What is the recommended dose of Trazodone (triazolopyridine antidepressant) for adults with depression or insomnia?

Trazodone Dosing Recommendations for Depression and Insomnia

For depression, trazodone should be initiated at 150 mg/day in divided doses, while for insomnia, low-dose trazodone (50-100 mg) at bedtime is recommended, though the American Academy of Sleep Medicine does not recommend trazodone for primary insomnia due to limited efficacy. 1, 2

Dosing for Depression

Initial Dosing

• Start with 150 mg/day in divided doses 1
• Consider administering a major portion of the daily dose at bedtime to minimize daytime drowsiness 1
• Trazodone should be taken shortly after a meal or light snack 1

Dose Titration

• Increase dose by 50 mg/day every 3-4 days based on clinical response and tolerability 1
• Maximum outpatient dose: 400 mg/day in divided doses 1
• Maximum inpatient dose (for severely depressed patients): 600 mg/day in divided doses 1
• For elderly patients: Maximum tolerated doses are typically 300-400 mg/day 3

Maintenance

• Once adequate response is achieved, dosage may be gradually reduced 1
• For optimal antidepressant efficacy, a dose of 200-300 mg is typically needed 4

Dosing for Insomnia

Important Considerations

• The AASM explicitly recommends against using trazodone for primary insomnia due to limited efficacy with no improvement in sleep quality compared to placebo 2
• Despite this recommendation, trazodone is commonly prescribed off-label for insomnia 5

Dosing for Secondary Insomnia

• For insomnia secondary to depression or other conditions: 50-100 mg at bedtime 5
• Lower doses (25-50 mg) may be effective for sleep in some patients 5
• For elderly patients with insomnia: Consider starting at 25 mg and titrating as needed 6

Special Populations

Elderly Patients

• Start with lower doses (25-50 mg) 6
• Titrate more slowly than in younger adults 3
• Maximum doses typically 300-400 mg/day, lower than for younger adults 3
• Elderly patients may respond better to higher initial therapeutic doses (150 mg daily) but should be monitored closely for side effects 6

Drug Interactions

• Consider reducing trazodone dose when coadministered with strong CYP3A4 inhibitors 1
• Consider increasing trazodone dose when coadministered with strong CYP3A4 inducers 1
• Allow at least 14 days between discontinuing MAOIs and starting trazodone, and vice versa 1

Side Effects and Monitoring

Common Side Effects

• Drowsiness (most common) 4, 3
• Orthostatic hypotension 3
• Dizziness 7
• Daytime sedation 7

Serious but Rare Side Effects

• Priapism (reported in 5 out of 74 patients in one study) 7
• Cardiac arrhythmias 3
• More vivid nightmares 7
• Severe agitation 7

Discontinuation

• Gradually reduce the dosage rather than stopping abruptly 1
• Monitor for discontinuation symptoms 1

Clinical Pearls

• Single nighttime dosing may be more productive for sleep with less daytime drowsiness compared to multiple daily dosing 4
• Trazodone has a favorable safety profile in overdose compared to tricyclic antidepressants 3, 8
• Trazodone has fewer anticholinergic side effects compared to older tricyclic antidepressants 3, 8
• In a retrospective study of PTSD patients, the mean effective dose for reducing nightmares was 212 mg/day 7