Trazodone
DESYREL
Pronunciation: TRAZ-oe-doen (DEZ-er-el)
“Desy’s Trays o’ bone”
Polka dots on pink → α1 blocker → syncope if titrated too quickly (hit the floor)
Trazodone is a serotonin antagonist and reuptake inhibitor (SARI)
Bone → risk of priapism
What it isSerotonin antagonist and reuptake inhibitor; licensed for depression, used almost entirely for insomnia.
Why this oneSedating without the dependence liability of a benzodiazepine or z-drug, and it is not a controlled substance.
What limits itOrthostatic hypotension from alpha-1 blockade is the main hazard in the elderly. Priapism is rare but a surgical emergency.
FDA-approved for
- depression (1981)
Off-label
- insomnia
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Major depressive disorder | Outpatients | 150 mg/day in divided doses | — | 400 mg/day in divided doses |
| Major depressive disorder | Inpatients (more severe) | 150 mg/day in divided doses | — | 600 mg/day in divided doses |
Titration May increase by 50 mg/day every 3 to 4 days
Renal Undefined
Hepatic Undefined
Instructions
- Take shortly after a meal or light snack
- Swallow whole or break in half along the score line; do not chew or crush
- Taper gradually to discontinue
- Consider dose reduction with strong CYP3A4 inhibitors and dose increase with strong CYP3A4 inducers
- At least 14 days between an MAOI and trazodone in either direction
Available strengths
- tab 50, 100, 150, 300 mg
Contraindications
- MAOIs (concurrently or within 14 days) due to risk of serotonin syndrome
Cautions
- Serotonin syndrome (can occur even alone)
- QT prolongation and cardiac arrhythmias including torsade de pointes
- Orthostatic hypotension and syncope
- Increased risk of bleeding (with NSAIDs/antiplatelets/anticoagulants)
- Priapism
- Activation of mania/hypomania
- Discontinuation syndrome
- Cognitive and motor impairment
- Angle-closure glaucoma
- Hyponatremia/SIADH
Adverse reactions
- Drowsiness
- Dizziness/light-headedness
- Dry mouth
- Blurred vision
- Edema
- Fatigue
- Syncope
- Nausea/vomiting
- Nasal congestion
- Weight change
Pregnancy Published data over decades have not identified drug-associated risks of major birth defects, miscarriage, or adverse outcomes
Lactation Transfers into human milk; limited postmarketing data have not identified adverse effects on the breastfed child
Cost
Generic entry1986
⚠ BOXED WARNING
- Suicidal thoughts and behaviors in patients under 25
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilitySedation, orthostasis and priapism; overdose can cause QT prolongation and CNS depression.
Serotonicity
This drug is routinely called serotonergic. By Gillman’s human-effect criteria it does not raise serotonin in the synapse.
Not a clinically significant SRI; receptor antagonism is not serotonin elevation.
Label contraindicationMAOIs (concurrently or within 14 days) due to risk of serotonin syndrome. The label governs prescribing; Gillman’s point concerns serotonin toxicity only.
It binds the serotonin transporter, and its SERT peg is drawn to that textbook affinity. The pale halo around the peg marks binding that, by Gillman’s human-effect criteria, does not produce clinical serotonin reuptake inhibition.
Gillman’s four human testsA measurable SERT affinity that fails all four is not clinical serotonicity.
- Retarded orgasm
- Efficacy in OCD and cataplexy
- Clonus and hyperreflexia in single-drug overdose
- Serotonin toxicity when combined with an MAOI
Non-elevating action5-HT2A antagonist
Evidence confidenceHigh
Background: what serotonicity is · what is and is not an SRI · what counts as a relevant MAOI.
Active metabolites
Open Trazodone in the interactive console ↗
Memory aids: interaction avatars
