Trazodone

Here is basic Trazodone information for student nurses and nurse practitioners.

I work in a psychiatric clinic. Part of my job is to cover the Crisis Stabilization Unit, which is a facility that “provides a safe, structured environment for mental health stabilization and/or medically assisted detoxification.” We are open 24/7 and have 6 detoxification beds and 6 mental health beds. People stay for 1 night, or longer than a month, depending on what their goals are and where they are headed when they leave.

One of the PRN (as needed) medications that are on our routine standing orders is Trazodone for sleep.

Sopoforic effects.

Trazodone is a pretty cool medication because it helps you to sleep. According to one of my favorite sources, it was originally invented in Italy in the 1960s and approved by the FDA in this country in 1981.

Brand names are Desyrel, Oleptro in the USA, although this medication is literally all over the world with different names.

It is kind of like an SSRI, but not really. Technically, it is an SARI — serotonin 2 antagonist/reuptake inhibitor and is in the antidepressant and hypnotic classes of medication.

What do we use it for? Depression, insomnia, and anxiety. It works for insomnia immediately (if the dose is correct). For depression, it takes 2-4 weeks and you may need a dose increase in 6-8 weeks if it is not working. It can work for many years for depression, without losing efficacy.

Like most older medications, there are few long-term studies. But it should work long-term for insomnia, and there is no reliable evidence of tolerance, dependence, or withdrawal.

Second only to benzos. Trazodone is the most prescribed sleep medication except for the benzodiazepine class of medications.

Less anti-histamine effects than benzos, so fewer side effects. However, it can cause orthostatic hypotension in the elderly. Orthostatic hypotension is when you get dizzy, possibly even pass out, when you stand up too fast. It can cause falls, which for old folk is downright life-threateningly dangerous!

Alpha-blocker.
When you hear “adrenergic” think “adrenalin”. Trazodone blocks alpha-1 (α1) adrenergic -receptors, which can cause dizziness, sedation, hypotension (low blood pressure), orthostatic hypotension (low blood pressure when you stand up). Occasionally, you can even get sinus bradycardia (low heart rate) with long term use.
Therefore, Trazodone is not recommended for use during the initial recovery phase of myocardial infarction, because of the concern about bradycardia, and possible prolonged Q-T.

Weight gain is not common. Neither is constipation.

Trazadone does not have much anticholinergic side effects, so it is okay in situations like BPH (benign prostatic hyperplasia), glaucoma, and constipation.

Did Trazodone cause my spontaneous orgasm, increased libido, and inappropriate erection?

Trazodone can potentiate normal erections. It can prolong erection time and turgidity in some men with erectile disorder. Doses for this indication are 150-200mg per day. Trazodone is not used much for erectile dysfunction ever since the phosphodiesterase(PDE)-5 agents (sildenafil -Viagra, tadalafil-Cialis, and vardenafil-Levitra) were introduced.

Trazodone probably works on genital tissue due to its alpha-blocking properties.

A dramatic side effect associated with trazodone is priapism. Priapism is an erection lasting more than 3 hours, with pain, and is a medical emergency. Early indications of impending priapism may be slow penile detumescence when awakening from REM sleep. More than 200 cases have been reported, and the manufacturer estimated that the incidence of any abnormal erectile function is about one in 6,000-8,000 male patients treated with trazodone. The risk for this side effect appears to be greatest during the first month of treatment at low dosages (i.e.

Clinical reports have also described trazodone-associated psychosexual side effects in women, including increased libido, priapism of the clitoris, and spontaneous orgasms. (Clomipramine and fluoxetine have case reports of spontaneous orgasms, also.)

Trazodone is not in the SSRI class of antidepressants but it still may have that discontinuation syndrome if the medication is stopped too quickly. You may want to wean off it slowly.

Since trazodone may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks, don’t drive or operate chainsaws while taking it. Also, don’t do potentially hazardous tasks if you have priapism.

Start low and go slow.
For insomnia, low doses are good. Start at 25-50 mg, can go up to 50-100mg. For depression, doses of 150 all the way up to 600 mg can be used. For depression, start at 150 mg, increase by 50 mg every 4 days or so.

When adding this on to other antidepressants, start at the low-doses used for insomnia.
25-50 mg. Otherwise, it may cause ataxia, that annoying intoxicated feeling, and carryover sedation. If low doses don’t work, don’t give up. Try higher doses, 150-300 mg (even up to 600mg).

Half life is biphasic. The first phase is 3-6 hours, the second phase is 5-9 hours. Peak plasma levels in about 1 hour.

When to use Trazodone.
For insomnia when you want to avoid benzos.
As an add-on for depression and anxiety.
It does not usually cause weight gain or sexual side effects, so it is a good choice there.
It may help with drug-induced dyskinesias, mainly because it reduces anxiety about them.
Maybe helpful with agitation and aggression associated with dementia.

When not to use:
Fatigue or hypersomnia.
It may cause sexual dysfunction. Maybe. Or it may improve sexual function.
Seizure risk if taken with Tramadol. And possible if you are on anti-epileptic medications.
It may monkey with your INR if you are on Warfarin.
May monkey with your antihypertensive meds, especially clonidine. May increase digoxin and phenytoin concentrations.

Toxicity.

Yes, you can die from an overdose of Trazodone. It’s not easy, but it can happen. Here is some tox info.

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