Box 1.

Clinical Practice Recommendations

CBT-I represents the first approach to consider in the management of insomnia; with or without pharmacotherapy, changes to lifestyle and diet may be essential.
Considering that one of the major critical issues in the treatment of patients with insomnia is drug resistance, the orexin receptor antagonists seem to open up important therapeutic perspectives, as they have limited abuse liability and their discontinuation does not seem associated with significant rebound effects.
DORAs showed good tolerance profile, even in the long term, which may be important for the treatment of a chronic disorder such as insomnia, often associated with other comorbid conditions.
Some orexin receptor antagonists have shown good efficacy and tolerance profiles in both sexes, in adults, older subjects, and adolescents, an important fact in consideration of the groups and categories of patients most affected by the disorder and the fragility of some of them.
An important aspect in the management of patients with insomnia is the consideration of the different phenotypes of the disease; for example, DORAs do not seem to exert a negative impact on respiratory parameters, which is of value in patients with COMISA, and some DORAs have been shown to be particularly effective in women after menopause.
CBT-I: Cognitive and Behavioral Therapy for Insomnia. DORA: dual orexin receptor antagonist. COMISA: comorbid insomnia and sleep apnea.