What sleep medications are safe for patients with glaucoma?

Sleep Medications Safe for Patients with Glaucoma

For patients with glaucoma, melatonin receptor agonists like ramelteon are the safest sleep medications, while trazodone and other sedating antidepressants should be avoided in patients with untreated narrow-angle glaucoma. 1, 2

Safe Sleep Medication Options

First-Line Options

• Melatonin receptor agonists (ramelteon 8mg at bedtime) are safe for patients with glaucoma as they do not affect intraocular pressure or pupillary dilation 1
• Ramelteon is primarily used for sleep-onset insomnia, is short-acting, and has no short-term usage restrictions 1

Second-Line Options

• Non-benzodiazepine benzodiazepine receptor agonists (Z-drugs) may be used with caution:
  • Eszopiclone (1-3mg at bedtime) for sleep onset and maintenance insomnia 1
  • Zaleplon (5-10mg at bedtime) for sleep onset insomnia 1
  • Zolpidem (5-10mg at bedtime) for sleep onset insomnia 1

Medications to Use with Caution

Benzodiazepines

• Can be used but require careful monitoring:
  • Estazolam (1-2mg at bedtime) - short to intermediate acting 1
  • Temazepam (15-30mg at bedtime) - short to intermediate acting 1
  • Triazolam (0.125-0.25mg at bedtime) - short acting 1
• Lower doses should be used in elderly or debilitated patients 1

Pregabalin

• Has no known negative effects on intraocular pressure in patients with open-angle glaucoma 3
• Can be safely used in patients with open-angle glaucoma according to the American Academy of Ophthalmology 3

Medications to Avoid

Sedating Antidepressants

• Trazodone and other antidepressants with anticholinergic properties carry a warning for angle-closure glaucoma 2
• The FDA label for trazodone specifically warns: "The pupillary dilation that occurs following use of many antidepressant drugs including Trazodone Hydrochloride Tablets may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy" 2
• Avoid use of trazodone in patients with untreated anatomically narrow angles 2

Anticholinergics

• First-generation antihistamines (found in many OTC sleep aids) should be avoided in glaucoma patients due to their anticholinergic properties 1, 4
• These medications can cause pupillary dilation which may precipitate an acute angle-closure attack in susceptible individuals 2, 4

Important Considerations

Glaucoma Type Matters

• The risk of medication-induced complications differs between open-angle and angle-closure glaucoma 4
• Most medication warnings are more critical for angle-closure glaucoma than for open-angle glaucoma 4
• Patients with open-angle glaucoma generally have fewer medication restrictions than those with angle-closure glaucoma 3, 4

Administration Guidelines

• Sleep medications should be administered on an empty stomach to maximize effectiveness 1
• Avoid combining sleep medications with alcohol or other CNS depressants 1
• Caution is advised in elderly patients, with downward dosage adjustment recommended 1

Monitoring

• Regular monitoring of intraocular pressure is important for glaucoma patients on any medication regimen 1
• If a patient with glaucoma experiences any visual changes or eye discomfort after starting a sleep medication, they should seek immediate medical attention 2

Special Populations

Pregnant/Nursing Women

• Sleep medications are generally not recommended during pregnancy or nursing 1
• If treatment is necessary, consult with both ophthalmology and obstetrics before prescribing 1

Elderly Patients

• Lower doses of sleep medications are recommended for elderly patients 1
• Elderly patients are at higher risk for adverse effects from sedative-hypnotics 1