What is the optimal management approach for a 76-year-old male patient with insomnia and hypertension who is currently taking Vraylar (cariprazine) 1.5mg every evening, Lisinopril 10mg once daily, Hydroxyzine 25mg once a day at bedtime, Fluoxetine 40mg once a day every morning, Gabapentin 100mg three times a day, and Adderall (dextroamphetamine and amphetamine) 5mg once a day in the morning, but reports inadequate symptom control?

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Dainyal Siddiqui, MD

Internal Medicine

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Manuel Jimenez, MD

Cardiology

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Franz Pierre-Louis, MD

Infectious Disease

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Last updated: April 17, 2025 • View editorial policy

From the Guidelines

I strongly recommend adjusting this patient's medication regimen to prioritize their morbidity, mortality, and quality of life, focusing on evidence-based treatments for insomnia and hypertension. The patient's current regimen, including Vraylar, Lisinopril, Hydroxyzine, fluoxetine, gabapentin, and Adderall, may be contributing to their insomnia and hypertension.

Key Considerations

  • The Adderall (5mg) should be evaluated as it may be contributing to both hypertension and insomnia, especially in an elderly patient, and consider discontinuing or switching to a non-stimulant alternative 1.
  • For hypertension management, increasing Lisinopril from 10mg to 20mg daily may provide better blood pressure control, as suggested by general hypertension management guidelines.
  • Alternatively, adding a thiazide diuretic like hydrochlorothiazide 12.5mg daily could enhance antihypertensive effects.
  • For insomnia, hydroxyzine may not be the most effective option at this age, and consider replacing it with a low-dose eszopiclone (2-3mg at bedtime) or suvorexant (10-20mg at bedtime), which can help with sleep without significant next-day effects, as recommended by the American Academy of Sleep Medicine 1.

Non-Pharmacological Approaches

  • Emphasize non-pharmacological approaches, including sleep hygiene practices, limiting caffeine, maintaining consistent sleep schedules, and relaxation techniques.
  • Cognitive behavioral therapy for insomnia (CBT-I) is a recommended treatment for chronic insomnia disorder, as it can improve sleep quality and reduce symptoms of insomnia 2, 3, 4, 5.

Medication Reconciliation

  • A medication reconciliation is essential to determine if all these medications are necessary and appropriately dosed.
  • Consider the potential interactions between the patient's current medications and their impact on sleep quality.

Monitoring and Follow-Up

  • Blood pressure monitoring at home would help evaluate treatment effectiveness for hypertension.
  • Regular follow-up appointments should be scheduled to monitor the patient's response to treatment and adjust the medication regimen as needed.

From the FDA Drug Label

WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS and SUICIDAL THOUGHTS AND BEHAVIORS Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death VRAYLAR is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Precautions (5. 1)].

The patient is taking Vraylar 1.5mg every evening for an unspecified condition. The FDA drug label warns of increased mortality in elderly patients with dementia-related psychosis, but it does not specify the patient's condition.

  • The patient's current dosage of Vraylar is within the recommended range for various conditions, including schizophrenia, manic or mixed episodes associated with bipolar I disorder, depressive episodes associated with bipolar I disorder, and adjunctive therapy to antidepressants for the treatment of major depressive disorder.
  • However, the patient's age (76 years) and the presence of dementia-related psychosis (if applicable) may increase the risk of adverse reactions.
  • The patient's insomnia and hypertension may be related to their current medications or underlying conditions, but the FDA drug label does not provide direct information on managing these conditions with Vraylar.
  • It is essential to monitor the patient's response to treatment and adjust the dosage as needed, considering the potential risks and benefits of Vraylar in elderly patients 6.

From the Research

Patient's Medication Regimen

The patient is currently taking multiple medications, including Vraylar, Lisinopril, Hydroxyzine, fluoxetine, gabapentin, and Adderall. This complex medication regimen may be contributing to the patient's insomnia and hypertension, as well as potentially increasing the risk of medication errors and non-adherence 7.

Simplifying the Medication Regimen

Simplifying the patient's medication regimen may be beneficial in improving adherence and reducing the risk of medication errors. Strategies for simplification include consolidating dosing times, standardizing routes of administration, and using long-acting formulations instead of shorter-acting ones 7, 8. A study found that simplifying medication regimens in older adults with depression can reduce complexity and improve ease of self-care 9.

Treatment of Insomnia

For the treatment of insomnia, controlled-release melatonin and doxepin are recommended as first-line agents in older adults 10. The patient is currently taking Hydroxyzine, an antihistamine, which is not recommended for the treatment of insomnia unless it is used primarily to treat another condition 10. The use of antidepressants, such as fluoxetine, for insomnia is widespread, but the evidence for their efficacy is unclear 11. Low-dose doxepin and trazodone may be effective in improving sleep quality, but the tolerability and safety of antidepressants for insomnia are uncertain due to limited reporting of adverse events 11.

Potential Changes to the Medication Regimen

Potential changes to the patient's medication regimen could include:

  • Simplifying the dosing schedule to reduce complexity and improve adherence
  • Switching to long-acting formulations of medications such as Lisinopril and gabapentin
  • Discontinuing Hydroxyzine and considering alternative treatments for insomnia, such as controlled-release melatonin or doxepin
  • Monitoring the patient's response to fluoxetine and considering alternative treatments for depression if necessary
  • Evaluating the patient's overall medication regimen and making adjustments as needed to minimize complexity and improve adherence 7, 8, 9.

References

1
Guideline

clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an american academy of sleep medicine clinical practice guideline.

Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 2017

7
Research

Strategies to simplify complex medication regimens.

Australian journal of general practice, 2021

10
Research

Insomnia: Pharmacologic Therapy.

American family physician, 2017

11
Research

Antidepressants for insomnia in adults.

The Cochrane database of systematic reviews, 2018

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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