contraindications

Narcolepsy, a neurological disorder caused by orexin deficiency, is a contraindication to the use of orexin antagonists. [31]

Pharmacology

Pharmacokinetics

The elimination half-lives of clinically used orexin receptor antagonists are 12 hours for suvorexant, about 17 to 19 hours ("effective" half-life) or 55 hours (terminal elimination half-life) for lemborexant, and 6 to 10 hours for daridorexant. [8] The elimination half-lives of investigational orexin receptor antagonists are 2 to 3 hours for seltorexant and about 1.5 to 3 hours for vornorexant. [8] [32]

The pharmacokinetics of suvorexant are significantly affected by age, sex, and other factors, leading to increased blood concentrations in female, obese, and older patients. [7] These factors do not significantly affect the pharmacokinetics of lemborexant [7] or daridorexant. [33]

All three marketed orexin antagonists do not need to be dose adjusted in patients with reduced renal function, as the pharmacokinetic profiles of these medications are not significantly affected. [34] [33] [35] In patients with moderate to severe hepatic impairment, dose adjustments of these medications may be necessary. [36]

Research

Filorexant was studied for but was not found to be effective in the treatment of diabetic neuropathy, migraine, and major depressive disorder in phase 2 clinical trials. [37] [38] [39] Seltorexant is under development for treatment of major depressive disorder however and is in phase 3 trials for this indication. [40] Also, suvorexant is in a phase 4 trial for use as an adjunct to antidepressant therapy in people with major depressive disorder and residual insomnia. [40] [41] [42]

References

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  2. Roecker AJ, Coleman PJ (2008). "Orexin receptor antagonists: medicinal chemistry and therapeutic potential". Current Topics in Medicinal Chemistry. 8 (11): 977–987. doi:10.2174/156802608784936746. PMID   18673167.
  3. Cao M, Guilleminault C (April 2011). "Hypocretin and its emerging role as a target for treatment of sleep disorders". Current Neurology and Neuroscience Reports. 11 (2): 227–234. doi:10.1007/s11910-010-0172-9. PMID   21170610. S2CID   42562238.
  4. 1 2 3 Preskorn SH (January 2023). "Comparative Pharmacology of the 3 Marketed Dual Orexin Antagonists-Daridorexant, Lemborexant, and Suvorexant-Part 2. Principal Drug Metabolizing Enzyme, Drug-Drug Interactions, and Effects of Liver and Renal Impairment on Metabolism". Journal of Psychiatric Practice. 29 (1): 38–41. doi:10.1097/PRA.0000000000000690. PMID   36649550. S2CID   255944492.
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  8. 1 2 3 Muehlan C, Vaillant C, Zenklusen I, Kraehenbuehl S, Dingemanse J (November 2020). "Clinical pharmacology, efficacy, and safety of orexin receptor antagonists for the treatment of insomnia disorders". Expert Opinion on Drug Metabolism & Toxicology. 16 (11): 1063–1078. doi:10.1080/17425255.2020.1817380. PMID   32901578. S2CID   221572078.
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  33. 1 2 Ziemichód W, Grabowska K, Kurowska A, Biała G (September 2022). "A Comprehensive Review of Daridorexant, a Dual-Orexin Receptor Antagonist as New Approach for the Treatment of Insomnia". Molecules. 27 (18): 6041. doi: 10.3390/molecules27186041 . PMC   9502995 . PMID   36144776.
  34. Preskorn SH (January 2023). "Comparative Pharmacology of the 3 Marketed Dual Orexin Antagonists-Daridorexant, Lemborexant, and Suvorexant-Part 2. Principal Drug Metabolizing Enzyme, Drug-Drug Interactions, and Effects of Liver and Renal Impairment on Metabolism". Journal of Psychiatric Practice. 29 (1): 38–41. doi:10.1097/PRA.0000000000000690. PMID   36649550. S2CID   255944492.
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  36. Muehlan C, Vaillant C, Zenklusen I, Kraehenbuehl S, Dingemanse J (November 2020). "Clinical pharmacology, efficacy, and safety of orexin receptor antagonists for the treatment of insomnia disorders". Expert Opinion on Drug Metabolism & Toxicology. 16 (11): 1063–1078. doi:10.1080/17425255.2020.1817380. PMID   32901578. S2CID   221572078.
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  42. Clinical trial number NCT02669030 for "A Six Week, Randomized, Double-Blind Placebo-Controlled, Suvorexant Augmentation Study of Antidepressant Treatment of Major Depressive Disorder With Residual Insomnia" at ClinicalTrials.gov