Insomnia Treatment Selection: DORA


Charlene Gamaldo, MD, discusses patient criteria for selecting a dual orexin receptor agonist (DORA) for insomnia treatment.

Charlene Gamaldo, MD: How do you decide on the specific DORA [dual orexin receptor agonist] that you would use in a patient? I need to preface this by saying that in general, once a patient has come to me and said that they’re pregnant, I don’t typically recommend a medication. I may not have the safety profile to ensure that it’s not going to impact the fetus, or there may be some reported cases where there could be concern. Generally speaking, I don’t recommend staying on it. We use CBTI [cognitive behavioral therapy for insomnia] techniques as much as we can. Short of that, for the DORAs, there are 2 main elements that dictate which medications I end up with. One, what is the insurance company most likely to cover? I feel comfortable with all of them from an efficacy standpoint. But if the insurance company doesn’t cover, they’re not getting any of them. That’s from a practical standpoint. The second is based on what can come out in literature in terms of other aspects of daytime functioning.

I have some take-home pearls for caring for female patients with insomnia. Remember, for that patient sitting in front of you who’s female, it’s a flip of a coin whether they’re suffering from insomnia at this moment. It’s always worth at least 1 question: how are you sleeping? If that question has a very lengthy response because it’s not going so well, that may be an immediate red flag to refer that patient to a sleep doctor, especially if it’s beyond your comfort zone of addressing the problem.

That’s the biggest pearl: it’s likely that 50% of the women sitting in your office have that. You don’t have to be the end of the process, but you can start the process. That gets us way further along in caring for all our patients. At this point, at least 50% to 60% are still walking around undiagnosed. That’s the way we can all be part of solving this problem. The sleep community is going to continue to work with our medical community to partner with us because we know we can’t do this alone.

Transcript Edited for Clarity

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