What is the recommended protocol for discontinuing Trazodone (triazolopyridine antidepressant)?

Trazodone Discontinuation Protocol

Trazodone should be gradually tapered over 10 to 14 days to minimize withdrawal symptoms, rather than being abruptly discontinued. 1

Recommended Tapering Approach

The FDA-approved labeling for Trazodone specifically states that the medication should be gradually reduced rather than stopped abruptly whenever possible to prevent adverse reactions upon discontinuation 2. This approach is supported by clinical evidence showing that abrupt discontinuation can lead to withdrawal symptoms.

Tapering Schedule:

1. Initial reduction: Decrease the dose by approximately 25% of the original dose
2. Subsequent reductions: Continue reducing by 25% every 3-4 days
3. Total duration: Complete the taper over 10-14 days 1

Monitoring During Taper:

• Watch for emergence of withdrawal symptoms including:
  • Somatic symptoms: dizziness, nausea, fatigue, sensory disturbances
  • Psychological symptoms: anxiety, irritability, agitation 3
• If withdrawal symptoms emerge, slow the taper rate by returning to the previous dose and then reducing more gradually

Special Considerations

Withdrawal Risk Factors

• Patients on higher doses (>200 mg/day)
• Longer duration of treatment
• History of withdrawal symptoms from other medications
• Concurrent discontinuation of other psychotropic medications

Managing Withdrawal Symptoms

• For mild symptoms: Reassure the patient that symptoms are usually transient 3
• For severe symptoms: Return to the previous dose and slow the rate of taper 3
• Case reports suggest that trazodone withdrawal can occur despite gradual discontinuation, indicating some patients may need an even slower taper 4

Clinical Pitfalls to Avoid

1. Misdiagnosing withdrawal as relapse: Withdrawal symptoms can be mistaken for recurrence of depression or anxiety, potentially leading to unnecessary continuation of medication 3

2. Tapering too quickly: Even with gradual discontinuation, some patients may develop withdrawal symptoms, suggesting that trazodone should be tapered very slowly in sensitive individuals 4

3. Overlooking drug interactions: If the patient is on medications that affect CYP3A4 (which metabolizes trazodone), adjustment of the tapering schedule may be needed 2

4. Ignoring comorbidities: For patients with comorbid conditions like insomnia, additional supportive measures may be needed during discontinuation

Evidence Quality Assessment

The recommendation for gradual tapering of trazodone over 10-14 days comes from established guidelines for antidepressant discontinuation 1. The FDA labeling also explicitly recommends gradual reduction 2. While specific research on trazodone discontinuation is limited, case reports indicate that withdrawal symptoms can occur even with gradual discontinuation, suggesting caution is warranted 4.

The American Academy of Sleep Medicine does not recommend trazodone for treating insomnia 1, and the VA/DoD guidelines advise against its use for chronic insomnia disorder 1, which may influence decisions about discontinuation in patients taking it for sleep.

By following this structured tapering approach, clinicians can minimize the risk of withdrawal symptoms while safely discontinuing trazodone.