| Major depressive disorder. View labelExact | Typical adult initiation: 15 mg at bedtime; increase to 30 mg after 1–2 weeks based on response; usual maintenance 15–45 mg nightly. | Central presynaptic alpha-2 antagonist; enhances noradrenergic and serotonergic transmission (NaSSA). | CYP1A2, CYP2D6, CYP3A4 | Single-dose mean 30 h; Single-dose range 20–40 h; Steady-state mean 37 h | No | | - Weight and appetite changes, plus fasting lipids and glucose at baseline and periodically, given weight gain and dyslipidemia risk.
- Daytime sedation and falls risk, especially in older adults and when other sedatives are co-prescribed.
- Infection symptoms (fever, sore throat) given rare neutropenia; prompt evaluation is appropriate when symptoms arise.
- Mood elevation or agitation in bipolar-spectrum illness; coordinate prevention plans via the bipolar disorder hub.
| No | 2025-10-05 |
|---|
trazodoneAdjunctive therapyBrands: DESYREL, OLEPTRO | Major depressive disorder (label); commonly used off label for insomnia. View labelExact | Insomnia (off label): start 25–50 mg at bedtime; typical 50–150 mg nightly based on tolerability; reassess frequently and avoid open-ended dose escalation. | Serotonin antagonist and reuptake inhibitor (SARI); 5-HT2 antagonism with weak SERT inhibition plus H1/α1 effects. | CYP3A4 | Single-dose mean 7 h; Single-dose range 5–13 h | No | | - Monitor orthostatic symptoms and falls risk during initiation and after dose increases, especially in older adults or those on antihypertensives.
- Reassess mood and suicidality during antidepressant initiation and titration; ensure the dose matches the target (sleep vs depression).
- Review QT-risk co-medications and consider ECG/electrolytes when risk factors stack.
- If used primarily for insomnia, document a stop plan and reassess regularly rather than continuing indefinitely.
| No | 2026-02-22 |
|---|
doxepinAdjunctive therapyBrands: Sinequan, Silenor | Depression and anxiety; low-dose formulation approved for insomnia. View labelExact | Depression/anxiety: typical start is 25–50 mg at bedtime; titrate by 25–50 mg every 3–4 days to 75–150 mg/day (single HS dose or divided BID). Max 300 mg/day inpatient with ECG monitoring. | Tricyclic antidepressant; strong antihistamine with serotonin and norepinephrine reuptake inhibition. | CYP2D6, CYP2C19 | Single-dose mean 28 h; Steady-state mean 31 h | 150–250 ng/mL | | - Sedation, next-day impairment, and falls risk (especially in older adults); driving and occupational safety are often reassessed after dose changes.
- Orthostatic vitals during titration and when combined with other hypotensive medications; hydration and slow position changes are commonly emphasized.
- Anticholinergic burden (constipation, urinary retention, confusion); bowel regimen planning and avoiding additive anticholinergic polypharmacy are common considerations when feasible.
- ECG monitoring for patients with cardiac disease, electrolyte abnormalities, or higher antidepressant doses; repeat ECGs are often considered when adding other QT-active agents.
- Therapeutic drug monitoring can be helpful in higher-dose depression regimens, drug interactions (CYP2D6/2C19 inhibitors), unexpected nonresponse, or suspected toxicity.
- Mood activation (mania/hypomania) in bipolar-spectrum illness and suicidal thinking during initiation; coordination via the bipolar disorder hub can support planning.
| No | 2025-12-29 |
|---|
| Insomnia (label). View labelExact | Take 8 mg within 30 minutes of bedtime (label). | Melatonin receptor agonist (MT1/MT2); hypnotic for sleep onset insomnia. | CYP1A2, CYP3A4, CYP2C9 | Single-dose mean 1.5 h; Single-dose range 1–2.6 h | No | | - Reassess sleep latency and next-day functioning within a few weeks; stop if benefit is minimal rather than escalating.
- Review interacting medications (especially CYP1A2 inhibitors/inducers) and timing with meals when response changes.
- Monitor mood and suicidality in patients with depression or mood instability when insomnia is part of a mood episode.
- Reinforce CBT-I and sleep hygiene and address sleep apnea/substance use when insomnia persists.
| No | 2026-03-31 |
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