Daridorexant
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Edzel Lorraine Co, DMD, MD[2]
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Overview
Daridorexant is an orexin receptor antagonist that is FDA approved for the treatment of adult patients with insomnia, characterized by difficulties with sleep onset and/or sleep maintenance. Common adverse reactions include Common adverse reactions (reported in ≥ 5% of patients treated with QUVIVIQ and at an incidence ≥ than placebo) include headache and somnolence or fatigue.
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
The recommended dosage is 25 mg to 50 mg once per night, taken orally within 30 minutes before going to bed, with at least 7 hours remaining prior to planned awakening.
Time to sleep onset may be delayed if taken with or soon after a meal.
- Hepatic Impairment:
- Moderate hepatic impairment: Maximum recommended dosage is 25 mg no more than once per night.
- Severe hepatic impairment: Not recommended.
Off-Label Use and Dosage (Adult)
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding Daridorexant FDA-Labeled Indications and Dosage (Pediatric) in the drug label.
Off-Label Use and Dosage (Pediatric)
Contraindications
- Narcolepsy
- Known hypersensitivity to daridorexant or other components of QUVIVIQ
Warnings
- CNS-Depressant Effects and Daytime Impairment
- QUVIVIQ is a central nervous system (CNS) depressant that can impair daytime wakefulness even when used as prescribed. CNS-depressant effects may persist in some patients for up to several days after discontinuing QUVIVIQ. Prescribers should advise patients about the potential for next-day somnolence.
- Driving ability was impaired in some subjects taking QUVIVIQ 50 mg. If QUVIVIQ is taken in these circumstances, caution patients against driving and other activities requiring complete mental alertness.
- Co-administration with other CNS depressants (e.g., benzodiazepines, opioids, tricyclic antidepressants, alcohol) increases the risk of CNS depression, which can cause daytime impairment. Dosage adjustments of QUVIVIQ and of concomitant CNS depressants may be necessary when administered together because of potentially additive effects. The use of QUVIVIQ with other drugs to treat insomnia is not recommended. Advise patients not to consume alcohol in combination with QUVIVIQ because co-administration of QUVIVIQ with alcohol resulted in additive effects on psychomotor performance.
- Because QUVIVIQ can cause drowsiness, patients, particularly the elderly, are at a higher risk of falls.
- Worsening of Depression/Suicidal Ideation
- Patients with psychiatric disorders, including insomnia, are at increased risk of suicide. In primarily depressed patients treated with hypnotics, worsening of depression and suicidal thoughts and actions (including completed suicides) have been reported. As with other hypnotics, QUVIVIQ should be administered with caution in patients exhibiting symptoms of depression. Monitoring of suicide risk and protective measures may be required.
- Sleep Paralysis, Hypnagogic/Hypnopompic Hallucinations, and Cataplexy-like Symptoms
- Sleep paralysis, an inability to move or speak for up to several minutes during sleep-wake transitions, and hypnagogic/hypnopompic hallucinations, including vivid and disturbing perceptions, can occur with the use of QUVIVIQ. Prescribers should explain the nature of these events to patients when prescribing QUVIVIQ.
- Symptoms similar to mild cataplexy have been reported with orexin receptor antagonists. Such symptoms can include periods of leg weakness lasting from seconds to a few minutes, can occur either at night or during the day, and may not be associated with an identified triggering event (e.g., laughter or surprise)
- Complex Sleep Behaviors
- Complex sleep behaviors, including sleepwalking, sleep driving, and engaging in other activities while not fully awake (e.g., preparing and eating food, making phone calls, having sex), have been reported to occur with the use of hypnotics, including orexin receptor antagonists such as QUVIVIQ. These events can occur in hypnotic-naïve as well as in hypnotic-experienced persons. Patients usually do not remember these events. Complex sleep behaviors may occur following the first or any subsequent use of hypnotics, such as QUVIVIQ, with or without the concomitant use of alcohol and other CNS depressants. Discontinue QUVIVIQ immediately if a patient experiences a complex sleep behavior.
- Patients with Compromised Respiratory Function
- The effects of QUVIVIQ on respiratory function should be considered if prescribed to patients with compromised respiratory function. QUVIVIQ has not been studied in patients with moderate OSA requiring CPAP or severe OSA. QUVIVIQ has not been studied in patients with severe COPD.
- Need to Evaluate for Co-morbid Diagnoses
- Because sleep disturbances may be the presenting manifestation of a medical and/or psychiatric disorder, treatment of insomnia should be initiated only after careful evaluation of the patient. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. Worsening of insomnia or the emergence of new cognitive or behavioral abnormalities may be the result of an unrecognized underlying psychiatric or medical disorder and can emerge during the course of treatment with sleep-promoting drugs such as QUVIVIQ.
Adverse Reactions
Clinical Trials Experience
The following are discussed in detail in other sections of the labeling:
- CNS-Depressant Effects and Daytime Impairment
- Worsening of Depression/Suicidal Ideation
- Sleep Paralysis, Hypnagogic/Hypnopompic Hallucinations, and Cataplexy-like Symptoms
- Complex Sleep Behaviors
- Patients with Compromised Respiratory Function
Postmarketing Experience
The following adverse reactions have been identified during post-approval use of QUVIVIQ. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Psychiatric disorders: Nightmares or abnormal dreams
Immune system disorders: Hypersensitivity (including angioedema, rash, urticaria)
Drug Interactions
- Effects of Other Drugs on QUVIVIQ
- Strong or Moderate CYP3A4 Inhibitors
- Clinical Implications: Concomitant use with a strong or moderate CYP3A4 inhibitor increases exposure to daridorexant, which may increase the risk of QUVIVIQ adverse reactions.
- Prevention or Management:The recommended dose of QUVIVIQ is 25 mg when used with a moderate CYP3A4 inhibitor. Concomitant use of QUVIVIQ with a strong inhibitor of CYP3A4 is not recommended.
- Strong and Moderate CYP3A4 Inducers
- Clinical Implications: Concomitant use with a strong or moderate CYP3A4 inducer decreases exposure to daridorexant [see Clinical Pharmacology (12.3)], which may reduce the efficacy of QUVIVIQ.
- Prevention or Management: Concomitant use of QUVIVIQ with a strong or moderate inducer of CYP3A4 is not recommended
- Alcohol and Other CNS Depressants
- Clinical Implications:Concomitant use of alcohol or other CNS depressants with QUVIVIQ may lead to additive impairment of psychomotor performance and risk of CNS depression
- Prevention or Management:Avoid alcohol consumption with QUVIVIQ.
- Strong or Moderate CYP3A4 Inhibitors
Use with caution in patients receiving CNS depressants. Consider dose adjustment of QUVIVIQ and/or the CNS depressant(s) if used concomitantly
- Effects of QUVIVIQ on Other Drugs
- CYP3A4 Substrates
- Clinical Implications:Concomitant use of QUVIVIQ with CYP3A4 substrates increases the exposure to CYP3A4 substrate
- Prevention or Management:Use with caution in patients receiving CYP3A4 substrates with narrow therapeutic index.
- P-gp Substrates
- Clinical Implications: Concomitant use of QUVIVIQ with P-gp substrates increases the exposure to P-gp substrate
- Prevention or Management: Use with caution in patients receiving P-gp substrates with a narrow therapeutic index.
- CYP3A4 Substrates
Use in Specific Populations
Pregnancy
Pregnancy Category (FDA):
There is no FDA guidance on usage of Daridorexant in women who are pregnant.
Pregnancy Category (AUS):
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Daridorexant in women who are pregnant.
Labor and Delivery
Pregnancy Exposure Registry
There will be a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to QUVIVIQ during pregnancy. Pregnant women exposed to QUVIVIQ and healthcare providers are encouraged to call Idorsia Pharmaceuticals Ltd at 1-833-400-9611.
Risk Summary
There are no available data on QUVIVIQ use in pregnant women to evaluate for drug-associated risks of major birth defects, miscarriage, or other adverse maternal or fetal outcomes. In animal reproduction studies, oral administration of daridorexant to pregnant rats and rabbits during the period of organogenesis did not cause fetal toxicity or malformation at doses up to 8 and 10 times the maximum recommended human dose (MRHD) of 50 mg, respectively, based on AUC. Oral administration of daridorexant to pregnant and lactating rats did not cause any maternal or developmental toxicity at doses up to 9 times the MRHD, based on AUC.
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Data
Animal Data
Daridorexant was administered orally to pregnant rats during the period of organogenesis at doses of 30, 100, and 300 mg/kg/day, which are approximately 1, 3, and 8 times the MRHD of 50 mg, respectively, based on AUC. Daridorexant did not cause any maternal or embryofetal toxicities or fetal malformation at doses up to 300 mg/kg/day. The NOAEL for maternal and fetal toxicity is 300 mg/kg/day, which is approximately 8 times the MRHD of 50 mg, based on AUC.
Daridorexant was administered orally to pregnant rabbits during the period of organogenesis at doses of 30, 60, and 120 mg/kg/day, which are approximately 3, 4, and 10 times the MRHD of 50 mg, respectively, based on AUC. Daridorexant did not cause any fetal toxicity or malformation at doses up to 120 mg/kg/day. Daridorexant caused maternal toxicities of decreased weight gain and food consumption at the dose of 120 mg/kg/day. The NOAELs for maternal and fetal toxicity are 60 and 120 mg/kg/day, respectively, which are approximately 4 and 10 times the MRHD of 50 mg, respectively, based on AUC.
Daridorexant was administered orally to pregnant rats during gestation and lactation at doses of 50, 100, and 300 mg/kg/day, which are approximately 1, 3, and 9 times the MRHD of 50 mg, respectively, based on AUC. Daridorexant did not cause any maternal or developmental toxicities at doses up to 300 mg/kg/day. The NOAEL for maternal and developmental toxicity is 300 mg/kg/day, which is approximately 9 times the MRHD of 50 mg, based on AUC.
Nursing Mothers
Risk Summary
There are no data on the presence of daridorexant in human milk, the effects on the breastfed infant, or the effects on milk production. Daridorexant and its metabolites were present in the milk of lactating rats. When a drug is present in animal milk, it is likely that the drug will be present in human milk.
Infants exposed to QUVIVIQ through breastmilk should be monitored for excessive sedation. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for QUVIVIQ and any potential adverse effects on the breastfed infant from QUVIVIQ or from the underlying maternal condition.
Pediatric Use
The safety and effectiveness of QUVIVIQ have not been established in pediatric patients.
Geriatic Use
No dose adjustment is required in patients over the age of 65 years.
Of the total number of subjects in the clinical studies of QUVIVIQ with insomnia (N = 1854), approximately 39% (N = 727) were ≥ 65 years and 5.9% (N = 110) were ≥ 75 years. The likelihood of somnolence and fatigue increased with patient age.
Because QUVIVIQ can increase somnolence and drowsiness, patients, particularly the elderly, are at higher risk of falls
Gender
There is no FDA guidance on the use of Daridorexant with respect to specific gender populations.
Race
There is no FDA guidance on the use of Daridorexant with respect to specific racial populations.
Renal Impairment
There is no FDA guidance on the use of Daridorexant in patients with renal impairment.
Hepatic Impairment
QUVIVIQ has not been studied in patients with severe hepatic impairment (Child-Pugh score ≥ 10). Use in this population is not recommended.
Reduce the dose of QUVIVIQ in patients with moderate hepatic impairment (Child-Pugh score 7–9). Moderate hepatic impairment may increase daridorexant systemic exposure to a clinically relevant extent, which may increase the frequency or severity of adverse reactions.
Females of Reproductive Potential and Males
There is no FDA guidance on the use of Daridorexant in women of reproductive potentials and males.
Immunocompromised Patients
There is no FDA guidance one the use of Daridorexant in patients who are immunocompromised.
Compromised respiratory function
Obstructive sleep apnea
The respiratory depressant effect of QUVIVIQ was evaluated after one night and after five consecutive nights of treatment in a randomized, placebo-controlled, two-period crossover study in 25 patients with mild to moderate OSA (apnea-hypopnea index [AHI] 5 to 30 events per hour) not requiring CPAP. Following once-daily dosing of 50 mg, the mean treatment difference (daridorexant – placebo) on Day 5 for AHI was 0.74 (90% CI, -1.43 to 2.92).
Due to study limitations, including the short duration of the study, clinically meaningful respiratory effects of QUVIVIQ in OSA cannot be excluded, including for long-term treatment.
QUVIVIQ has not been studied in patients with severe OSA (AHI ≥ 30) or those requiring CPAP.
Chronic obstructive pulmonary disease
The respiratory depressant effect of QUVIVIQ was evaluated after one night and after five consecutive nights of treatment in a randomized, placebo-controlled, two-period crossover study in 25 patients with moderate COPD (FEV1/FVC ratio ≤ 70% and 40% ≤ FEV1 < 80% of predicted). Following once-daily dosing of 50 mg, the mean SpO2 treatment difference (daridorexant – placebo) on Day 5 was 0.18% (90% CI, -0.21 to 0.57).
QUVIVIQ has not been studied in patients with severe COPD (FEV1 < 40% of predicted).
Clinically meaningful respiratory effects of QUVIVIQ in patients with compromised respiratory function cannot be excluded
Administration and Monitoring
Administration
There is limited information regarding Daridorexant Administration in the drug label.
Monitoring
There is limited information regarding Daridorexant Monitoring in the drug label.
IV Compatibility
There is limited information regarding the compatibility of Daridorexant and IV administrations.
Overdosage
There is limited clinical experience with QUVIVIQ overdose. In clinical pharmacology studies, healthy subjects were administered single doses of up to 200 mg (4 times the maximum recommended dose) of QUVIVIQ. The following adverse reactions were observed: somnolence, muscle weakness, cataplexy-like symptoms, sleep paralysis, disturbance in attention, fatigue, headache, and constipation.
There is no specific antidote to an overdosage of QUVIVIQ. In the event of an overdose, general symptomatic and supportive medical care, along with immediate gastric lavage where appropriate, should be provided and patients should be carefully monitored. Dialysis is unlikely to be effective as daridorexant is highly protein bound. Consult a Certified Poison Control Center for the most up to date information on the management of overdosage (1-800-222-1222 or www.poison.org).
Pharmacology
Mechanism of Action
The mechanism of action of daridorexant in the treatment of insomnia is presumed to be through antagonism of orexin receptors. The orexin neuropeptide signaling system plays a role in wakefulness. Blocking the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R is thought to suppress wake drive.
Structure
QUVIVIQ contains daridorexant, an orexin receptor antagonist, present as daridorexant hydrochloride salt. The chemical name of daridorexant hydrochloride is (S)-(2-(5-chloro-4-methyl-1H-benzo[d]imidazol-2-yl)-2-methylpyrrolidin-1-yl)(5-methoxy-2-(2H-1,2,3-triazol-2-yl)phenyl)methanone hydrochloride. The molecular formula is C23H23N6O2Cl * HCl. The molecular weight is 487.38 g/mol.
Daridorexant hydrochloride is a white to light yellowish powder that is very slightly soluble in water.
QUVIVIQ tablets are intended for oral administration. Each film-coated tablet contains daridorexant 25 mg or 50 mg, equivalent to 27 mg or 54 mg of daridorexant hydrochloride, respectively. The inactive ingredients are croscarmellose sodium, magnesium stearate, mannitol, microcrystalline cellulose, povidone, and silicon dioxide.
In addition, the film coating contains the following inactive ingredients: glycerin, hypromellose, iron oxide black, iron oxide red, microcrystalline cellulose, talc, titanium dioxide, and, in the 50 mg tablet only, iron oxide yellow.
Pharmacodynamics
Daridorexant binds to and inhibits the orexin receptors OX1R and OX2R (Ki = 0.47 and 0.93 nM, respectively).
Cardiac Electrophysiology
At a dose 4 times the maximum recommended dose, QUVIVIQ does not prolong the QTc interval to any clinically relevant extent.
Alcohol
Co-administration of a single 50 mg dose of QUVIVIQ with alcohol at a blood level of 0.6 g/L led to additive effects on impairment of psychomotor performance (postural stability and alertness). Daridorexant did not affect alcohol concentrations and alcohol did not affect daridorexant concentrations.
Citalopram
No clinically significant effect on psychomotor performance was observed when 50 mg QUVIVIQ was co-administered with 20 mg citalopram in healthy subjects at steady state.
Pharmacokinetics
Daridorexant plasma exposure is dose proportional from 25 mg to 50 mg. The daridorexant pharmacokinetic profile is similar following multiple-dose and single-dose administration with no accumulation.
Absorption
Daridorexant reaches peak plasma concentrations within 1–2 hours (Tmax). Daridorexant has an absolute bioavailability of 62%.
Effect of food
In healthy subjects, a high-fat and high-calorie meal delayed the Tmax by 1.3 hours and decreased the Cmax by 16%, but did not affect the total exposure (AUC).
Distribution
Daridorexant has a volume of distribution of 31 L. Daridorexant is 99.7% bound to plasma proteins. The blood to plasma ratio is 0.64.
Elimination
The terminal half-life of daridorexant is approximately 8 hours.
Metabolism
Daridorexant undergoes extensive metabolism and is primarily metabolized by CYP3A4 (89%). Other CYP enzymes individually contribute to less than 3% of metabolic clearance of daridorexant.
Excretion
The primary route of daridorexant excretion is via feces (approximately 57%), followed by urine (approximately 28%), primarily as metabolites. Trace amounts of parent drug were found in feces and urine.
Specific Populations
Age, sex, race (White, Black, Asian), body size, and mild to severe renal impairment (Cockcroft-Gault < 30 mL/min, not on dialysis) did not have a clinically significant effect on the pharmacokinetics of daridorexant. The effect of severe hepatic impairment (Child-Pugh score ≥ 10) on the pharmacokinetics of daridorexant has not been studied. Daridorexant 50 mg was administered with interacting drugs, except with diltiazem (25 mg daridorexant). Interacting drugs were administered in multiple-dose fashion, except famotidine (single dose) and alcohol (5 h infusion at 0.6 g/L). Based on PBPK analysis: Concomitant use of itraconazole (a strong CYP3A4 inhibitor) increased daridorexant AUC by more than 400%. Concomitant use of rifampin (a strong CYP3A4 inducer) decreased daridorexant AUC by more than 50%. Data are GMRs and 90% CIs. Some 90% CIs are too narrow to be shown. AUC = area under the plasma concentration-time curve; CI = confidence interval; Cmax = maximum plasma concentration; GMR = geometric mean ratio; SSRI = selective serotonin reuptake inhibitor.
Effect of QUVIVIQ on Other Compounds
AUC = area under the plasma concentration-time curve; BCRP = breast cancer resistance protein; CI = confidence interval; Cmax = maximum plasma concentration; CP = cytochrome P450 enzyme; P-gp = P-glycoprotein; SSRI = selective serotonin reuptake inhibitor.
Nonclinical Toxicology
Carcinogenesis
Daridorexant did not increase the incidence of tumors in rats treated for 2 years at oral doses of 15, 50, and 150 mg/kg/day. The high dose of 150 mg/kg/day is approximately 4 times the MRHD of 50 mg, based on AUC. Daridorexant did not increase the incidence of tumors in Tg.rasH2 mice treated for 26 weeks at oral doses of 100, 300, and 1000 mg/kg/day in males or 100, 200, and 1000 mg/kg/day in females.
Mutagenesis
Daridorexant was not mutagenic in the in vitro bacterial reverse mutation (Ames) assay or in the in vitro mammalian chromosome aberration assay in human lymphocytes and was not clastogenic in the in vivo rat micronucleus assay.
Impairment of Fertility
Daridorexant was orally administered to female rats at doses of 30, 100, and 300 mg/kg/day prior to and throughout mating and continuing to gestation Day 6. These doses are approximately 0.5, 3, and 9 times the MRHD of 50 mg, based on AUC. Daridorexant increased pre-implantation loss and decreased implantation sites without affecting mating or fertility at 300 mg/kg/day. The NOAEL for female fertility is 100 mg/kg/day, which is approximately 3 times the MRHD of 50 mg, based on AUC.
Daridorexant did not affect fertility when orally administered to male rats at doses of 50, 150, and 450 mg/kg/day prior to and throughout mating. These doses are approximately 1, 3, and 7 times the MRHD of 50 mg, based on AUC.
Clinical Studies
Controlled Clinical Studies
The efficacy of QUVIVIQ was evaluated in two multicenter, randomized, double-blind, placebo-controlled, parallel-group studies, Study 1 (NCT03545191) and Study 2 (NCT03575104).
A total of 1854 patients with Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5®) insomnia were randomized to receive QUVIVIQ or placebo once daily, in the evening, for 3 months. Study 1 randomized 930 subjects to QUVIVIQ 50 mg (N = 310), 25 mg (N = 310) or placebo (N = 310). Study 2 randomized 924 subjects to QUVIVIQ 25 mg (N = 309), 10 mg (N = 307), or placebo (N = 308). The 10 mg dose is not an approved dose.
At the end of the 3-month treatment period, both studies included a 7-day placebo run-out period, after which patients could enter a 9-month, double-blind, placebo-controlled extension study (Study 3, NCT03679884).
In Study 1, patients had a mean age of 55.4 years (range 18 to 88 years), with 39.1% of subjects ≥ 65 years of age, including 5.8% ≥ 75 years of age. Patients were identified as female or male and by US census-based racial and ethnic categories. The percentages of patients in the respective categories were: female sex (67.1%), White (90%), Black or African American (8%), Asian (1.0%), or Other race (< 1%).
In Study 2, patients had a mean age of 56.7 years (range 19 to 85 years), with 39.3% of subjects ≥ 65 years of age, including 6.1% ≥ 75 years of age. Patients were identified as female or male and by US census-based racial and ethnic categories. The percentages of patients in the respective categories were: female sex (69.0%), White (88%), Black or African American (8%), Asian (4%), or Other race (< 1%).
Primary efficacy endpoints for both studies were the change from baseline to Month 1 and Month 3 in Latency to Persistent Sleep (LPS) and Wake After Sleep Onset (WASO), measured objectively by polysomnography in a sleep laboratory. LPS is a measure of sleep induction and WASO is a measure of sleep maintenance.
Secondary endpoint included in the statistical testing hierarchy with Type 1 error control was patient-reported Total Sleep Time (sTST), evaluated every morning at home using a validated Sleep Diary Questionnaire (SDQ).
In Study 1, doses of 25 and 50 mg QUVIVIQ showed a statistically significant improvement vs placebo on polysomnography (LPS, WASO) and self-reported total sleep (sTST), at Month 1 and Month 3 (Table 4).
In Study 2, QUVIVIQ 25 mg showed a statistically significant improvement vs placebo on WASO and sTST at Month 1 and Month 3 (Table 5). QUVIVIQ 10 mg did not show a statistically significant improvement on LPS, WASO, or sTST at Month 1 or Month 3.
The efficacy of QUVIVIQ was similar across subgroups based on age, sex, race, and region.
The effects of QUVIVIQ on LPS, WASO, and sTST were observed at Month 1 and were maintained through Month 3. The change from baseline of sTST by week in Study 1 is presented below.
Effects on Driving
A randomized, double-blind, placebo- and active-controlled, four-way crossover study evaluated the effects of nighttime administration of QUVIVIQ on next-morning driving performance, using a driving simulator, 9 hours after dosing in 30 healthy elderly subjects (65–79 years, median age 70 years; 15 men, 15 women) and 30 healthy adult subjects (50–64 years, median age 58 years; 15 men, 15 women). The primary driving performance outcome measure was change in Standard Deviation of Lateral Position (SDLP). Testing was conducted after one night (initial dosing) and after four consecutive nights of treatment with QUVIVIQ 50 mg and 100 mg (two times the maximum recommended daily dose). Zopiclone 7.5 mg was used as an active comparator. For both doses, QUVIVIQ caused a statistically significant impairment in next-morning driving performance in adult or elderly subjects (compared with placebo) after the first dose. Although the mean effect on driving performance was not statistically significant (compared to placebo) after 4 consecutive nights of treatment with either dose of QUVIVIQ, driving ability was impaired in some subjects taking QUVIVIQ.
Patients should be cautioned about the potential for next-morning driving impairment because there is individual variation in sensitivity to QUVIVIQ.
Withdrawal of Therapy
Withdrawal Symptoms
In controlled efficacy and safety studies, withdrawal effects were assessed by the Tyrer Benzodiazepine Withdrawal Symptom Questionnaire following discontinuation of QUVIVIQ, and by adverse event reporting during a single-blind placebo run-out period. No evidence of withdrawal symptoms was observed upon treatment discontinuation.
Loss of Treatment Effect After Discontinuation
The loss of effect from stopping treatment with QUVIVIQ was assessed during the placebo run-out period after 3 months of treatment with QUVIVIQ in Study 1 and Study 2.
After treatment discontinuation, in Study 1, patients previously treated with QUVIVIQ 50 mg experienced mean increases of 25 minutes in WASO, 16 minutes in LPS during the next night of sleep, and a mean decrease in sTST of 14 minutes per night over the next week, as compared to the last assessment on treatment. Following QUVIVIQ 25 mg discontinuation, a similar pattern was observed with mean increases in WASO of 19 minutes, 15 minutes in LPS, and a mean decrease in sTST of 7 minutes. Similar changes were observed with the 25 mg dose in Study 2. In both studies, patients who were on placebo and continued on placebo in the run-out period experienced minimal changes in WASO, LPS, or sTST.
How Supplied
QUVIVIQ tablets are available as:
25 mg, light purple, arc-triangle shaped film-coated tablets debossed with "25" on one side, and "i" on the other side. NDC 80491-7825-3, bottle of 30 with child-resistant closure 50 mg: light orange, arc-triangle shaped film-coated tablets debossed with "50" on one side, and "i" on the other side. NDC 80491-7850-3, bottle of 30 with child-resistant closure
Storage
Store at 20°C to 25°C (68°F to 77°F), excursions permitted between 15°C and 30°C (59°F and 86°F)
Images
Drug Images
{{#ask: Page Name::Daridorexant |?Pill Name |?Drug Name |?Pill Ingred |?Pill Imprint |?Pill Dosage |?Pill Color |?Pill Shape |?Pill Size (mm) |?Pill Scoring |?NDC |?Drug Author |format=template |template=DrugPageImages |mainlabel=- |sort=Pill Name }}
Package and Label Display Panel
PRINCIPAL DISPLAY PANEL - 25 mg Tablet Bottle Carton NDC 80491-7825-3
QUVIVIQ® (daridorexant) tablets
25 mg CIV
Rx only
For oral use
30 tablets
Dispense the accompanying Medication Guide to each patient.
idorsia
PRINCIPAL DISPLAY PANEL - 50 mg Tablet Bottle Carton NDC 80491-7850-3
QUVIVIQ® (daridorexant) tablets
50 mg CIV
Rx only
For oral use
30 tablets
Dispense the accompanying Medication Guide to each patient.
idorsia
{{#ask: Label Page::Daridorexant |?Label Name |format=template |template=DrugLabelImages |mainlabel=- |sort=Label Page }}
Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Medication Guide).
Administration Instructions
Advise patients to take QUVIVIQ only in the evening within 30 minutes before going to bed and only if they can stay in bed for a full night (at least 7 hours) before being active again [see Dosage and Administration (2.1)].
Advise patients that the effect of QUVIVIQ may be delayed if taken with or soon after a meal [see Dosage and Administration (2.1), Clinical Pharmacology (12.3)].
CNS-Depressant Effects and Daytime Impairment
Advise patients that QUVIVIQ can impair daytime wakefulness even when used as prescribed. The risk of daytime impairment is increased if QUVIVIQ is taken with less than a full night of sleep remaining or if a higher than recommended dose is taken. If QUVIVIQ is taken in these circumstances, caution patients against driving and other activities requiring complete mental alertness. Advise patients that increased drowsiness may increase the risk of falls in some patients.
Worsening of Depression/Suicidal Ideation
Tell patients to report any worsening of depression or suicidal thoughts immediately. Sleep Paralysis, Hypnagogic/Hypnopompic Hallucinations, and Cataplexy-Like Symptoms
Advise patients and their families that QUVIVIQ may cause sleep paralysis, which is an inability to move or speak for several minutes during sleep-wake transitions and hypnagogic/hypnopompic hallucinations, including vivid and disturbing perceptions. Symptoms similar to mild cataplexy have occurred with orexin receptor antagonists
Complex Sleep Behaviors
Instruct patients and their families that hypnotics may cause complex sleep behaviors, including sleep-walking, sleep driving, preparing and eating food, making phone calls, or having sex while not being fully awake. Tell patients to discontinue QUVIVIQ and notify their healthcare provider immediately if they develop any of these symptoms.
Concomitant Medications
Ask patients about alcohol consumption, medicines they are taking, and drugs they may be taking without a prescription. Advise patients to avoid consuming alcohol with QUVIVIQ.
Pregnancy
Advise patients that there is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to QUVIVIQ during pregnancy [see Use in Specific Populations (8.1)].
Tolerance, Abuse, and Dependence
Tell patients not to increase the dose of QUVIVIQ on their own, and to inform you if they believe the drug "does not work"
Precautions with Alcohol
Alcohol-Daridorexant interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication.
Brand Names
QUVIVIQ®
Look-Alike Drug Names
There is limited information regarding Daridorexant Look-Alike Drug Names in the drug label.
Drug Shortage Status
Price
References
The contents of this FDA label are provided by the National Library of Medicine.
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