What is the best course of action for managing a patient's anxiety and insomnia when their trazodone (trazodone) is held due to strict NPO (nothing by mouth) status following bowel resection?

From the Guidelines

For a patient on NPO status after bowel resection who cannot take their usual oral trazodone for anxiety and insomnia, I recommend using parenteral benzodiazepines as the primary alternative. Specifically, lorazepam (Ativan) 0.5-1 mg IV every 6 hours as needed for anxiety or insomnia would be appropriate, with dose adjustments based on the patient's age, weight, and prior sedative exposure 1. For elderly patients or those with hepatic impairment, start with 0.25-0.5 mg. Alternatively, midazolam 1-2 mg IV can be used for short-term management. Non-pharmacological interventions should be implemented concurrently, including:

• Maintaining a quiet environment
• Adjusting lighting to match circadian rhythms
• Minimizing nighttime interruptions
• Encouraging relaxation techniques when possible Once the patient can resume oral intake, trazodone should be restarted at their previous dose. This approach is recommended because benzodiazepines provide both anxiolytic and sedative effects, can be administered parenterally, have a relatively rapid onset, and address both target symptoms 1. The short-acting nature of lorazepam also minimizes prolonged sedation that could complicate post-surgical recovery assessment. It's worth noting that the use of trazodone for insomnia is not recommended by the American Academy of Sleep Medicine due to lack of evidence supporting its efficacy for this indication 1. However, in this case, the patient was already taking trazodone for anxiety and insomnia, and restarting it once oral intake is resumed is a practical approach. The choice of benzodiazepines as an alternative is based on their established efficacy for short-term management of anxiety and insomnia, as well as their safety profile when used appropriately 1.

From the FDA Drug Label

As with all antidepressants, the use of trazodone hydrochloride should be based on the consideration of the physician that the expected benefits of therapy outweigh potential risk factors Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking trazodone Clinical Worsening and Suicide Risk Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Trazodone hydrochloride tablets should be given shortly after a meal or light snack. Prior to elective surgery, trazodone hydrochloride should be discontinued for as long as clinically feasible

The patient's trazodone is being held due to strict NPO status. Alternative anxiety and insomnia management should be considered, as the patient is experiencing mild anxiety. The prescriber should weigh the benefits and risks of trazodone therapy and consider alternative treatments.

• The patient should be closely monitored for worsening of anxiety, agitation, or other symptoms.
• Non-pharmacological interventions, such as relaxation techniques or counseling, may be considered to manage the patient's anxiety and insomnia. 2

From the Research

Managing Anxiety and Insomnia in a Patient with Held Trazodone

• The patient is currently taking trazodone 200mg at night for anxiety and insomnia, but it is being held due to strict NPO status following bowel resection.
• According to 3, trazodone is commonly used off-label for treating primary or secondary insomnia, Generalised Anxiety Disorder, and other conditions.
• A systematic review 4 found that trazodone has adequate data supporting its efficacy and general safety for the treatment of insomnia, with the most common side effect being drowsiness.
• Another study 5 found that trazodone can be used as an alternative anxiolytic in patients at risk for benzodiazepine abuse, with significant improvement in anxiety and depressive symptoms.

Alternative Management Options

• Considering the patient's strict NPO status, alternative management options for anxiety and insomnia may be necessary.
• A review of safety and efficacy of sleep medicines in older adults 6 suggests that sedating low-dose antidepressants, such as trazodone, should only be used for insomnia when the patient has comorbid depression.
• The same review 6 recommends cognitive behavioral therapy as the first-line treatment for insomnia, with pharmacologic options used only when necessary.

Considerations for Trazodone Use

• A study on the confirmation of the neurophysiologically predicted therapeutic effects of trazodone 7 found that trazodone is a safe and effective antidepressant, specifically regarding its target symptoms insomnia, depression, and anxiety.
• However, the patient's current NPO status may require alternative management options for anxiety and insomnia until trazodone can be resumed.