Can I add trazodone 50mg to a patient's current regimen of temazepam (Restoril) 15mg at bedtime for insomnia?

Should You Add Trazodone to Temazepam for Insomnia?

No, you should not add trazodone 50mg to temazepam 15mg—instead, optimize or switch the temazepam regimen to a more effective evidence-based alternative, as the American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment. 1

Why Trazodone Should Not Be Added

Guideline Recommendations Against Trazodone

• The American Academy of Sleep Medicine gives trazodone a "WEAK" recommendation against its use for both sleep onset and sleep maintenance insomnia, based on trials of 50mg doses 1
• The clinical benefits are minimal: trazodone 50mg reduced sleep latency by only 10.2 minutes, increased total sleep time by only 21.8 minutes, and reduced wake after sleep onset by only 7.7 minutes—all below clinical significance thresholds 2
• Subjective sleep quality showed no significant improvement versus placebo (difference of −0.13 points on a 4-point scale) 2
• The harms potentially outweigh benefits, with 75% of subjects experiencing adverse events versus 65.4% on placebo, including headache and somnolence 2

Safety Concerns with Combination Therapy

• Combining two sedating medications (temazepam + trazodone) increases risks of excessive daytime drowsiness, psychomotor impairment, falls (especially in elderly), and cognitive impairment 3, 4
• Trazodone causes orthostatic hypotension, dizziness, and has been associated with priapism requiring discontinuation 3
• The VA/DOD guidelines explicitly advise against trazodone for chronic insomnia disorder 3

What You Should Do Instead

Option 1: Optimize Current Temazepam Regimen

• Increase temazepam dose to 30mg at bedtime, as the American Academy of Sleep Medicine recommends temazepam 15-30mg for sleep maintenance insomnia 2
• Temazepam has established efficacy for both sleep onset and sleep maintenance insomnia at these doses 1

Option 2: Switch to Alternative Evidence-Based Medications

For sleep onset insomnia:

• Zolpidem 10mg at bedtime 2
• Zaleplon 10mg at bedtime 2
• Ramelteon 8mg at bedtime 2

For sleep maintenance insomnia:

• Eszopiclone 2-3mg at bedtime 2
• Doxepin 3-6mg at bedtime 2
• Suvorexant 10-20mg at bedtime 1

Option 3: Address Non-Pharmacological Factors First

• Ensure Cognitive Behavioral Therapy for Insomnia (CBT-I) has been offered as first-line treatment, as it should precede or accompany pharmacotherapy 3
• CBT-I includes stimulus control therapy, sleep restriction therapy, and relaxation therapy 3

Important Clinical Caveats

When Trazodone Might Be Considered (Third-Line Only)

• Trazodone may be appropriate only as a third-line agent when comorbid depression is present, though the low doses used for insomnia (50mg) do not constitute adequate treatment for major depression 2, 3
• Even in depression with insomnia, trazodone should only be considered after benzodiazepine receptor agonists and ramelteon have failed 3

Medication Safety Principles

• Use the lowest effective dose for the shortest possible duration 3
• Counsel patients about potential risks including sleep behaviors (sleepwalking, sleep driving) with all sedative medications 3
• Regular follow-up is essential to assess effectiveness, side effects, and ongoing need for pharmacotherapy 3
• Administer on an empty stomach to maximize effectiveness 3

Special Population Concerns

• Elderly patients are at particularly high risk for adverse effects from trazodone, including orthostatic hypotension, falls, and daytime drowsiness 2, 4
• Caution is warranted if signs/symptoms of compromised respiratory function or hepatic/heart failure are present 3