Suvorexant: A Dual Orexin Receptor Antagonist for Treating Sleep Disturbance in Posttraumatic Stress

• Status: Recruiting
• Trial end date: 2024-12-31
• Target enrollment: 0
• Participant gender: All

Summary

Post-traumatic stress disorder (PTSD) is a common consequence of combat that can result in trauma-related hyperarousal and sleep disturbances. Poor sleep, one of the most common complaints in Veterans with PTSD, can be distressing, impair concentration and memory, and contribute to physical health conditions, such as metabolic syndrome, inflammation, and cardiovascular disease. The orexin neuropeptide system underlies both sleep and stress reactivity. Suvorexant, a drug that reduces orexin, improves sleep in civilians, but has not yet been tested in Veterans with PTSD. This study will test whether suvorexant can improve sleep disturbances and PTSD symptoms in Veterans. Suvorexant may benefit Veterans by improving sleep quickly while also reducing PTSD symptoms over the long term, and with fewer side effects that were common in previous medications used to treat these conditions. Improving Veterans' sleep and PTSD symptoms could lead to better emotional and physical well-being, quality of life, relationships, and functioning.

• Phase: Phase 4
• Accepts Healthy Volunteers?: No

Details

• Lead Sponsor: VA Office of Research and Development
• Collaborator: Birmingham, Alabama VA Medical Center
• Treatments: Orexin Receptor Antagonists; Suvorexant

Criteria

Inclusion Criteria:

• Men and Women, age range of 18 to 75, with a history of US military service, capable of reading and understanding English, and able to provide written informed consent

• Criterion A event meets DSM-5 criteria and occurred during military service, including combat and military sexual trauma

• Chronic full syndromal PTSD diagnosis >3 months duration as indexed by CAPS-5 score >12 at screening

• Insomnia indicated by an ISI score > 14

• Subjects on non-exclusionary medications must be on a stable dose for at least 4 weeks prior to randomization, which includes the Selective Serotonin Reuptake Inhibitors (SSRIs) e.g.:

• Sertraline

• Paroxetine

• Fluoxetine

• Fluvoxamine

• Citalopram

• Escitalopram

• Serotonin-norepinephrine reuptake inhibitors (SNRIs), e.g.:

• Desvenlafaxine

• Duloxetine

• Levomilnacipran

• Venlafaxine

• For subjects who are in psychotherapy, treatment must be stable for 6 weeks

• Women of child-bearing potential must not be pregnant or have plans for pregnancy or breastfeeding during the study and must use a medically acceptable method of birth control, e.g.:

• oral

• implantable

• injectable

• transdermal contraceptive

• intrauterine device

• double-barrier method

Exclusion Criteria:

• DSM-5 alcohol, marijuana, and/or other drug use disorder in the last 3 months

• Mild alcohol and marijuana use not being criteria for use disorder will be allowed

• Manic or psychotic episode in the last 5 years

• Exposure to trauma in the last 3 months

• Prominent suicidal or homicidal ideation or any suicidal behavior in the past 3 months on the Columbia Suicide Severity Rating Scale (C-SSRS) or increased risk of suicide that necessitates additional therapy or inpatient treatment

• Pre-existing sleep apnea in the absence of adherence to effective treatment (such as CPAP or oral device) or positive screen for sleep apnea by type III device

• Neurologic disorder or systemic illness affecting CNS function

• Chronic or unstable medical illness including:

• unstable angina

• myocardial infarction within the past 6 months

• congestive heart failure

• preexisting hypotension or orthostatic hypotension

• heart block or arrhythmia

• chronic renal or hepatic failure

• pancreatitis

• severe chronic obstructive pulmonary disease

• History of moderate or severe traumatic brain injury

• Mild cognitive impairment assessed by the Montreal Cognitive Assessment

• Pregnancy, breastfeeding and/or refusal to use effective birth control (for women)

• Previous adverse reaction to a hypnotic

• Current use of benzodiazepines, strong CYP3A inhibitors, or Digoxin

Prohibited:

• benzodiazepines

• strong CYP3A inhibitors

• Digoxin

• Furthermore, CNS depressants (e.g., benzodiazepines, opioids, alcohol) increase the risk of CNS depression when co-administered with suvorexant and will not be allowed for safety reasons.

• Since metabolism by CYP3A is the major elimination pathway for suvorexant, concomitant use of suvorexant with strong inhibitors of CYP3A (e.g., ketoconazole, itraconazole, posaconazole, clarithromycin, nefazodone, ritonavir, saquinavir, nelfinavir, indinavir, boceprevir, telaprevir, telithromycin and conivaptan), moderate CYP3A inhibitors (e.g., amprenavir, aprepitant, atazanavir, ciprofloxacin, diltiazem, erythromycin, fluconazole, fosamprenavir, grapefruit juice, imatinib, verapamil), or strong CYP3A inducers (e.g., rifampin, carbamazepine and phenytoin) will not be allowed.

• All concomitant medication use will be monitored and documented