Pharmacological Options for Sleep Management
For insomnia treatment, I recommend starting with trazodone 25-100 mg at bedtime as the first-line pharmacological intervention. 1
First-Line Pharmacological Options
Trazodone
- Start with 25-100 mg PO at bedtime
- Particularly effective for sleep initiation and maintenance
- Advantages: non-habit forming, can be effective at low doses, and may be especially beneficial in patients with comorbid depression 1
- Administer shortly after a meal or light snack to minimize side effects 2
- Monitor for daytime drowsiness; if present, adjust timing or reduce dosage
Melatonin
- Alternative first-line option: 3 mg immediate-release 30-60 minutes before bedtime
- Can be titrated up to 5 mg if needed 3
- Particularly effective for sleep onset issues and circadian rhythm disorders
- Works best in patients with documented low melatonin levels 4
- Non-habit forming and generally well-tolerated 5
- Most effective when administered 30-60 minutes before desired sleep time 6
Second-Line Options
Sedating Antidepressants
- Mirtazapine: 7.5-30 mg PO at bedtime
- Particularly effective in patients with comorbid depression and anorexia 1
Benzodiazepine Receptor Agonists
- Zolpidem: 5 mg PO at bedtime
- Note: Should be used cautiously in older adults due to risk of cognitive impairment 1
- FDA recommends lower doses (5 mg for immediate-release products) due to risk of next-morning impairment 1
Antipsychotics (for refractory cases)
- Olanzapine: 2.5-5 mg PO at bedtime
- Quetiapine: 2.5-5 mg PO at bedtime
- Chlorpromazine: 25-50 mg PO at bedtime 1
Non-Pharmacological Interventions (to use concurrently)
Cognitive Behavioral Therapy for Insomnia
- Most effective non-pharmacological intervention 1
- Components include:
- Stimulus control (use bed only for sleep and sex)
- Sleep restriction (limiting time in bed to actual sleep time)
- Cognitive therapy to address unrealistic beliefs about sleep
Sleep Hygiene
- Maintain consistent sleep-wake schedule
- Create a quiet, dark, and comfortable sleep environment
- Avoid caffeine, alcohol, and heavy meals before bedtime
- Regular daytime exercise (but not close to bedtime)
- Avoid napping, especially after 3 PM 1
Special Considerations
For Elderly Patients
- Start with lower doses of all medications
- Avoid benzodiazepines due to risk of falls and cognitive impairment 1
- Melatonin 0.3 mg may be sufficient to restore normal sleep efficiency in older adults 4
For Patients with Daytime Sedation
- Consider adding daytime interventions if needed:
- Caffeine: 100-200 mg PO q 6 hours (last dose no later than 4 PM)
- Methylphenidate: 2.5-20 mg PO BID (second dose no later than 6 hours before bedtime) 1
Monitoring and Follow-up
- Reassess efficacy and side effects within 2-4 weeks
- Monitor for residual daytime sedation, cognitive effects, or paradoxical reactions
- Consider dose adjustment or medication switch if inadequate response or intolerable side effects
- For long-term use, periodically attempt to taper medication to lowest effective dose
Pitfalls to Avoid
- Don't continue ineffective treatments beyond 2-4 weeks without reassessment
- Avoid combining multiple sedating medications without careful monitoring
- Be cautious with benzodiazepines in elderly patients or those with respiratory conditions
- Remember that pharmacotherapy should complement, not replace, behavioral interventions for optimal outcomes