What is the safest maximum dose of trazodone (Trazodone hydrochloride) for a geriatric patient?

From the Guidelines

The safest maximum dose of trazodone for a geriatric patient is 200 to 400 mg per day in divided doses, as recommended in the guidelines for managing Alzheimer's disease 1. When prescribing trazodone to geriatric patients, it is essential to consider their increased sensitivity to medication effects and altered pharmacokinetics.

• Dosing should begin low, typically at 25 mg per day, and increase gradually as needed and tolerated.
• The dose can be increased in 25 mg increments every 3-7 days, with close monitoring for adverse effects, particularly during dose adjustments.
• Geriatric patients are at higher risk for side effects such as dizziness, sedation, orthostatic hypotension, and falls, so caution is advised when prescribing trazodone.
• Trazodone has a relatively long half-life in older adults, so once-daily dosing at bedtime is usually sufficient, but divided doses may be necessary to minimize side effects.
• Patients should be monitored closely for adverse effects, and renal and hepatic function should be considered when determining dosage, with further reductions potentially needed in patients with significant organ impairment 1.

From the FDA Drug Label

1. Dosage and Administration 2. 1 Dose Selection An initial dose of 150 mg/day in divided doses is suggested. ... The maximum dose for outpatients usually should not exceed 400 mg/day in divided doses.
2. 5 Geriatric Use Reported clinical literature and experience with trazodone has not identified differences in responses between elderly and younger patients. However, as experience in the elderly with trazodone hydrochloride is limited, it should be used with caution in geriatric patients

The safest maximum dose of trazodone for a geriatric patient is 400 mg/day in divided doses, however, it should be used with caution in this population due to limited experience and potential risk of adverse reactions such as hyponatremia 2.

From the Research

Trazodone Dosage for Geriatric Patients

• The safest maximum dose of trazodone for geriatric patients is not strictly defined, but several studies provide guidance on dosing and tolerability 3, 4, 5.
• A study published in 1990 suggests that trazodone is best dosed at 150 mg given predominantly at bedtime and increased as needed to 200 to 300 mg for full antidepressant efficacy 3.
• Another study from 1994 notes that maximum tolerated doses of trazodone in the elderly are 300 to 400 mg/day, although higher doses of up to 600 mg/day are tolerated by younger patients 4.
• A more recent study from 2019 recommends that the maximum outpatient dose of trazodone should not exceed 400 mg per day in divided doses, but in hospitalized patients, the dose may be increased to a maximum dose of 600 mg daily in divided doses while the patient is being actively monitored for side effects 6.
• A retrospective study from 2024 found that trazodone was effective in older persons living in long-term care facilities, with the main reasons for prescription including agitation, insomnia, depression, and anxiety 7.
• A study from 1986 investigated the comparative efficacy and tolerance of two initial starting doses of trazodone in elderly inpatients suffering from depressive illness, and found that a higher dose (150 mg total daily) was well tolerated and proved effective over the course of 6 weeks' treatment 5.

Key Considerations

• Trazodone has a mild side effect profile, with sedation being the most common side effect 3.
• The incidence of anticholinergic and cardiovascular effects is lower in elderly patients treated with trazodone compared to older tricyclic antidepressants 4.
• Trazodone is relatively safe in overdose, but undesirable effects such as orthostatic hypotension, arrhythmias, and priapism need to be closely monitored 4.
• Falls were the most frequent adverse event reported in a study of trazodone use in older persons living in long-term care facilities 7.