Opinion
Video
DORA Class for Treating Insomnia
Author(s):
A panelist discusses how dual orexin receptor antagonists (DORAs) offer a novel approach to treating insomnia by reducing wakefulness rather than inducing sedation, highlighting the importance of patient education on their gradual onset, distinct mechanism, and the need for consistent use to achieve long-term benefits.
A newer class of medications, known as dual orexin receptor antagonists (DORAs), has emerged as a treatment option for insomnia. Unlike traditional sleep aids that act on GABA receptors to promote sedation and sleepiness—such as benzodiazepines or similar agents—DORAs work by targeting a different mechanism. They inhibit the action of orexin, a chemical that helps regulate wakefulness. Many people with insomnia don't necessarily lack sleepiness but instead struggle with excessive alertness or a racing mind at night. By reducing the activity of wake-promoting signals, these medications aim to make it easier for natural sleep to occur.
When discussing the onset of action for these newer medications, it’s important to help patients understand how they differ from older sleep aids. Traditional medications might cause a noticeable sedative effect soon after taking them, creating an immediate sense of drowsiness. In contrast, DORAs do not create that same pronounced feeling. Instead, they subtly lower wakefulness without artificially boosting sleep pressure. As a result, patients may mistakenly think the medication isn’t working if they don’t feel an immediate “sleepy” sensation. Education about this distinction, along with information from clinical studies showing that improvements may unfold over several weeks or even months, helps reinforce realistic expectations.
To support adherence in the first weeks of therapy, setting the right expectations from the beginning is crucial. Patients are encouraged not to judge the medication’s effectiveness based on the first night alone, especially since anticipation or stress about the new treatment might interfere with sleep. Additionally, those transitioning from one medication to another may experience temporary worsening of sleep, known as rebound insomnia. For this reason, it is often recommended to allow at least 2 weeks before evaluating whether a new sleep aid is truly beneficial, avoiding premature changes and promoting consistent use.
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