What is the preferred treatment for insomnia with mirtazapine (Remeron) versus trazodone (Oleptro) in an obese patient?

From the Guidelines

For insomnia in an obese patient, mirtazapine would not be the preferred choice due to its potential to cause weight gain, and trazodone is also not recommended as a first-line treatment according to the American Academy of Sleep Medicine clinical practice guideline 1. Instead, consideration should be given to other treatment options that are recommended for insomnia, such as eszopiclone, zaleplon, or zolpidem, which have been suggested for use in adults with sleep onset and sleep maintenance insomnia 1. Some key points to consider when selecting a treatment for insomnia in an obese patient include:

• The potential for weight gain or loss associated with the medication
• The presence of any comorbid medical conditions that may be affected by the medication
• The patient's sleep patterns and the specific type of insomnia they are experiencing (sleep onset vs. sleep maintenance)
• The use of non-medication approaches, such as sleep hygiene practices, to complement medication therapy. It's also important to note that trazodone is not recommended as a treatment for sleep onset or sleep maintenance insomnia in adults, according to the guideline 1. Mirtazapine's side effects, including weight gain and increased appetite, make it a less desirable option for obese patients, and trazodone's lack of recommendation as a first-line treatment limits its use in this context. Therefore, alternative treatments, such as eszopiclone or zolpidem, should be considered, and the patient's response to treatment should be closely monitored.

From the Research

Comparison of Mirtazepine and Trazodone for Insomnia

• Both trazodone and mirtazapine are used to treat insomnia, with studies suggesting their efficacy in improving sleep quality 2.
• A retrospective comparative study found that both trazodone and mirtazapine were effective in treating chronic insomnia, with no significant difference in the proportion of responders between the two medication groups 2.
• The study also found that lower dosages of both medications (25 mg for trazodone and 7.5 mg for mirtazapine) corresponded to the highest percentage of responders 2.

Considerations for Obese Patients

• Obesity may affect the pharmacokinetics of trazodone, with increased volume of distribution and prolonged elimination half-life in obese individuals 3.
• The study suggests that the choice of dosage for trazodone in obese patients should be based on ideal rather than total body weight 3.
• There is limited research on the association between obesity and insomnia diagnosis and symptoms, with some studies suggesting a small but significant correlation between insomnia symptoms and body mass index 4.

Efficacy and Safety of Trazodone

• Trazodone has been shown to be effective in treating insomnia, with a systematic review finding adequate data supporting its efficacy and general safety 5.
• However, another study found that the evidence for the efficacy of trazodone in treating insomnia is limited, and that side effects such as sedation, dizziness, and psychomotor impairment are not inconsequential 6.
• The study also found that there is some evidence of tolerance related to the use of trazodone 6.

Efficacy and Safety of Mirtazapine

• Mirtazepine has been shown to be effective in treating chronic insomnia, with a retrospective comparative study finding that it was as effective and well-tolerated as trazodone 2.
• The study also found that mirtazapine was efficacious at very low doses and had sustained efficacy, likely without problems of tolerance 2.