How to safely discontinue Lunesta (eszopiclone) and start Trazodone (trazodone) for insomnia treatment?

Safely Discontinuing Lunesta (Eszopiclone) and Starting Trazodone for Insomnia

When transitioning from Lunesta (eszopiclone) to trazodone for insomnia treatment, gradually taper off Lunesta over 1-2 weeks while starting trazodone at a low dose (25-50mg) at bedtime to minimize withdrawal symptoms and ensure treatment efficacy. 1, 2

Discontinuing Lunesta (Eszopiclone)

Tapering Schedule

• Gradually reduce the Lunesta dose rather than stopping abruptly to minimize withdrawal symptoms 1
• For patients on 3mg Lunesta, reduce to 2mg for 3-4 days, then to 1mg for 3-4 days before discontinuation 1
• For patients on 2mg Lunesta, reduce to 1mg for 5-7 days before discontinuation 1
• Monitor for withdrawal symptoms including rebound insomnia, anxiety, and abnormal dreams during the tapering process 1

Potential Withdrawal Effects

• Rebound insomnia may occur, particularly on the first night after discontinuation, characterized by increased wake time after sleep onset (WASO) and decreased sleep efficiency 1
• Anxiety, abnormal dreams, and hyperesthesia have been reported during withdrawal periods 1
• These withdrawal effects are typically mild and resolve by the second night after discontinuation 1

Starting Trazodone

Initial Dosing

• Begin with a low dose of 25-50mg taken at bedtime 2
• Administer shortly after a meal or light snack to maximize effectiveness and minimize side effects 2
• Trazodone is not FDA-approved specifically for insomnia but is commonly used off-label at lower doses than those used for depression 3, 4

Dose Adjustment

• If needed, the dose can be gradually increased by 25-50mg every 3-4 days based on response and tolerability 2
• For insomnia treatment, doses typically range from 25-100mg, which is lower than the antidepressant dosage range (150-400mg) 5
• Monitor for effectiveness and side effects, particularly morning drowsiness 5

Timing of Transition

Overlap Period

• Begin trazodone at a low dose (25-50mg) while still on the lowest dose of Lunesta during the final 2-3 days of the taper 3, 2
• This approach may help minimize rebound insomnia while the body adjusts to the new medication 3

Complete Transition

• Once Lunesta is fully discontinued, continue with trazodone and adjust the dose as needed based on response 2
• Allow 1-2 weeks to assess the full effect of trazodone on sleep parameters 6

Monitoring and Precautions

Efficacy Assessment

• Evaluate sleep onset, maintenance, and overall quality after transition 3
• Be aware that the American Academy of Sleep Medicine has issued a weak recommendation against trazodone for insomnia due to limited efficacy evidence compared to potential harms 4
• Clinical trials showed modest improvements in sleep parameters with trazodone 50mg but no significant improvement in subjective sleep quality 4

Side Effect Management

• Monitor for common trazodone side effects including sedation, dizziness, and dry mouth 7
• Elderly patients may be more sensitive to side effects and should start at lower doses (25mg) 3, 7
• Be aware of rare but serious side effects such as priapism 4

Special Considerations

• Avoid alcohol and other CNS depressants during the transition period 3
• Trazodone should be tapered very slowly when discontinuing to avoid withdrawal symptoms 8
• Consider cognitive behavioral therapy for insomnia (CBT-I) as a non-pharmacological approach to be used alongside or instead of medication 9

Alternative Approaches

If Transition Is Unsuccessful

• Consider other FDA-approved medications for insomnia such as suvorexant, ramelteon, or doxepin (3-6mg) 4
• The American Academy of Sleep Medicine recommends short-to-intermediate-acting benzodiazepine receptor agonists or ramelteon as first-line pharmacological treatments for insomnia 9
• CBT-I should be considered the first-line treatment for chronic insomnia before any pharmacological intervention 9

Combination Therapy

• While no specific research studies have examined combinations of benzodiazepine receptor agonists and antidepressants, clinical experience suggests the general safety of this approach during transition periods 3
• A combination may improve efficacy by targeting multiple sleep-wake mechanisms while minimizing toxicity 3

Pitfalls to Avoid

• Do not stop Lunesta abruptly as this increases the risk of withdrawal symptoms 1
• Do not start trazodone at high doses (>100mg) as this increases the risk of side effects without necessarily improving efficacy for insomnia 6
• Be aware that trazodone's efficacy for insomnia is not well established, especially for long-term use 3, 4
• Avoid using trazodone with monoamine oxidase inhibitors (MAOIs) or within 14 days of discontinuing an MAOI 2