Daridorexant for post-stroke sleep disorders comorbid with obstructive sleep apnea: a case report

Post-stroke sleep disorders (PSSD) have a high incidence. Insomnia can significantly exacerbate neurological impairment in stroke patients, adversely affect neurological recovery, lead to greater dependence in daily activities, and increase the risk of stroke recurrence and mortality. Approximately 30%–50% of patients with insomnia also suffer from obstructive sleep apnea (OSA). These patients exhibit more severe sleep fragmentation, daytime dysfunction, and cardiovascular risk. Traditional hypnotics may adversely affect cognition and neurological recovery, and increase the risk of stroke recurrence, in addition to their potential for respiratory depression and worsening of OSA [1].

This study aims to explore daridorexant, a novel anti-insomnia drug and dual orexin receptor antagonist, as a potential safe and effective alternative for managing stroke-related sleep disorders. Daridorexant selectively blocks the binding of orexin to its receptors, thereby inhibiting hyperarousal, promoting sleep onset and maintenance while avoiding the heavy sedation or dependence risks associated with conventional hypnotics [2].

We present a detailed clinical case report of a stroke patient with comorbid insomnia. The patient experienced post-infarction insomnia, including difficulty falling asleep, fragmented sleep, marked snoring, nocturia, and daytime dizziness. Upon admission, the patient was diagnosed with acute insomnia disorder following cerebral infarction. The Pittsburgh Sleep Quality Index (PSQI) score was 15, the Insomnia Severity Index (ISI) score was 18, and polysomnography (PSG) revealed prolonged wakefulness after sleep onset, significantly reduced sleep efficiency, sleep fragmentation, increased N1 sleep, decreased deep sleep, reduced rapid eye movement (REM) sleep, an apnea-hypopnea index (AHI) of 23.1 (predominantly hypopneas), and a lowest oxygen saturation of 86%. Given safety concerns and the need for a safe medication, daridorexant was initiated at a dose of 50 mg taken approximately half an hour before bedtime.

Methodological approaches included comprehensive clinical interviews to obtain the patient’s sleep history and comorbidities, analysis of sleep assessment results to objectively monitor sleep patterns, and an extensive literature review of existing evidence on stroke, insomnia comorbid with OSA (COMISA), and the pharmacological profile of daridorexant. Follow-up assessments were conducted weekly for one month to evaluate treatment efficacy and safety.

Results based on subjective patient reports and PSG data showed significant improvement following daridorexant treatment. The PSQI score decreased to 8. The patient reported shorter sleep latency, reduced nocturnal wake time, increased deep sleep, longer total sleep time, and improved sleep efficiency. Moreover, daytime dizziness and headache were markedly alleviated, and attention and alertness were significantly enhanced. No adverse effects or signs of dependence were observed during the follow-up period.

In conclusion, this case report suggests that daridorexant may represent a promising alternative for treating stroke-related sleep disorders, particularly in patients with comorbid OSA. Its non-sedating mechanism of action may improve sleep quality and daytime function without compromising respiratory function. Although these findings are encouraging, further controlled studies with larger sample sizes are needed to validate these results.

References

1. Ragnoli,B, Pochetti,P. Raie,A. Malerba,M.（2021）.Comorbid Insomnia and Obstructive Sleep Apnea (COMISA): Current Concepts of Patient Management. Int J Environ Res Public Health,18(17),9248.
2. Herring, W. J., et al. (2020). Daridorexant in the treatment of insomnia disorder: A randomized, double-blind, placebo-controlled phase 3 trial. The Lancet, 396(10252), 855-866.