What can I start a patient with insomnia on, considering their complex medical history?

First-Line Treatment Options for Insomnia

For a patient with insomnia, I recommend starting with low-dose trazodone (25-50 mg) at bedtime as the first-line pharmacological treatment due to its effectiveness, safety profile, and non-habit forming properties. 1, 2, 3

Treatment Algorithm for Insomnia

Step 1: Non-Pharmacological Interventions (First Line)

• Implement sleep hygiene practices:
  • Maintain consistent sleep/wake schedule
  • Create comfortable sleep environment (quiet, dark, comfortable temperature)
  • Limit exposure to light in evening
  • Avoid stimulating activities before bedtime 4, 1
• Consider stimulus control therapy:
  • Only go to bed when sleepy
  • Use bed only for sleep (not watching TV, using phone, etc.)
  • Leave bed if unable to sleep within 20 minutes 4, 1

Step 2: Pharmacological Options (When Non-Pharmacological Approaches Are Insufficient)

For Sleep Onset Insomnia:

1. Trazodone 25-50 mg at bedtime (preferred option)

   • Effective for both sleep onset and maintenance
   • Non-habit forming
   • Better tolerated than many alternatives 1, 3

2. Alternative options:

   • Zolpidem 5-10 mg (5 mg for elderly)
   • Zaleplon 10 mg
   • Ramelteon 8 mg 1

For Sleep Maintenance Insomnia:

1. Trazodone 25-50 mg at bedtime (preferred option)
2. Alternative options:
   • Low-dose doxepin 3-6 mg
   • Eszopiclone 2-3 mg (1 mg for elderly)
   • Suvorexant 10-20 mg (5 mg for elderly) 1

Medication Selection Based on Comorbidities

• With depression/anxiety: Trazodone 50-100 mg or mirtazapine 7.5-15 mg 1, 5, 6
• With PTSD/nightmares: Prazosin (first-line for trauma-related sleep disturbances) 1
• With neuropathic pain: Consider gabapentin 1
• With substance use history: Prefer non-scheduled options like low-dose doxepin or trazodone 1
• With respiratory conditions: Avoid benzodiazepines; consider trazodone or ramelteon 1

Evidence Supporting Trazodone as First Choice

• Trazodone demonstrated longer total sleep time compared to quetiapine (7.80 vs 6.75 hours) and fewer nighttime awakenings (0.52 vs 0.75) 3
• Low-dose trazodone (25-75 mg) showed 100% response rate in treating chronic insomnia 6
• Trazodone blocks 5-HT2 receptors, which helps alleviate insomnia and improves sleep architecture 5
• The FDA-approved dosing starts at low doses that can be gradually increased, with lower doses often being effective for insomnia 2

Important Monitoring and Follow-up

• Assess response within 2-4 weeks of starting treatment
• Monitor for side effects, particularly:
  • Gastrointestinal effects (constipation, nausea, diarrhea) which are more common with trazodone 3
  • Daytime sedation
  • Orthostatic hypotension
• Start with the lowest effective dose (25 mg for trazodone) and titrate as needed 1, 6

Cautions and Contraindications

• Screen for bipolar disorder before starting trazodone, as antidepressants can trigger manic episodes 2
• Allow at least 14 days between MAOI use and trazodone initiation 2
• Consider dose reduction when used with strong CYP3A4 inhibitors 2
• Avoid abrupt discontinuation; taper gradually when stopping 2
• For elderly patients, use lower doses due to increased sensitivity and fall risk 1

Trazodone at low doses (25-50 mg) represents an optimal balance of efficacy and safety for most patients with insomnia, with the added benefit of addressing comorbid mood symptoms that often accompany sleep disturbances 1, 6, 3.