Insomnia
31-year-old Male

31-year-old Male

 

Decision Point One


Trazodone 50 mg po at bedtime

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what you should do next:


Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose

RESULTS OF DECISION POINT TWO

  • Patient returns to clinic in 2 weeks
  • Patient states priapism has diminished over time
  • Patient denies auditory/visual hallucinations and is future oriented
  • Patient states trazodone is effective at 50 mg dose but sometimes wakes up following day with next-day drowsiness
  • Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three
Select what you should do next:


Discontinue trazodone. Initiate therapy with sonata 10 mg nightly at bedtime. Follow up in 4 weeks
Guidance to Student

Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it carries with it the risk of complex sleep behaviors. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.

The patient is presenting with excessive somnolence. It would be prudent to reduce the dose of trazodone by 50% and reassess in 4 weeks.


Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg at bedtime. Follow up in 4 weeks
Guidance to Student

Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it carries with it the risk of complex sleep behaviors. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.

The patient is presenting with excessive somnolence. It would be prudent to reduce the dose of trazodone by 50% and reassess in 4 weeks.


Continue dose. Explain to patient he may split the 50 mg tablet in half. The decreased dose should minimize next-day drowsiness. Follow up in 4 weeks
Guidance to Student

Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it carries with it the risk of complex sleep behaviors. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.

The patient is presenting with excessive somnolence. It would be prudent to reduce the dose of trazodone by 50% and reassess in 4 weeks.


Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime

RESULTS OF DECISION POINT TWO

  • Patient returns to clinic in 2 weeks
  • Patient states suvorexant works well for sleep but leaves him with an awful next-day feeling, and “it’s very difficult to get out of bed.”
  • Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three
Select what you should do next:


Continue dose. Explain next-day drowsiness is a common side effect. Follow up in 4 weeks
Guidance to Student

Next day drowsiness is a common side effect of suvorexant. This would be a major concern as it can affect the patient's ability to perform daily activities such as driving or going to work. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia. The patient is presenting with excessive somnolence from the suvorexant. It would be prudent to discontinue therapy and initiate trazodone for insomnia, reassessing in 4 weeks.


Discontinue suvorexant. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks
Guidance to Student

Next day drowsiness is a common side effect of suvorexant. This would be a major concern as it can affect the patient's ability to perform daily activities such as driving or going to work. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia. The patient is presenting with excessive somnolence from the suvorexant. It would be prudent to discontinue therapy and initiate trazodone for insomnia, reassessing in 4 weeks.


Discontinue suvorexant. Initiate therapy with trazodone 50–100 mg nightly at bedtime. Follow up in 4 weeks
Guidance to Student

Next day drowsiness is a common side effect of suvorexant. This would be a major concern as it can affect the patient's ability to perform daily activities such as driving or going to work. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia. The patient is presenting with excessive somnolence from the suvorexant. It would be prudent to discontinue therapy and initiate trazodone for insomnia, reassessing in 4 weeks.


Decrease trazodone to 25 mg daily at bedtime

RESULTS OF DECISION POINT TWO

  • Patient returns to clinic in 2 weeks
  • Patient states trazodone is very effective for sleep
  • Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night
  • Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three
Select what you should do next:


Discontinue trazodone. Initiate therapy with ramelteon 8 mg nightly at bedtime. Follow up in 4 weeks
Guidance to Student

Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn't practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.


Continue dose. Encourage sleep hygiene. Follow up in 4 weeks
Guidance to Student

Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn't practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.


Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks
Guidance to Student

Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn't practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.