- Design
- Systematic review and meta-analysis of RCTs and observational studies
- Population
- 183,595 participants in 19 studies of DORA users and non-users
- Primary outcome
- Falls and fractures
- Effect
- Falls OR 0.76 (0.56 to 1.04); RCTs OR 0.59 (0.35 to 0.98); fractures OR 1.05 (0.94 to 1.18)
This meta-analysis, published in the Journal of the American Geriatrics Society, pooled 19 studies (10 randomised trials, 9 observational; 183,595 participants) of dual orexin receptor antagonists such as suvorexant, lemborexant and daridorexant, comparing falls and fractures in users and non-users.
Overall, DORA use was not associated with more falls (OR 0.76, 95% CI 0.56 to 1.04) or fractures (OR 1.05, 0.94 to 1.18). Randomised trials suggested fewer falls (OR 0.59, 0.35 to 0.98), while observational studies showed no clear effect (OR 0.88). Event rates were low, the optimal information size was not reached, and data specific to older adults were limited.
Benzodiazepines and Z-drugs are well-established contributors to falls in older people, and insomnia remains common. This review supports DORAs as a potentially safer pharmacological option when one is needed, but not as a reason to prescribe more hypnotics. CBT for insomnia remains first line.
- Offer CBT for insomnia and sleep hygiene first in older adults.
- If a hypnotic is needed, consider a DORA in preference to a benzodiazepine or Z-drug where available.
- Deprescribe long-term benzodiazepines and Z-drugs in older adults at risk of falls, tapering gradually.
- Monitor for next-day drowsiness with any hypnotic, including DORAs.
Why it matters
It offers a possible alternative to hypnotics that clearly raise falls risk.
Don't overread it
Few events and limited older-adult data; the fall reduction in trials may reflect selected populations.
The statistics, in plain English
An overall odds ratio of 0.76 with an interval from 0.56 to 1.04 crosses 1.0, so the data are compatible with no effect as well as a reduction. Not reaching the optimal information size means there were too few events to be confident.
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