Can I give a patient with insomnia a single dose of trazodone (antidepressant medication)?

Trazodone for Inpatient Insomnia

I would not recommend giving trazodone as a first-line treatment for insomnia in your inpatient, as major clinical guidelines explicitly advise against its use for this indication. 1, 2

Why Trazodone Is Not Recommended

The American Academy of Sleep Medicine issued a "WEAK" recommendation against using trazodone for either sleep onset or sleep maintenance insomnia in adults. 1, 2 This recommendation is based on clinical trials showing that even at 50 mg doses, trazodone produced only minimal improvements:

• Sleep latency reduced by only 10.2 minutes 2
• Total sleep time increased by only 21.8 minutes 2
• Wake after sleep onset reduced by only 7.7 minutes 2
• No significant improvement in subjective sleep quality (−0.13 points on a 4-point scale) 2

These benefits fall below the threshold for clinical significance, and the potential harms outweigh the modest benefits. 1, 2

Significant Safety Concerns

The FDA labeling highlights multiple serious risks that are particularly concerning in the inpatient setting:

• Orthostatic hypotension and syncope, which increases fall risk 3
• Priapism requiring emergency intervention if erection lasts >4 hours 3
• Cognitive and motor impairment with somnolence and sedation 3
• QT prolongation, especially problematic with concurrent medications 3
• Hyponatremia (SIADH), particularly in elderly or volume-depleted patients 3
• Increased bleeding risk when combined with antiplatelet agents or anticoagulants 3

In clinical trials, 75% of subjects experienced adverse events versus 65.4% on placebo, with headache and somnolence being most common. 2

Recommended Alternatives

For sleep onset insomnia, the American Academy of Sleep Medicine recommends: 2

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

For sleep maintenance insomnia, the American Academy of Sleep Medicine recommends: 2

• Eszopiclone 2-3 mg at bedtime
• Doxepin 3-6 mg at bedtime
• Temazepam 15-30 mg at bedtime

These agents have stronger evidence for efficacy and more favorable risk-benefit profiles. 1, 2

When Trazodone Might Be Considered

Trazodone may be appropriate as a third-line agent only after benzodiazepine receptor agonists and ramelteon have failed, particularly when: 1

• Comorbid depression is present (though 25-50 mg doses used for insomnia are below therapeutic antidepressant range) 1, 2
• Comorbid anxiety exists 1
• First and second-line treatments have been unsuccessful 1

If You Must Use Trazodone Despite Guidelines

If clinical circumstances absolutely require trazodone use:

• Dose: The studied dose is 50 mg at bedtime (not 25 mg, which has even less evidence) 1, 2
• Administration: Give shortly after a meal or light snack 3
• Screen first: Assess for personal/family history of bipolar disorder, mania, or hypomania before initiating 3
• Monitor closely: Watch for orthostatic hypotension, falls, daytime drowsiness, and other adverse effects 1, 2
• Patient education: Counsel about side effects, priapism risk (in men), and allowing adequate sleep time 1
• Avoid in elderly: Particular caution warranted due to increased risk of orthostatic hypotension, falls, and cognitive impairment 2

Critical Pitfalls to Avoid

• Do not assume lower doses are safer: The 25 mg dose has not been systematically studied and would likely provide even less benefit than the already insufficient 50 mg dose 1
• Check drug interactions: Avoid with strong CYP3A4 inhibitors, QT-prolonging drugs, and MAOIs (14-day washout required) 3
• Do not abruptly discontinue: Gradual taper is necessary to avoid discontinuation syndrome 3
• Recognize this is off-label use: Trazodone is FDA-approved for depression at 150-600 mg/day in divided doses, not for insomnia 3