New insomnia drugs appear safe from fall and fracture risk, meta-analysis suggests

Good news for clinicians treating older adults with insomnia: a new meta-analysis published in the Journal of the American Geriatrics Society finds that dual orexin receptor antagonists (DORAs) — a newer class of sleep medications — are not associated with increased odds of falls or fractures. The analysis pooled data from 19 studies and nearly 184,000 participants with an average age of 68.

The drugs studied — suvorexant, lemborexant, daridorexant, almorexant, and filorexant — were compared against placebo or no treatment. Randomized controlled trials showed a 41% lower odds of falls among DORA users vs. placebo, though this benefit wasn't replicated in observational studies. Only two studies examined fracture outcomes, and neither found a significant link to DORA use.

Key Takeaways:

• No significant association between DORAs and fall or fracture risk across pooled data from 19 studies
• RCTs showed 41% lower fall odds with DORAs vs. placebo (OR 0.59; 95% CI, 0.35–0.98), but observational studies did not confirm this
• Evidence was rated moderate certainty, limited by low event counts and variability in dosing and follow-up duration

Why it matters: Older adults are frequently prescribed sedative-hypnotics for insomnia despite guidelines flagging them as potentially inappropriate. DORAs could offer a safer alternative — but clinicians should note the evidence remains moderate in certainty and further real-world data are needed.