Can trazodone be prescribed to a patient suspected of having obstructive sleep apnea (OSA) until sleep study results are available?

From the Guidelines

I would not recommend prescribing trazodone to a patient suspected of having sleep apnea until testing is complete. Trazodone is a sedating antidepressant that can relax upper airway muscles and potentially worsen sleep-disordered breathing in patients with sleep apnea, as noted in a study on the pharmacologic treatment of chronic insomnia in adults 1. This medication may cause respiratory depression and could mask symptoms while increasing the frequency and duration of apneic events, potentially putting the patient at greater risk for cardiovascular complications.

Key Considerations

• The American Academy of Sleep Medicine clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults found that trazodone 50 mg did not improve sleep outcome variables to a clinically significant degree 1.
• The guideline suggests that the harms of trazodone may outweigh the benefits, especially in patients with sleep apnea, due to the potential for worsening sleep-disordered breathing 1.
• The Veterans Administration and Department of Defense clinical practice guidelines for the diagnosis and management of sleep disorders recommend a comprehensive approach to diagnosing and treating sleep disorders, including sleep apnea and insomnia 1.

Alternative Management Strategies

• Focus on sleep hygiene measures such as maintaining a regular sleep schedule, avoiding alcohol and sedatives before bedtime, sleeping on one's side rather than back, and elevating the head of the bed.
• If insomnia is severe and requires intervention before sleep apnea testing is complete, consider consulting with a sleep specialist for appropriate temporary management strategies, such as cognitive behavioral therapy for insomnia (CBT-I) 1.
• The priority should be expediting the sleep study to establish a diagnosis and implement appropriate treatment such as CPAP therapy, which would address both the sleep apnea and often improve associated insomnia symptoms.

From the Research

Trazodone Prescription for Patients with Suspected Sleep Apnea

• There is no direct evidence to suggest that trazodone should be prescribed to a patient suspected with sleep apnea until testing is complete 2, 3, 4.
• However, studies have shown that cognitive behavioral therapy for insomnia (CBT-i) can be an effective treatment for patients with comorbid insomnia and sleep apnea 5, 6.
• CBT-i has been found to improve sleep parameters, reduce daytime sleepiness, and increase the use of continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea (OSA) and comorbid insomnia 5, 6.
• Trazodone, on the other hand, has been shown to improve objective sleep duration and reduce hypothalamic-pituitary-adrenal axis activation in patients with insomnia, but its effects on sleep apnea are not well studied 2.
• Therefore, it is essential to conduct thorough testing to confirm the diagnosis of sleep apnea before prescribing any treatment, including trazodone 5, 6.

Considerations for Prescribing Trazodone

• Patients with suspected sleep apnea should be closely monitored for increased daytime sleepiness during the initial weeks of treatment with trazodone or CBT-i 5.
• The bedtime restriction component of CBT-i may exacerbate daytime sleepiness in patients with comorbid insomnia and sleep apnea, but this effect is typically short-lived 5.
• CBT-i has been found to be a safe and effective treatment for patients with comorbid insomnia and sleep apnea, and it may improve CPAP adherence and reduce insomnia symptoms 5, 6.