Comprehensive management of chronic insomnia in Spain: a multidisciplinary modified RAND/UCLA consensus with...

Chronic insomnia is a prevalent 24-hour disorder with significant daytime impact. Its management is frequently complicated by conceptual barriers, limited use of standardised diagnostic tools and prolonged benzodiazepine use, while insomnia is often overlooked or inadequately coded as an independent disorder. These challenges highlight the need for improved recognition and clearer therapeutic pathways. Dual orexin receptor antagonists (DORAs), particularly daridorexant, offer a new pharmacological option targeting wake-promoting pathways, yet practical guidance on their clinical use remains limited.

A multidisciplinary panel of seven experts conducted a national consensus using the RAND/UCLA Appropriateness Method. Seventy-four statements addressing the nature, diagnosis and treatment of chronic insomnia, including the clinical use of daridorexant, were evaluated across two rating rounds and a structured discussion. Consensus was reached on 36 statements in round one; one statement was removed; and the remaining 37 achieved consensus in round two.

Experts agreed that chronic insomnia is a distinct disorder, with hyperarousal as a central mechanism, and emphasised the importance of targeting daytime functioning and preserving sleep architecture. Daridorexant was considered appropriate across heterogeneous clinical profiles, supported by evidence demonstrating improvements in nocturnal sleep, daytime functioning and sleep architecture, along with favourable tolerability and low abuse potential.

This consensus supports a pragmatic and patient-centred approach to chronic insomnia management, integrating current evidence with expert clinical experience. The recommendations may help guide decision-making in routine practice, including the use of daridorexant when pharmacological treatment is considered appropriate.