Safety of trazodone as a sleep agent for inpatients

Trazodone in the Management of Major Depression Among Elderly Patients with Dementia: A Narrative Review and Clinical Insights

Objective

Major depressive disorder (MDD) often co-occurs with dementia and other neurological disorders, and treatment with antidepressants can improve symptoms, quality of life, and survival in these patients. This narrative review provides an expert opinion about the role and effectiveness of trazodone in the treatment of older adults with MDD and cognitive impairment due to physical illnesses, such as dementia.

Results

Because of its mechanism of action, trazodone can treat several depression symptoms often seen in people with dementia, including insomnia, agitation, anxiety, cognitive impairment, and irritability.

Conclusion

Trazodone may be beneficial for patients with dementia or other neurological disorders comorbid with MDD, especially when the clinical picture of depression includes or is comorbid to symptoms of insomnia, irritability, inner tension, anxiety, or psychomotor agitation.

Pharmacogenetics of trazodone in healthy volunteers: association with pharmacokinetics, pharmacodynamics and safety

Aim: The aim was to evaluate the effect of polymorphisms in metabolizing enzymes and transporters on the pharmacokinetics, pharmacodynamics and adverse effects of trazodone in healthy volunteers. Materials & methods: 36 healthy volunteers receiving a single 100-mg oral dose of trazodone were genotyped for 11 variants in CYP3A4, CYP3A5, CYP2D6 and ABCB1 by real-time PCR. Plasma concentrations were measured using liquid chromatography-tandem mass spectrometry method. Results & conclusion: Sex affected the pharmacokinetics of trazodone with higher clearance in women. Polymorphisms in ABCB1, but not in CYP3A or CYP2D6, influenced trazodone pharmacokinetics. Trazodone decreased blood pressure and prolonged the corrected QT interval interval. CYP2D6 and ABCB1 polymorphisms were associated with the incidence of dizziness and prolonged corrected QT interval, respectively. Subjects with adverse drug reactions had lower concentrations of trazodone suggesting its metabolite (m-chlorophenylpiperazine) could be responsible for these effects.

Trazodone Addition to Paroxetine and Mirtazapine in a Patient with Treatment-Resistant Depression: The Pros and Cons of Combining Three Antidepressants

Dual antidepressant combination for treatment-resistant depression is a strategy well supported by literature and accepted in clinical practice. Rather, the usefulness of the combination of more than two antidepressants is controversial. This may be related to the possibility of higher side-effect burden and to doubts about its pharmacological effectiveness and therapeutic advantage compared to other standard treatment options. We report a relapse of moderate-to-severe depressive symptoms with insomnia that successfully remitted after the addition of trazodone to a dual combination of paroxetine and mirtazapine (in standard effective doses) in a patient with treatment-resistant depression. We also review the literature and discuss the utility of triple antidepressant combination in treatment-resistant depression. This clinical case highlights the utility of combining trazodone as a third antidepressant for the relapse of depressive symptoms after the failure of a dual antidepressant combination. Trazodone may be advantageous in patients presenting recurrence of moderate-to-severe depressive symptoms that include sleep problems and/or insomnia and may be particularly useful when benzodiazepines are not recommended. Although its use may be controversial and associated with higher risk of side-effects, more investigation is needed to determine the efficacy and safety for triple antidepressant combinations as reliable strategies for treatment-resistant depression in clinical practice.

Pharmacotherapy Treatment Options for Insomnia: A Primer for Clinicians

Insomnia is a prevalent disorder with deleterious effects such as decreased quality of life, and a predisposition to a number of psychiatric disorders. Fortunately, numerous approved hypnotic treatments are available. This report reviews the state of the art of pharmacotherapy with a reference to cognitive behavioral therapy for insomnia (CBT-I) as well. It provides the clinician with a guide to all the Food and Drug Administration (FDA) approved hypnotics (benzodiazepines, nonbenzodiazepines, ramelteon, low dose sinequan, and suvorexant) including potential side effects. Frequently, chronic insomnia lasts longer than 2 years. Cognizant of this and as a result of longer-term studies, the FDA has approved all hypnotics since 2005 without restricting the duration of use. Our manuscript also reviews off-label hypnotics (sedating antidepressants, atypical antipsychotics, anticonvulsants and antihistamines) which in reality, are more often prescribed than approved hypnotics. The choice of which hypnotic to choose is discussed partially being based on which segment of sleep is disturbed and whether co-morbid illnesses exist. Lastly, we discuss recent label changes required by the FDA inserting a warning about “sleep-related complex behaviors”, e.g., sleep-driving for all hypnotics. In addition, we discuss FDA mandated dose reductions for most zolpidem preparations in women due to high zolpidem levels in the morning hours potentially causing daytime carry-over effects.

Rediscovering trazodone for the treatment of major depressive disorder

Trazodone is a triazolopyridine derivative that belongs to the class of serotonin receptor antagonists and reuptake inhibitors (SARIs). The drug is approved and marketed in several countries worldwide for the treatment of major depressive disorder (MDD) in adult patients. In clinical studies, trazodone has demonstrated comparable antidepressant activity to other drug classes, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline (norepinephrine) reuptake inhibitors (SNRIs). Moreover, the SARI action of trazodone may overcome the tolerability issues that are often associated with second-generation antidepressants such as SSRIs (i.e. insomnia, anxiety and sexual dysfunction). Recent focus has been placed on the development of a new prolonged-release once-a-day formulation of trazodone (TzCOAD), which may provide improved tolerability over the conventional immediate-release formulation of trazodone. Clinical studies have led to the recent approval in the USA of TzCOAD (as Oleptro™; Angelini Labopharm LLC, Princeton, NJ, USA), which may see resurgence of interest in the drug for the management of patients with MDD. Although trazodone is approved for the treatment of depression, evidence supports the use of low-dose trazodone as an off-label hypnotic for the treatment of sleep disorders in patients with MDD. The most common adverse effects reported with trazodone are drowsiness (somnolence/sedation), headache, dizziness and dry mouth. Other events reported, albeit with low incidence, include orthostatic hypotension (particularly in elderly patients or those with heart disease), minimal anticholinergic activity, corrected QT interval prolongation and torsade de pointes, cardiac arrhythmias, and rare occurrences of priapism and suicidal ideation. Overall, trazodone is an effective and well tolerated antidepressant (SARI) with an important role in the current treatment of MDD both as monotherapy and as part of a combination strategy. Trazodone is effective in controlling a wide range of symptoms of depression, while avoiding the negative effects on sleep seen with SSRI antidepressants. The recently approved prolonged-release formulation should provide further optimization of this antidepressant and may be useful for enabling an appropriate therapeutic dose to be administered with improved patient compliance.

Medical complications of psychiatric treatment

Psychiatric medications are frequently an essential component of care for critically ill patients. Their use may lead to medical complications, however, as a result of (1) direct toxicity from psychotropic medications, (2) drug-drug interactions, or (3) intoxication or withdrawal states. These complications may be a nuisance (eg, dry mouth and nausea) or serious and life-threatening (eg, neuroleptic malignant syndrome and cardiac arrhythmias). This article addresses the most important medical complications (organized by organ systems) of psychiatric treatment.

Does trazodone have a role in palliating symptoms?

INTRODUCTION

Trazodone is a unique antidepressant, which blocks the postsynaptic serotonin (5-HT) receptors, 5-HT(2A) and 5-HT(2C), and weakly inhibits presynaptic 5-HT transporters.

DISCUSSION

Trazodone is well-absorbed by the mouth and is metabolized by three cytochromes: CYP1A2, CYP2D6, and CYP3A4. Clinical benefits include reduced insomnia in those depressed and/or on antidepressants. Pain may be relieved by mechanisms similar to venlafaxine. Delirium unresponsive to neuroleptics has been reported to respond to trazodone. Drug interactions are a risk due to cytochrome metabolism.

CONCLUSION

Trazodone has a unique pharmacology, which may be an advantage in palliating symptoms; however, little evidence is available through cohort or randomized trials to give guidance to its use.

Counseling Patients About Sexual Issues

In recent years, the frequency of antidepressant drug-induced sexual dysfunction has increased, along with the use of new drugs for the treatment of erectile dysfunction and premature ejaculation. It has thus become common for pharmacists to counsel patients about sexual issues. Pharmacists must not only become knowledgeable about these drugs and their indications, but they must also become skilled and comfortable with counseling patients and answering questions from both patients and other health care providers. In addition to therapeutic information, pharmacists' discussions with patients should take into account factors that contribute to treatment nonadherence and treatment failure. Patient education is essential to ensure optimum outcomes for pharmacologic treatments for both erectile dysfunction and premature ejaculation. Improper use of phosphodiesterase-5 inhibitor drugs for erectile dysfunction accounts for most nonresponsiveness and discontinuation of treatment. Drug-induced sexual dysfunction is common with some psychotropic drugs. Up to 50% of men will experience delayed ejaculation, and at least 30% of men and women will experience anorgasmia from antidepressant drugs with serotonin agonist activity. Trazodone is the drug most commonly associated with the rare but very serious adverse effect of priapism. The pharmacist who is both competent and comfortable discussing sexual function and dysfunction with patients can make positive contributions to their therapeutic outcomes as well as their quality of life.