Is it okay to start trazodone for someone with a moderate risk score for sleep apnea who is being referred to a sleep clinic?

Trazodone Use in Patients Awaiting Sleep Apnea Evaluation

It is not advisable to start trazodone in someone with moderate risk for sleep apnea who is awaiting sleep clinic evaluation, as trazodone is not recommended for insomnia treatment by sleep medicine guidelines and lacks evidence of efficacy for this indication. 1

Primary Concerns with Trazodone for Sleep

Lack of Guideline Support

• The American Academy of Sleep Medicine explicitly does not recommend trazodone for treatment of sleep onset or sleep maintenance insomnia, as evidence demonstrates only minimal benefits even at 50 mg doses 1
• The evidence base for trazodone's efficacy in insomnia is very limited, with most studies being small, conducted in depressed populations, and lacking objective efficacy measures 2

Specific Risks in Sleep Apnea Context

• Trazodone does not worsen the apnea-hypopnea index (AHI) based on available data (MD = -4.21,95% CI -14.02 to 5.59, P = 0.40), suggesting it does not directly exacerbate sleep apnea severity 3
• However, starting any sedating medication before confirming or ruling out sleep apnea is problematic because it may mask symptoms, complicate diagnostic interpretation, and delay appropriate treatment 4
• The sedating effects of trazodone could potentially worsen daytime sleepiness in someone who already has undiagnosed OSA 2

Adverse Effect Profile

Common Side Effects

• Trazodone causes significantly more daytime drowsiness (OR = 2.53,95% CI 1.14-5.64, P = 0.02) and decreased appetite (OR = 2.81,95% CI 1.14-6.92, P = 0.02) compared to placebo 3
• High incidence of discontinuation due to side effects including sedation, dizziness, and psychomotor impairment, which raise particular concern in elderly patients 2
• Patients report worsened self-reported sleep quality despite objective improvements in some polysomnographic parameters 5

Tolerability Issues

• Evidence suggests tolerance may develop with trazodone use over time 2
• The risk-benefit ratio is uncertain in non-depressed patients with insomnia given the relative absence of efficacy data and significant adverse events 2

Clinical Reasoning for Waiting

Diagnostic Clarity

• With 62-85% of sleep clinic patients ultimately diagnosed with OSA (AHI ≥5), the pretest probability is substantial even with moderate risk scores 6
• Starting trazodone could confound the sleep study results by altering sleep architecture, including increasing N3 sleep and decreasing arousals 3
• The medication may mask important diagnostic features that the sleep clinic needs to observe 4

Treatment Sequencing

• If OSA is confirmed, CPAP therapy is the primary evidence-based treatment that improves cardiovascular comorbidities and reduces disease-related morbidity 4
• CPAP often resolves insomnia symptoms that are secondary to untreated OSA, making trazodone unnecessary 4
• Starting trazodone prematurely adds medication burden and potential side effects without addressing the underlying sleep-disordered breathing 1

Alternative Management Approach

Before Sleep Clinic Evaluation

• Focus on sleep hygiene optimization and behavioral interventions rather than pharmacotherapy 1
• Counsel on positional therapy (avoiding supine sleep) and weight management if applicable 4
• Avoid alcohol and sedatives that could worsen potential OSA 4

If Insomnia Treatment Is Urgently Needed

• Consider guideline-recommended alternatives such as eszopiclone, zolpidem, or zaleplon for sleep onset issues, or suvorexant or doxepin for sleep maintenance problems 1
• However, even these agents should be used cautiously pending sleep apnea evaluation, as sedative-hypnotics can theoretically worsen upper airway collapsibility 1

Special Consideration: Cardiovascular Monitoring

• For patients with cardiovascular conditions, more careful monitoring is required during any dose escalation of trazodone 1
• Given that OSA itself increases cardiovascular disease risk including hypertension, heart failure, and stroke, adding a medication with cardiac implications before confirming the diagnosis is particularly problematic 4

Bottom Line

Wait for the sleep clinic evaluation before initiating trazodone. The medication lacks strong efficacy evidence for insomnia, carries significant side effects including daytime drowsiness, and could complicate both diagnosis and treatment of potential OSA. If the patient has OSA, treating it with CPAP may resolve sleep complaints without need for additional medications. 4, 1, 2