Introduction
The patient is a 31-year-old male with a chief complaint of insomnia. According to the patient, problems with insomnia began six months ago after losing his fiancée (Insomnia, n.d.). Since then, insomnia symptoms have worsened, and the patient cannot fall asleep or remain asleep throughout the night. It significantly affects the patient’s quality of life, as well as his work activities. Therefore, the problem requires immediate intervention to improve the man’s condition.
The patient notes that he has previously taken diphenhydramine, which had adverse side effects. Based on this, the choice of medications should be made to minimize risks for the patient while maintaining effectiveness. In addition, the patient’s medical records contain a history of opiate abuse, so the medications prescribed must not be highly addictive (Insomnia, n.d.).
The patient has recently used alcohol to help him fall asleep, which should also be considered when choosing an intervention. Even though the assessment of the man’s mental state did not show significant deviations, there is reason to believe that his insomnia may be associated with depression. These disorders are often linked, and poor sleep hygiene is a common symptom of depression (Riemann et al., 2020). The patient experienced a severe shock associated with losing a loved one, which catalyzed this condition.
Decision 1
Trazodone 50 mg orally at bedtime was chosen as the drug treatment for the patient. Although according to Pelayo et al. (2023), this drug should not be the first-line treatment for patients, it is quite effective in overcoming insomnia. Additionally, it has fewer significant renal effects that impact patients’ quality of life. In addition, trazodone is an antidepressant that could positively affect the patient’s general condition.
Other proposed treatment options, like zolpidem (10 mg) and hydroxyzine (50 mg), may have unwanted side effects for the patient. Although zolpidem is often recommended for insomnia, it can cause “amnesia, dizziness, headache, nausea, somnolence, and taste perversion” (Sateia et al., 2017, p. 323). In addition, this drug may react with alcohol, causing adverse effects and creating unnecessary risks that outweigh the potential benefits. Hydroxyzine is an antihistamine with strong sedative properties (Hydroxyzine, n.d.). Since the patient had previous experience with drugs of this type, which showed significant unpleasant side effects, hydroxyzine is not recommended.
Prescribing trazodone (50 mg) as the primary treatment for insomnia aims to eliminate the problems with falling asleep and waking up at night (Pelayo et al., 2023). Ethical considerations for selecting a specific drug include informing the patient about the characteristics of the drug, its potential effects, and potential side effects (Sateia et al., 2017). Since a man uses alcohol to help him sleep, it follows the ethics required to inform him about the interaction between trazodone and alcohol. Additionally, it is crucial to consider the patient’s views and preferences when creating a medication intervention plan.
Decision 2
Based on the results obtained during the first two weeks of treatment, the decision was made to continue the current dose of trazodone. The goals set when choosing a drug intervention were partially achieved, determining the effectiveness of further drug use. Two other options include discontinuing trazodone by prescribing another medication and decreasing the dosing of the current drug to 25 mg.
Initiating other medications, such as suvorexant, may compromise the patient’s previous treatment effectiveness and impact the overall treatment outcome (Sateia et al., 2017). At this stage, reducing the dose of medication may lead to worse results, as its onset period is 4-6 weeks (Trazodone, n.d.). Therefore, continuing the prescribed treatment is the best choice to improve the results achieved.
Moreover, one of the side effects experienced by the patient is priapism. Although this is not common, it can occur in some cases (Trazodone, n.d.). In most cases, this side effect typically resolves over time. It is essential to explain to the patient that such a reaction to the medication is normal and, despite temporary discomfort, will be eliminated soon.
Continued use of trazodone aims to stabilize the patient’s sleep patterns. Considering that the drug previously had a positive effect on managing insomnia in men, its continued prescription is highly justified. However, informing the patient about the benefits and risks of continuing treatment (Sateia et al., 2017) is vital.
Additionally, it is essential to be aware of the importance of adhering to the drug’s dosage and frequency of administration. For adult patients, the daily dosage cannot exceed 100 mg, and the patient must be aware of the risks of overdosing (Trazodone, n.d.). Constant monitoring of the patient’s condition is necessary for timely adjustments to the dosage of medication or treatment plan.
Decision 3
Since the results obtained after four weeks of treatment met the stated goals, continued use of trazodone is recommended. However, the patient can reduce the dosage by 50% by taking half a tablet, which may help minimize unwanted side effects such as next-day drowsiness. A dose of 25 mg of trazodone is effective for maintaining a regular sleep schedule (Trazodone, n.d.). Moreover, stopping the drug and initiating other medications offered in other options, like Sonata and hydroxyzine, may cause adverse side effects and a reversal of the results obtained.
Before taking trazodone, it is vital to inform the patient about the importance of maintaining the correct dosage. Moreover, in the case of prescribing other drugs, it is necessary to find out about their interaction with the antidepressant being taken since trazodone has a reasonably extensive list of contradictions (Trazodone, n.d.). It is essential to constantly monitor the patient’s condition to identify deteriorations promptly and take the necessary actions to eliminate them. Given the patient’s history of opiate abuse, ethical considerations require constant monitoring of prescribed medications and withdrawal of them under the supervision of a specialist (Pelayo et al., 2023). The patient must undergo follow-up every four weeks to monitor the progress of their treatment.
Conclusion
Choosing trazodone as a drug intervention for insomnia may be effective. However, it is crucial to consider that this drug is primarily an antidepressant and is not recommended by the FDA as an optimal medication for sleep disorders (Pelayo et al., 2023). It is essential to notify the patient about this when initially prescribing the medication and to consider their opinion when finalizing the treatment strategy.
Although treating insomnia is not the primary function of trazodone, in this case study, the drug showed positive results. It is essential to consider that men’s sleep disturbances may be associated with severe emotional distress (Riemann et al., 2020). This factor justifies the use of an antidepressant as the primary medical intervention.
Side effects such as drowsiness and priapism are common and usually stabilize 4-6 weeks after starting the medication. Moreover, the results obtained from the treatment in the first four weeks indicate that there is no need to change the medication intervention (Pelayo et al., 2023). Moreover, the patient reported negative experiences with antihistamines, which were also considered when choosing the optimal treatment. However, trazodone use should be monitored to ensure timely dosage adjustments and prevent dangerous consequences for the patient.
References
Hydroxyzine (Rx). (n.d.). Medscape.
Insomnia. 31-year-old male. (n.d.) Insomnia.
Pelayo, R., Bertisch, S. M., Morin, C. M., Winkelman, J. W., Zee, P. C., & Krystal, A. D. (2023). Should trazodone be first-line therapy for insomnia? A clinical suitability appraisal. Journal of Clinical Medicine, 12(8), 2933-2942.
Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020). Sleep, insomnia, and depression. Neuropsychopharmacology: Official Publication of The American College of Neuropsychopharmacology, 45(1), 74–89.
Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349.
Trazodone (Rx). (n.d.). Medscape.