What is the recommended starting dose and titration schedule of trazodone for insomnia in adults, including older adults and patients with hepatic impairment, and what are the contraindications?

Trazodone Dosing for Sleep

The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment, whether for sleep onset or sleep maintenance, because the harms outweigh its minimal benefits. 1, 2

Why Trazodone Is Not Recommended

• Clinical trials using trazodone 50 mg showed only trivial improvements: sleep latency decreased by merely 10 minutes, total sleep time increased by only 22 minutes, and wake after sleep onset reduced by just 8 minutes—all below clinically meaningful thresholds. 2

• Subjective sleep quality did not improve versus placebo, with no meaningful difference on validated sleep quality scales. 2

• Adverse events are common: 75% of patients experienced side effects (versus 65% on placebo), with headache and daytime somnolence being most frequent. 2

• Cognitive and motor impairments persist the next day: even at 50 mg, trazodone produces measurable deficits in short-term memory, verbal learning, balance (body sway), and muscle endurance that last into the following morning. 3

If Trazodone Must Be Used Despite Guidelines

Starting Dose & Titration

• Begin with 25–50 mg taken 30–60 minutes before bedtime (not immediately at bedtime, as trazodone requires earlier administration than hypnotics for optimal effect). 1, 4

• If insufficient after 1–2 weeks, increase to 100 mg, then to 150–200 mg if needed; the therapeutic range for insomnia in clinical studies averaged 150–212 mg nightly. 5, 6

• Maximum dose for insomnia is typically 200 mg at bedtime; higher doses approach antidepressant dosing (300 mg) and are not indicated for primary insomnia. 7, 6

Special Populations

• Older adults: start at 25 mg and increase cautiously due to heightened risk of orthostatic hypotension, falls, dizziness, and daytime drowsiness. 2

• Hepatic impairment: reduce dose and monitor closely, as trazodone clearance is significantly decreased in liver dysfunction. 1

Administration Instructions

• Take on an empty stomach to maximize sedative effect. 1

• Allow at least 7–8 hours of sleep time to minimize next-day impairment. 1

• Avoid alcohol and other CNS depressants due to additive sedation and respiratory depression risk. 1, 5

Monitoring & Safety

• Reassess after 1–2 weeks for changes in sleep onset, total sleep time, nocturnal awakenings, and daytime functioning; if no improvement, switch to a guideline-recommended agent rather than continuing trazodone. 1, 5

• Screen male patients for priapism: approximately 6–12% of patients may experience prolonged, painful erections requiring emergency care; counsel all male patients to seek immediate medical attention if erection lasts >4 hours. 1, 6

• Monitor for orthostatic hypotension and falls, especially in older adults; instruct patients to rise slowly from sitting or lying positions. 1

• Watch for complex sleep behaviors (sleep-walking, sleep-driving) and discontinue immediately if they occur. 1

Contraindications

• Compromised respiratory function (asthma, COPD, sleep apnea). 1

• Severe hepatic impairment or heart failure. 1

• Pregnancy and breastfeeding. 1

• Concurrent use with other QTc-prolonging medications (e.g., hydroxyzine, certain antibiotics). 5

Guideline-Recommended Alternatives (Preferred Over Trazodone)

For Sleep Onset Insomnia

• Zolpidem 10 mg (5 mg if age ≥65 years) – reduces sleep latency by 25 minutes. 1, 2

• Zaleplon 10 mg (5 mg if age ≥65 years) – ultrashort half-life, minimal next-day effects. 1, 2

• Ramelteon 8 mg – no abuse potential, ideal for patients with substance use history. 1, 2

For Sleep Maintenance Insomnia

• Low-dose doxepin 3–6 mg – reduces wake after sleep onset by 22–23 minutes, minimal anticholinergic effects, no abuse potential. 1, 2

• Suvorexant 10 mg – orexin antagonist, reduces wake after sleep onset by 16–28 minutes. 1, 2

For Combined Sleep Onset & Maintenance

• Eszopiclone 2–3 mg (1 mg if age ≥65 years or hepatic impairment) – increases total sleep time by 28–57 minutes with moderate-to-large improvement in sleep quality. 1, 5

• Temazepam 15–30 mg (7.5 mg if age ≥65 years). 1, 2

Essential Non-Pharmacologic Therapy

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated before or alongside any sleep medication, as it provides superior long-term efficacy with sustained benefits after discontinuation, whereas medication effects cease when stopped. 1, 5

• Core components include stimulus control, sleep restriction, relaxation techniques, cognitive restructuring, and sleep hygiene education. 1, 5

• CBT-I can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books—all formats show comparable effectiveness. 1, 5

Common Pitfalls to Avoid

• Using trazodone as first-line therapy when guideline-recommended agents (zolpidem, eszopiclone, doxepin, ramelteon) have superior efficacy and safety profiles. 1, 2

• Prescribing trazodone without concurrent CBT-I, which provides more durable benefits than medication alone. 1, 5

• Combining trazodone with benzodiazepines or other CNS depressants, which markedly increases risk of respiratory depression, falls, and cognitive impairment. 1, 5

• Continuing trazodone beyond 4 weeks without reassessment; persistent insomnia warrants evaluation for underlying sleep disorders (sleep apnea, restless legs syndrome). 1, 5

• Using adult dosing in older adults; age-adjusted dosing is essential to reduce fall and cognitive impairment risk. 1, 2