What is the best next long-term treatment for sleep in a patient with anxiety and panic disorders taking Prozac (fluoxetine) 30 mg, who had to discontinue trazodone due to orthostatic hypertension and is currently taking hydroxyzine 50 mg at bedtime?

Best Long-Term Sleep Treatment for Anxiety and Panic Disorders After Trazodone Discontinuation

For a patient with anxiety and panic disorders who discontinued trazodone due to orthostatic hypotension and is finding hydroxyzine 50mg ineffective, low-dose doxepin (3-6mg) is the recommended next long-term treatment for sleep.

Rationale for Doxepin Recommendation

The American Academy of Sleep Medicine specifically recommends doxepin for sleep maintenance insomnia in adults 1. This recommendation is particularly relevant for several reasons:

1. Doxepin at low doses (3-6mg) has minimal cardiovascular effects, making it suitable for a patient with orthostatic hypotension concerns
2. Unlike trazodone, which is specifically not recommended for insomnia by sleep medicine guidelines 1
3. Doxepin works well with the patient's current SSRI (fluoxetine) therapy for anxiety and panic disorders

Treatment Algorithm

First-line option:

• Doxepin 3mg at bedtime
  • Start at 3mg and titrate to 6mg if needed after 1 week
  • Monitor for effectiveness and side effects
  • Advantages: FDA-approved for insomnia, minimal cardiovascular effects, compatible with fluoxetine

Alternative options (if doxepin is ineffective or not tolerated):

1. Eszopiclone 1-2mg at bedtime

   • Effective for both sleep onset and maintenance 1
   • Less likely to cause orthostatic hypotension than trazodone
   • Monitor for taste disturbances and potential for tolerance

2. Ramelteon 8mg at bedtime

   • Melatonin receptor agonist effective for sleep onset 1
   • No cardiovascular concerns
   • No risk of dependence or tolerance

3. Suvorexant 10-15mg at bedtime

   • Orexin receptor antagonist for sleep maintenance 1
   • Different mechanism than other sleep medications
   • Less likely to cause orthostatic effects

Important Considerations

• Avoid diphenhydramine (similar to hydroxyzine) as the American Academy of Sleep Medicine specifically recommends against its use for insomnia 1

• Avoid benzodiazepines for routine use in anxiety with insomnia due to risk of dependence and potential to worsen anxiety long-term 2

• Medication timing: Take doxepin approximately 30 minutes before desired bedtime

• Duration of therapy: Continue effective treatment for approximately 1 year following symptom remission, with consideration for longer therapy given the patient's anxiety and panic disorders 2

Monitoring Plan

• Assess sleep quality, daytime functioning, and any side effects at 2 weeks
• Monitor blood pressure in both sitting and standing positions at follow-up visits
• Evaluate anxiety symptoms to ensure sleep medication is not exacerbating underlying condition
• If treatment is effective, continue for at least 6-12 months before considering gradual tapering

Special Considerations with Current Medications

• Fluoxetine interaction: No significant interactions between low-dose doxepin and fluoxetine
• Hydroxyzine: Can be discontinued once doxepin is effective, or continued short-term during transition if needed
• Gradual discontinuation: When eventually discontinuing any effective sleep medication, reduce by no more than 25% every 1-2 weeks to minimize withdrawal symptoms 2

Pitfalls to Avoid

• Continuing hydroxyzine long-term despite ineffectiveness (antihistamines are not recommended for chronic insomnia)
• Using benzodiazepines as a quick solution (risk of dependence and rebound insomnia)
• Overlooking the connection between anxiety management and sleep quality
• Failing to address sleep hygiene practices alongside pharmacological treatment

By following this approach with doxepin as the primary recommendation, you're addressing the patient's sleep needs while considering their cardiovascular concerns and ongoing anxiety treatment.