From the Guidelines
For a patient with insomnia who hasn't responded to trazodone and zolpidem, a good alternative would be to try eszopiclone (2-3 mg at bedtime) or doxepin (3-6 mg at bedtime). These medications offer different mechanisms of action than the previously tried medications, which may help address the patient's sleep difficulties through alternative pathways. Eszopiclone is a benzodiazepine receptor agonist that can help with sleep onset and maintenance insomnia, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1. Doxepin is a tricyclic compound that works as a histamine H1 receptor antagonist at low doses, promoting sleep without significant anticholinergic effects or next-day sedation. Before starting either medication, it's essential to evaluate the patient's sleep hygiene practices and consider cognitive behavioral therapy for insomnia (CBT-I), which is highly effective and recommended as first-line treatment 1. Additionally, the patient should undergo a comprehensive sleep assessment to rule out underlying conditions like sleep apnea, restless legs syndrome, or circadian rhythm disorders that might be contributing to their insomnia. Some key points to consider when prescribing these medications include:
- Evaluating the patient's overall health and potential interactions with other medications
- Starting with a low dose and gradually increasing as needed
- Monitoring for potential side effects, such as drowsiness or dizziness
- Encouraging the patient to establish a consistent sleep schedule and bedtime routine
- Considering alternative therapies, such as CBT-I, if the patient does not respond to medication or prefers a non-pharmacological approach.
From the Research
Alternative Options for Insomnia Treatment
When trazodone and Ambien (zolpidem) are ineffective for treating insomnia, several alternative options can be considered.
- Ramelteon: A melatonin receptor agonist that has been shown to be effective in improving sleep quality and reducing sleep latency 2, 3. It is a nonscheduled drug with a low potential for abuse and does not interact with neurotransmitter receptors associated with abuse phenomena.
- Non-benzodiazepine hypnotics: Such as zaleplon, zopiclone, and eszopiclone, which are generally well-tolerated and have favorable safety profiles compared to older benzodiazepines and barbiturates 4.
- Melatonin: A hormone that regulates sleep-wake cycles, which can be used as a supplement to treat insomnia 5.
- Valerian: A natural herb that has been used to treat insomnia, although its effectiveness is not well-studied 5.
Considerations for Treatment
When selecting an alternative treatment for insomnia, it is essential to consider the patient's individual needs and medical history.
- Dose-dependent side effects: Trazodone's side effects, such as drowsiness, are dose-dependent, and low-dose use may be effective for treating insomnia 6.
- Potential for abuse: Non-benzodiazepine hypnotics, such as zolpidem, have a risk of dependence and abuse, although this risk is generally considered low 4.
- Rare adverse events: Hypnotics, including zolpidem, have been associated with rare but serious adverse events, such as anaphylaxis, angio-oedema, and complex sleep-related behaviors 4.