What is the next step for a 57-year-old patient with insomnia who has tried trazodone, promethazine (Phenergan), and pregabalin without relief?

Next-Step Treatment for Refractory Insomnia at Age 57

You should start with Cognitive Behavioral Therapy for Insomnia (CBT-I) immediately while initiating a trial of a first-line benzodiazepine receptor agonist such as zolpidem 10 mg or eszopiclone 2-3 mg, as the medications you've tried (trazodone, promethazine, pregabalin) are not guideline-recommended first-line agents for primary insomnia. 1, 2

Why Your Previous Medications Failed

You've been prescribed medications that are explicitly not recommended by major sleep medicine guidelines:

• Trazodone: The American Academy of Sleep Medicine recommends against using trazodone for insomnia based on clinical trials showing only modest improvements with no subjective sleep quality benefit, and the harms outweigh benefits 3
• Promethazine (Phenergan): Antihistamines are not recommended due to lack of efficacy data, anticholinergic burden causing confusion and daytime sedation, and tolerance development after 3-4 days 1, 2
• Pregabalin: Not included in any major insomnia treatment guidelines as an approved option and should only be considered when other options have failed and you have comorbid neuropathic pain 1

Recommended Treatment Algorithm

Step 1: Implement CBT-I Immediately (First-Line Treatment)

The American Academy of Sleep Medicine and American College of Physicians recommend CBT-I as the standard of care before or alongside any medication, with superior long-term outcomes 1, 2. Key components include:

• Sleep restriction therapy: Limit time in bed to match actual sleep time (e.g., if sleeping only 5.5 hours but spending 8.5 hours in bed, restrict to 5.5-6 hours initially), then gradually increase by 15-20 minutes every 5 days as sleep efficiency improves 4
• Stimulus control: Go to bed only when sleepy, leave bedroom if unable to fall asleep within 20 minutes, use bedroom only for sleep and sex, maintain consistent wake times regardless of sleep obtained 4
• Relaxation techniques: Progressive muscle relaxation, guided imagery, diaphragmatic breathing 4

CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, or web-based modules—all showing effectiveness 2

Step 2: Start First-Line Pharmacotherapy

The American Academy of Sleep Medicine recommends short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon as first-line medications 1, 2:

For combined sleep onset and maintenance insomnia:

• Eszopiclone 2-3 mg: Addresses both falling asleep and staying asleep 1, 2
• Zolpidem 10 mg: Effective for both sleep initiation and maintenance 1, 2

For sleep onset insomnia specifically:

• Zaleplon 10 mg: Very short half-life with minimal morning sedation 1, 2
• Ramelteon 8 mg: Zero addiction potential, particularly suitable if you have concerns about dependence 1, 2

For sleep maintenance insomnia specifically:

• Low-dose doxepin 3-6 mg: Particularly effective with minimal side effects and no addiction potential 1, 2
• Suvorexant: Orexin receptor antagonist for staying asleep 1, 2

Step 3: If First-Line Agents Fail

Only after trying the above should you consider:

• Alternative BzRAs from the same class 1
• Sedating antidepressants only if you have comorbid depression or anxiety 1, 2

Critical Implementation Details

Dosing strategy:

• Start with the lowest effective dose 1, 2
• Take medication 30-60 minutes before desired sleep time (except zaleplon, which can be taken at bedtime) 5
• Ensure you can dedicate 7-8 hours for sleep to avoid morning impairment 2

Monitoring requirements:

• Reassess after 1-2 weeks to evaluate efficacy on sleep latency, maintenance, and daytime functioning 1
• Screen for complex sleep behaviors (sleepwalking, sleep-driving) 1, 2
• Use for shortest duration possible with regular reassessment of continued need 1, 2

Common Pitfalls to Avoid

• Don't skip CBT-I: Medication alone provides inferior long-term outcomes compared to CBT-I plus medication 1, 2
• Don't use multiple sedating medications simultaneously: This significantly increases risks of falls, cognitive impairment, and complex sleep behaviors 2
• Don't continue medication indefinitely without reassessment: Regular follow-up every few weeks initially is essential 1, 3
• Don't use over-the-counter sleep aids: Diphenhydramine and similar antihistamines lack efficacy data and cause problematic side effects 1, 2

Why This Approach Is Different

The medications you were prescribed represent third-line or non-recommended options. You essentially haven't tried the evidence-based first-line treatments yet. The American Academy of Sleep Medicine's treatment sequence explicitly places BzRAs and ramelteon first, with trazodone only considered after these fail and when comorbid depression exists 1, 3, 2. At 57, you're not elderly (guidelines define elderly as ≥65), so standard adult dosing applies without the dose reductions needed for older adults 2.