What is the next dose increase for a patient on trazodone (antidepressant) 50 mg?

Trazodone Dose Escalation from 50 mg

For a patient currently on trazodone 50 mg, increase to 100 mg daily, with subsequent increases of 50 mg every 3-4 days as tolerated, up to 150-200 mg for insomnia or 150-400 mg for depression. 1

Initial Dose Increase

• Increase from 50 mg to 100 mg as the next step, following the FDA-approved titration schedule of 50 mg increments every 3-4 days 1
• The starting therapeutic dose for depression is 150 mg/day in divided doses, so 100 mg represents an intermediate step toward this target 1
• For insomnia (off-label use), doses of 50-100 mg are often sufficient, as low doses primarily block histamine H1 and serotonin 5-HT2A receptors responsible for sedation 2

Dosing Strategy Based on Indication

For Depression (Primary FDA-Approved Indication)

• Continue titrating by 50 mg every 3-4 days until reaching 150 mg/day minimum 1
• Outpatient maximum: 400 mg/day in divided doses 1
• Inpatient maximum: 600 mg/day in divided doses for more severely depressed patients 1
• Full antidepressant efficacy typically requires 200-300 mg daily 3

For Insomnia or Agitation (Off-Label)

• Target dose: 25-200 mg at bedtime 4
• Lower doses (50-100 mg) are usually adequate for sleep improvement without requiring higher antidepressant doses 2
• Maximum for behavioral management in dementia: 200-400 mg/day 4

Administration Recommendations

• Give the dose predominantly or entirely at bedtime to maximize sedative benefits and minimize daytime drowsiness 1, 3
• Single nighttime dosing shows equal antidepressant efficacy to divided dosing but produces better sleep with less daytime sedation, especially during treatment initiation 3, 5
• Administer shortly after a meal or light snack to optimize absorption 1

Monitoring During Titration

• Watch for dose-limiting drowsiness, which may require slowing titration or giving a larger proportion of the dose at bedtime 1
• Monitor for orthostatic hypotension, particularly in elderly patients 4, 6
• Assess for priapism risk in male patients (rare but serious) 6
• Anticholinergic effects are notably lower than with tricyclic antidepressants 6

Special Population Adjustments

• Elderly patients: Maximum tolerated doses typically 300-400 mg/day (versus 600 mg/day in younger adults) 6
• CYP3A4 inhibitor use (ketoconazole, erythromycin, clarithromycin): Consider slower titration and lower maximum doses due to increased trazodone levels 1
• CYP3A4 inducer use: May require higher doses to achieve therapeutic effect 1

Common Pitfall to Avoid

• Do not increase too rapidly in elderly or medically compromised patients, as orthostatic hypotension can occur even though cardiovascular effects are generally milder than with tricyclic antidepressants 4, 6
• Avoid abrupt discontinuation; taper gradually when stopping to prevent withdrawal symptoms 1