What are the recommended sleep management options for patients with a family history of glaucoma who are taking trazodone (an antidepressant)?

Sleep Management for Patients with Family History of Glaucoma Taking Trazodone

For patients with a family history of glaucoma who are taking trazodone, Cognitive Behavioral Therapy for Insomnia (CBT-I) is strongly recommended as the first-line treatment for sleep management, rather than continuing or increasing trazodone dosage. 1

Concerns with Trazodone in Patients with Glaucoma Risk

Trazodone requires careful consideration in patients with a family history of glaucoma due to:

• Case reports have documented acute myopia with mild intraocular pressure elevation as a rare but serious side effect of trazodone 2
• This reaction can potentially trigger acute angle-closure glaucoma or supraciliary choroidal effusion in predisposed individuals
• The only correct treatment for this adverse effect is discontinuation of the drug 2

First-Line Treatment: CBT-I

CBT-I should be implemented as the primary intervention because:

• The American Academy of Sleep Medicine recommends CBT-I as first-line treatment for insomnia with high-quality evidence 1
• CBT-I avoids medication-related risks in patients with glaucoma predisposition
• It has demonstrated effectiveness and an excellent safety profile 1

Key Components of CBT-I to Implement:

1. Sleep Restriction Therapy

   • Limit time in bed to match actual sleep time based on 2-week sleep logs
   • Gradually increase time in bed by 15-20 minutes every 5 days as sleep efficiency improves 1

2. Stimulus Control

   • Associate bedroom only with sleep and sex
   • Leave bedroom if unable to fall asleep within 15-20 minutes
   • Return only when sleepy 1

3. Sleep Hygiene Education

   • Maintain consistent sleep-wake schedule
   • Limit daytime naps to 30 minutes before 2 PM
   • Avoid caffeine, alcohol, and nicotine, especially in evening
   • Create comfortable sleep environment (quiet, dark, comfortable temperature) 1

4. Relaxation Techniques

   • Progressive muscle relaxation
   • Guided imagery
   • Diaphragmatic breathing
   • Meditation 1

Alternative Pharmacological Options (If CBT-I is Insufficient)

If CBT-I alone is insufficient after 4 weeks of consistent implementation, consider these medication alternatives that have better safety profiles for patients with glaucoma risk:

1. Ramelteon (8mg)

   • For sleep onset difficulties
   • Has minimal impact on intraocular pressure 1

2. Low-dose Doxepin (3mg)

   • For sleep maintenance difficulties
   • Less likely to affect intraocular pressure 1

3. Melatonin

   • Studies show comparable efficacy to trazodone for hospitalized patients with new-onset insomnia
   • Lower risk of adverse effects in patients with glaucoma risk 3

Monitoring and Follow-up

• Track progress using the Insomnia Severity Index (ISI) 1
• Schedule follow-up within 7-10 days of initiating any new treatment 1
• Monitor for any visual changes, eye pain, or other ocular symptoms that could indicate glaucoma
• If insomnia persists despite multiple interventions, consider referral to a sleep specialist 1

Important Considerations When Transitioning from Trazodone

• Gradual tapering of trazodone is recommended to minimize withdrawal symptoms and rebound insomnia 1
• Monitor for daytime drowsiness and decreased appetite, which are common side effects of trazodone 4
• Trazodone has been shown to increase total sleep time and deep sleep (N3) while decreasing sleep latency 4, so patients should be informed that their subjective sleep experience may change during transition

Cautions and Contraindications

• Avoid benzodiazepines due to risks of tolerance, dependence, withdrawal seizures, and cognitive impairment 1
• Use Z-drugs (zolpidem, eszopiclone) with caution due to risks of cognitive impairment and falls 1
• Be aware that trazodone at 50-100 mg/day has been shown to improve sleep disorders, particularly at the 100 mg/day dosage 5, but the glaucoma risk outweighs this benefit in this patient population