What medications can help control nighttime cravings?

Medications for Controlling Nighttime Cravings

For nighttime cravings, the most effective FDA-approved medications include trazodone (50-100mg), low-dose doxepin (3-6mg), and mirtazapine (7.5-30mg), with trazodone being the preferred first-line option due to its established efficacy for both sleep onset and maintenance insomnia. 1

First-Line Medications

Trazodone

• Dosage: 25-100mg PO at bedtime 2, 1
• Evidence: Shown to decrease nighttime awakening frequency from 3.3 to 1.3 nights/week in patients with nighttime disturbances 2
• Mechanism: Triazolopyridine derivative that promotes sleep while reducing nighttime disturbances
• Considerations:
  • Most commonly prescribed non-benzodiazepine sleep medication (0.97% of population) 1
  • May cause daytime sedation, dizziness in 60% of patients 2
  • Rare but serious side effects include priapism (reported in 5 of 74 patients in one study) 2

Mirtazapine

• Dosage: 7.5-30mg PO at bedtime 2
• Evidence: Effective for both sleep onset and maintenance issues
• Mechanism: Increases norepinephrine and serotonin neurotransmission
• Considerations: May stimulate appetite, which can be beneficial for those with nighttime cravings but potentially problematic for weight management

Low-dose Doxepin

• Dosage: 3-6mg at bedtime 1
• Evidence: Effective for sleep maintenance insomnia
• Mechanism: Histamine H1 receptor antagonist at low doses
• Considerations: Particularly suitable for elderly patients due to fewer anticholinergic effects and minimal next-day impairment 1

Second-Line Options

Topiramate

• Dosage: Starting at 50mg/day, titrated to target dose of 200mg/day 2, 3
• Evidence: Reduced nighttime eating behaviors in patients with nocturnal eating syndrome and sleep-related eating disorder 3
• Mechanism: Anticonvulsant that may reduce appetite and cravings
• Considerations: Also effective for binge eating disorder with mean weight loss of 11.1kg in one study 3, 4

Olanzapine

• Dosage: 2.5-5mg PO at bedtime 2
• Evidence: Listed in palliative care guidelines for insomnia management
• Mechanism: Atypical antipsychotic with sedative properties
• Considerations: Risk of metabolic side effects including weight gain, which may be counterproductive for some patients with food cravings

Specific Clinical Scenarios

For patients with binge eating disorder with nighttime cravings:

1. Lisdexamfetamine (FDA-approved for BED) 5, 6

   • Not for bedtime use but may help control daytime and evening binge eating behaviors
   • Should be taken earlier in the day to avoid sleep disruption

2. Topiramate (off-label for BED) 6, 4

   • Effective for both binge eating and weight loss
   • Dosage: 100-1400mg/day (mean effective dose ~492mg/day) 4
   • Response maintained for 3-30 months in one case series 4

For patients with PTSD-related nightmares and cravings:

• Prazosin is first-line (Level A recommendation) for PTSD-related nightmares 1

For patients with REM sleep behavior disorder:

• Clonazepam (0.25-1.0mg at bedtime) or immediate-release melatonin (3-15mg) 2
• These may help with sleep quality which can indirectly reduce nighttime awakenings and subsequent cravings

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Sleep hygiene education
   • Cognitive-behavioral therapy for insomnia (CBT-I)
   • Stimulus control techniques
   • Progressive muscle relaxation

2. If non-pharmacological approaches are insufficient:

   • First choice: Trazodone 25-50mg, titrate up to 100mg as needed
   • Alternative first choices: Mirtazapine 7.5-15mg or Doxepin 3-6mg

3. For persistent cravings with binge eating features:

   • Add topiramate starting at 50mg/day, titrate slowly to effective dose

4. Monitor and follow-up:

   • Assess response within 2-4 weeks
   • Monitor for side effects including daytime sedation
   • Adjust dosage or switch medications if inadequate response or intolerable side effects

Important Cautions

• Avoid benzodiazepines for long-term management due to risks of dependency, cognitive impairment, falls, and respiratory depression 1
• Avoid antihistamines due to antimuscarinic effects and rapid development of tolerance 1
• Use caution with antipsychotics due to metabolic side effects and limited evidence for insomnia treatment 1
• Avoid quetiapine for primary insomnia due to significant safety concerns and metabolic risks 1

Remember that treating the underlying causes of nighttime cravings (such as poor sleep quality, psychological factors, or eating disorders) is essential for long-term management.