No, Do Not Give 150mg Trazodone This Morning
The patient should not receive 150mg of trazodone this morning for several critical reasons: trazodone is not recommended for insomnia treatment by current guidelines, the timing is inappropriate (daytime dosing defeats the purpose), and the dose escalation is premature after only one night. 1
Why Trazodone Should Not Be Used for Insomnia
The American Academy of Sleep Medicine explicitly recommends against using trazodone as a treatment for sleep onset or sleep maintenance insomnia in adults. 1 This recommendation is based on:
Lack of clinically significant efficacy: A rigorous trial of trazodone 50mg showed it reduced sleep latency by only 10.2 minutes (below clinical significance threshold), increased total sleep time by only 21.8 minutes (clinically insignificant), and failed to meaningfully improve sleep quality. 1
Substantial adverse effects: 75% of trazodone users experienced adverse events compared to 65.4% on placebo, with headache (30% vs 19%) and somnolence (23% vs 8%) being most common. 1
Harms potentially outweigh benefits: Given the absence of demonstrated efficacy coupled with significant side effect burden, the risk-benefit ratio is unfavorable. 1
Why This Morning Dose Is Particularly Problematic
Timing Issues
Trazodone is sedating and should only be given at bedtime, not in the morning. 2, 3 The FDA-approved dosing explicitly states that "occurrence of drowsiness may require the administration of a major portion of the daily dose at bedtime." 2
Giving 150mg in the morning would cause significant daytime sedation, dizziness, and psychomotor impairment, which are dose-dependent side effects. 4, 5
Premature Dose Escalation
One night of treatment failure is insufficient to justify dose escalation. The FDA label recommends increasing the dose by 50mg every 3-4 days, not after a single night. 2
Even for depression (its approved indication), trazodone requires 4-8 weeks for full therapeutic effect. 1
What Should Be Done Instead
Immediate Management
Reassess the initial treatment choice: Consider switching to evidence-based insomnia medications rather than escalating an ineffective agent. 6
Tonight's dosing options (if continuing trazodone despite guidelines):
Evidence-Based Alternatives
The American Academy of Sleep Medicine recommends these agents instead of trazodone:
- Zolpidem 5-10mg at bedtime for both sleep onset and maintenance 6
- Zaleplon 10mg specifically for sleep onset difficulty with minimal next-day effects 6
- Eszopiclone for sleep maintenance throughout the night 6
- Temazepam 15mg for both initiation and maintenance 6
Non-Pharmacologic Approach
- Cognitive Behavioral Therapy for Insomnia (CBT-I) should be strongly considered as it addresses underlying sleep dysfunction without medication risks. 6
Critical Safety Considerations
If Trazodone Must Be Continued
- Never administer during daytime hours due to sedation risk 2, 3
- Maximum outpatient dose is 400mg/day in divided doses (for depression, not insomnia) 2
- Gradual dose reduction is required when discontinuing to avoid withdrawal symptoms 2
Special Populations
- Elderly patients are at particular risk for sedation, dizziness, and falls with trazodone 5
- Dose adjustments downward are recommended in older adults 6
Common Pitfalls to Avoid
Do not mistake lack of immediate response as need for higher doses: Insomnia medications work acutely; if 100mg didn't work night one, the problem is likely the wrong medication choice, not insufficient dose. 1
Do not give sedating medications during waking hours: This creates daytime impairment without addressing nighttime sleep. 2, 3
Do not continue ineffective treatments: Switch to guideline-recommended agents rather than escalating doses of medications with poor evidence. 1, 6