How to increase sleep duration in a patient with schizophrenia taking Cogentin (Benztropine), Keppra (Levetiracetam), Remeron (Mirtazapine), and Geodon (Ziprasidone) with current sleep duration of 4.5 hours?

Increasing Sleep Duration in a Patient with Schizophrenia on Multiple Medications

Increasing the dose of Remeron (mirtazapine) to 15-30 mg at bedtime is the most effective strategy to improve sleep in this patient with schizophrenia who is currently only sleeping 4.5 hours per night. 1

Current Medication Assessment

• Patient is taking:
  • Cogentin (benztropine) 1mg - anticholinergic for EPS symptoms 1
  • Keppra (levetiracetam) 500mg - antiepileptic 1
  • Remeron (mirtazapine) 7.5mg - sedating antidepressant 1, 2
  • Geodon (ziprasidone) 60mg - atypical antipsychotic 1

Recommended Approach

Step 1: Optimize Mirtazapine (First-Line)

• Increase mirtazapine from 7.5mg to 15mg at bedtime 1, 2
  • Current dose of 7.5mg is subtherapeutic for optimal sleep effects
  • FDA-approved starting dose is 15mg at bedtime 2
  • Can be titrated up to 30mg if needed after 1-2 weeks 2, 3
  • Mirtazapine promotes sleep through:
    • Potent histamine H1 receptor blockade 4
    • 5-HT2 and 5-HT3 receptor antagonism 4

Step 2: Administration Timing and Monitoring

• Administer mirtazapine 30 minutes before bedtime 3
• Monitor for:
  • Increased appetite and weight gain (common side effect) 2, 5
  • Excessive daytime sedation (usually transient) 3
  • Sleep quality improvement 6, 3

Step 3: If Inadequate Response After 2 Weeks

• Consider increasing mirtazapine to 30mg at bedtime 1, 2
• If still inadequate, consider adding one of these agents:
  • Eszopiclone 2-3mg at bedtime (for sleep maintenance) 1
  • Zolpidem 10mg at bedtime (for sleep onset and maintenance) 1
  • Doxepin 3-6mg at bedtime (for sleep maintenance) 1

Rationale for Recommendation

1. Mirtazapine is already part of the patient's regimen and is known to be effective for sleep 1
2. Clinical studies show mirtazapine increases total sleep time and improves sleep quality 6, 3
3. Fixed dosing regimen (15mg) shows greater sleep benefits than lower doses 3
4. Mirtazapine has been shown to increase alertness during the day despite improving nighttime sleep 3
5. Avoids adding another medication to an already complex regimen 1

Important Considerations

Avoid These Options

• Benzodiazepines: Not recommended due to risk of dependency, falls, and potential worsening of respiratory function 1
• Trazodone: Limited efficacy data for insomnia and potential adverse effects 1
• Diphenhydramine: Not recommended due to anticholinergic burden, especially with concurrent Cogentin 1
• Melatonin: Limited efficacy data for chronic insomnia 1

Cautions with Mirtazapine

• Monitor for weight gain (occurs in approximately 7.5% of patients) 2
• Be aware of potential QTc prolongation, especially with concurrent Geodon 2
• Use caution in patients with obstructive sleep apnea as mirtazapine may worsen this condition 1, 7

Medication Timing

• Ensure Geodon is taken with food (at least 500 calories) to maximize absorption
• Administer mirtazapine consistently 30 minutes before desired sleep time 3
• Consider administering Keppra earlier in the day if currently given at night 1

By optimizing the mirtazapine dose that the patient is already taking, you can improve sleep duration while minimizing the risks associated with adding new medications to the regimen.