How to manage a patient with dizziness and lightheadedness on trazodone, hydroxyzine, Adderall ER (amphetamine and dextroamphetamine), and propranolol?

Management of Patient with Medication-Induced Dizziness and Lightheadedness

The most appropriate management for this patient is to discontinue trazodone, start mirtazapine 7.5mg for sleep, continue hydroxyzine for anxiety, and monitor blood pressure regularly while maintaining propranolol for anxiety management.

Medication-Related Dizziness Assessment

Identifying the Culprit

• The patient's symptoms of dizziness and lightheadedness appear temporally related to trazodone use, particularly occurring the day after taking the medication
• Trazodone is known to cause dizziness as one of its common side effects 1
• The combination of trazodone and hydroxyzine may be problematic due to:
  • Potentiation of CNS depression when hydroxyzine is used with other CNS depressants 2
  • Potential for QT prolongation with both medications 1, 2

Medication Interactions

• Hydroxyzine carries a warning about potentiating action when used with other CNS depressants 2
• Trazodone FDA labeling warns about dizziness as a common side effect 1
• The combination of multiple medications affecting the CNS (trazodone, hydroxyzine, Adderall, propranolol) may be contributing to symptoms

Management Plan

1. Medication Adjustments

• Discontinue trazodone as it appears to be the primary cause of the patient's dizziness
• Start mirtazapine 7.5mg at bedtime for sleep, which is appropriate for:
  • Promoting sleep and appetite 3
  • Having less dizziness as a side effect compared to trazodone
  • Potentially helping with appetite that might be suppressed by Adderall

2. Medication to Continue

• Continue hydroxyzine for anxiety management as the patient expressed concern about stopping it
• Continue propranolol for anxiety as the patient wishes to maintain this medication
  • Propranolol (30-60mg daily) is an appropriate choice for anxiety 3
• Continue Adderall ER 10mg as it is helping with focus, motivation, and concentration

3. Monitoring

• Regular blood pressure monitoring is essential:
  • Patient should obtain a home blood pressure machine
  • Monitor for hypotension, which is a potential side effect of propranolol 3
  • Check for orthostatic changes that could contribute to dizziness

4. Follow-up Care

• Primary care evaluation to:
  • Rule out other causes of dizziness (cardiovascular, neurological, vestibular)
  • Perform comprehensive physical examination
  • Consider laboratory testing to rule out metabolic causes

Rationale for Mirtazapine Selection

• Mirtazapine 7.5mg is an excellent choice for this patient because:
  • It promotes sleep and appetite 3
  • It has a lower risk of dizziness compared to trazodone
  • Initial dosage of 7.5mg at bedtime is appropriate, with maximum dosage of 30mg at bedtime if needed 3
  • It may counteract the appetite-suppressing effects of Adderall

Important Precautions

• Monitor for drug interactions:

  • Adderall and propranolol may have opposing effects on blood pressure
  • Mirtazapine and hydroxyzine may both cause sedation

• Watch for side effects of mirtazapine:

  • Sedation (beneficial for sleep but may persist into morning)
  • Increased appetite and potential weight gain 4
  • Dizziness (though less common than with trazodone)

• Avoid common pitfalls:

  • Avoid using multiple sedating medications at the same time
  • Do not abruptly discontinue propranolol (can cause rebound hypertension)
  • Monitor for excessive daytime sedation with mirtazapine

Follow-up Recommendations

• Schedule follow-up within 2 weeks to assess:
  • Resolution of dizziness symptoms
  • Efficacy of mirtazapine for sleep
  • Blood pressure measurements
  • Any new side effects from medication changes
• Consider dose adjustment of mirtazapine if 7.5mg is insufficient for sleep (can increase to 15mg)

By discontinuing trazodone and replacing it with mirtazapine, while maintaining the other medications that are beneficial, this approach directly addresses the likely cause of the patient's dizziness while still managing her anxiety, sleep issues, and ADHD symptoms.