Trazodone Dose Escalation from 50mg
For a patient currently on trazodone 50mg, increase the dose by 50mg every 3-4 days, bringing the next dose to 100mg daily. 1
Standard Titration Protocol
The FDA-approved dosing strategy for trazodone follows a clear escalation pattern:
- Starting dose: 150mg/day in divided doses (though many clinicians start lower at 50-100mg) 1
- Dose increases: Add 50mg every 3-4 days based on clinical response and tolerability 1
- Target therapeutic range: 150-300mg/day for full antidepressant efficacy 2, 3
- Outpatient maximum: 400mg/day in divided doses 1
- Inpatient maximum: 600mg/day in divided doses (for severely depressed patients under close monitoring) 1
Practical Dosing Approach from 50mg
Since your patient is at 50mg, the next logical step is:
- Increase to 100mg daily (can be given as single nighttime dose or divided) 2, 3
- Wait 3-4 days to assess tolerability 1
- If tolerated, increase to 150mg daily 2, 1
- Continue escalating by 50mg increments every 3-4 days until therapeutic benefit or dose-limiting side effects 2, 1
Critical Context: The 50mg Dose Problem
If this patient is taking trazodone 50mg for insomnia, you should reconsider the entire treatment plan. The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia, as 50mg showed no clinically significant benefit—reducing sleep latency by only 10.2 minutes and increasing total sleep time by only 21.8 minutes, both below clinical significance thresholds. 4, 5 Additionally, 75% of patients experienced adverse events versus 65.4% on placebo, with harms potentially outweighing benefits. 4, 5
Dosing Strategy Based on Indication
For depression treatment:
- The 50mg dose is subtherapeutic for antidepressant effect 2, 6
- Increase to 100mg, then target 150-300mg for full efficacy 2, 1, 3
- Allow 4-8 weeks at therapeutic dose before concluding treatment failure 2
For off-label insomnia use (despite guideline recommendations against it):
- The studied dose is 50mg at bedtime 5
- Higher doses (150mg+) given predominantly at bedtime may improve sleep as part of antidepressant action 3
- Consider switching to evidence-based alternatives: zolpidem 10mg, zaleplon 10mg, or ramelteon 8mg for sleep onset; eszopiclone 2-3mg, doxepin 3-6mg, or temazepam 15-30mg for sleep maintenance 5
Administration Considerations
- Timing: Can be given as single nighttime dose or divided doses; single nighttime dosing reduces daytime drowsiness initially 3, 7
- Food: Take shortly after a meal or light snack to optimize absorption 1
- Monitoring: Watch for orthostatic hypotension, especially in elderly patients 4, 2
- Drug interactions: Consider dose reduction if using strong CYP3A4 inhibitors; consider dose increase with strong CYP3A4 inducers 1
Common Pitfalls to Avoid
- Staying at subtherapeutic doses: 50mg is insufficient for depression; don't mistake sedation for therapeutic effect 2, 6
- Too rapid titration: Increase every 3-4 days, not faster, to assess tolerability 1
- Using for insomnia without considering alternatives: This is explicitly not recommended by sleep medicine guidelines 4, 5
- Abrupt discontinuation: Taper over 10-14 days when stopping to limit withdrawal symptoms 2