Contraindications for Trazodone
Trazodone is absolutely contraindicated in patients taking, or within 14 days of stopping, monoamine oxidase inhibitors (MAOIs) due to increased risk of serotonin syndrome. 1
Primary Contraindications
Concurrent use with MAOIs: This includes prescription MAOIs such as phenelzine, tranylcypromine, isocarboxazid, and selegiline, as well as antibiotics with MAOI properties like linezolid and intravenous methylene blue 1
Pregnancy or attempting to conceive: While not specifically contraindicated for trazodone, all weight loss medications (which sometimes include trazodone for off-label use) are contraindicated in women who are pregnant or actively trying to conceive 2
Cautions and Relative Contraindications
Cardiac Conditions
- History of cardiac arrhythmias
- Congenital QT interval prolongation
- Symptomatic bradycardia
- Initial recovery phase of myocardial infarction
- Preexisting cardiac disease (may be arrhythmogenic) 1
Electrolyte Abnormalities
- Hypokalemia
- Hypomagnesemia (increase risk of torsade de pointes) 1
Drug Interactions
- Strong CYP3A4 inhibitors (e.g., itraconazole, clarithromycin, voriconazole)
- Medications known to prolong QT interval:
- Class 1A antiarrhythmics (e.g., quinidine, procainamide)
- Class 3 antiarrhythmics (e.g., amiodarone, sotalol)
- Certain antipsychotics (e.g., ziprasidone, chlorpromazine, thioridazine)
- Certain antibiotics (e.g., gatifloxacin) 1
Other Precautions
- Pediatric and young adult patients (increased risk of suicidal thoughts and behaviors)
- Patients with bipolar disorder (risk of inducing mania)
- Patients with seizure disorders
- Patients with severe hepatic or renal impairment 1
Special Considerations
Erectile Dysfunction
- The American Urological Association specifically recommends against using trazodone for erectile dysfunction treatment 2
Insomnia
- The VA/DoD Clinical Practice Guidelines advise against using trazodone for chronic insomnia disorder due to limited efficacy evidence and potential adverse effects 2
Monitoring Requirements
- Patients on trazodone should be monitored for:
Adverse Effects to Consider
- Priapism (rare but serious side effect requiring immediate medical attention)
- Serotonin syndrome (when combined with other serotonergic agents)
- Cardiac arrhythmias including torsade de pointes
- Orthostatic hypotension and syncope 4, 1
When prescribing trazodone, carefully weigh the benefits against these contraindications and potential risks, particularly in patients with cardiac conditions or those taking medications that might interact with trazodone.