When do you consider using dual orexin receptor antagonists (DORAs) for the treatment of insomnia?

I only consider using any hypnotic in insomnia when the patient is getting only 5 hours or less of sleep. In those cases, I will sometimes try using DORAs. I am a sleep neurologist who sees patients with MCI/early dementia, and I have found these medications useful in this population of patients wit...

My typical algorithm is:

• Screen for alcohol use and work towards cessation.
• Reduce/eliminate heavy marijuana use.
• Sleep hygiene counseling and information handout.
• Consider/recommend CBT-I, which may also diagnose and clarify comorbid anxiety spectrum disorder that needs to be addressed and treated...

I like them a lot for patients who have not responded well to reasonably dosed melatonin and antihistaminic sleep aids. And that equation changes as patients are older, sicker, more prone to falls, etc. We might not want to push our luck with drugs containing antihistaminic or GABAergic activity for...