I have a patient who has been on xanax for years, been on 0.5 mg at bedtime for the past year. She states that it helps her with sleep, but she wants off the medication due to cognitive concerns and concerns for addiction. I told her to cut it to 0.25 mg at bedtime, with a plan to slowly switch to trazodone. Anyone have experience with this or advice?
Switching patient from xanax to trazodone?
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Why slowly switch? Why not just start trazodone the first day of the dose decrease?
Was it every single night Xanax or just as needed?
While Xanax is especially habit forming and anything for sleep is habit forming, idk if it will be nearly as bad as trying to take her off a higher dose or multiple daily doses. Though it sounds like she's been coming off it since you said multiple years but 0.5 at night for just one year. That last half mg can be super hard for some people. Other people don't find it as hard as the first 2 mg.
When it is especially difficult to get off the last 0.5, sometimes I have them do 0.5 for six nights a week with 0.25 once a week, then 0.5 five nights a week, etc. Though usually I'm dealing with mornings, not nights. Why use Xanax for sleep?
Was it every single night Xanax or just as needed?
While Xanax is especially habit forming and anything for sleep is habit forming, idk if it will be nearly as bad as trying to take her off a higher dose or multiple daily doses. Though it sounds like she's been coming off it since you said multiple years but 0.5 at night for just one year. That last half mg can be super hard for some people. Other people don't find it as hard as the first 2 mg.
When it is especially difficult to get off the last 0.5, sometimes I have them do 0.5 for six nights a week with 0.25 once a week, then 0.5 five nights a week, etc. Though usually I'm dealing with mornings, not nights. Why use Xanax for sleep?
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What specific concerns do you have? Can't you just start the Trazodone as you would with anyone, while reducing Xanax, and then adjust based on response? It's not as though the 2 meds should impact each other in some interesting way.
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Secondary idea, sounds like the right sort of patient for this: why not have her start doing CBTI and taper the xanax while immersed in CBTI? Our CBTI therapists have pts taper sedating QHS meds by ~25% once per week while in their (can't recall if 4 or 6 weeks) protocol. Could present it as "maybe it would be best to help you to no longer depend on taking any medication at bedtime so that you can sleep naturally."
Kinda an aside, but new article on newly recognized theoretical potential risks of TZD. Desmosterol and 7-dehydrocholesterol concentrations in post mortem brains of depressed people: The role of trazodone - Translational Psychiatry
Kinda an aside, but new article on newly recognized theoretical potential risks of TZD. Desmosterol and 7-dehydrocholesterol concentrations in post mortem brains of depressed people: The role of trazodone - Translational Psychiatry
She takes it nightly and has had withdrawal when stopped abruptly in the past. I'm not sure why she's on this regimen. She's coming to me after being on it for years.
One approach I've taken with switching from nightly benzos and z-drugs (especially if patient has misgivings about the transition) is start the replacement medication and tell the patient to take half their usual dose of the benzo/z-drug scheduled and they can take the other half PRN if needed. After two weeks, if they aren't needing the PRN dose they change from half-scheduled and half-PRN to just half-PRN. This way, at one month follow-up they've optimally been weaned off the benzo/z-drug. Alternatively, if the replacement medication is ineffective then they can still get adequate sleep in the interval and will be more willing to trial uptitration/augmentation/replacement.
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AASM guidelines list psychological/behavioral treatment as first line and say anyone with insomnia should have an adequate trial of CBTi prior to starting medication. Chronic pharmacological treatment of insomnia should be limited to those with severe refractory insomnia or with chronic comorbid medical illness.
Journal of Clinical Sleep Medicine
The official peer-reviewed journal of the American Academy of Sleep Medicine.
jcsm.aasm.org
0.25 mg of xanax is equivalent to 5 mg of valium, likely more like 2.5 mg of valium
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Sorry I don't know where my head was.
I'm usually good with remembering those equivalencies off the top of my head.
Not sure how I made that mix up.
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Let’s be clear about terms here, does she have rebound anxiety or actual physiologic withdrawals? Those are VERY different situations and I’m having a hard time believing she experiences true withdrawal that would warrant medical concern from stopping 0.5 of Xanax. Not saying it’s impossible or you shouldn’t cut to 0.25 before stopping, but if she’s experiencing actual withdrawals it seems like there’s more info missing here…
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Really? I don't find it at all surprising that someone would have withdrawal symptoms upon stopping Xanax 0.5. That's not a negligible dose, especially for a woman. Also she might not be a seizure risk but you don't want to force people to grit their teeth through anxiety, tremulousness, and tachycardia; it just makes them warier of the whole idea of discontinuation.
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Maybe if it's an 80 yo or she has a seizure disorder she'd have more significant withdrawal, but 0.5 would likely only cause mild withdrawal. If we're really that worried about her going through significant withdrawal, just give her 2.5-5mg of valium for a week or two and see if they report symptoms. Makes it pretty easy to differentiate rebound anxiety from actual withdrawal.
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<Not a doctor or medical student>
Not denying anyone's experiences, but such an easy taper is not one I've experienced or elsewhere commonly seen described. To avoid discussing me, you can look at a colleague in medicine, Dr. Christy Huff, who runs Benzo Info and her experience withdrawing from Xanax. Although, I am curious whether this patient has daytime symptoms, as taking it once daily would think you would have interdose withdrawal.
Is it possible that, like with opioids, when benzos become more potent and the dosages smaller, the withdrawal effect is less expected?
Another thing to keep in mind is kindling as she's had several previous failed withdrawal attempts.
Not denying anyone's experiences, but such an easy taper is not one I've experienced or elsewhere commonly seen described. To avoid discussing me, you can look at a colleague in medicine, Dr. Christy Huff, who runs Benzo Info and her experience withdrawing from Xanax. Although, I am curious whether this patient has daytime symptoms, as taking it once daily would think you would have interdose withdrawal.
Is it possible that, like with opioids, when benzos become more potent and the dosages smaller, the withdrawal effect is less expected?
Another thing to keep in mind is kindling as she's had several previous failed withdrawal attempts.
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You just can't predict people's responses based on administered dose alone. Age and comorbidities are obviously important, but intrinsic interindividual variability in pharmacokinetics is massive. For example, the following paper reports that there is "a large interindividual variation (up to 30-fold) in dose/blood level ratios" of diazepam. Clinical Pharmacokinetics of Diazepam - Clinical Pharmacokinetics
So if you give two different people 20 mg of diazepam, one may have 30-fold higher serum concentration than the other and will likely also evince a very different symptom trajectory upon drug withdrawal. Yes I have seen people who are able to d/c 0.5 mg Xanax no problem. I have also seen others who needed to do successively tinier doses over many months to get off that dose.
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I think its a good time to check in about why she needs the med in the first place.
She’s using it stably for years. Is it sleep onset insomnia? maintenance? is her sleep restful? Does she sleep during the day? Has she tried CBTi? Does she snore?
I would do that whole sleep oriented history. Also throw in a stop bang if you are suspicious of OSA as a potential confounder.
Given that she has sought a switch on her own, I would exploit that to see how much you can help.
She’s using it stably for years. Is it sleep onset insomnia? maintenance? is her sleep restful? Does she sleep during the day? Has she tried CBTi? Does she snore?
I would do that whole sleep oriented history. Also throw in a stop bang if you are suspicious of OSA as a potential confounder.
Given that she has sought a switch on her own, I would exploit that to see how much you can help.
