From the Guidelines
Trazodone can cause hypotension, particularly orthostatic hypotension, as a side effect due to its alpha-1 adrenergic blocking properties. This effect is more pronounced when starting the medication, increasing the dose, or in patients who are elderly, have cardiovascular conditions, or are taking other blood pressure-lowering medications. According to the most recent evidence available, specifically from the study on polypharmacy management in older patients 1, it is crucial to be cautious with medications that can cause hypotension, as they can lead to falls and injuries. The study highlights the importance of managing polypharmacy in older adults and being aware of the potential risks associated with certain medications, including antihypertensive drugs and other classes that can result in blood pressure drops.
Some key points to consider when prescribing trazodone include:
- Starting with a low dose (typically 25-50mg) and gradually increasing as tolerated
- Taking the medication at bedtime to minimize the risk of orthostatic hypotension
- Changing positions slowly, especially when getting up from lying down
- Advising patients to stay well-hydrated and monitor for symptoms like dizziness, especially during the initial treatment period or after dose increases
- Being cautious in patients with a history of cardiovascular disease, as they may be more susceptible to the hypotensive effects of trazodone, as noted in the context of managing polypharmacy in older adults 1.
It's also important to note that while the provided evidence does not directly discuss trazodone, the principles of managing medications that can cause hypotension, as outlined in the study on polypharmacy management in older patients 1, can be applied to the use of trazodone, emphasizing the need for careful consideration and monitoring in vulnerable populations.
From the FDA Drug Label
Hypotension, including orthostatic hypotension and syncope has been reported in patients receiving trazodone hydrochloride. Concomitant use with an antihypertensive may require a reduction in the dose of the antihypertensive drug. Trazodone antagonizes alpha 1-adrenergic receptors, a property which may be associated with postural hypotension.
Trazodone can cause hypotension, including orthostatic hypotension and syncope, as reported in patients receiving the drug. Its mechanism of action, which includes antagonism of alpha 1-adrenergic receptors, may contribute to this effect 2, 2.
From the Research
Trazodone and Hypotension
- Trazodone is a medication that can cause hypotension, as seen in a case report of intentional ingestion of an estimated 2500 mg of trazodone leading to persistent hypotension 3.
- The mechanism of action of trazodone includes blockade of alpha-1-adrenergic receptors, which can contribute to its hypotensive effects 3.
- Orthostatic hypotension is a common physical finding among older adults and is associated with significant morbidity and mortality, with medications such as trazodone being a potential cause 4, 5.
Risk of Orthostatic Hypotension
- Trazodone use has been associated with a greater orthostatic blood pressure drop and an increased risk of syncope and falls in older hypertensive outpatients 6.
- The prevalence of orthostatic hypotension is high in older adults, and the use of multiple potentially causative medications, including trazodone, can increase this risk 5.
- Receiving trazodone has been associated with a high prevalence of orthostatic hypotension, with a prevalence of 58% in one study 5.
Clinical Implications
- Clinicians should be aware of the potential for trazodone to cause hypotension and orthostatic hypotension, particularly in older adults 3, 4.
- A medication review is advisable in all patients presenting with orthostatic hypotension, particularly at advanced age, to optimize medical treatment and minimize the risk of iatrogenic orthostatic hypotension 4.