What is the recommended dosage and administration for a trazodone (antidepressant) prescription?

Trazodone Prescription Dosing and Administration

For Major Depression (Primary FDA-Approved Indication)

Start trazodone at 150 mg/day in divided doses, increase by 50 mg/day every 3-4 days as tolerated, with outpatient maximum of 400 mg/day and inpatient maximum of 600 mg/day. 1

Initial Dosing Strategy

• Starting dose: 150 mg/day in divided doses 1
• Administration timing: Take shortly after a meal or light snack to optimize absorption 1
• Tablet administration: Can be swallowed whole or broken along score line for half-tablet dosing 1

Titration Protocol

• Increase by 50 mg/day every 3-4 days based on clinical response and tolerability 1
• If drowsiness occurs, administer the major portion of daily dose at bedtime or reduce total dosage 1
• Outpatient maximum: 400 mg/day in divided doses 1
• Inpatient maximum: 600 mg/day in divided doses for more severely depressed patients 1

Alternative Single-Dose Regimen

• For patients preferring once-daily dosing: 150 mg given predominantly at bedtime, increased to 200-300 mg as needed for full antidepressant efficacy 2
• Single nighttime dosing shows equal efficacy to multiple daily dosing, with better sleep promotion and less daytime drowsiness at treatment onset 2
• This approach is supported by trazodone's 3-9 hour half-life 2

For Off-Label Use in Insomnia

The American Academy of Sleep Medicine recommends against using trazodone for sleep onset or sleep maintenance insomnia in adults based on insufficient evidence of benefit. 3

If Prescribed Despite Guideline Recommendation

• Lower doses of 25-50 mg are typically employed for insomnia 4
• Initial dose: 25 mg per day 4
• Note: This use lacks strong evidence support and carries the same adverse effect risks 3

For Agitation/Behavioral Symptoms (e.g., Alzheimer's Disease)

• Initial dose: 25 mg at bedtime 3
• Maximum dose: 200-400 mg/day in divided doses 3, 4
• Useful for agitated depression and insomnia in geriatric patients 3

Critical Prescribing Considerations

Pre-Treatment Screening

• Screen for bipolar disorder (personal or family history of mania/hypomania) before initiating treatment 1

Drug Interactions Requiring Dose Adjustment

• With strong CYP3A4 inhibitors: Consider reducing trazodone dose based on tolerability 1
• With strong CYP3A4 inducers: Consider increasing trazodone dose based on therapeutic response 1

MAOI Interactions

• At least 14 days must elapse between discontinuing an MAOI and starting trazodone 1
• At least 14 days must elapse after stopping trazodone before starting an MAOI 1

Duration and Discontinuation

Treatment Duration

• Minimum trial period: 4-8 weeks required to assess full therapeutic benefit 3, 4
• Dosage adjustments: Increase using increments of initial dose every 5-7 days until therapeutic benefits or significant side effects appear 3, 4
• Reassessment: After 9 months, consider dosage reduction to reassess need for continued medication 3, 4

Discontinuation Protocol

• Gradually reduce dosage rather than stopping abruptly to minimize withdrawal symptoms 1
• Taper over 10-14 days to limit withdrawal symptoms 3

Special Populations

Geriatric Patients

• Maximum tolerated doses typically 300-400 mg/day (compared to 600 mg/day in younger patients) 5
• Geriatric patients respond similarly to single nighttime dosing regimens 2
• Use with caution in patients with premature ventricular contractions 4
• Enhanced drowsiness may pose fall risk in elderly patients 6

Common Pitfalls to Avoid

• Avoid starting at full therapeutic doses: Begin at 150 mg/day and titrate gradually to minimize drowsiness 1
• Don't prescribe for insomnia as first-line: Guidelines recommend against this use 3
• Don't overlook cardiac monitoring: Despite lower cardiovascular effects than tricyclics, orthostatic hypotension and arrhythmias require monitoring 5
• Don't forget food: Administration with food is important for optimal absorption 1
• Don't abruptly discontinue: Always taper to avoid withdrawal symptoms 1