Low-Dose Doxepin (Silenor)

FDA Approved 2010

Reviewed by the HeyPsych Medical Review Board

Board-certified psychiatrists and mental health professionals

Indications

Primary Indications

Sleep maintenance insomnia in adults

Mechanism

At low doses (≤6 mg), doxepin selectively antagonizes central histamine H1 receptors, promoting sleep maintenance with minimal anticholinergic or adrenergic effects.

Dosing

Adult Dosing

insomnia: 3–6 mg once nightly within 30 minutes of bedtime

Dosage Forms

Tablets: 3 mg, 6 mg

Onset Duration

Onset: within 30–60 minutes; Duration: up to 7–8 hours.

Adverse Effects

Common Side Effects

• drowsiness

• dry mouth

• nausea

⚠️ Serious Side Effects

allergic reactions
angle-closure glaucoma exacerbation

Warnings

Critical Safety Information

Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults. Although risk is minimal at low doses, caution is advised.

→Avoid alcohol and other CNS depressants
→Not recommended for early insomnia (sleep onset)
→May cause next-day drowsiness in sensitive individuals

Interactions

With: MAOIs

Risk: Potential for serious reactions

Action: Contraindicated; 14-day washout

With: CNS depressants

Risk: Additive sedation

Action: Use caution

With: Strong CYP2D6 inhibitors

Risk: Increased doxepin levels

Action: Monitor and adjust dose

Monitoring

Daytime alertness
Signs of hypersensitivity
Sleep quality and duration

Special Populations

👶Pregnancy

Use only if benefits outweigh risks

🤱Breastfeeding

Excreted in breast milk; use with caution

👧Children & Adolescents (Under 18)

Not approved for children

👴Older Adults (65+)

Increased sensitivity; start with lowest dose

Tapering

Not usually required for doses ≤6 mg, but gradual discontinuation can be considered if used for extended periods.

Clinical Notes

Minimal next-day impairment compared to many other hypnotics
Primarily improves sleep maintenance rather than sleep onset
Has less abuse potential than benzodiazepines or Z-drugs

This medication information is for educational purposes only and is not a substitute for professional medical advice. Always consult your healthcare provider before starting, stopping, or changing any medication. Never take medication without a prescription from a licensed healthcare provider.

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