TRAZ-oh-done

Therapeutic Classification: antidepressants

• Major depression.

Unlabeled Uses:

• Insomnia.

• Alters the effects of serotonin in the CNS.

• Antidepressant action, which may develop only over several wk.

Absorption: Well absorbed after oral administration.

Distribution: Widely distributed to tissues.

Protein Binding: 89–95%.

Metabolism/Excretion: Extensively metabolized by the liver via the CYP3A4 isoenzyme; minimal excretion of unchanged drug by the kidneys.

Half-life: 5–9 hr.

(antidepressant effect)

Contraindicated in:

• Hypersensitivity
• Recovery period after MI
• Concurrent electroconvulsive therapy
• Concurrent use of MAO inhibitors or MAO inhibitor-like drugs (linezolid or methylene blue)
• Angle-closure glaucoma
• Lactation: Lactation.

Use Cautiously in:

• Cardiovascular disease
• Suicidal behavior
• Severe renal impairment (dose ↓ recommended)
• Severe hepatic impairment (dose ↓ recommended)
• OB: Other agents preferred for treatment of depression or insomnia in pregnancy
• Pedi: Safety and effectiveness not established in children; suicide risk may be greater in children and adolescents
• Geri: Initial dose ↓ recommended in older adults.

CV: hypotension, arrhythmias, chest pain, hypertension, palpitations, QT interval prolongation, tachycardia.

Derm: rash.

EENT: blurred vision, tinnitus.

GI: dry mouth, constipation, diarrhea, excess salivation, flatulence, nausea, vomiting.

GU: erectile dysfunction, hematuria, priapism, urinary frequency.

Hemat: anemia, leukopenia.

MS: myalgia.

Neuro: drowsiness, confusion, dizziness, dysgeusia, fatigue, hallucinations, headache, insomnia, nightmares, slurred speech, SUICIDAL THOUGHTS, syncope, tremor, weakness.

Drug-Drug:

• Serious, potentially fatal reactions (hyperthermia, rigidity, myoclonus, autonomic instability, with fluctuating vital signs and extreme agitation, which may proceed to delirium and coma) may occur with concurrent MAO inhibitors. MAO inhibitors should be stopped at least 14 days before trazodone therapy. Trazodone should be stopped at least 14 days before MAO inhibitor therapy.
• Concurrent use with MAO-inhibitor like drugs, such as linezolid or methylene blue, may ↑ risk of serotonin syndrome; concurrent use contraindicated; do not start therapy in patients receiving linezolid or methylene blue; if linezolid or methylene blue need to be started in a patient receiving trazodone, immediately discontinue trazodone and monitor for signs/symptoms of serotonin syndrome for 2 wk or until 24 hr after last dose of linezolid or methylene blue, whichever comes first (may resume trazodone therapy 24 hr after last dose of linezolid or methylene blue).
• May ↑ digoxin or phenytoin levels and the risk of toxicity.
• ↑CNS depression with other CNS depressants, including alcohol, opioid analgesics, and sedative/hypnotics.
• ↑risk of hypotension with antihypertensives, acute ingestion of alcohol, or nitrates.
• Fluoxetine may ↑ levels and the risk of toxicity.
• CYP3A4 inhibitors, including ritonavir and ketoconazole, may ↑ levels and the risk of toxicity.
• CYP3A4 inducers, including carbamazepine, may ↓ levels and its effectiveness.
• Drugs that affect serotonergic neurotransmitter systems, including tricyclic antidepressants, fentanyl, buspirone, tramadol and triptans, may ↑ the risk of serotonin syndrome.
• ↑risk of bleeding with NSAIDs, aspirin, clopidogrel, prasugrel, ticagrelor, or warfarin.

Drug-Natural Products:

• Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression.
• ↑risk of serotonergic side effects including serotonin syndrome with St. John’s wort and SAMe.

Depression

• PO (Adults): 150 mg/day in 3 divided doses; ↑ by 50 mg/day every 3–4 days until desired response (not to exceed 400 mg/day in outpatients or 600 mg/day in hospitalized patients).
• PO (Geriatric Patients): 75 mg/day in divided doses initially; may be ↑ every 3–4 days.

Insomnia

• PO (Adults): 25–100 mg at bedtime.

(Generic available)

• Tablets: 50 mg; 100 mg; 150 mg; 300 mg;

• Monitor BP and pulse rate before and during initial therapy. Monitor ECGs in patients with pre-existing cardiac disease before and periodically during therapy to detect arrhythmias.
• Assess for possible sexual dysfunction.
• Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyper-reflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs, triptans).
• Depression: Assess mental status (orientation, mood, and behavior) frequently.
  • Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults 24 yr. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for next 4 wk, and on advice of health care professional thereafter.

• Assess CBC and renal and hepatic function before and periodically during therapy. Slight, clinically insignificant ↓ in leukocyte and neutrophil counts may occur.

• Do not confuse trazodone with tramadol.
• PO: Administer with or immediately after meals to minimize side effects (nausea, dizziness) and allow maximum absorption of trazodone. A larger portion of the total daily dose may be given at bedtime to decrease daytime drowsiness and dizziness.

• Instruct patient to take medication as directed. If a dose is missed, take as soon as remembered. Do not take if within 4 hr of next scheduled dose; do not double doses. Consult health care professional before discontinuing medication; gradual dose reduction is necessary to prevent aggravation of condition. Advise patient to read Medication Guide prior starting therapy and with each Rx refill in case of changes.
• May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is known.
• Caution patient to change positions slowly to minimize orthostatic hypotension.
• Advise patient to avoid concurrent use of alcohol or other CNS depressant drugs.
• Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur.
• Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially aspirin and NSAIDs.
• Inform patient that frequent rinses, good oral hygiene, and sugarless candy or gum may diminish dry mouth. Health care professional should be notified if this persists >2 wk. An increase in fluid intake, fiber, and exercise may prevent constipation.
• Advise patient to notify health care professional of medication regimen before treatment or surgery.
• Instruct patient to notify health care professional if priapism, irregular heartbeat, fainting, confusion, skin rash, or tremors occur or if dry mouth, nausea and vomiting, dizziness, headache, muscle aches, constipation, or diarrhea becomes pronounced.
• Instruct patient to notify health care professional if signs of serotonin syndrome (mental status changes: agitation, hallucinations, coma; autonomic instability: tachycardia, labile BP, hyperthermia; neuromuscular aberrations: hyperreflexia, incoordination; and/or gastrointestinal symptoms: nausea, vomiting, diarrhea) occur.
• Advise females of reproductive potential to notify health care professional if pregnancy is planned and to not breastfeeding during therapy.
• Emphasize the importance of follow-up exams to evaluate progress.

• Resolution of depression.
  • Increased sense of well-being.
  • Renewed interest in surroundings.
  • Increased appetite.
  • Improved energy level.
  • Improved sleep.

Desyrel