Can trazodone 25mg be given at night with Ambien (zolpidem) 7.5mg to a patient in their late 60s on sertraline 100mg and Wellbutrin (bupropion) 150mg for insomnia?

Trazodone with Ambien in a Late 60s Patient on Sertraline and Bupropion

Trazodone 25mg should NOT be added to Ambien 7.5mg in this patient—instead, optimize the existing Ambien dose or address medication-induced insomnia from the current regimen.

Why Trazodone is Not Recommended

• Trazodone is not recommended for insomnia treatment due to insufficient efficacy data and a concerning side effect profile including daytime drowsiness, dizziness, and psychomotor impairment 1
• The evidence supporting trazodone for insomnia is weak, with most studies using higher doses (≥100mg) rather than the proposed 25mg dose 2
• In elderly patients (late 60s), combining sedating medications increases fall risk and cognitive impairment, particularly when multiple CNS depressants are used together 1

Critical Safety Concern with Current Regimen

• The FDA has issued a black box warning about serious effects including respiratory depression and death from combining sedatives with other CNS depressants 1
• Adding trazodone to existing Ambien creates polypharmacy with multiple sedating agents, which should be avoided when possible 1

Address the Root Cause First

Bupropion-Induced Insomnia

• Bupropion (Wellbutrin) is activating and commonly causes insomnia—the second dose should be given before 3 p.m. to minimize sleep disturbance 3
• Bupropion should not be prescribed if insomnia is present, as it will worsen sleep disturbance 1
• Consider timing adjustment: ensure the 150mg Wellbutrin dose is taken in the morning, not afternoon or evening

Sertraline Contribution

• SSRIs including sertraline commonly cause insomnia and can compound sleep problems 1
• Sertraline side effects include nervousness and insomnia 3

Optimize Ambien Before Adding Anything

Current Ambien Dose is Suboptimal

• The patient is on Ambien 7.5mg, but the FDA-approved dose for elderly patients (late 60s) is 5mg 4
• However, zolpidem 10mg was superior to placebo in elderly patients (mean age 68) on sleep latency and efficiency measures 4
• The current 7.5mg dose is neither the recommended elderly dose (5mg) nor the standard adult dose (10mg)

Recommended Approach

• First, assess if the 7.5mg Ambien dose is providing adequate benefit—if not, consider adjusting to either 5mg (if side effects present) or discussing with the patient about tolerability at current dose 4
• Zolpidem has demonstrated efficacy for both transient and chronic insomnia in elderly patients without significant next-day residual effects 4

If Additional Sleep Medication is Absolutely Necessary

Preferred Alternatives to Trazodone

• Eszopiclone (Lunesta) 1mg at bedtime is recommended for elderly patients for both sleep-onset and maintenance insomnia, with no short-term usage restriction 1
• Ramelteon 8mg at bedtime is a melatonin receptor agonist with no abuse potential or withdrawal, particularly useful for sleep-onset insomnia 1
• Melatonin as an initial adjunct is recommended by the American Academy of Sleep Medicine for sleep onset delay 1

If Benzodiazepine Receptor Agonists Must Be Combined

• If combining sedatives is unavoidable, use the lowest effective dose and monitor closely for excessive sedation 1
• The combination increases risk of falls, confusion, and respiratory depression in elderly patients

Documented Adverse Interactions with Trazodone

• Trazodone combined with SSRIs (like sertraline) can cause excessive sedation requiring discontinuation in a significant proportion of patients 5
• In one study, 5 out of 16 patients needed to stop trazodone due to excessive sedation when combined with fluoxetine (another SSRI) 5
• Trazodone addition to antidepressants may alleviate insomnia but does not address underlying anxiety/inner tension, suggesting it treats symptoms rather than causes 6

Specific Algorithm for This Patient

1. Evaluate medication timing: Ensure Wellbutrin 150mg is taken in early morning (before 10 a.m.)
2. Assess Ambien efficacy: Determine if current 7.5mg dose provides adequate sleep without morning sedation
3. Consider non-pharmacologic intervention: Implement sleep hygiene and Cognitive Behavioral Therapy for Insomnia (CBT-I) 1
4. If medication adjustment needed:
   • Option A: Continue Ambien 7.5mg alone with optimized timing of daytime medications
   • Option B: Add melatonin 3-5mg at bedtime as first-line adjunct 1
   • Option C: Switch to eszopiclone 1mg if Ambien inadequate 1
5. Avoid trazodone addition due to insufficient evidence, polypharmacy concerns, and increased fall risk in elderly 1, 2

Common Pitfalls to Avoid

• Do not add trazodone 25mg to existing Ambien—this creates unnecessary polypharmacy with marginal benefit 1, 2
• Do not ignore the activating effects of bupropion—timing adjustment may resolve insomnia without additional medication 3
• Do not exceed recommended elderly doses of sedatives—elderly patients are prone to neurotoxicity and falls at higher doses 3
• Do not combine multiple CNS depressants without careful monitoring—FDA black box warning for respiratory depression applies 1