Trazodone Dose Tolerance and APAP Adherence

Study Overview
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Brief Summary
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Trazodone may help obstructive sleep apnea patients to stick to their therapy, but optimal dosing is unknown. This study looks at what dose of trazodone has the best balance of potential benefits to side-effects in people with obstructive sleep apnea who are either starting on positive airway pressure therapy or not adherent to it. Participants will be randomly assigned to one of three groups: trazodone 50 mg, trazodone 100 mg, or placebo for 14 days. The investigators will monitor side-effects and adherence to positive airway pressure therapy.

Detailed Description
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Clinical Significance: Trazodone is an often-used medication in clinical sleep medicine. However, there is a dearth of information on side-effects with doses typically used for sleep. In addition, a significant proportion of the VA population have obstructive sleep apnea for which the primary treatment is positive airway therapy. However, many patients have difficulty adhering to this treatment long-term. Increased adherence to this modality has been shown to improve risk for cardiovascular and neurologic co-morbidity associated with obstructive sleep apnea. This project explores both the tolerability and safety of common doses of trazodone used in clinical sleep practice as well explores potential effects on positive airway pressure therapy adherence. Objectives: This project seeks to determine the tolerability and multi-domain effect on sleep and mood of a 14 day course of trazodone at either 50 mg or 100 mg or placebo. Research Plan: This is a three-group, randomized, double-blind, placebo-controlled trial with prospective data collection of VA outpatient sleep clinic patients with obstructive sleep apnea with who are non-adherent or newly started on auto-titrating positive airway pressure therapy. Evaluation focuses on medication tolerability as measured by number of days before study drug discontinuation by the participant, the Treatment Satisfaction Questionnaire for Medication, the side-effect profile at the two doses (50mg and 100mg) compared to placebo as well as longitudinal collection of adherence data and standardized questionnaires on sleepiness, insomnia, depression, anxiety, and self-efficacy. The investigators also plan to longitudinally monitor coefficient of variation of breath-to-breath tidal volume, a measure of respiratory mechanics which may be affected by trazodone use. Study participants will have 2 visits at baseline and 2 weeks after randomization. Methodology: This study will be conduced in the Louis Stokes Cleveland Medical Center - Wade Park Sleep Clinic, a tertiary institutional referral facility. Participants must be adults with obstructive sleep apnea prescribed auto-titrating positive airway therapy who are either newly initiated or do not fulfill standard criteria for adherence and do not have allergy to trazodone; current use of trazodone, monoamine oxidase inhibitors, or sedative hypnotics; alcohol or drug abuse; severe psychiatric disease; epilepsy; significant cardiac disease; liver disease; pregnancy; hypotension; or predisposition to priapism. Study staff will interview the potential participant and do a review of the medical record for exclusion criteria before consent is obtained. The investigators expect to recruit 45 participants into the study with a 20% attrition rate before completion. Hypothesis about the tolerability of trazodone and effect on positive airway therapy adherence was prespecified.

Official Title
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Randomized Controlled Trial of Trazodone Dose Tolerance and APAP Adherence

Conditions
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Sleep Apnea, Obstructive

Intervention / Treatment
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* Drug: Trazodone
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Louis Stokes Cleveland VA Sleep Medicine clinic patient AHI greater than or equal to 5 obstructive sleep apnea new initiation or nonadherence to APAP Exclusion Criteria: schizophrenia bipolar disorder current use of trazodone or sedative hypnotics allergy to trazodone current use of tricyclic antidepressants or monoamine oxidase inhibitors current alcohol or drug abuse heart failure heart attack in past 3 months congenital long QT, ventricular arrhythmia (including Torsades de Pointes), bradycardia, or digoxin therapy use of amiodarone, sotalol, dofetilide, or dronedarone epilepsy liver disease pregnancy (or planning pregnancy) right of priapism: history of priapism, sickle cell disease, Farby disease

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: Placebo<br>pill filled with inert material | Drug: Placebo<br>* take at bedtime for 14 days<br>|
| Active Comparator: Trazodone 50mg<br> | Drug: Trazodone<br>* take at bedtime for 14 days<br>* Other names: Desyrel;|
| Active Comparator: Trazodone 100mg<br> | Drug: Trazodone<br>* take at bedtime for 14 days<br>* Other names: Desyrel;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Discontinuation rate by participant | Did the participant discontinue trazodone at a higher rate than placebo? | 14-16 days post-randomization | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 3 month APAP adherence | APAP use in last 30 days (of the 3 month period) as measured by (1) average hours/day and (2) percent days with 4 or more hours use | 3 months post-randomization assessing 30 days before this 3 month period | 
| Respiratory patterning | Variation of breath to breath tidal volume obtained from plethysmography (a stretchy band around the chest x 20 minutes while wearing APAP) | 14-16 days post-randomization | 
| Medication Satisfaction | Treatment Satisfaction Questionnaire for Medications version II overall and subscale scores | 14-16 days post-randomization | 
| side-effect profile | participant-reported side effects of study drug | 14-16 days post-randomization | 
| sleepiness | Epworth Sleepiness Scale | 14-16 days post-randomization | 
| insomnia | Insomnia Severity Index | 14-16 days post-randomization | 
| general self-efficacy | General Self-Efficacy Scale | 14-16 days post-randomization | 
| depression | Clinically Useful Depression Outcome Scale (CUDOS) | 14-16 days post-randomization | 
| anxiety | Clinically Useful Anxiety Outcome Scale (CUXOS) | 14-16 days post-randomization | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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positive airway pressure, obstructive sleep apnea, trazodone, adherence