Trazodone for Nocturnal Awakenings: Not Recommended
Introduction to Trazodone and Nocturnal Awakenings
- The American Academy of Sleep Medicine explicitly recommends not using trazodone to treat sleep maintenance insomnia (nocturnal awakenings), as the benefits do not outweigh the potential risks 1, 2, 3
Efficacy of Trazodone
- Trazodone at 50 mg demonstrates clinically insignificant efficacy for nocturnal awakenings, with a reduction of only 7.7 minutes in wake time after sleep onset compared to placebo 4, 5, 6
- Trazodone at 50 mg results in a clinically non-significant increase of 21.8 minutes in total sleep time compared to placebo 4, 5, 6
- Trazodone does not significantly improve sleep quality compared to placebo 4, 5, 6
- Trazodone reduces the number of awakenings by only 0.4, which is below the threshold of 0.5 6, 7
Risk Profile
- 75% of patients on trazodone report adverse effects, compared to 65.4% on placebo 7
- Trazodone is associated with a higher incidence of headaches (30% vs 19% with placebo) 7
- Trazodone is associated with a higher incidence of daytime somnolence (23% vs 8% with placebo) 7
Recommended Alternatives for Nocturnal Awakenings
- For sleep maintenance insomnia (nocturnal awakenings), the following are recommended as first-line treatments: eszopiclone 2-3 mg at bedtime, doxepin 3-6 mg at bedtime, temazepam 15 mg at bedtime, zolpidem 10 mg at bedtime, and suvorexant 10-20 mg at bedtime 1, 2, 3
- Doxepin at a low dose (3-6 mg) is particularly suitable for nocturnal awakenings due to its targeted efficacy for sleep maintenance insomnia and favorable side effect profile at these doses 5, 6
Special Considerations
- Trazodone may be considered as a third-line agent only if there is comorbid depression (although 50 mg is insufficient for treating major depression) or if all first-line treatments have failed or are contraindicated 8
- If trazodone is used despite the recommendation, the dose should be 50 mg at bedtime (the studied dose, although ineffective) 1, 4, 5
Important Warnings
- Elderly patients are at increased risk of orthostatic hypotension, falls, and daytime somnolence 8