What is the plan for titrating off trazodone and starting escitalopram (Lexapro) and eszopiclone (Lunesta)?

Titration Plan for Transitioning from Trazodone to Escitalopram and Eszopiclone

Taper trazodone gradually over 10-14 days while simultaneously initiating escitalopram, then add eszopiclone for persistent insomnia once the trazodone taper is complete. 1, 2

Trazodone Discontinuation Strategy

Trazodone must be tapered very slowly to avoid withdrawal symptoms, not abruptly discontinued. 1, 2

• Reduce trazodone by 25-50 mg every 3-5 days depending on the starting dose, extending the taper to 10-14 days minimum 2, 3
• Trazodone's short half-life (3-9 hours) and effects on the serotonergic system create risk for noradrenergic rebound and withdrawal symptoms including anxiety, agitation, insomnia, dizziness, and sensory disturbances 2
• Do not stop trazodone abruptly - withdrawal reactions can occur even with gradual discontinuation if tapered too quickly 1, 2

Example Taper Schedule (if starting from 150 mg/day):

• Days 1-3: Reduce to 100 mg at bedtime 2
• Days 4-7: Reduce to 50 mg at bedtime 2
• Days 8-10: Reduce to 25 mg at bedtime 2
• Days 11-14: Discontinue completely 2

Escitalopram Initiation

Start escitalopram at a low "test dose" during the trazodone taper to assess tolerability, as initial SSRI side effects can include anxiety and agitation. 4

• Begin with escitalopram 5 mg daily in the morning on Day 1 of the trazodone taper 4
• Continue escitalopram 5 mg for 5-7 days to assess tolerance 4
• Increase to escitalopram 10 mg daily after 1 week if well-tolerated 4
• Target therapeutic dose is typically 10-20 mg daily, with dose increases in 5 mg increments every 1-2 weeks as needed 4
• Escitalopram has minimal CYP450 interactions compared to other SSRIs, making it a safer choice during polypharmacy transitions 4

Critical Monitoring During Overlap:

• Watch for serotonin syndrome during the overlap period when both trazodone and escitalopram are present, though risk is relatively low 1
• Monitor for increased anxiety, agitation, or insomnia as trazodone's sedating effects diminish 4, 2
• Assess for suicidal ideation, especially in the first 24-48 hours after dose changes 4, 1

Eszopiclone Addition for Insomnia

Add eszopiclone only after trazodone is fully discontinued to avoid excessive sedation and to clearly assess whether insomnia persists without trazodone's sedating effects. 4, 5

• Start eszopiclone 2-3 mg at bedtime for sleep-onset and maintenance insomnia 4
• Reduce to 1 mg in elderly, debilitated, or those with severe hepatic impairment 4
• Take immediately before bed with at least 7-8 hours available for sleep 5
• Do not take with or immediately after meals - absorption is reduced 5
• Eszopiclone has no short-term usage restriction and is intermediate-acting, making it suitable for both sleep onset and maintenance 4

Important Safety Warnings for Eszopiclone:

• Risk of complex sleep behaviors including sleep-driving, sleep-eating, and sleep-walking - patients must be counseled about these risks 5
• Do not combine with alcohol or other CNS depressants during the transition period 5
• Most common side effects include unpleasant taste, dry mouth, drowsiness, and dizziness 5
• Next-day impairment is possible - caution patients about driving or dangerous activities until they know how they respond 5

Timeline Summary

Week 1-2:

• Day 1: Start escitalopram 5 mg AM + begin trazodone taper
• Days 1-14: Complete trazodone taper as outlined above
• Day 7: Increase escitalopram to 10 mg if tolerated

Week 3+:

• Assess sleep quality after trazodone fully discontinued
• If insomnia persists after 3-5 days off trazodone, initiate eszopiclone 2-3 mg at bedtime 4
• Continue escitalopram titration to therapeutic dose (typically 10-20 mg) over subsequent weeks 4

Common Pitfalls to Avoid

• Never taper trazodone too rapidly - even therapeutic doses can cause withdrawal with abrupt cessation 1, 2
• Do not add eszopiclone while still on trazodone - excessive sedation and inability to assess true insomnia severity 4
• Do not start escitalopram at full therapeutic dose - initial anxiety/agitation can worsen withdrawal symptoms 4
• Avoid evening dosing of escitalopram - SSRIs can be activating and worsen insomnia 4
• Do not assume insomnia will persist - reassess sleep 3-5 days after trazodone discontinuation before adding eszopiclone 4