What can a patient taking trazodone (an antidepressant) take for anxiety?

Anxiety Treatment Options for Patients on Trazodone

For patients already taking trazodone who need treatment for anxiety, benzodiazepines are the most appropriate first-line option, particularly lorazepam, oxazepam, or temazepam.

First-Line Options for Anxiety While on Trazodone

Benzodiazepines

• Recommended agents: Lorazepam (Ativan), oxazepam (Serax), or temazepam (Restoril) 1
• Starting dosage: Varies by specific agent, use lowest effective dose
• Benefits: Rapid onset of action for acute anxiety symptoms
• Important considerations:
  • Short-acting agents with minimal drug interactions with trazodone
  • Regular use can lead to tolerance and dependence
  • Infrequent, low doses of agents with short half-lives are least problematic 1
  • Approximately 10% of patients may experience paradoxical agitation

Buspirone (BuSpar)

• Starting dosage: 5 mg twice daily
• Maximum dosage: 20 mg three times daily
• Benefits: Non-benzodiazepine option with less risk of dependence
• Limitations:
  • Only useful for mild to moderate anxiety
  • Takes 2-4 weeks to become effective 1
  • Less effective for acute anxiety symptoms

Second-Line Options

SSRIs

• Options: Sertraline, citalopram, escitalopram
• Considerations:
  • Well-tolerated but require 4-8 weeks for full effect
  • Monitor for serotonin syndrome when combined with trazodone 2
  • Sertraline has less effect on metabolism of other medications compared to other SSRIs 1

SNRIs

• Options: Duloxetine, venlafaxine
• Caution: Higher risk of serotonin syndrome when combined with trazodone 2
• Monitoring: Blood pressure should be monitored regularly with venlafaxine 1

Important Precautions

Serotonin Syndrome Risk

• Combining trazodone with other serotonergic medications (SSRIs, SNRIs) increases risk of serotonin syndrome 2
• Symptoms include agitation, hallucinations, coordination problems, fast heartbeat, tight muscles, sweating, fever, nausea, vomiting, and diarrhea
• Avoid combining trazodone with triptans, tramadol, St. John's Wort, or other serotonergic medications 2

Drug Interactions

• Trazodone may interact with:
  • Medications for mood, anxiety, or psychotic disorders
  • NSAIDs, aspirin, warfarin
  • Phenytoin
  • Diuretics 2
• Keep a comprehensive list of all medications and supplements

Off-Label Uses of Trazodone for Anxiety

While trazodone is primarily prescribed for depression, it has shown efficacy for:

• Generalized Anxiety Disorder
• Panic Disorder
• Post-Traumatic Stress Disorder 3
• Adjustment disorders with anxiety 4

However, evidence for trazodone in panic disorder is mixed, with one study showing poor efficacy compared to imipramine and alprazolam 5, while another small study suggested potential benefit 6.

Practical Recommendations

1. For acute anxiety: Short-acting benzodiazepines (lorazepam, oxazepam) are most appropriate
2. For chronic anxiety: Consider buspirone if not requiring immediate relief
3. Dosing considerations:
   • Take trazodone shortly after a meal or light snack
   • Avoid alcohol and other sedating medications while taking trazodone 2
   • Start with low doses of any added anxiety medication and titrate slowly

Monitoring and Follow-up

• Monitor for excessive sedation, dizziness, or confusion
• Evaluate for orthostatic hypotension, especially in elderly patients
• Schedule regular follow-up appointments to assess efficacy and side effects

Remember that combining multiple CNS depressants can increase risk of sedation, falls, and cognitive impairment, particularly in elderly patients.