Safety and efficacy of daridorexant in patients with insomnia disorder: results from two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials

摘要

Background Daytime functioning is impaired in people with insomnia disorder. Currently available dual orexin receptor antagonists have shown efficacy in insomnia disorder, but do not address all aspects of this disease. We aimed to assess safety and efficacy of daridorexant, a novel orexin receptor antagonist, on night-time and daytime symptoms of insomnia. Methods We did two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials at 156 sites in 17 countries. Adults (aged >= 18 years) with insomnia disorder were randomly assigned using interactive response technology (1:1:1) to receive daridorexant 50 mg, 25 mg, or placebo (study 1) or daridorexant 25 mg, 10 mg, or placebo (study 2) every evening for 3 months. Participants, investigators, and site personnel were masked to treatment allocation. The primary endpoints were change from baseline in wake time after sleep onset (WASO) and latency to persistent sleep (LPS), measured by polysomnography, at months 1 and 3. The secondary endpoints were change from baseline in self-reported total sleep time and the sleepiness domain score of the Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ) at months 1 and 3. Study-wise type I error rate (5%) was controlled for all pairwise comparisons. Efficacy was analysed in all randomly assigned participants, and safety in all participants who received at least one dose of treatment. The studies are registered at ClinicalTrials.gov, NCT03545191 (study 1) and NCT03575104 (study 2). Findings Between June 4, 2018 and Feb 25, 2020, 930 participants were randomly assigned to receive daridorexant 50 mg (n=310), daridorexant 25 mg (n=310), or placebo (n= 310) in study 1. Between May 29, 2018, and May 14, 2020, 924 participants were randomly assigned to receive daridorexant 25 mg (n=309), daridorexant 10 mg (n=307), or placebo (n=308) in study 2. In study 1, WASO and LPS were significantly reduced among participants in the daridorexant 50 mg group compared with participants in the placebo group at month 1 (least squares mean [LSM] difference -22.8 min [95% CI -28.0 to -17.6], p<0.0001 for WASO; -11.4 min [-16.0 to - 6.7], p<0.0001 for LPS) and month 3 (-18.3 min [-23.9 to -12.7], p< 0.0001 for WASO; -11.7 min [-16.3 to -7.0], p<0.0001 for LPS). WASO and LPS were significantly reduced among participants in the daridorexant 25 mg group compared with the placebo group at month 1 (LSM difference -12.2 min [-17.4 to -7.0], p<0.0001 for WASO; -8.3 min [-13.0 to -3.6], p=0.0005 for LPS) and month 3 (-11.9 min [-17.5 to -6.2], p<0.0001 for WASO; -7.6 min [-12.3 to -2.9], p=0.0015 for LPS). Compared with placebo, participants in the daridorexant 50 mg group had significantly improved self-reported total sleep time at month 1 (LSM difference 22.1 min [14.4 to 29.7], p<0.0001) and month 3 (19.8 min [10.6 to 28.9], p<0.0001), and IDSIQ sleepiness domain scores at month 1 (-1.8 [- 2.5 to -1.0], p<0.0001) and month 3 (-1.9 [-2.9 to -0.9], p= 0.0002). Compared with the placebo group, participants in the daridorexant 25 mg group had significantly improved self-reported total sleep time at month 1 (LSM difference 12.6 min [5.0 to 20.3], p=0.0013) and month 3 (9.9 min [0.8 to 19.1], p=0.033), but not IDSIQ sleepiness domain scores (-0.8 [-1.5 to 0.01], p=0.055 at month 1; -1.0 [- 2.0 to 0.01], p=0.053 at month 3). In study 2, WASO was significantly reduced among participants in the daridorexant 25 mg group compared with participants in the placebo group at month 1 (LSM difference -11.6 min [-17.6 to -5.6], p=0.0001) and month 3 (-10.3 min [-17.0 to - 3.5], p=0.0028), whereas no significant differences in LPS were observed at month 1 (-6.5 min [-12.3 to -0.6], p=0.030) or month 3 (-9.0 [-15.3 to -2.7], p=0.0053). Compared with the placebo group, participants in the daridorexant 25 mg group had significant improvement in self-reported total sleep time at month 1 (LSM difference 16.1 min [8.2 to 24.0], p<0.0001) and month 3 (19.1 [10.1 to 28.0],