Should trazodone be used for anxiety‑related insomnia in a 72‑year‑old man after cardiac surgery?

Trazodone for Post-Cardiac Surgery Anxiety-Related Insomnia in a 72-Year-Old Male

Do not use trazodone as first-line therapy for this patient. The American Academy of Sleep Medicine explicitly recommends against trazodone for insomnia treatment, and the American Heart Association guidelines for cardiovascular patients specifically advise cognitive behavioral therapy for insomnia (CBT-I) first, followed by sedating antidepressants like mirtazapine or melatonin receptor agonists—not trazodone—when pharmacotherapy is necessary. 1, 2

Why Trazodone Should Be Avoided

Lack of Efficacy Evidence

• The American Academy of Sleep Medicine states that trazodone provides only minimal, clinically insignificant benefit: approximately 10 minutes reduction in sleep-onset latency and 8 minutes reduction in wake after sleep onset, with no improvement in subjective sleep quality. 2
• In the single high-quality trial in older adults, 75% of trazodone-treated patients experienced adverse events (versus 65% on placebo), with headache in 30% and somnolence in 23%. 2
• The guideline task force concluded that harms outweigh any modest benefits despite widespread clinical use. 2

Cardiac Safety Concerns in Post-Surgical Patients

• The FDA label warns that trazodone is arrhythmogenic in patients with preexisting cardiac disease, including isolated premature ventricular contractions, ventricular couplets, ventricular tachycardia with syncope, and torsade de pointes. 3
• Post-marketing reports document torsade de pointes at doses as low as 100 mg or less. 3
• Trazodone prolongs the QT/QTc interval and should be avoided in patients with known QT prolongation or recent cardiac events. 3
• The drug is not recommended during the initial recovery phase of myocardial infarction and requires extreme caution in any patient with cardiac disease. 3
• Case reports demonstrate that fatal arrhythmias, QTc prolongation evolving into ventricular tachycardia, bundle-branch blocks, and variable degrees of AV nodal blocks can occur 12–24 hours after trazodone administration. 4

Additional Safety Risks in Elderly Post-Surgical Patients

• Orthostatic hypotension and syncope are common with trazodone, which can be particularly dangerous in a 72-year-old recovering from cardiac surgery. 3
• The drug carries risk of serotonin syndrome if combined with other serotonergic agents, and increased bleeding risk when used with antiplatelet drugs or anticoagulants—both commonly prescribed post-cardiac surgery. 3

Recommended Treatment Algorithm

Step 1: Initiate Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is the first-line treatment for all adults with insomnia, including post-surgical patients, providing superior long-term efficacy with sustained benefits after discontinuation. 1, 2
• CBT-I includes stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring, and can be delivered via individual therapy, telephone, or web-based modules. 2
• The American Heart Association specifically recommends CBT-I before pharmacotherapy for cardiovascular patients with insomnia. 1

Step 2: If Pharmacotherapy Is Necessary After CBT-I Initiation

For Combined Anxiety and Insomnia (Most Appropriate for This Patient)

• Mirtazapine 7.5–15 mg at bedtime is the preferred choice for post-cardiac surgery patients with comorbid anxiety and insomnia. 1
  • The American Heart Association states that mirtazapine has been shown to be safe in cardiovascular disease and offers additional benefits including appetite stimulation and sleep promotion. 1
  • Mirtazapine addresses both anxiety and insomnia simultaneously without the cardiac risks of trazodone. 1
  • Must be taken nightly on a scheduled basis, not PRN, as it requires consistent dosing to maintain therapeutic levels. 2

Alternative First-Line Options for Sleep-Maintenance Insomnia

• Low-dose doxepin 3–6 mg reduces wake after sleep onset by 22–23 minutes with minimal anticholinergic effects at hypnotic doses and no abuse potential. 2
• Ramelteon 8 mg is a melatonin receptor agonist with no cardiovascular risks, no abuse potential, and no withdrawal symptoms. 1, 2

For Sleep-Onset Insomnia Specifically

• Zolpidem 5 mg (reduced dose for age ≥65 years) shortens sleep-onset latency by approximately 25 minutes. 2
• Zaleplon 5 mg (reduced dose for elderly) has a very short half-life with minimal residual sedation. 2

Step 3: Monitor and Reassess

• Reassess after 1–2 weeks to evaluate efficacy on sleep parameters, daytime functioning, and adverse effects including morning sedation, cognitive impairment, or cardiac symptoms. 2
• Use the lowest effective dose for the shortest necessary duration, integrating CBT-I to enable eventual tapering. 2

Common Pitfalls to Avoid

• Do not prescribe trazodone based solely on familiarity or perceived safety—the evidence does not support its use as first-line therapy for insomnia, particularly in elderly cardiac patients. 2, 5
• Do not use adult dosing in a 72-year-old patient—age-adjusted dosing is essential to reduce fall risk and adverse effects. 2
• Do not initiate pharmacotherapy without first employing CBT-I, which provides more durable benefits than medication alone. 1, 2
• Do not overlook cardiac monitoring if any sedative-hypnotic is prescribed in the immediate post-cardiac surgery period. 3
• Avoid combining multiple sedating agents, which markedly increases risk of respiratory depression, cognitive impairment, and falls. 2

Special Considerations for Post-Cardiac Surgery

• Sertraline is the preferred SSRI if antidepressant therapy is needed for anxiety, as it has a lower risk of QTc prolongation than citalopram or escitalopram. 1
• Monoamine oxidase inhibitors and tricyclic antidepressants should be avoided due to significant cardiovascular side effects including hypertension, hypotension, and arrhythmias. 1
• Screen for and treat underlying causes of insomnia, including pain, medication side effects (e.g., β-blockers, diuretics), and sleep-disordered breathing, which is common post-cardiac surgery. 1