What sleep aid can be given to a patient taking Trintellix (vortioxetine) 15mg, propranolol 10mg twice daily (bid), and buspirone 10mg three times a day, who needs to temporarily stop hydroxyzine?

Sleep Aid Options for Patient on Trintellix, Propranolol, and Buspirone

For a patient taking Trintellix 15mg, propranolol 10mg twice daily, and buspirone 10mg three times daily who needs to temporarily stop hydroxyzine, I recommend low-dose doxepin (3-6mg) as the most appropriate sleep aid for both sleep onset and maintenance issues.

Medication Selection Rationale

When selecting a sleep aid for this patient, several factors must be considered:

1. Current medication regimen:

   • Trintellix (vortioxetine) - antidepressant
   • Propranolol - beta-blocker used for anxiety
   • Buspirone - anxiolytic

2. Potential interactions and contraindications:

   • Propranolol can cause sleep disturbances 1
   • Buspirone lacks sedative effects and may have stimulant properties 2
   • The patient was previously using hydroxyzine, which commonly causes sleepiness (28% vs 14% with placebo) 3

3. Sleep aid options based on guidelines:

First-line options:

• Doxepin (3-6mg) - Recommended by the American Academy of Sleep Medicine for sleep maintenance insomnia 4

  • Has a different mechanism than trazodone
  • Effective for sleep maintenance
  • Lower risk of interactions with current medications

• Eszopiclone (2-3mg) - Effective for both sleep onset and maintenance 4

• Zolpidem (5-10mg) - Effective for sleep onset issues 4

• Ramelteon (8mg) - Specific for sleep onset issues 4

Treatment Algorithm

1. Start with low-dose doxepin (3mg) at bedtime

   • Targets sleep maintenance issues
   • Has minimal risk of interactions with current medications
   • Can be increased to 6mg if needed after 1 week

2. If doxepin is ineffective after 2 weeks, consider alternatives:

   • For predominant sleep onset issues: Ramelteon 8mg
   • For both onset and maintenance issues: Eszopiclone 2mg

3. Implement non-pharmacological approaches concurrently:

   • Sleep hygiene education
   • Consistent sleep/wake schedule
   • Avoiding caffeine and stimulating activities before bedtime
   • Relaxation techniques

Important Considerations

• Avoid benzodiazepines due to potential interactions with the patient's current medication regimen 4

• Monitor for side effects - particularly daytime sedation that could compound with propranolol's effects

• Reassess sleep quality within 2-4 weeks of initiating treatment 4

• Temporary use - emphasize that this is for temporary use while hydroxyzine is discontinued

Potential Pitfalls and Caveats

• Avoid trazodone as it may have similar mechanisms to the patient's current medications

• Avoid antihistamines (like diphenhydramine) since the patient is discontinuing hydroxyzine (an antihistamine) for a reason

• Be cautious with mirtazapine despite its sedating properties, as it may have complex interactions with Trintellix

• Start with lower doses of any sleep medication due to the patient's multiple CNS-active medications

• Propranolol can cause sleep disturbances - be aware that the patient's sleep issues may be partially related to this medication 1

• Buspirone may have stimulant properties that could contribute to sleep difficulties 2