What is the recommended dosage and precautions for using Trazodone (triazolopyridine) for insomnia?

Trazodone for Insomnia: Dosage and Precautions

Trazodone is not recommended as a first-line treatment for chronic insomnia due to its limited efficacy and potential adverse effects. 1, 2

Recommended Dosage (When Used)

• For insomnia, trazodone is typically used at lower doses than for depression, ranging from 25-100 mg taken before bedtime 1
• Start with the lowest effective dose (25-50 mg) and increase only if necessary 3, 4
• Administer approximately 1 hour before bedtime for optimal effect on sleep onset 5
• Take shortly after a meal or light snack to improve absorption and potentially reduce side effects 3

Efficacy Considerations

• Trazodone shows modest improvement in subjective sleep quality but limited effect on sleep onset latency, total sleep time, or wake time after sleep onset 1, 2
• More effective for sleep maintenance insomnia than for sleep onset insomnia 5
• May be more beneficial in patients with comorbid depression or when used with activating antidepressants 2, 5
• Unlike benzodiazepines, trazodone increases deep sleep duration, which may improve subjective sleep quality 5

Important Precautions

• Monitor for common side effects including:
  • Drowsiness/daytime sedation (most common) 1, 6
  • Dizziness and psychomotor impairment (particularly concerning in elderly patients) 2
  • Priapism (reported in up to 12% of patients in some studies) 2, 7
• Use with caution in patients with:
  • Compromised respiratory function (e.g., asthma, COPD, sleep apnea) 1
  • Hepatic heart failure 1
  • Risk factors for QT prolongation 3
• Not recommended during pregnancy or nursing 1
• Avoid abrupt discontinuation; gradually taper dose when stopping 3

Alternative Treatments

• Cognitive behavioral therapy for insomnia (CBT-I) should be considered first-line treatment for chronic insomnia 1, 2
• If pharmacotherapy is needed, preferred options include:
  • Non-benzodiazepine BZRAs (eszopiclone, zolpidem, zaleplon) for sleep onset and/or maintenance insomnia 1, 2
  • Ramelteon for sleep onset insomnia 1, 2
  • Low-dose doxepin (3-6 mg) for sleep maintenance insomnia 1, 2

Special Considerations

• Avoid concomitant use with other CNS depressants and alcohol due to additive effects 1
• Consider drug interactions, particularly with strong CYP3A4 inhibitors or inducers which may require dose adjustments 3
• Elderly patients may be more sensitive to side effects and should generally receive lower doses 1, 2
• Screen for bipolar disorder before initiating treatment 3
• Allow for appropriate sleep time when using trazodone for insomnia 1, 2