Belsomra

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, also known as Suvorexant, is a medication used to treat the inability to fall asleep or stay asleep ^[3]. While most other insomnia drugs, like Ambien and Lunesta, are GABA agonists and work to slow down neuronal firings, Belsomra is the first drug to target orexin ^[4]. Orexin, also known as hypocretin, is a neurotransmitter that binds to receptors in order to cause alertness and wakefulness. By targeting these neurotransmitters, it cuts off the signals causing one to be awake, and will result in sleep (1).

Function

The orexin neuropeptides, Orexin-A and Orexin-B, can excite neurons in the brain and affect multiple systems, including the acetylcholine, dopamine, histamine, and norepinephrine systems (4). These orexin neuropeptides bind to the receptors, Orexin receptors types 1 and 2, which are G protein coupled receptors (GPCRs). The GPCRs can sense a molecule outside the cell and send a signal through transduction in order to cause the cells to respond (5). Thus, binding of the two can control wakefulness and sleep in homo sapiens. In studies, Orexin-B has shown to be more selective in binding, choosing to bind to Orexin receptor type 2 a majority of the time. Orexin-A has shown an equal selectivity at both types of receptors (4). Belsomra is a dual orexin receptor antagonist, and has the ability to block both Orexin receptors 1 and 2, thus inhibiting the neuropeptides from binding. By blocking this interaction, sleep can occur (1).

Structural Highlights

Relationship to Insomnia

Insomnia is a sleep disorder that is seen to be mostly caused by stress, and results in inefficient cooperation between the sleep and wake pathways of the arousal system. The branch of the arousal system that reaches the lateral hypothalamus, which contains the melanin-concentrated orexin neuropeptide signaling system, is one of the most significantly affected areas of the wakefulness network. This orexin system is a major promoter for wakefulness and is most active during efforts to sustain and maintain arousal, while showing little activity during sleep. Orexins show little activity during sleep because the systems to promote wakefulness are blocked by neurons of the ventrolateral preoptic nucleus and thus cannot fire. During sleep, these VLPO neurons are activated and form dense clusters containing GABA and galanin, which aid in their function as inhibitors for arousal. With insomnia, the structures regulating a patient’s arousal system are unusually active during sleep, and thus the system fails to deactivate. Belsomra is a drug that counteracts this by serving as a dual antagonist in its interactions with Orexin receptors 1 and 2, in the aim of deactivating the arousal system in order for patients to sleep with little orexin activity present. This could also exacerbate the symptoms of narcolepsy, as the already little orexin activity would be diminished at great risk to patients with the sleep disorder.

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