What is the recommended treatment approach for insomnia using Trazodone (triazolopyridine antidepressant)?

From the Guidelines

Trazodone is not recommended as a first-line treatment for insomnia due to its adverse effect profile and limited efficacy. The 2020 clinical practice guideline for the management of chronic insomnia disorder and obstructive sleep apnea, published in the Annals of Internal Medicine 1, advises against the use of trazodone for treatment of chronic insomnia disorder. This recommendation is based on fair-quality systematic reviews that evaluated the use of pharmacologic agents, including trazodone, and found that the benefits of trazodone were outweighed by its adverse effects.

Key Points to Consider

• The American Academy of Sleep Medicine clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults also suggests that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia 1.
• Trazodone may be considered for patients with comorbid depression and insomnia, but its use should be carefully weighed against its potential risks and benefits.
• Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the initial treatment intervention for patients with chronic insomnia, and pharmacotherapy should only be considered after CBT-I has been tried 1.
• When pharmacotherapy is necessary, other agents such as eszopiclone, zaleplon, and zolpidem may be considered, but their use should be limited to the shortest possible duration and at the lowest effective dose.

Important Considerations for Trazodone Use

• If trazodone is used, the dose should be started at 25-50 mg taken 30 minutes before bedtime, and gradually increased if needed, but not exceeding 100 mg.
• Patients should be counseled on the potential risks of trazodone, including morning drowsiness, dizziness, dry mouth, and priapism.
• Trazodone should be discontinued gradually to avoid withdrawal symptoms.

From the Research

Trazodone for Insomnia

• Trazodone is a triazolopyridine antidepressant that is commonly used off-label for the treatment of insomnia, with its use surpassing its original purpose as an antidepressant 2.
• The efficacy of trazodone for insomnia has been demonstrated in various studies, including those on primary insomnia and secondary insomnia, with the medication showing effectiveness in improving sleep quality and duration 2, 3, 4.
• The recommended dosage of trazodone for insomnia is typically lower than that used for depression, with most studies suggesting a dose of 50-100mg per day 2, 3.
• Trazodone has been shown to be effective in treating sleep-maintenance insomnia, particularly in patients with comorbid mental disorders or those taking activating antidepressants 3.
• The medication works by antagonizing 5-HT2 serotonin receptors, which promotes sleep, and has been found to increase the duration of deep sleep, leading to better sleep quality 3.

Safety and Efficacy

• The safety and efficacy of trazodone for insomnia have been evaluated in several studies, with the medication generally considered to be well-tolerated and effective in improving sleep outcomes 2, 3, 4.
• Common side effects of trazodone include drowsiness, dizziness, and psychomotor impairment, with the risk of side effects increasing with higher doses 2, 5.
• Trazodone has been found to have a lower risk of weight gain compared to other sedating antidepressants, making it a potentially useful option for patients with insomnia who are concerned about weight gain 3.
• The use of trazodone in older adults with insomnia has been evaluated, with the medication considered to be a viable option for those with comorbid depression, but with caution due to the potential for side effects such as drowsiness and dizziness 6.

Comparison to Other Treatments

• Trazodone has been compared to other treatments for insomnia, including hypnotics and cognitive behavioral therapy (CBT), with the medication found to be effective in improving sleep outcomes, particularly when combined with CBT 3, 4.
• Trazodone has been found to be less effective than hypnotics in treating sleep onset insomnia, but more effective in treating sleep-maintenance insomnia, particularly in patients with comorbid mental disorders or those taking activating antidepressants 3.
• The use of trazodone in combination with CBT has been found to be effective in improving sleep outcomes, with the medication increasing the duration of slow wave sleep and improving sleep quality 4.