What adjustments can be made to a regimen of Trazodone (triazolopyridine) and BelSomra (suvorexant) for insomnia if it is not effective?

Adjusting an Ineffective Trazodone and Suvorexant (BelSomra) Regimen for Insomnia

For patients with insomnia not responding to a combination of trazodone and suvorexant (BelSomra), the recommended approach is to optimize the suvorexant dose to 20mg while discontinuing trazodone, as trazodone is not recommended for insomnia treatment according to current guidelines. 1, 2

Current Medication Assessment

• Trazodone is not recommended by the American Academy of Sleep Medicine for treatment of insomnia due to limited efficacy and potential adverse effects 1
• Clinical trials showed trazodone produced only modest improvements in sleep parameters with no significant improvement in subjective sleep quality 1
• Suvorexant (BelSomra) is FDA-approved for insomnia characterized by difficulties with sleep onset and/or sleep maintenance 3

Recommended Medication Adjustments

First Step: Optimize Suvorexant (BelSomra)

• Increase suvorexant to the maximum recommended dose of 20mg if currently on a lower dose 3
• Ensure proper administration:
  • Take no more than once per night within 30 minutes of going to bed 3
  • Allow at least 7 hours remaining prior to planned awakening 3
  • Take on an empty stomach, as food can delay onset of action 3

Second Step: Consider Discontinuing Trazodone

• The American Academy of Sleep Medicine explicitly advises against using trazodone for chronic insomnia 1
• Trazodone has been associated with significant side effects including daytime sedation, dizziness, and in some cases, priapism 4, 1
• Systematic reviews show trazodone has limited efficacy for primary insomnia 5

Alternative Medication Options

If optimizing suvorexant alone is ineffective, consider these alternatives according to clinical guidelines:

1. Short-intermediate acting benzodiazepine receptor agonists (BZRAs):

   • Zolpidem, eszopiclone, zaleplon, or temazepam 4, 2
   • These are recommended as first-line pharmacological options for insomnia 4

2. Ramelteon:

   • Particularly effective for sleep onset insomnia 4, 2

3. Low-dose doxepin (3-6mg):

   • Recommended for sleep maintenance insomnia 1, 2

Non-Pharmacological Interventions

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be incorporated into the treatment plan 4, 1
• CBT-I components include:
  • Cognitive therapy
  • Stimulus control therapy
  • Sleep restriction therapy
  • Relaxation techniques 1

Important Monitoring Considerations

• Follow patients regularly, especially during the initial period of treatment adjustment 4
• Assess for medication effectiveness and possible side effects 4
• Monitor for daytime impairment, as suvorexant can affect driving ability and increase fall risk 3
• Use the lowest effective maintenance dosage and consider tapering medication when conditions allow 4

Common Pitfalls to Avoid

• Avoid combining multiple CNS depressants without appropriate dose reduction, as this increases risk of side effects 3
• Do not use over-the-counter antihistamines or herbal supplements (valerian, melatonin) as they lack efficacy and safety data for chronic insomnia 4, 1
• Be cautious with suvorexant in obese women, as they may have increased exposure and risk of adverse effects 3
• Avoid older medications such as barbiturates and chloral hydrate for insomnia treatment 4

By following this structured approach, patients with insomnia not responding to trazodone and suvorexant can receive evidence-based care that prioritizes both efficacy and safety.