Trazodone Therapy

Indications and Dosage

• The American Academy of Sleep Medicine does not recommend trazodone as first-line therapy for chronic insomnia, due to relatively weak evidence for efficacy when used alone 1
• Trazodone is used at lower doses (25-100 mg) for insomnia, compared to depression 2
• Initial dosage for agitation in dementia and other psychiatric conditions is 25 mg per day, with a maximum of 200-400 mg per day in divided doses, as an alternative to antipsychotics for control of agitation 3
• Trazodone has shown efficacy in reducing nightmare frequency from 3.3 to 1.3 nights/week at a mean dose of 212 mg/day for nightmares associated with PTSD 4, 5

Side Effects and Precautions

• Use of trazodone requires caution in patients with premature ventricular contractions, due to potential cardiovascular effects 3
• Trazodone has minimal anticholinergic activity compared to tricyclic antidepressants, making it potentially better tolerated in elderly patients 6

Drug Interaction Concerns with Trazodone, Fluvoxamine, and Buspirone

Key Drug Interaction Considerations

• Monitor for agitation, confusion, tremor, tachycardia, hypertension, hyperthermia, hyperreflexia, and diaphoresis when combining trazodone with fluvoxamine, as recommended by the National Comprehensive Cancer Network 7

Practical Dosing Recommendations

• The National Comprehensive Cancer Network recommends monitoring for excessive morning sedation or "hangover effect" at follow-up when using trazodone at 25 mg PRN, due to its extensive hepatic metabolism via CYP3A4, which is inhibited by fluvoxamine 7