What is the best way to manage a patient with dizziness and lightheadedness on Trazodone (trazodone), Hydroxyzine (hydroxyzine), Adderall ER (amphetamine and dextroamphetamine), and Propranolol (propranolol)?

Management of a Patient with Dizziness and Lightheadedness on Multiple Medications

The best approach for this patient is to discontinue trazodone and start mirtazapine 7.5mg for sleep, while continuing hydroxyzine and propranolol for anxiety management, and maintaining Adderall ER for ADHD symptoms.

Medication Analysis and Decision-Making

Trazodone Issues

• The patient's primary complaint of dizziness and lightheadedness appears to be directly related to trazodone use, particularly occurring the day after taking the medication
• Trazodone is known to cause significant side effects including dizziness, daytime sedation, and orthostatic hypotension in up to 60% of patients 1
• A retrospective study found that while trazodone can be effective for sleep, 19% of patients discontinued it due to intolerable side effects including daytime sedation and dizziness 1
• Recent research indicates trazodone has a high incidence of morning grogginess (15%) and orthostatic hypotension (10%) compared to alternative sleep medications 2

Mirtazapine as a Replacement

• Mirtazapine 7.5mg is an excellent alternative for this patient because:

  • It promotes sleep and appetite 1
  • It has a well-tolerated side effect profile at lower doses 1
  • It has a potent sedating effect that can help with insomnia 1
  • It may counteract the appetite-suppressing effects of Adderall ER that the patient is taking 1

• The American Family Physician guidelines specifically note that mirtazapine "promotes sleep, appetite, and weight gain" making it particularly suitable for this patient's needs 1

Medication Interactions

• The combination of hydroxyzine and trazodone may be contributing to the patient's symptoms, as hydroxyzine carries a warning that "the potentiating action of hydroxyzine must be considered when used with central nervous system depressants" 3
• Both hydroxyzine and trazodone can cause QT prolongation, creating a potentially dangerous additive effect 3
• Since the patient finds hydroxyzine helpful for anxiety and wishes to continue it, removing trazodone from the regimen is the most appropriate step

Implementation Plan

1. Discontinue trazodone immediately due to the clear temporal relationship between its use and the patient's dizziness/lightheadedness

2. Start mirtazapine 7.5mg at bedtime for sleep management

   • This low dose is appropriate as a starting point 1
   • Mirtazapine has the added benefit of potentially stimulating appetite to counteract Adderall's appetite-suppressing effects

3. Continue hydroxyzine for anxiety as the patient finds it beneficial and wishes to continue it

   • With trazodone removed, the CNS depressant interaction will be reduced

4. Maintain propranolol for anxiety management as the patient expressed a desire to continue this medication

5. Continue Adderall ER 10mg daily for ADHD symptoms

   • While the patient reports only modest improvement in focus and motivation, some benefit is noted
   • The dose could potentially be reassessed in the future if needed

Monitoring and Follow-up

• Blood pressure monitoring is essential as recommended to the patient, especially given:

  • Propranolol can cause hypotension
  • Mirtazapine may cause orthostatic hypotension, particularly in the initial treatment period
  • Adderall ER can increase blood pressure

• Sleep quality assessment at follow-up to ensure mirtazapine is effectively managing insomnia

• Appetite and weight monitoring to assess if mirtazapine is counteracting Adderall's appetite-suppressing effects

• Continued assessment for dizziness/lightheadedness to confirm resolution after trazodone discontinuation

Potential Pitfalls to Avoid

• Abrupt discontinuation of trazodone may cause withdrawal symptoms; however, since the patient is amenable to discontinuing it and the side effects are concerning, immediate discontinuation is warranted in this case

• Starting mirtazapine at too high a dose could cause excessive sedation; 7.5mg is an appropriate starting dose 1

• Failing to monitor for QT prolongation when using hydroxyzine, especially in combination with other medications

• Not addressing the underlying cause of dizziness - the recommendation to see a primary care physician to rule out other causes of dizziness is appropriate and should be emphasized