Is trazodone (antidepressant) contraindicated in patients with a family history of glaucoma?

Trazodone Use in Patients with Family History of Glaucoma

Trazodone is contraindicated in patients with untreated anatomically narrow angles but not specifically contraindicated in patients with only a family history of glaucoma, though caution is warranted due to its potential to trigger angle closure attacks in predisposed individuals. 1

Mechanism of Risk

Trazodone, like many antidepressants, can cause pupillary dilation that may trigger an angle closure attack in anatomically predisposed individuals. The FDA label specifically warns that "the pupillary dilation that occurs following use of many antidepressant drugs including Trazodone Hydrochloride Tablets may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy." 1

Risk Assessment for Patients with Family History of Glaucoma

• Family history of glaucoma is a significant risk factor for developing primary open-angle glaucoma (POAG), with 9.2-fold higher odds for individuals with a first-degree relative with confirmed POAG 2, 3
• The risk increases further when multiple family members are affected, rising to fivefold higher when two or more siblings have glaucoma 2
• However, family history alone does not necessarily mean the patient has anatomically narrow angles, which is the specific risk factor for angle closure with antidepressant use

Clinical Decision Algorithm

1. For patients with family history of glaucoma but no personal diagnosis:

   • Perform gonioscopy to assess anterior chamber angle anatomy before prescribing trazodone
   • If angles are open and normal, trazodone can be prescribed with appropriate monitoring
   • If angles are narrow or suspicious, refer for ophthalmologic evaluation before initiating therapy

2. For patients with known narrow angles:

   • Avoid trazodone unless the patient has had a patent iridectomy 1
   • Consider alternative antidepressants with less risk of pupillary effects

3. For patients already on trazodone:

   • Monitor for symptoms of angle closure (eye pain, blurred vision, halos around lights, headache, nausea)
   • Case reports have documented acute myopia with mild IOP elevation in patients using trazodone 4
   • Discontinue immediately if such symptoms occur

Important Considerations

• There is at least one documented case report of acute myopia with elevated intraocular pressure in a young patient using trazodone 4
• Other antidepressants in related classes (SNRIs and SSRIs) have been associated with acute angle-closure glaucoma 5
• The mechanism is likely related to mydriasis caused by adrenergic effects, weak anticholinergic activities, or increased serotonin levels 5

Monitoring Recommendations

• Patients with family history of glaucoma who are prescribed trazodone should undergo regular comprehensive eye examinations 3
• Educate patients about symptoms of angle closure that require immediate medical attention
• Consider baseline ophthalmologic evaluation before starting therapy in high-risk patients

Remember that while family history alone is not an absolute contraindication, the presence of anatomically narrow angles is a specific contraindication for trazodone use unless the patient has had a preventive iridectomy.