2. How safe are DORAs and how do they compare to other insomnia medications?
4. How long should I take them?
5. How much do they cost, and how does that compare to other insomnia medications? Are they covered by insurance?
6. These medications are fairly new. What should I know about them?
7. Should I try another insomnia medication first?
3. I’ve heard that some insomnia medications may be addictive. Is that something I need to worry about with DORAs?
FAQs About Dual Orexin Receptor Antagonists, Answered
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8. Are DORAs more effective than other insomnia medications?
7. Will I still need to diet and exercise?
1. Why do doctors recommend CBT-I before medication?
1. Will I have to take this medication forever?
This form of psychotherapy tends to be brief and has a high success rate, says Martin. “The vast majority of people experience benefit from CBT-I,” she adds. According to SleepFoundation.org, as many as 70 to 80 percent of people who undergo CBT-I experience improvement, including sleeping longer, waking up less often during the night, and taking less time to fall asleep. If you haven’t tried CBT-I, Martin suggests working with a sleep therapist or trying a free app, such as Insomnia Coach.
As with most drugs that are approved by the FDA, clinical development of DORAs went on for years before they were given the green light, which means they’ve been studied for a long time even if they seem new to us, explains Khanna. “They go through rigorous studies to prove their safety and efficacy before they come to market,” he says. “I try to reassure people that by the time that they’re hearing about [FDA-approved medications], there is a lot of safety data behind them.” In terms of safety, DORAs fall somewhere between melatonin receptor antagonists, which are the safest, and benzodiazepines, which require the most caution, Khanna notes.
So far, the data show that DORAs are not addictive when taken as prescribed. A ClinicalTrials.gov study on lemborexant looked at its effects over a 12-month period — participants were given the drug for 6 months and a placebo for 6 months — and the results were promising. “The study so far shows that it has really little to no withdrawal or signs of dependency when we do try to take [patients off them],” Khanna says.
Simply put, “The medicine works while you’re taking it,” says Kumar, noting that it’s no different than taking drugs to control blood pressure or lower cholesterol. “If you stop, your body will try to go back to ‘factory settings.’”
Although each case is different, “Our typical goal of therapy is to do it for three months,” Khanna says. “Hopefully, that helps somebody get into a routine, and then we sort of try to pull back.” As mentioned, they’ve been shown to be safe for 6 months. “That’s not saying that you couldn’t be on the drug for longer than that, but the study shows that for 6 months, they continue to be safe and okay,” Emmel says. During the months you’re taking DORAs, it’s also advised to learn CBT-I and implement good sleep hygiene techniques, so you’ll still be able to sleep well after you’re weaned off the medications, Khanna notes.
Most people regain weight after they stop taking the medication, because the appetite-regulating hormones return to baseline. Stopping and restarting these medications can also lead to obesity sarcopenia, where muscle that was lost as part of the overall weight loss is replaced by fat when the medication is stopped. “People on GLP-1s are losing fat and muscle,” says Saleh. “When they stop these medications and gain weight, they gain weight in fat, not muscle.”
2. What happens if I stop taking the medication?
Because they are newer, DORAs cost more than some of the older sleep aids. They can be prohibitively expensive out of pocket, but insurance may cover them, either as a first-line treatment or after you’ve tried other medications. “It’s going to differ with every insurance plan,” Emmel says. “Some may require documentation or some sort of prior authorization letter from the pharmacy or from the physician, stating that the patient’s already failed other, cheaper options like nonbenzodiazepines.” You may be able to find coupons that lower the cost. Out of pocket, the list price for a 30-day supply ranges from around $300 to $600.
Weight loss is one sign, but it’s not the only one. Improvements in blood sugar, blood pressure, and cholesterol are all indicators that the medication is having a positive effect. Your provider will monitor your lab work and other health outcomes, in addition to tracking changes on the scale. You may also experience reduced cravings, better mobility, and more energy. “The number on the scale is one thing, but nonscale victories are the most amazing thing ever,” says Saleh. “When a patient’s blood pressure is lower, their blood sugars improve, they can take a medication out of their daily regimen … [sit] comfortably on an airplane without a seat belt extender, or [be] able to play with a young child without huffing and puffing, those are the changes that really improve quality of life.”
3. How do I know if the medication is really working for me?
Yes, it’s important to make lifestyle changes while taking the medication. Think of it as an opportunity to learn healthier eating patterns. It’s also important to work with your doctor to begin an exercise routine, especially one that builds muscle mass, such as strength training. “When you lose weight on these medications, your body can’t distinguish between body fat, muscle, or collagen. With rapid weight loss, you lose all of it,” says Saleh. “That’s where you can get sagginess of the skin (Ozempic face) and hair loss.” To combat this, you need protein, which is the building block of muscles.
4. Do I really need to eat healthy and exercise while taking this medication?
So far DORAs have been shown to be safe and effective. Still, it’s natural to wonder if there are longer-term effects that aren’t known yet. “The orexin pathway itself has only been discovered in the past few decades,” Emmel says. “You always worry about, okay, does that pathway do other things? What’s this altering?” Since they already have a decade or more of research behind them, though, “You’re pretty confident you’ve seen much of what you need to see long term where these weird, rare side effects could pop up,” says Emmel.
If your insurance company is willing to cover DORAs up front, there’s no reason to try a different insomnia medication first if you’d rather try these. “There’s no hierarchy of which drug you have to start with versus another,” Khanna says.
Even people who fear needles are often surprised at the simplicity of the injection pens, says Kumar. “Many people actually think it’s easier than taking a daily pill.” Ask your doctor to demonstrate how to inject yourself in the office or even guide your first injection over telehealth.
5. What if I'm scared of injections?
There’s no one insomnia medication that is more effective for everyone, so the answer to this will vary by person. “It really does depend, but this is sort of one of our bigger guns. It has a very strong efficacy rate,” Khanna says. A research review, published in September 2025 in the International Journal of Molecular Sciences, found that DORAs have a lower potential for overdosing and fewer cognitive and motor side effects than GABAergic hypnotics, making DORAs a potentially safer treatment.
