The following Structured Product Label (SPL) was submitted to the FDA by Asclemed Usa, Inc. for the product Trazodone Hydrochloride (NDC 76420-648). This document serves as the official prescribing information, containing essential scientific data and clinical materials required for healthcare providers and patients.
This specific version of the label includes detailed information regarding warning: suicidal thoughts and behaviors, other, 2.1 dose selection, 2.2 improtant administration instructions, 2.3 screen for bipolar disorder prior to starting trazodone, 2.4 switchning to or from monoamine oxidase inhibitor antidepressant, 2.5 dosage recommendations for concomitant use with strong cyp3a4 inhibitors or inducers, 2.6 discontinuation of treatment with trazodone, and other regulatory disclosures. Use the navigation below to review specific sections of the FDA submission.
Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors [see Warnings and Precautions ( 5.1)] . Trazodone is not approved for use in pediatric patients [see Use in Specific Populations ( 8.4)] .
Trazodone hydrochloride tablets are indicated for the treatment of major depressive disorder (MDD) in adults.
Trazodone hydrochloride tablets, USP are available in the following strengths:
Trazodone hydrochloride tablets USP, 50 mg are white to off-white, round-shape, biconvex beveled tablets, bisect on one side and plain on other side. The bisected side of tablet is debossed with '8' on upper side of bisect and '05' on lower side of bisect.
Trazodone hydrochloride tablets USP, 100 mg are white to off-white, round-shape, biconvex beveled tablets, bisect on one side and plain on other side. The bisected side of tablet is debossed with '8' on upper side of bisect and '06' on lower side of bisect.
Trazodone hydrochloride tablets USP, 150 mg are white to off-white, oval-shape, flat faced beveled tablets having one full bisect and two trisect notches on one side and two trisects on other side. The full bisected side of tablet is debossed with '8' on one side of bisect and '07' on other bisect segments.
Trazodone hydrochloride tablets USP, 300 mg are white to off-white, oval-shape, flat faced beveled tablets having one full bisect and two trisect notches on one side and two trisects on other side. The full bisected side of tablet is debossed with '8' on one side of bisect and '08' on other bisect segment.
Trazodone hydrochloride tablets are contraindicated in:
The following serious adverse reactions are described elsewhere in the labeling:
MAOIs
MAOIs should not be used within 14 days of trazodone [see Warnings and Precautions ( 5.8)].
Central Nervous System (CNS) Depressants
Trazodone may enhance the response to alcohol, barbiturates, and other CNS depressants.
Cytochrome P450 3A4 Inhibitors
In vitrodrug metabolism studies suggest that there is a potential for drug interactions when trazodone is given with cytochrome P450 3A4 (CYP3A4) inhibitors. The effect of short-term administration of ritonavir (200 mg twice daily, 4 doses) on the pharmacokinetics of a single dose of trazodone (50 mg) has been studied in 10 healthy subjects. The C maxof trazodone increased by 34%, the AUC increased 2.4 fold, the half-life increased by 2.2 fold, and the clearance decreased by 52%. Adverse effects including nausea, hypotension, and syncope were observed when ritonavir and trazodone were coadministered. It is likely that ketoconazole, indinavir, and other CYP3A4 inhibitors such as itraconazole may lead to substantial increases in trazodone plasma concentrations with the potential for adverse effects. If trazodone is used with a potent CYP3A4 inhibitor, the risk of cardiac arrhythmia may be increased [see Warnings and Precautions ( 5.4)] and a lower dose of trazodone should be considered.
Cytochrome P450 Inducers (e.g., Carbamazepine)
Carbamazepine induces CYP3A4. Following coadministration of carbamazepine 400 mg per day with trazodone 100 mg to 300 mg daily, carbamazepine reduced plasma concentrations of trazodone and m-chlorophenlypiperazine (an active metabolite) by 76% and 60% respectively, compared to pre-carbamazepine values. Patients should be closely monitored to see if there is a need for an increased dose of trazodone when taking both drugs.
Digoxin and Phenytoin
Increased serum digoxin or phenytoin levels have been reported in patients receiving trazodone concurrently with either of these drugs. Monitor serum levels and adjust dosages as needed.
Serotonergic Drugs
Based on the mechanism of action of trazodone and the potential for serotonin syndrome, caution is advised when trazodone is coadministered with other drugs that may affect the neurotransmitter systems [ see Warnings and Precautions ( 5.2) ].
NSAIDs, Aspirin, or Other Drugs Affecting Coagulation or Bleeding
Due to a possible association between serotonin modulating drugs and gastrointestinal bleeding, patients should be monitored for and cautioned about the potential risk of bleeding associated with the concomitant use of trazodone and NSAIDs, aspirin, or other drugs that affect coagulation or bleeding [s ee Warnings and Precautions ( 5.7) ].
Warfarin
There have been reports of altered (either increased or decreased) prothrombin times in taking both warfarin and trazodone.
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An initial dose of 150 mg/day in divided doses is suggested. The dosage should be initiated at a low-dose and increased gradually, noting the clinical response and any evidence of intolerance. Occurrence of drowsiness may require the administration of a major portion of the daily dose at bedtime or a reduction of dosage.
The dose may be increased by 50 mg/day every 3 to 4 days. The maximum dose for outpatients usually should not exceed 400 mg/day in divided doses. Inpatients (i.e., more severely depressed patients) may be given up to but not in excess of 600 mg/day in divided doses.
Once an adequate response has been achieved, dosage may be gradually reduced, with subsequent adjustment depending on therapeutic response.
Trazodone hydrochloride tablets can be swallowed whole or administered as a half tablet by breaking the tablet along the score line.
Trazodone hydrochloride tablets should be taken shortly after a meal or light snack.
Prior to initiating treatment with trazodone hydrochloride tablets or another antidepressant, screen patients for a personal or family history of bipolar disorder, mania, or hypomania [see Warnings and Precautions ( 5.7)].
At least 14 days must elapse between discontinuation of a monoamine oxidase inhibitor (MAOI) antidepressant and initiation of trazodone hydrochloride tablets. In addition, at least 14 days must elapse after stopping trazodone hydrochloride tablets before starting an MAOI antidepressant [see Contraindications ( 4), Warnings and Precautions ( 5.2)].
Coadministration with Strong CYP3A4 Inhibitors
Consider reducing trazodone dose based on tolerability when trazodone is coadministered with a strong CYP3A4 inhibitor [see Drug Interactions ( 7.1)].
Coadministration with Strong CYP3A4 Inducers
Consider increasing trazodone dose based on therapeutic response when trazodone is coadministered with a strong CYP3A4 inducer [see Drug Interactions ( 7.1)].
Adverse reactions may occur upon discontinuation of trazodone [See Warnings and Precautions ( 5.8)]. Gradually reduce the dosage rather than stopping trazodone abruptly whenever possible.
In pooled analyses of placebo-controlled trials of antidepressant drugs (SSRIs and other antidepressant classes) that included approximately 77,000 adult patients and over 4,400 pediatric patients, the incidence of suicidal thoughts and behaviors in pediatric and young adult patients was greater in antidepressant-treated patients than in placebo-treated patients. The drug-placebo differences in the number of cases of suicidal thoughts and behaviors per 1,000 patients treated are provided in Table 1.
No suicides occurred in any of the pediatric studies. There were suicides in the adult studies, but the number was not sufficient to reach any conclusion about antidepressant drug effect on suicide.
| Age Range (years) | Drug-Placebo Difference in Number of Patients of Suicidal Thoughts or Behaviors per 1,000 Patients Treated |
| Increases Compared to Placebo | |
| < 18
| 14 additional patients
|
| 18 to 24
| 5 additional patients
|
| Decreases Compared to Placebo | |
| 25 to 64
| 1 fewer patient
|
| ≥ 65
| 6 fewer patients
|
It is unknown whether the risk of suicidal thoughts and behaviors in pediatric and young adult patients extends to longer-term use, i.e., beyond four months. However, there is substantial evidence from placebo-controlled maintenance trials in adults with MDD that antidepressants delay the recurrence of depression.
Monitor all antidepressant-treated patients for clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy and at times of dosage changes. Counsel family members or caregivers of patients to monitor for changes in behavior and to alert the healthcare provider. Consider changing the therapeutic regimen, including possibly discontinuing trazodone, in patients whose depression is persistently worse, or who are experiencing emergent suicidal thoughts or behaviors.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) and SSRIs, including trazodone, can precipitate serotonin syndrome, a potentially life-threatening condition. The risk is increased with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and St. John's Wort) and with drugs that impair metabolism of serotonin, i.e., MAOIs [see Contraindications( 4), Drug Interactions ( 7.1)] . Serotonin syndrome can also occur when these drugs are used alone.
Serotonin syndrome signs and symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea).
The concomitant use of trazodone with MAOIs is contraindicated. In addition, do not initiate trazodone in a patient being treated with MAOIs such as linezolid or intravenous methylene blue. No reports involved the administration of methylene blue by other routes (such as oral tablets or local tissue injection). If it is necessary to initiate treatment with an MAOI such as linezolid or intravenous methylene blue in a patient taking trazodone, discontinue trazodone before initiating treatment with the MAOI [see Contraindications ( 4), Drug Interactions ( 7.1)].
Monitor all patients taking trazodone for the emergence of serotonin syndrome. Discontinue treatment with trazodone and any concomitant serotonergic agents immediately if the above symptoms occur, and initiate supportive symptomatic treatment. If concomitant use of trazodone with other serotonergic drugs is clinically warranted, inform patients of the increased risk for serotonin syndrome and monitor for symptoms.
Clinical studies indicate that trazodone hydrochloride may be arrhythmogenic in patients with preexisting cardiac disease. Arrhythmias identified include isolated PVCs, ventricular couplets, tachycardia with syncope, and torsade de pointes. Postmarketing events, including torsade de pointes have been reported at doses of 100 mg or less with the immediate-release form of trazodone. Trazodone should also be avoided in patients with a history of cardiac arrhythmias, as well as other circumstances that may increase the risk of the occurrence of torsade de pointes and/or sudden death, including symptomatic bradycardia, hypokalemia or hypomagnesemia, and the presence of congenital prolongation of the QT interval. Trazodone is not recommended for use during the initial recovery phase of myocardial infarction. Caution should be used when administering trazodone to patients with cardiac disease and such patients should be closely monitored, since antidepressant drugs (including trazodone) may cause cardiac arrhythmias [see Adverse Reactions ( 6.2)] .
Trazodone prolongs the QT/QTc interval. The use of trazodone should be avoided in patients with known QT prolongation or in combination with other drugs that are inhibitors of CYP3A4 (e.g., itraconazole, clarithromycin, voriconazole), or known to prolong QT interval including Class 1A antiarrhythmics (e.g., quinidine, procainamide) or Class 3 antiarrhythmics (e.g., amiodarone, sotalol), certain antipsychotic medications (e.g., ziprasidone, chlorpromazine, thioridazine), and certain antibiotics (e.g., gatifloxacin). Concomitant administration of drugs may increase the risk of cardiac arrhythmia [see Drug Interactions ( 7.1)].
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.
Drugs that interfere with serotonin reuptake inhibition, including trazodone, increase the risk of bleeding events. Concomitant use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDS), other antiplatelet drugs, warfarin, and other anticoagulants may add to this risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated an association between use of drugs that interfere with serotonin reuptake and the occurrence of gastrointestinal bleeding. Bleeding events related to drugs that interfere with serotonin reuptake have ranged from ecchymosis, hematoma, epistaxis, and petechiae to life-threatening hemorrhages.
Inform patients about the risk of bleeding associated with the concomitant use of trazodone and antiplatelet agents or anticoagulants. For patients taking warfarin, carefully monitor coagulation indices when initiating, titrating, or discontinuing trazodone.
Cases of priapism (painful erections greater than 6 hours in duration) have been reported in men receiving trazodone. Priapism, if not treated promptly, can result in irreversible damage to the erectile tissue. Men who have an erection lasting greater than 4 hours, whether painful or not, should immediately discontinue the drug and seek emergency medical attention [see Adverse Reactions ( 6.2), Overdosage ( 10)].
Trazodone should be used with caution in men who have conditions that might predispose them to priapism (e.g., sickle cell anemia, multiple myeloma, or leukemia), or in men with anatomical deformation of the penis (e.g., angulation, cavernosal fibrosis, or Peyronie's disease).
In patients with bipolar disorder, treating a depressive episode with trazodone or another antidepressant may precipitate a mixed/manic episode. Activation of mania/hypomania has been reported in a small proportion of patients with major affective disorder who were treated with antidepressants. Prior to initiating treatment with trazodone, screen patients for any personal or family history of bipolar disorder, mania, or hypomania [see Dosage and Administration ( 2.3)] .
Adverse reactions after discontinuation of serotonergic antidepressants, particularly after abrupt discontinuation, include: nausea, sweating, dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesia, such as electric shock sensations), tremor, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. A gradual reduction in dosage rather than abrupt cessation is recommended whenever possible [See Dosage and Administration ( 2.6)].
Trazodone may cause somnolence or sedation and may impair the mental and/or physical ability required for the performance of potentially hazardous tasks. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug treatment does not affect them adversely.
The pupillary dilation that occurs following use of many antidepressant drugs including trazodone may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy. Avoid use of antidepressants, including trazodone, in patients with untreated anatomically narrow angles.
Hyponatremia may occur as a result of treatment with SNRIs and SSRIs, including trazodone. Cases with serum sodium lower than 110 mmol/L have been reported. Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which can lead to falls. Signs and symptoms associated with more severe and/or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
In patients with symptomatic hyponatremia, discontinue trazodone and institute appropriate medical intervention. Elderly patients, patients taking diuretics, and those who are volume-depleted may be at greater risk of developing hyponatremia with SSRIs and SNRIs [see Use in Specific Populations ( 8.5)] .
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
| Inpatients | Outpatients | |||
| Trazodone | Placebo | Trazodone | Placebo | |
| N=142 | N=95 | N=157 | N=158 | |
| Allergic | ||||
| Skin Condition/Edema
| 3%
| 1%
| 7%
| 1%
|
| Autonomic | ||||
| Blurred Vision
| 6%
| 4%
| 15%
| 4%
|
| Constipation
| 7%
| 4%
| 8%
| 6%
|
| Dry Mouth
| 15%
| 8%
| 34%
| 20%
|
| Cardiovascular | ||||
| Hypertension
| 20%
| 1%
| 1%
| * |
| Hypotension
| 7%
| 1%
| 4%
| 0
|
| Syncope
| 3%
| 2%
| 5%
| 1%
|
| CNS | ||||
| Confusion
| 5%
| 0
| 6%
| 8%
|
| Decreased Concentration
| 3%
| 2%
| 1%
| 0
|
| Disorientation
| 2%
| 0
| * | 0
|
| Dizziness/Light-Headedness
| 20%
| 5%
| 28%
| 15%
|
| Drowsiness
| 24%
| 6%
| 41%
| 20%
|
| Fatigue
| 11%
| 4%
| 6%
| 3%
|
| Headache
| 10%
| 5%
| 20%
| 16%
|
| Nervousness
| 15%
| 11%
| 6%
| 8%
|
| Gastrointestinal | ||||
| Abdominal/Gastric Disorder
| 4%
| 4%
| 6%
| 4%
|
| Diarrhea
| 0
| 1%
| 5%
| 1%
|
| Nausea/Vomiting
| 10%
| 1%
| 13%
| 10%
|
| Musculoskeletal | ||||
| Aches/Pains
| 6%
| 3%
| 5%
| 3%
|
| Neurological | ||||
| Incoordination
| 5%
| 0
| 2%
| *
|
| Tremors
| 3%
| 1%
| 5%
| 4%
|
| Other | ||||
| Eyes Red/Tired/Itching
| 3%
| 0
| 0
| 0
|
| Head Full-Heavy
| 3%
| 0
| 0
| 0
|
| Malaise
| 3%
| 0
| 0
| 0
|
| Nasal/Sinus Congestion
| 3%
| 0
| 6%
| 3%
|
| Weight Gain
| 1%
| 0
| 5%
| 2%
|
| Weight Loss
| * | 3%
| 6%
| 3%
|
Other adverse reactions occurring at an incidence of <2% with the use of trazodone hydrochloride in the controlled clinical studies: akathisia, allergic reaction, anemia, chest pain, delayed urine flow, early menses, flatulence, hallucinations/delusions, hematuria, hypersalivation, hypomania, impaired memory, impaired speech, impotence, increased appetite, increased libido, increased urinary frequency, missed periods, muscle twitches, numbness, paresthesia, retrograde ejaculation, shortness of breath, and tachycardia/palpitations. Occasional sinus bradycardia has occurred in long-term studies.
The following adverse reactions have been identified during post-approval use of trazodone. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency or establish a causal relationship to drug exposure:
Blood and lymphatic system disorders:hemolytic anemia, leukocytosis
Cardiac disorders:cardiospasm, congestive heart failure, conduction block, orthostatic hypotension and syncope, palpitations, bradycardia, atrial fibrillation, myocardial infarction, cardiac arrest, arrhythmia, ventricular ectopic activity, including ventricular tachycardia and QT prolongation. Prolonged QT interval, torsade de pointes, and ventricular tachycardia have been reported at doses of 100 mg per day or less [see Warnings and Precautions ( 5.3)].
Endocrine disorders:inappropriate ADH syndrome
Eye disorders:diplopia
Gastrointestinal disorders:increased salivation, nausea/vomiting
General disorders and administration site conditions:chills, edema, unexplained death, weakness
Hepatobiliary disorders:cholestasis, jaundice, hyperbilirubinemia, liver enzyme alterations
Investigations:increased amylase
Metabolism and nutrition disorders:methemoglobinemia
Nervous system disorders:aphasia, ataxia, cerebrovascular accident, extrapyramidal symptoms, grand mal seizures, paresthesia, tardive dyskinesia, vertigo
Psychiatric disorders:abnormal dreams, agitation, anxiety, hallucinations, insomnia, paranoid reaction, psychosis, stupor
Renal and urinary disorders:urinary incontinence, urinary retention
Reproductive system and breast disorders:breast enlargement or engorgement, clitorism, lactation, priapism [see Warnings and Precautions ( 5.6)]
Respiratory, thoracic and mediastinal disorders:apnea
Skin and subcutaneous tissue disorders:alopecia, hirsutism, leukonychia, pruritus, psoriasis, rash, urticaria
Vascular disorders:vasodilation
| Monoamine Oxidase Inhibitors (MAOIs) | |
| Clinical Impact:
| The concomitant use of MAOIs and serotonergic drugs including trazodone increases the risk of serotonin syndrome.
|
| Intervention:
| Trazodone is contraindicated in patients taking MAOIs, including MAOIs such as linezolid or intravenous methylene blue
[see Contraindications (4), Dosage and Administration (2.3, 2.4), and Warnings and Precautions (5.2)]. |
| Examples:
| isocarboxazid, moclobemide, phenelzine, selegiline, tranylcypromine
|
| Other Serotonergic Drugs | |
| Clinical Impact:
| The concomitant use of serotonergic drugs including trazodone and other serotonergic drugs increases the risk of serotonin syndrome.
|
| Intervention:
| Monitor patients for signs and symptoms of serotonin syndrome, particularly during trazodone initiation. If serotonin syndrome occurs, consider discontinuation of trazodone and/or concomitant serotonergic drugs
[see Warnings and Precautions (5.2)]. |
| Examples:
| triptans, antidepressants (tricyclic and serotonin uptake inhibitors), fentanyl, lithium, tramadol, tryptophan, buspirone, and St. John's Wort
|
| Antiplatelet Agents and Anticoagulants | |
| Clinical Impact:
| Serotonin release by platelets plays an important role in hemostasis. The concurrent use of an antiplatelet agent or anticoagulant with trazodone may potentiate the risk of bleeding.
|
| Intervention:
| Inform patients of the increased risk of bleeding with the concomitant use of trazodone and antiplatelet agents and anticoagulants. For patients taking warfarin, carefully monitor the international normalized ratio (INR) when initiating or discontinuing trazodone
[see Warnings and Precautions (5.5)]. |
| Examples:
| warfarin, rivaroxaban, dabigatran, clopidogrel
|
| Strong CYP3A4 Inhibitors | |
| Clinical Impact:
| The concomitant use of trazodone and strong CYP3A4 inhibitors increased the exposure of trazodone compared to the use of trazodone alone
. |
| Intervention:
| If trazodone is used with a potent CYP3A4 inhibitor, the risk of adverse reactions, including cardiac arrhythmias, may be increased and a lower dose of trazodone should be considered
[see Dosage and Administration (2.5), Warnings and Precautions (5.3)]. |
| Examples:
| itraconazole, ketoconazole, clarithromycin, indinavir
|
| Strong CYP3A4 Inducers | |
| Clinical Impact:
| The concomitant use of trazodone and strong CYP3A4 inducers decreased the exposure of trazodone compared to the use of trazodone alone
. |
| Intervention:
| Patients should be closely monitored to see if there is a need for an increased dose of trazodone when taking CYP3A4 inducers
[see Dosage and Administration (2.5)]. |
| Examples:
| rifampin, carbamazepine, phenytoin, St. John's wort
|
| Digoxin and Phenytoin | |
| Clinical Impact:
| Digoxin and phenytoin are narrow therapeutic index drugs. Concomitant use of trazodone can increase digoxin or phenytoin concentrations.
|
| Intervention:
| Measure serum digoxin or phenytoin concentrations before initiating concomitant use of trazodone. Continue monitoring and reduce digoxin or phenytoin dose as necessary.
|
| Examples:
| digoxin, phenytoin
|
| Central Nervous System (CNS) Depressants | |
| Clinical Impact:
| Trazodone may enhance the response CNS depressants.
|
| Intervention:
| Patients should be counseled that trazodone may enhance the response to alcohol, barbiturates, and other CNS depressants.
|
| Examples:
| alcohol, barbiturates
|
| QT Interval Prolongation | |
| Clinical Impact:
| Concomitant use of drugs that prolong the QT interval may add to the QT effects of trazodone and increase the risk of cardiac arrhythmia.
|
| Intervention:
| Avoid the use of trazodone in combination with other drugs known to prolong QTc
[see Warnings and Precautions (5.3)].
|
| Examples:
| Class 1A antiarrhythmics: quinidine, procainamide, disopyramide; Class 3 antiarrhythmics: amiodarone, sotalol;
Antipsychotics: ziprasidone, chlorpromazine, thioridazine; Antibiotics: gatifloxacin |
Pregnancy Exposure Registry
There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to antidepressants during pregnancy. Healthcare providers are encouraged to register patients by calling the National Pregnancy Registry for Antidepressants at 1-844-405-6185 or visiting online at https://womensmentalhealth.org/clinical-and-research-programs/ pregnancyregistry/ antidepressants/
Risk Summary
Published prospective cohort studies, case series, and case reports over several decades with trazodone hydrochloride tablets use in pregnant women have not identified any drug-associated risks of major birth defects, miscarriage, or adverse maternal or fetal outcomes (see Data). Trazodone hydrochloride has been shown to cause increased fetal resorption and other adverse effects on the fetus in the rat when given at dose levels approximately 7.3 times to 11 times the maximum recommended human dose (MRHD) of 400 mg/day in adults on a mg/m 2basis. There was also an increase in congenital anomalies in the rabbit at approximately 7.3 times to 22 times the MRHD on a mg/m 2basis (see Data).
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Clinical Considerations
Disease-associated maternal and/or embryofetal risk
A prospective, longitudinal study followed 201 pregnant women with a history of major depressive disorder who were euthymic and taking antidepressants at the beginning of pregnancy. The women who discontinued antidepressants during pregnancy were more likely to experience a relapse of major depression that women who continued antidepressants. Consider the risk of untreated depression when discontinuing or changing treatment with antidepressant medication during pregnancy and postpartum.
Data
Human Data
While available studies cannot definitively establish the absence of risk, published data from prospective cohort studies, case series, and case reports over several decades have not identified an association with trazodone use during pregnancy and major birth defects, miscarriage, or other adverse maternal or fetal outcomes. All available studies have methodological limitations, including small sample size and inconsistent comparator groups.
Animal Data
No teratogenic effects were observed when trazodone was given to pregnant rats and rabbits during the period of organogenesis at oral doses up to 450 mg/kg/day. This dose is 11 times and 22 times, in rats and rabbits, respectively, the maximum recommended human dose (MRHD) of 400 mg/day in adults on a mg/m 2basis. Increased fetal resorption and other adverse effects on the fetus in rats at 7.3 times to 11 times the MRHD and increase in congenital anomalies in rabbits at 7.3 times to 22 times the MRHD on a mg/m 2basis were observed. No further details on these studies are available.
Risk Summary
Data from published literature report the transfer of trazodone into human milk. There are no data on the effect of trazodone on milk production. Limited data from postmarketing reports have not identified and association of adverse effects on the breastfed child. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for trazodone hydrochloride tablets and any potential adverse effects on the breastfed child from trazodone hydrochloride tablets or from the underlying maternal condition.
Safety and effectiveness in the pediatric population have not been established. Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric patients [ see Boxed Warning, Warnings and Precautions ( 5.1) ].
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.
Serotonergic antidepressants have been associated with cases of clinically significant hyponatremia in elderly patients who may be at greater risk for this adverse reaction [ see Warnings and Precautions ( 5.11) ].
Trazodone has not been studied in patients with renal impairment. Trazodone should be used with caution in this population.
Trazodone has not been studied in patients with hepatic impairment. Trazodone should be used with caution in this population.
Trazodone hydrochloride tablets are not a controlled substance.
Although trazodone hydrochloride has not been systematically studied in preclinical or clinical studies for its potential for abuse, no indication of drug-seeking behavior was seen in the clinical studies with trazodone hydrochloride.
Death from overdose has occurred in patients ingesting trazodone and other CNS depressant drugs concurrently (alcohol; alcohol and chloral hydrate and diazepam; amobarbital; chlordiazepoxide; or meprobamate).
The most severe reactions reported to have occurred with overdose of trazodone alone have been priapism, respiratory arrest, seizures, and ECG changes, including QT prolongation. The reactions reported most frequently have been drowsiness and vomiting. Overdosage may cause an increase in incidence or severity of any of the reported adverse reactions.
There is no specific antidote for trazodone hydrochloride overdose. In managing overdosage, consider the possibility of multiple drug involvement. For current information on the management of poisoning or overdose, contact a poison control center (1-800-222-1222 or www.poison.org).
Trazodone hydrochloride is a selective serotonin reuptake inhibitor and 5HT2 receptor antagonist. Trazodone hydrochloride, USP is a triazolopyridine derivative designated as 2-[3-[4-(3-chlorophenyl)-1-piperazinyl]propyl]- 1,2,4-triazolo[4, 3-a]pyridin-3(2H)-one hydrochloride. It is a white to off-white, crystalline powder which is sparingly soluble in chloroform and in water. The structural formula is represented as follows:
Trazodone Hydrochloride Tablets Usp (Label 01)
Molecular Formula:C 19H 22C lN 5O•HCl
Molecular Weight:408.33
Each trazodone hydrochloride tablet, USP for oral administration contains 50 mg, 100 mg, 150 mg or 300 mg of trazodone hydrochloride, USP. In addition, each tablet contains the following inactive ingredients: colloidal silicon dioxide, magnesium stearate, microcrystalline cellulose, pregelatinized starch, sodium lauryl sulfate, and sodium starch glycolate.
The USP Dissolution Test is pending.
The mechanism of trazodone's antidepressant action is not fully understood, but is thought to be related to its enhancement of serotonergic activity in the CNS. Trazodone is both a selective serotonin reuptake inhibitor (SSRI) and a 5HT2 receptor antagonist and the net result of this action on serotonergic transmission and its role in trazodone's antidepressant effect is unknown.
Preclinical studies have shown that trazodone selectively inhibits neuronal reuptake of serotonin (Ki = 367 nM) and acts as an antagonist at 5-HT-2A (Ki = 35.6 nM) serotonin receptors. Trazodone is also an antagonist at several other monoaminergic receptors including 5-HT2B (Ki = 78.4 nM), 5-HT2C (Ki = 224 nM), α1A (Ki = 153 nM), α2C (Ki = 155 nM) receptors and it is a partial agonist at 5HT1A (Ki = 118 nM) receptor.
Trazodone antagonizes alpha 1-adrenergic receptors, a property which may be associated with postural hypotension.
Absorption
In humans, trazodone hydrochloride is absorbed after oral administration without selective localization in any tissue. When trazodone hydrochloride is taken shortly after ingestion of food, there may be an increase in the amount of drug absorbed, a decrease in maximum concentration and a lengthening in the time to maximum concentration. Peak plasma levels occur approximately one hour after dosing when trazodone hydrochloride is taken on an empty stomach or 2 hours after dosing when taken with food.
Metabolism
In vitrostudies in human liver microsomes show that trazodone is metabolized, via oxidative cleavage, to an active metabolite, m-chlorophenylpiperazine (mCPP) by CYP3A4. Other metabolic pathways that may be involved in the metabolism of trazodone have not been well characterized. Trazodone is extensively metabolized; less than 1% of an oral dose is excreted unchanged in the urine.
Elimination
In some patients trazodone may accumulate in the plasma.
Protein Binding
Trazodone is 89 to 95% protein bound in vitroat concentrations attained with therapeutic doses in humans.
Carcinogenesis
No drug- or dose-related occurrence of carcinogenesis was evident in rats receiving trazodone in daily oral doses up to 7.3 times the maximum recommended human dose (MRHD) of 400 mg/day in adults on a mg/m 2basis.
Mutagenesis
No genotoxicity studies were conducted with trazodone.
Impairment of Fertility
Trazodone has no effect on fertility in rats at doses up to 7.3 times the MRHD in adults on a mg/m 2basis.
The efficacy and safety of trazodone hydrochloride were established from inpatient and outpatient trials of the trazodone immediate release formulation in the treatment of major depressive disorder.
Trazodone Hydrochloride Tablets USP, 50 mg are white to off-white, round-shape, biconvex beveled tablets, bisect on one side and plain on other side. The bisected side of tablet is debossed with '8' on upper side of bisect and '05' on lower side of bisect and are supplied as follows:
NDC 76420-672-30 in bottle of 30 tablets (repackaged from NDC 68382-805-XX)
NDC 76420-672-60 in bottle of 60 tablets (repackaged from NDC 68382-805-XX)
NDC 76420-672-90 in bottle of 90 tablets (repackaged from NDC 68382-805-XX)
NDC 76420-672-01 in bottle of 100 tablets (relabeled from NDC 68382-805-01)
Trazodone Hydrochloride Tablets USP, 100 mg are white to off-white, round-shape, biconvex beveled tablets, bisect on one side and plain on other side. The bisected side of tablet is debossed with '8' on upper side of bisect and '06' on lower side of bisect and are supplied as follows:
NDC 76420-648-30 in bottle of 30 tablets (repackaged from NDC 68382-806-XX)
NDC 76420-648-60 in bottle of 60 tablets (repackaged from NDC 68382-806-XX)
NDC 76420-648-90 in bottle of 90 tablets (repackaged from NDC 68382-806-XX)
NDC 76420-648-01 in bottle of 100 tablets (relabeled from NDC 68382-806-01)
Trazodone Hydrochloride Tablets USP, 150 mg are white to off-white, oval-shape, flat faced beveled tablets having one full bisect and two trisect notches on one side and two trisects on other side. The full bisected side of tablet is debossed with '8' on one side of bisect and '07' on other bisect segments and are supplied as follows:
NDC 76420-675-30 in bottle of 30 tablets (repackaged from NDC 68382-807-XX)
NDC 76420-675-60 in bottle of 60 tablets (repackaged from NDC 68382-807-XX)
NDC 76420-675-90 in bottle of 90 tablets (repackaged from NDC 68382-807-XX)
NDC 76420-675-01 in bottle of 100 tablets (relabeled from NDC 68382-807-01)
Directions for using the correct score when breaking the tablet, please refer to the
following:
-For 50 mg, break the score on either the left or right side of the tablet (one-third of a
tablet).
Trazodone Hydrochloride Tablets Usp (Label 02)
-For 75 mg, break the score down the middle of the tablet (one-half of a tablet).
Trazodone Hydrochloride Tablets Usp (Label 03)
-For 100 mg, break the score on either the left or right side of the tablet (two-thirds of a
tablet).
Trazodone Hydrochloride Tablets Usp (Label 04)
-For 150 mg, use the entire tablet.
Trazodone Hydrochloride Tablets Usp (Label 05)
Trazodone Hydrochloride Tablets USP, 300 mg are white to off-white, oval-shape, flat
faced beveled tablets having one full bisect and two trisect notches on one side and two
trisects on other side. The full bisected side of tablet is debossed with '8' on one side of
bisect and '08' on other bisect segment and are supplied as follows:
NDC 76420-676-30 in bottle of 30 tablets (repackaged from NDC 68382-808-XX)
NDC 76420-676-60 in bottle of 60 tablets (repackaged from NDC 68382-808-XX)
NDC 76420-676-90 in bottle of 90 tablets (repackaged from NDC 68382-808-XX)
NDC 76420-676-01 in bottle of 100 tablets (relabeled from NDC 68382-808-01)
Directions for using the correct score when breaking the tablet, please refer to the
following:
-For 100 mg, break the score on either the left or right side of the tablet (one-third of a
tablet).
Trazodone Hydrochloride Tablets Usp (Label 06)
-For 150 mg, break the score down the middle of the tablet (one-half of a tablet).
Trazodone Hydrochloride Tablets Usp (Label 07)
-For 200 mg, break the score on either the left or right side of the tablet (two-thirds of a
tablet).
Trazodone Hydrochloride Tablets Usp (Label 08)
-For 300 mg, use the entire tablet.
Trazodone Hydrochloride Tablets Usp (Label 09)
Store at 20°C to 25°C (68°F to 77°F) [See USP Controlled Room Temperature].
Dispense with a child-resistant closure in a tight, light-resistant container.
Advise the patient to read the FDA-approved patient labeling (Medication Guide).
Suicidal Thoughts and Behaviors
Advise patients and caregivers to look for the emergence of suicidality, especially early during treatment and when the dosage is adjusted up or down and instruct them to report such symptoms to the healthcare provider [ see Box Warning and Warnings and Precautions ( 5.1) ].
Dosage and Administration
Advise patients that trazodone hydrochloride tablets should be taken shortly after a meal or light snack. Advise patients regarding the importance of following dosage titration instructions [see Dosage and Administration ( 2)] .
Serotonin Syndrome
Caution patients about the risk of serotonin syndrome, particularly with the concomitant use of trazodone hydrochloride tablets with other serotonergic drugs including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, St. John's Wort, and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid). Patients should contact their health care provider or report to the emergency room if they experience signs or symptoms of serotonin syndrome [see Warnings and Precautions ( 5.2) and Drug Interactions ( 7)] .
Activation of Mania/Hypomania
Advise patients and their caregivers to observe for signs of activation of mania/hypomania and instruct them to report such symptoms to the healthcare provider [see Warnings and Precautions ( 5.7)] .
Increased Risk of Bleeding
Inform patients about the concomitant use of trazodone hydrochloride tablets with aspirin, NSAIDs, other antiplatelet drugs, warfarin, or other anticoagulants because the combined use of drugs that interfere with serotonin reuptake and these medications has been associated with an increased risk of bleeding. Advise them to inform their health care providers if they are taking or planning to take any prescription or over-the-counter medications that increase the risk of bleeding [see Warnings and Precautions ( 5.5)] .
Discontinuation Syndrome
Advise patients not to abruptly discontinue trazodone hydrochloride tablets and to discuss any tapering regimen with their healthcare provider. Adverse reactions can occur when trazodone hydrochloride tablets are discontinued [see Warnings and Precautions ( 5.8)].
Concomitant Medications
Advise patients to inform their health care providers if they are taking, or plan to take any prescription or over-the-counter medications since there is a potential for interactions [see Drug Interactions ( 7.1)].
Pregnancy
Advise patients to notify their healthcare provider if they become pregnant or intend to become pregnant during therapy with trazodone hydrochloride tablets. Advise patients that there is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to trazodone hydrochloride tablets during pregnancy [see Use in Special Populations ( 8.1)] .
Medication Guide available at www.zydususa.com/medguides or call 1-877-993-8779.
| MEDICATION GUIDE Trazodone Hydrochloride (traz' oh done hye'' droe klor' ide) Tablets USP, for oral use |
| What is the most important information I should know about trazodone hydrochloride tablets? Antidepressant medicines, depression or other serious mental illnesses, and suicidal thoughts or actions: Talk to your healthcare provider about:
|
What else do I need to know about antidepressant medicines?
|
| What are trazodone hydrochloride tablets? Trazodone hydrochloride tablets are prescription medicine used in adults to treat major depressive disorder (MDD). Trazodone hydrochloride tablets belong to a class of medicines known as SSRIs (or selective serotonin reuptake inhibitors). |
Do not take trazodone hydrochloride tablets:
|
Before you take trazodone hydrochloride tablets tell your healthcare provider about all of your medical conditons, including if you:
Especially tell your healthcare provider if you take: |
How should I take trazodone hydrochloride tablets?
|
What should I avoid while taking trazodone hydrochloride tablets?
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| What are the possible side effects of trazodone hydrochloride tablets? Trazodone hydrochloride tablets can cause serious side effects or death, including:
The most common side effects of trazodone hydrochloride tablets include: |
How should I store trazodone hydrochloride tablets?
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| General information about the safe and effective use of trazodone hydrochloride tablets. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use trazodone hydrochloride tablets for a condition for which it was not prescribed. Do not give trazodone hydrochloride tablets to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about trazodone hydrochloride tablets that is written for health professionals . Please address medical inquiries to [email protected] or Tel.: 1-877-993-8779. |
| What are the ingredients in trazodone hydrochloride tablets? Active ingredient:trazodone hydrochloride, USP Inactive ingredients:colloidal silicon dioxide, magnesium stearate, microcrystalline cellulose, pregelatinized starch, sodium lauryl sulfate, and sodium starch glycolate. This Medication Guide has been approved by the U.S. Food and Drug Administration. Medication Guide available at www.zydususa.com/medguides or call 1-877-993-8779. |
| Relabeled and Repackaged by: Enovachem PHARMACEUTICALS Torrance, CA 90501 |
| This Medication Guide has been approved by the U.S. Food and Drug Administration. |
Trazodone Hyadrochloride Tablets, Usp (Label 10)
Trazodone Hyadrochloride Tablets, Usp (Label 11)
Trazodone Hyadrochloride Tablets, Usp (Label 12)
Trazodone Hyadrochloride Tablets, Usp (Label 13)
* Please review the disclaimer below.
