For many individuals, taking the prescribed sleeping pill zolpidem (Ambien) shouldn’t be an unusual occurrence. This is a nightly routine, and the one way they feel they’ll sleep. But dependence on zolpidem carries serious risks. Now, the prescribing trend has shifted to the “off-label” (unapproved) use of one other pill known for its ability to make people drowsy: low doses of the antidepressant drug trazodone.
What are drugs?
Zolpidem and trazodone were developed for specific purposes.
Zolpidem is a sedative-hypnotic drug designed to treat insomnia. It increases the effect of a brain chemical called gamma-aminobutyric acid (GABA), which reduces nerve activity and promotes sleep.
Trazodone is a drug originally designed to treat depression. At the usual dose — 300 milligrams (mg) — the drug increases levels of the brain chemical serotonin, which helps regulate mood.
But at very low doses — 50 mg — the drug blocks chemicals that cause wakefulness, which in turn has the side effect of falling asleep. Because of this side effect, doctors began prescribing low-dose trazodone for insomnia.
Shift away from zolpidem
Zolpidem may cause the harmful side effect of daytime sleepiness and dangerous sleep behaviors, corresponding to sleepwalking or performing other activities while not fully awake (driving, eating, making phone calls, or having sex) and never remembering these behaviors. Some activities have resulted in death. The FDA has since issued a “black box” warning for zolpidem (the strongest available measure wanting withdrawing the drug from the market).
Zolpidem has other risks. It relies on drugs to place people to sleep. “It can also cause falls in older adults, and some studies link it to an increased risk of cognitive impairment and dementia, although this is debated,” says Dr. Burtish.
These risks are enough to steer doctors to prescribe zolpidem and switch to low-dose trazodone. “Many primary care physicians use trazodone as a first-line treatment for insomnia because it has fewer side effects, it’s not a controlled substance, and it’s cheaper,” she says.
Risks of Trazodone
Although trazodone doesn’t cause dangerous sleep behaviors, it may possibly cause other problems. “The biggest thing is that it hasn’t been studied for insomnia, and it’s not FDA-approved to treat it,” says Dr. Burtish. “We have very little safety information and very little data to show that it works for patients with insomnia.”
We know that the drug has common unwanted effects corresponding to drowsiness, confusion, falls, stomach upset, dry mouth, blurred vision, and headache. “And data from a recent study shows that trazodone can cause heart problems for patients on dialysis,” says Dr. Burtish.
Because of the potential harms and limited data on the effectiveness of trazodone, the American Academy of Sleep Medicine recommends that physicians not use trazodone as a treatment for insomnia.
What do you have to do?
If you’re taking zolpidem and wish to stop, discuss with your doctor first. Abrupt withdrawal may worsen insomnia, so you need to discontinue the medication.
If you desire to try one other drug, the alternative of drug needs to be based in your specific needs, not a trend. Dr. British first tries to search out out why an individual cannot sleep, ruling out any underlying conditions.
If medication is required for sleep, Dr. British often recommends other medications before trying trazodone. These include low doses of doxepin (Silenor), ramelteon (Rozarem), or a brand new class of medicine called dual orexin receptor antagonists, which include suvorixant (Belsumra), lamborixant (Davigo), and deridorixant (Covic).
She also recommends Cognitive Behavioral Therapy for Insomnia (CBT-i), a customized program that teaches people to vary behaviors and thoughts about sleep as some of the effective insomnia treatments we have now. “Evidence shows that you can try CBT-i even while you’re taking sleep medications and tapering them off,” she says. “It’s a myth that you have to stop using the drug first.”
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