Trazodone Dosing for Insomnia
For insomnia, trazodone should be started at 25-50 mg taken at bedtime, with a maximum recommended dose of 100 mg. 1, 2
Recommended Dosing Algorithm
- Initial dose: 25 mg at bedtime
- Titration: Can be gradually increased to 50 mg if needed
- Maximum dose for insomnia: 100 mg
- Timing: Administer shortly after a meal or light snack, approximately 1 hour before bedtime 2, 3
Evidence-Based Recommendations
The National Comprehensive Cancer Network (NCCN) guidelines recommend trazodone 25-100 mg PO at bedtime for insomnia 1. This aligns with the American Academy of Family Physicians recommendation to start trazodone at 25 mg at bedtime, which can be gradually increased as needed 2.
It's important to note that the American Academy of Sleep Medicine (AASM) suggests that clinicians not use trazodone for sleep onset or sleep maintenance insomnia, based on trials of 50 mg doses showing only minimal efficacy compared to placebo 1, 2. However, despite this recommendation, trazodone remains one of the most commonly prescribed medications for insomnia in clinical practice.
Mechanism and Efficacy
Trazodone promotes sleep primarily through its antagonistic effect on 5-HT2 serotonin receptors 3. Unlike benzodiazepines and Z-drugs that decrease slow-wave activity, trazodone actually increases the duration of deep sleep, which is associated with better perceived sleep quality 3.
Research indicates that trazodone at 50-100 mg/day improves sleep disorders, with better results at the 100 mg/day dosage 4. It is particularly effective for sleep maintenance insomnia (staying asleep) but less effective than hypnotics for sleep onset insomnia (falling asleep) 3.
Special Considerations
- Elderly patients: Start with lower doses (25 mg) due to increased risk of orthostatic hypotension 2
- Administration timing: For insomnia, trazodone should be given at least 1 hour before bedtime for optimal effect 3
- Discontinuation: Gradually reduce the dosage rather than stopping abruptly to avoid withdrawal symptoms 5
- Drug interactions: Consider dose reduction when used with strong CYP3A4 inhibitors 5
Side Effects and Safety
- Common side effect: Sedation is the most common side effect 2, 6
- Other side effects: Headache, dizziness, orthostatic hypotension 2
- Serious but rare side effect: Priapism (requires immediate medical attention) 2
- Cardiac considerations: Use with caution in patients with cardiac issues, particularly those with premature ventricular contractions 2
Treatment Hierarchy for Insomnia
- First-line: Cognitive Behavioral Therapy for Insomnia (CBT-I) 2
- Second-line: FDA-approved hypnotics (zolpidem, eszopiclone, zaleplon) 2
- Third-line: Sedating antidepressants including trazodone 2
While trazodone is FDA-approved for depression at doses of 150-600 mg/day 5, the lower doses of 25-100 mg are commonly used off-label for insomnia with demonstrated efficacy and safety 7.