Drug: Desyrel

DESYREL (trazodone hydrochloride) is an antidepressant chemically unrelated to tricyclic, tetracyclic, or other known antidepressant agents. Trazodone hydrochloride 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, odorless, crystalline powder which is freely soluble in water. Its molecular weight is 408.3. The empirical formula is C19H22ClN5O•HCl and the structural formula is represented as follows: DESYREL (trazodone hydrochloride) is supplied for oral administration in 50 mg, 100 mg, 150 mg, and 300 mg tablets. DESYREL (trazodone hydrochloride) Tablets, 150 mg, contain the following inactive ingredients: microcrystalline cellulose, FD&C Yellow No. 6 (aluminum lake), magnesium stearate, pregelatinized starch, and stearic acid. DESYREL (trazodone hydrochloride) Tablets, 300 mg, contain the following inactive ingredients: microcrystalline cellulose, yellow ferric oxide, magnesium stearate, sodium starch glycolate, pregelatinized starch, and stearic acid.

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Because the frequency of adverse drug effects is affected by diverse factors (eg, drug dose, method of detection, physician judgment, disease under treatment, etc.) a single meaningful estimate of adverse event incidence is difficult to obtain. This problem is illustrated by the variation in adverse event incidence observed and reported from the inpatients and outpatients treated with DESYREL (trazodone hydrochloride) . It is impossible to determine precisely what accounts for the differences observed. Clinical Trial Reports The table below is presented solely to indicate the relative frequency of adverse events reported in representative controlled clinical studies conducted to evaluate the safety and efficacy of DESYREL (trazodone hydrochloride). The figures cited cannot be used to predict precisely the incidence of untoward events in the course of usual medical practice where patient characteristics and other factors often differ from those which prevailed in the clinical trials. These incidence figures, also, cannot be compared with those obtained from other clinical studies involving related drug products and placebo as each group of drug trials is conducted under a different set of conditions. Treatment-Emergent Symptom Incidence
  Inpts. Outpts. D P D P Number of Patients 142 95 157 158 % of Patients Reporting         Allergic   Skin Condition/Edema 2.8 1.1 7.0 1.3   Autonomic           Blurred Vision 6.3 4.2 14.7 3.8   Constipation 7.0 4.2 7.6 5.7   Dry Mouth 14.8 8.4 33.8 20.3 Cardiovascular   Hypertension 2.1 1.1 1.3 *   Hypotension 7.0 1.1 3.8 0.0   Shortness of Breath * 1.1 1.3 0.0   Syncope 2.8 2.1 4.5 1.3   Tachycardia/Palpitations 0.0 0.0 7.0 7.0 CNS   Anger/Hostility 3.5 6.3 1.3 2.5   Confusion 4.9 0.0 5.7 7.6   Decreased Concentration 2.8 2.1 1.3 0.0   Disorientation 2.1 0.0 * 0.0   Dizziness/Lightheadedness 19.7 5.3 28.0 15.2   Drowsiness 23.9 6.3 40.8 19.6   Excitement 1.4 1.1 5.1 5.7   Fatigue 11.3 4.2 5.7 2.5   Headache 9.9 5.3 19.8 15.8   Insomnia 9.9 10.5 6.4 12.0   Impaired Memory 1.4 0.0 * *   Nervousness 14.8 10.5 6.4 8.2 Gastrointestinal   Abdominal/Gastric Disorder 3.5 4.2 5.7 4.4   Bad Taste in Mouth 1.4 0.0 0.0 0.0   Diarrhea 0.0 1.1 4.5 1.9   Nausea/Vomiting 9.9 1.1 12.7 9.5   Musculoskeletal           Musculoskeletal Aches/Pains 5.6 3.2 5.1 2.5 Neurological   Incoordination 4.9 0.0 1.9 0.0   Paresthesia 1.4 0.0 0.0 *   Tremors 2.8 1.1 5.1 3.8 Sexual Function   Decreased Libido * 1.1 1.3 * Other   Decreased Appetite 3.5 5.3 0.0 *   Eyes Red/Tired/Itching 2.8 0.0 0.0 0.0   Head Full-Heavy 2.8 0.0 0.0 0.0   Malaise 2.8 0.0 0.0 0.0   Nasal/Sinus Congestion 2.8 0.0 5.7 3.2   Nightmares/Vivid Dreams * 1.1 5.1 5.7   Sweating/Clamminess 1.4 1.1 * *   Tinnitus 1.4 0.0 0.0 *   Weight Gain 1.4 0.0 4.5 1.9   Weight Loss * 3.2 5.7 2.5 * Incidence less than 1%
D = DESYREL P = PLACEBO Occasional sinus bradycardia has occurred in long-term studies. In addition to the relatively common (ie, greater than 1%) untoward events enumerated above, the following adverse events have been reported to occur in association with the use of DESYREL® (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 speech, impotence, increased appetite, increased libido, increased urinary frequency, missed periods, muscle twitches, numbness, and retrograde ejaculation. Post-Introduction Reports Although the following adverse reactions have been reported in DESYREL (trazodone hydrochloride) users, the causal association has neither been confirmed nor refuted. Voluntary reports received since market introduction include the following: abnormal dreams, agitation, alopecia, anxiety, aphasia, apnea, ataxia, breast enlargement or engorgement, cardiospasm, cerebrovascular accident, chills, cholestatis, clitorism, congestive heart failure, diplopia, edema, extrapyramidal symptoms, grand mal seizures, hallucinations, hemolytic anemia, hirsutism, hyperbilirubinemia, increased amylase, increased salivation, insomnia, leukocytosis, leukonychia, jaundice, lactation, liver enzyme alterations, methemoglobinemia, nausea/vomiting (most frequently), paresthesia, paranoid reaction, priapism (See WARNINGS and PRECAUTIONS: Information for Patients; some patients have required surgical intervention), pruritus, psoriasis, psychosis, rash, stupor, inappropriate ADH syndrome, tardive dyskinesia, unexplained death, urinary incontinence, urinary retention, urticaria, vasodilation, vertigo and weakness. Cardiovascular system effects which have been reported include the following: conduction block, orthostatic hypotension and syncope, palpitations, bradycardia, atrial fibrillation, myocardial infarction, cardiac arrest, arrhythmia, and ventricular ectopic activity, including ventricular tachycardia (see WARNINGS). Read the Desyrel (trazodone hydrochloride) Side Effects Center for a complete guide to possible side effectsLearn More »

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The dosage should be initiated at a low level 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. DESYREL (trazodone hydrochloride) should be taken shortly after a meal or light snack. Symptomatic relief may be seen during the first week, with optimal antidepressant effects typically evident within two weeks. Twenty-five percent of those who respond to DESYREL (trazodone hydrochloride) require more than two weeks (up to four weeks) of drug administration. Usual Adult Dosage An initial dose of 150 mg/day in divided doses is suggested. The dose may be increased by 50 mg/day every three to four days. The maximum dose for outpatients usually should not exceed 400 mg/day in divided doses. Inpatients (ie, more severely depressed patients) may be given up to but not in excess of 600 mg/day in divided doses. Maintenance Dosage during prolonged maintenance therapy should be kept at the lowest effective level. Once an adequate response has been achieved, dosage may be gradually reduced, with subsequent adjustment depending on therapeutic response. Although there has been no systematic evaluation of the efficacy of DESYREL (trazodone hydrochloride) beyond six weeks, it is generally recommended that a course of antidepressant drug treatment should be continued for several months.

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In vitro drug metabolism studies suggest that there is a potential for drug interactions when trazodone is given with CYP3A4 inhibitors. Ritonavir, a potent CYP3A4 inhibitor, increased the Cmax, AUC, and elimination half-life, and decreased clearance of trazodone after administration of ritonavir twice daily for 2 days. 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 or nefazodone may lead to substantial increases in trazodone plasma concentrations, with the potential for adverse effects. If trazodone is used with a potent CYP3A4 inhibitor, a lower dose of trazodone should be considered. Carbamazepine reduced plasma concentrations of trazodone when co-administered. Patients should be closely monitored to see if there is a need for an increased dose of trazodone when taking both drugs. Increased serum digoxin or phenytoin levels have been reported to occur in patients receiving DESYREL (trazodone hydrochloride) concurrently with either of those two drugs. It is not known whether interactions will occur between monoamine oxidase (MAO) inhibitors and DESYREL (trazodone hydrochloride) . Due to the absence of clinical experience, if MAO inhibitors are discontinued shortly before or are to be given concomitantly with DESYREL (trazodone hydrochloride) , therapy should be initiated cautiously with gradual increase in dosage until optimum response is achieved. Therapeutic Interactions Concurrent administration with electroshock therapy should be avoided because of the absence of experience in this area. There have been reports of increased and decreased prothrombin time occurring in warfarinized patients who take DESYREL (trazodone hydrochloride) .Read the Desyrel Drug Interactions Center for a complete guide to possible interactions Learn More »

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DESYREL (trazodone hydrochloride) is indicated for the treatment of depression. The efficacy of DESYREL (trazodone hydrochloride) has been demonstrated in both inpatient and outpatient settings and for depressed patients with and without prominent anxiety. The depressive illness of patients studied corresponds to the Major Depressive Episode criteria of the American Psychiatric Association's Diagnostic and Statistical Manual, III1. Major Depressive Episode implies a prominent and relatively persistent (nearly every day for at least two weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least four of the following eight symptoms: change in appetite, change in sleep, psychomotor agitation or retardation, loss of interest in usual activities or decrease in sexual drive, increased fatigability, feelings of guilt or worthlessness, slowed thinking or impaired concentration, and suicidal ideation or attempts.

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DESYREL (trazodone hydrochloride) is contraindicated in patients hypersensitive to DESYREL (trazodone hydrochloride) . Last reviewed on RxList: 4/13/2011
This monograph has been modified to include the generic and brand name in many instances.

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Animal Oral LD50 The oral LD50 of the drug is 610 mg/kg in mice, 486 mg/kg in rats, and 560 mg/kg in rabbits. Signs and Symptoms Death from overdose has occurred in patients ingesting DESYREL (trazodone hydrochloride) and other drugs concurrently (namely, alcohol; alcohol + chloral hydrate + diazepam; amobarbital; chlordiazepoxide; or meprobamate). The most severe reactions reported to have occurred with overdose of DESYREL (trazodone hydrochloride) alone have been priapism, respiratory arrest, seizures, and EKG changes. 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 (see ADVERSE REACTIONS). Treatment There is no specific antidote for DESYREL (trazodone hydrochloride) . Treatment should be symptomatic and supportive in the case of hypotension or excessive sedation. Any patient suspected of having taken an overdose should have the stomach emptied by gastric lavage. Forced diuresis may be useful in facilitating elimination of the drug.

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DESYREL® (trazodone hydrochloride) Tablets, 150 mg—orange, in the Dividose® tablet design (debossed with MJ and 778 on front; “50,” “50,” “50” on reverse) NDC 0087-0778-43 Bottles of 100 Tablets, 300 mg—yellow, in the Dividose® tablet design (debossed with MJ and 796 on front; “100,”“100,”“100” on reverse) NDC 0087-0796-41 Bottles of 100 Storage Store at room temperature. Protect from temperatures above 104°F (40°C). Dispense in tight, light-resistant container (USP). REFERENCES 1. Williams JBW, Ed: Diagnostic and Statistical Manual of Mental Disorders-III, American Psychiatric Association May, 1980.Bristol-Myers Squibb Company Princeton, NJ 08543-4500, USA. Rev February 2009 Last reviewed on RxList: 4/13/2011
This monograph has been modified to include the generic and brand name in many instances.

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General The possibility of suicide in seriously depressed patients is inherent in the illness and may persist until significant remission occurs. Therefore, prescriptions should be written for the smallest number of tablets consistent with good patient management. Hypotension, including orthostatic hypotension and syncope, has been reported to occur in patients receiving DESYREL (trazodone hydrochloride) . Concomitant administration of antihypertensive therapy with DESYREL (trazodone hydrochloride) may require a reduction in the dose of the antihypertensive drug. Little is known about the interaction between DESYREL (trazodone hydrochloride) and general anesthetics; therefore, prior to elective surgery, DESYREL (trazodone hydrochloride) should be discontinued for as long as clinically feasible. As with all antidepressants, the use of DESYREL (trazodone hydrochloride) should be based on the consideration of the physician that the expected benefits of therapy outweigh potential risk factors. Information for Patients Prescribers or other health professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with DESYREL (trazodone hydrochloride) and should counsel them in its appropriate use. A patient Medication Guide About Using Antidepressants in Children and Teenagers is available for DESYREL (trazodone hydrochloride) . The prescriber or health professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients should be given the opportunity to discuss the contents of the Medication Guide and to obtain answers to any questions they may have. The complete text of the Medication Guide is reprinted at the end of this document. Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking DESYREL (trazodone hydrochloride) . Clinical Worsening and Suicide Risk Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should be advised to observe for the emergence of such symptoms on a day-today basis, since changes may be abrupt. Such symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly changes in the medication. Because priapism has been reported to occur in patients receiving DESYREL (trazodone hydrochloride) , patients with prolonged or inappropriate penile erection should immediately discontinue the drug and consult with the physician (see WARNINGS). Antidepressants may impair the mental and/or physical ability required for the performance of potentially hazardous tasks, such as operating an automobile or machinery; the patient should be cautioned accordingly. DESYREL (trazodone hydrochloride) may enhance the response to alcohol, barbiturates, and other CNS depressants. DESYREL (trazodone hydrochloride) should be given shortly after a meal or light snack. Within any individual patient, total drug absorption may be up to 20% higher when the drug is taken with food rather than on an empty stomach. The risk of dizziness/lightheadedness may increase under fasting conditions. Laboratory Tests Occasional low white blood cell and neutrophil counts have been noted in patients receiving DESYREL (trazodone hydrochloride) . These were not considered clinically significant and did not necessitate discontinuation of the drug; however, the drug should be discontinued in any patient whose white blood cell count or absolute neutrophil count falls below normal levels. White blood cell and differential counts are recommended for patients who develop fever and sore throat (or other signs of infection) during therapy. Carcinogenesis, Mutagenesis, Impairment of Fertility No drug- or dose-related occurrence of carcinogenesis was evident in rats receiving DESYREL (trazodone hydrochloride) in daily oral doses up to 300 mg/kg for 18 months. Pregnancy Category C DESYREL (trazodone hydrochloride) has been shown to cause increased fetal resorption and other adverse effects on the fetus in two studies using the rat when given at dose levels approximately 30 to 50 times the proposed maximum human dose. There was also an increase in congenital anomalies in one of three rabbit studies at approximately 15 to 50 times the maximum human dose. There are no adequate and well-controlled studies in pregnant women. DESYREL (trazodone hydrochloride) should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Nursing Mothers DESYREL (trazodone hydrochloride) and/or its metabolites have been found in the milk of lactating rats, suggesting that the drug may be secreted in human milk. Caution should be exercised when DESYREL (trazodone hydrochloride) is administered to a nursing woman. Pediatric Use Safety and effectiveness in the pediatric population have not been established (see BOXED WARNING and WARNINGS: Clinical Worsening and Suicide Risk). Anyone considering the use of DESYREL (trazodone hydrochloride) in a child or adolescent must balance the potential risks with the clinical need. REFERENCES 2. Lue TF, Physiology of erection and pathophysiology of impotence. In: Wash PC, Retik AB, Stamey TA, Vaughan ED, eds. Campbell's Urology. Sixth edition. Philadelphia: W.B. Saunders; 1992: 722-725. 3. Goldstein I, Krane RJ, Diagnosis and therapy of erectile dysfunction. In: Wash PC, Retik AB, Stamey TA, Vaughan ED, eds. Campbell's Urology. Sixth edition. Philadelphia: W.B. Saunders; 1992: 3071-3072. 4. Yealy DM, Hogya PT: Priapism. Emerg Med Clin North Am. 1988; 6:509-520. 5. Banos JE, Bosch F, Farre M, Drug-induced priapism. Its aetiology, incidence and treatment. Med Toxicol Adverse Drug Exp. 1989; 4:46-58. 6. O'Brien WM, O'Connor KP, Lynch JH. Priapism: current concepts. Ann Emerg Med. 1989: 980-983. 7. Bardin ED, Krieger JN. Pharmacological priapism: comparison of trazodone- and papaverine-associated cases. Int Urol Nephrol . 1990; 22:147-152. Last reviewed on RxList: 4/13/2011
This monograph has been modified to include the generic and brand name in many instances.

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