Doxepin + Seroquel

[sunlioness]

This might be a silly question, but I've never actually used these meds together. I have a patient with a psychotic disorder who has done the best on seroquel, but is still having trouble sleeping. He sleepwalks on Ambien, feels trazodone revs him up, and has a history of benzo abuse. Any suggestions for a sleep aid for him? And how much should I worry about the potential for QT prolongation with Doxepin?

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[billypilgrim37]

I'm not sure what benefit doxepin would give him, as you're probably already maxing out the H1 effects with the Seroquel after 2-300mg. The cardiac effects would be more worrisome depending on the dose of the doxepin, but most of the sleep benefit comes at pretty tiny doses, so I wouldn't think very much would be of additional benefit.

Other than H1, GABA, Alpha-2, and Melatonin, you only have so many receptors you can make people sleepy with, unfortunately.

Any idea what's keeping him up? Other drugs of abuse?

I'm not sure that sleepwalking on Ambien necessarily would mean he would do the same on Lunesta. And by "not sure" I mean "have no clue". Maybe Dr Rack can comment.

I'm guessing this guy wouldn't be a great candidate for chloral hydrate or Xyrem.

 

[sunlioness]

I was thinking about Lunesta first, actually. I just have a bear of a time getting insurances to pay for it. It might be worth a try. I hadn't thought of the H1 effects and I think you're probably right. I'm honestly not sure what's keeping him up. He states anxiety. I don't think he's using currently.

 

[BobA]

I was thinking about Lunesta first, actually. I just have a bear of a time getting insurances to pay for it. It might be worth a try. I hadn't thought of the H1 effects and I think you're probably right. I'm honestly not sure what's keeping him up. He states anxiety. I don't think he's using currently.

there's some small evidence for melatonin as a maintenance sleeper in patients with schizphrenia and alcohol dependence.

 

[michaelrack]

I'm not sure that sleepwalking on Ambien necessarily would mean he would do the same on Lunesta. And by "not sure" I mean "have no clue". Maybe Dr Rack can comment.

There was some research regarding sleepwalking and hypnotics presented at the last sleep meeting. Apparently, many people who sleepwalk on the non-benzo benzo receptor agonists have untreated restless leg syndrome. I would recommend screening (by asking questions) your patient for RLS.

I don't think there is high quality research showing that Ambien causes more sleepwalking than Lunesta, but many sleep docs (including myself) believe this.

 

[SpiritiualDuck]

Doxepin at the dose you'd use would be relatively free of s/es. But, then again, you're targeting H1 like Seroquel, and--from what I've been told--Doxepin is primarily good for sleep maintenance, but not for onset troubles.

So, with most patients you'd use like 5mg of Doxepin using the liquid ml formulation or you could give 10mg of the tablets. They have repackaged it as a new brand like a year or so ago as Silenor in 3 and 6mg tablets.

I've had some success with mirtazapine 7.5mg too.

So, there used to be some data that suggests that Gabapentin might help in alcohol dependent populations. I've tried Gabapentin on a few folks with limited success, but then again, my N is 3.

 

[NJWxMan]

High doses of Seroquel for "psychotic disorder" + history of Benzo. abuse + still not sleeping + trials of other sleep aids= Axis 2. This is one of the the major problems in psychiatry. I don't think throwing another drug such as Doxepin, at a patient is going to help much. It might offset further complaints by 1 or 2 months. Get them to stop napping during the day. Get them tired at bedtime. Minimize potential benefits of more medications. May I also add that by the book, Remeron should be a better sleeper at lower doses. Through my VA experience, it's simply not. Remeron 45 mg helps with sleep more than 15 mg from what I have seen.