TRAZODONE (Desyrel)
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• 0.0 OVERVIEW
• 0.1 LIFE SUPPORT
• A. This overview assumes that basic life support measures have been instituted.
• 0.2 CLINICAL EFFECTS
• 0.2.1 SUMMARY OF EXPOSURE
• A. The most common manifestation of overdose is CNS depression. Lethargy, drowsiness, and ataxia are the most frequent symptoms. Coma is rare, but can be prolonged. Nausea and vomiting are also frequent.
• B. Although seizures and mild cardiovascular abnormalities have been described, these are relatively rare. Bradycardia and transient first degree heart block have been the most frequently reported cardiovascular effects.
• 0.2.3 VITAL SIGNS
• A. Hypotension, bradycardia and respiratory depression may occur with significant ingestions.
• 0.2.4 HEENT
• A. Tinnitus has been infrequently reported.
• B. Mydriasis has been reported.
• 0.2.5 CARDIOVASCULAR
• A. Cardiovascular abnormalities in overdose have been infrequent and usually benign.
• 1. Sporadic reports of hypotension, nonspecific ST-T wave changes, QT prolongation, ventricular premature depolarization, right bundle-branch block, T-wave inversion, delayed intraventricular conduction, first degree AV block and torsades de pointes have been noted.
• 2. Bradycardia is a common side effect, and has been reported in overdose. Hypotension is a side effect due to alpha-receptor blockade after therapeutic use.
• 3. Reports of cardiovascular/ECG abnormalities of trazodone have not always ruled out co-ingestants or underlying cardiac disease.
• 0.2.6 RESPIRATORY
• A. Respiratory depression is an infrequent effect in overdose.
• 0.2.7 NEUROLOGIC
• A. Seizures have been reported in one published case after an ingestion of 23 g and in two unpublished overdoses reported to the manufacturer.
• B. The most common manifestation of overdose is CNS depression, ranging from lethargy to coma. Of 22 patients who ingested trazodone alone, 2 were comatose. Drowsiness occurred in 50% of these patients.
• 1. Prolonged duration of coma (20 hours) has been reported in one case.
• 2. Ataxia has also been reported.
• C. Myoclonus has been reported after therapeutic use.
• 0.2.8 GASTROINTESTINAL
• A. Nausea and vomiting are relatively common.
• 0.2.9 HEPATIC
• A. Liver damage has been reported following therapeutic trazodone doses.
• 0.2.10 GENITOURINARY
• A. Priapism has been noted in at least 1 overdose and in many other instances after therapeutic doses. This may be a very serious side effect requiring surgery.
• 0.2.12 FLUID-ELECTROLYTE
• A. Peripheral edema has been reported in 10% of patients receiving therapeutic doses.
• B. Hyponatremia and marked hypokalemia have been reported following overdose.
• 0.2.13 HEMATOLOGIC
• A. Leukopenia has been reported following therapeutic trazodone doses.
• 0.2.15 MUSCULOSKELETAL
• A. Muscle weakness has been reported in overdose.
• 0.3 LABORATORY/MONITORING
• A. Although cardiovascular toxicity has been minimal in reported overdose, ECG monitoring is recommended since reports of cardiotoxicity have occurred.
• B. Monitor vital signs following overdose. Hypotension and bradycardia have been reported.
• C. Monitor fluid and electrolyte status in symptomatic patients.
• 0.4 TREATMENT OVERVIEW
• 0.4.2 ORAL/PARENTERAL EXPOSURE
• A. EMESIS: Ipecac-induced emesis is not recommended because of the potential for CNS depression and seizures.
• B. GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in Trendelenburg and left lateral decubitus position or by endotracheal intubation. Control any seizures first.
• 1. CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.
• C. ACTIVATED CHARCOAL: Administer charcoal as slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
• D. HYPOTENSION: Infuse 10 to 20 mL/kg isotonic fluid, place in Trendelenburg position. If hypotension persists, administer dopamine (5 to 20 mcg/kg/min) or norepinephrine (0.1 to 0.2 mcg/kg/min), titrate to desired response.
• E. ATROPINE: ADULT DOSE: BRADYCARDIA: 0.5 to 1 mg IV every 5 min. BRADYASYSTOLIC ARREST: 1 mg IV every 5 min. Maximum total dose 0.04 mg/kg. Minimum single dose 0.5 mg. PEDIATRIC DOSE: 0.02 mg/kg IV repeat every 5 min, minimum single dose 0.1 mg; maximum single dose 0.5 mg child, 1 mg adolescent; maximum total dose 1 mg child, 2 mg adolescent.
• F. Administer diazepam IV bolus (DOSE: ADULT: 5 to 10 mg initially which may be repeated every 15 minutes PRN up to 30 mg. CHILD: 0.25 to 0.4 mg/kg/dose up to 10 mg/dose. If seizures cannot be controlled or recur, administer phenobarbital.
• 1. Phenytoin should be avoided due to the potential effect of trazodone on the QTc interval.
• 0.5 RANGE OF TOXICITY
• A. There is minimal experience in overdose in children. Accidental ingestion of 200 mg in a 6-year-old child did not result in toxicity.
• B. Ingestions in adults of 2 to 3 g without co-ingestants have produced respiratory arrest, however effects were limited to drowsiness and ataxia after 4 to 5 g in other cases.
• C. Post mortem blood concentrations of trazodone below 9.0 mg/L are rarely associated with fatalities due solely to trazodone.
• 1.0 SUBSTANCES INCLUDED/SYNONYMS
• 1.1 THERAPEUTIC/TOXIC CLASS
• A. Trazodone is a triazolopyridine derivative, chemically and structurally unrelated to tricyclic and tetracyclic antidepressants, but related to nefazodone. Trazodone is termed an "atypical" tetracyclic antidepressant.
• 1.2 SPECIFIC SUBSTANCES

o             AF 1161

o             Trazodone hydrochloride

o             CAS 19794-93-5 (trazodone)

o             CAS 25332-39-2 (trazodone hydrochloride)

• 1.6 AVAILABLE FORMS/SOURCES
• A. FORMS
• 1. Desyrel(R) is available as 50, 100, and 150 milligram tablets. Generic preparations are also available.
• 2. Trade Names include: Desyrel, Molipaxin, Pragmazone, Tombran, Thombran, Trittico, Manegan, Trazolan.
• 3. Trade names in other countries have included:

§            Molipaxin (U.K.)

§            Manegan (Argentina)

§            Thombran (Germany)

§            Trittico (Italy, Switzerland)

§            Trazolan (Belgium)

• B. USES
• 1. Trazodone is termed an "atypical" tetracyclic antidepressant since it has antidepressant and also anxiolytic and hypnotic activities. It is a powerful antagonist of 5HT2A receptors and has some serotonin reuptake blockade actions. Trazodone is used for the treatment of depression, and is particularly beneficial to older patients due to its combination of sedation without anticholinergic effects (Goeringer et al, 2000).
• 3.0 CLINICAL EFFECTS
• 3.1 SUMMARY OF EXPOSURE
• A. The most common manifestation of overdose is CNS depression. Lethargy, drowsiness, and ataxia are the most frequent symptoms. Coma is rare, but can be prolonged. Nausea and vomiting are also frequent.
• B. Although seizures and mild cardiovascular abnormalities have been described, these are relatively rare. Bradycardia and transient first degree heart block have been the most frequently reported cardiovascular effects.
• 3.3 VITAL SIGNS
• 3.3.1 SUMMARY
• A. Hypotension, bradycardia and respiratory depression may occur with significant ingestions.
• 3.4 HEENT
• 3.4.1 SUMMARY
• A. Tinnitus has been infrequently reported.
• B. Mydriasis has been reported.
• 3.4.3 EYES
• A. The reappearance or persistence of an image has been associated with dosage increases in patients receiving trazodone therapeutically (Hughes & Lessell, 1990).
• B. Mydriasis has been reported following an acute overdose (Vanpee et al, 1999).
• 3.4.4 EARS
• A. TINNITUS was reported in 1 of 20 patients who overdosed on trazodone alone (Henry & Ali, 1983).
• 3.5 CARDIOVASCULAR
• 3.5.1 SUMMARY
• A. Cardiovascular abnormalities in overdose have been infrequent and usually benign.
• 1. Sporadic reports of hypotension, nonspecific ST-T wave changes, QT prolongation, ventricular premature depolarization, right bundle-branch block, T-wave inversion, delayed intraventricular conduction, first degree AV block and torsades de pointes have been noted.
• 2. Bradycardia is a common side effect, and has been reported in overdose. Hypotension is a side effect due to alpha-receptor blockade after therapeutic use.
• 3. Reports of cardiovascular/ECG abnormalities of trazodone have not always ruled out co-ingestants or underlying cardiac disease.
• 3.5.2 CLINICAL EFFECTS
• A. HYPOTENSION
• 1. Hypotension was reported in 1 of 20 adult overdoses with trazodone alone (Henry & Ali, 1983).
• 2. CASE REPORT - A 49-year-old patient ingesting 4 to 8 grams had mild hypotension. Diazepam, acetaminophen, and caffeine were co-ingestants (Root & Ohlson, 1984).
• 3. CASE REPORT - Hypotension and respiratory arrest occurred after ingestion of 2200 mg of trazodone (no coingestants reported) in a 40-year-old woman (Gamble & Peterson, 1986).
• 4. CASE REPORT - Persistent hypotension requiring continuous dopamine infusion (up to 583 mcg/min) was reported in a 37-year-old female following the ingestion of 20 trazodone tablets and some ethanol. The patient also developed torsades de pointe. Her requirement for inotropic support lasted 6 days before she recovered (Wittebole et al, 2000).
• 5. The most frequent cardiovascular side effect during therapy is postural hypotension, which may be accompanied by syncope, especially in patients taking concomitant antihypertensive therapy. (Rakel, 1984; Spivak et al, 1987).
• B. AV BLOCK
• 1. CASE REPORT - One case of first degree AV block has been described following ingestion of an unknown amount of trazodone along with oxazepam in a 65-year-old woman, which did not require treatment (Lippmann et al, 1982).
• 2. CASE SERIES - One case of first-degree AV block (coingestants alprazolam and ibuprofen) and 2 cases of right bundle branch block (coingestants amphetamines in one case and quinidine plus lorazepam in the other) were reported to the manufacturer in 88 cases reviewed (Gamble & Peterson, 1986).
• 3. Reports of cardiovascular/electrocardiographic toxicity of trazodone have not always ruled out coingestants or underlying cardiac disease.
• C. ARRHYTHMIA
• 1. In a retrospective study of 40 patients who had ECGs after trazodone overdose a significant percentage of patients were found to have ECG abnormalities and/or dysrhythmias (Tibbles et al, 1997). Patients with underlying cardiac disease, an abnormal baseline ECG, or ingestion of other agents known to alter cardiac conduction were excluded.
• a. Eleven of the 40 patients (32%) developed dysrhythmias, including torsade de pointes (2), ventricular bigeminy (2), supraventricular tachycardia (2), atrial fibrillation (1), first degree AV block (2), and intraventricular conduction delay (2). Prolongation of the QTc interval developed in 77% of patients and all patients with dysrhythmias had prolonged QTc.
• D. BRADYCARDIA
• 1. Trazodone does not appear to produce tachycardia, even in patients with hypotension, and consistently lowers baseline heart rate in therapeutic doses (Himmelhoch et al, 1984).
• 2. CASE REPORT - Severe bradycardia and hypotension were reported in a 32-year- old woman who ingested 1000 mg of trazodone (20 mg/kg). Bradycardia developed about 4 hours postingestion and persisted for 32 hours (Dubot et al, 1986).
• 3. Reports of cardiovascular/electrocardiographic toxicity of trazodone have not always ruled out coingestants or underlying cardiac disease.
• E. ECG ABNORMAL
• 1. EKG changes are uncommon after overdose. In a review of 88 cases spontaneously reported to the manufacturer, 5 developed EKG changes.
• a. CASE SERIES - Two patients with coingestants developed right bundle-branch block, one had T wave inversion after trazodone alone, and the other had transient first-degree AV block (Gamble & Peterson, 1986).
• 2. CASE REPORT - One elderly patient developed torsades de pointes following a trazodone overdose (Augenstein et al, 1987).
• 3. CASE REPORT - Non-specific ST-T wave changes along with up to 5 ventricular premature beats per minute were reported in a 58-year-old woman who ingested 6 grams of trazodone, along with lithium, theophylline, and aspirin (Gamble & Peterson, 1986).
• 4. In 23 adult overdoses with trazodone alone, no cardiovascular abnormalities were reported, but EKG's were not examined (Ali & Henry, 1986).
• 5. Reports of cardiovascular/electrocardiographic toxicity of trazodone have not always ruled out coingestants or underlying cardiac disease.
• F. HEART BLOCK
• 1. CASE REPORT - There is one report of complete heart block with an idiojunction rhythm (rate 36 beats/min), requiring pacemaker insertion, in a 77-year-old man who received a single dose of 50 mg forty minutes previously. This patient appeared to have an underlying conduction defect (Rausch et al, 1984).
• 2. CASE REPORT - First-degree heart block was reported in a 74-year-old man after increasing the trazodone dose to 125 mg twice a day. The P-R interval normalized after dose reduction (Irwin & Spar, 1983).
• G. TACHYCARDIA VENTRICULAR
• 1. CASE REPORTS - In 3 patients, aged 26, 61 and 41 years with preexisting cardiac disease, therapeutic use of trazodone appears to have exacerbated premature ventricular contractions in 2 cases and ventricular tachycardia in one case (Janowsky et al, 1983; Vlay & Friedling, 1983).
• 2. CASE REPORT - In a hospitalized patient who developed ventricular fibrillation following surgery, administration of trazodone 75 mg for 3 days was associated with sinus tachycardia alternating with bradycardia and sinus arrest, hypotension, and premature ventricular contractions (Pellettier & Bartolucci, 1984).
• 3. CASE REPORT - Exercise-induced nonsustained ventricular tachycardia was described in a 79-year-old woman with no underlying heart disease receiving trazodone 50 mg twice daily.
• a. The relationship to trazodone was confirmed by treadmill testing initially, following discontinuation, and after rechallenge with trazodone (Vitullo et al, 1990).
• H. QT INCREASED
• 1. CASE SERIES - Trazodone 150 mg, administered in a single dose to 8 healthy volunteers, was found to significantly prolong the QTc interval and decrease T wave height at 30 minutes postingestion (Burgess et al, 1982).
• 2. QTc prolongation can be expected to be part of the clinical picture of overdose. The QTc interval was prolonged on day 1 but not on day 15 in another study (Van de Merwe et al, 1984).
• 3. CASE SERIES - In a retrospective review of 40 patients with trazodone ingestion 77% developed prolonged QTc and 11 patients developed dysrhythmias (Tibbles et al, 1997). All patients who developed dysrhythmias had prolonged QTc intervals.
• 4. CASE REPORT - Prolonged corrected QT interval (607 msec), sinus bradycardia (57 beats/min) and non-specific T-wave changes without dysrhythmia or other significant adverse effects, was reported in a 29-year-old female 12 hours following an overdose of 3000 mg trazodone. ECG 26 hours post-ingestion showed a less prolonged, corrected QT interval (486 msec) and the same non-specific T-wave changes. No baseline ECG was available. Complete recovery ensued (Levenson, 1999).
• 5. CASE REPORT - A case of torsades de pointe related to a prolonged QT interval (QT/QTc: 520/370 msec) has been reported in a 37-year-old female following an overdose of 20 trazodone tablets in conjunction with ethanol. Severe hypotension (bp 70/40 mmHg) and a relative bradycardia were noted on admission. Marked hypokalemia (2.7 mmol/L) was noted during the first episode of torsades de pointe but not with the second episode. Inotropic support was required for 6 days as was correction of the QT/QTc interval (Wittebole et al, 2000).
• 3.6 RESPIRATORY
• 3.6.1 SUMMARY
• A. Respiratory depression is an infrequent effect in overdose.
• 3.6.2 CLINICAL EFFECTS
• A. RESPIRATORY DEPRESSION
• 1. CASE REPORT - Brief intubation and ventilation was required in a 65-year-old woman who overdosed on an unknown amount of trazodone (Lippmann et al, 1982).
• 2. CASE SERIES - Respiratory arrest, requiring intubation and ventilatory assistance was reported in a 40-year-old woman who ingested 2200 mg of trazodone alone and in a woman who ingested 3000 mg of trazodone alone (Gamble & Peterson, 1986).
• 3.7 NEUROLOGIC
• 3.7.1 SUMMARY
• A. Seizures have been reported in one published case after an ingestion of 23 g and in two unpublished overdoses reported to the manufacturer.
• B. The most common manifestation of overdose is CNS depression, ranging from lethargy to coma. Of 22 patients who ingested trazodone alone, 2 were comatose. Drowsiness occurred in 50% of these patients.
• 1. Prolonged duration of coma (20 hours) has been reported in one case.
• 2. Ataxia has also been reported.
• C. Myoclonus has been reported after therapeutic use.
• 3.7.2 CLINICAL EFFECTS
• A. SEIZURES
• 1. CASE REPORT - Respiratory arrest and seizures were reported in a patient who took 2 to 3 grams in an overdose (Flomenbaum & Price, 1986).
• 2. CASE REPORT - Two brief tonic-clonic seizures and hyponatremia (sodium 118 mmol/liter) developed in a 72-year-old female approximately 30 hours following an overdose of 350 mg trazodone. The patient had also concurrently been on oxazepam and propranolol at the time of the overdose. Treatment consisted of intravenous diazepam and fluid restriction. She was discharged 9 days after her overdose with no further seizures (Balestrieri et al, 1992).
• 3. CASE REPORT - Seizures and hyponatremia (sodium 106 mmol/L) were reported about 40 hours following a 1200 mg overdose in a 60-year-old female. CT of the brain was normal. Following clonazepam therapy and fluid restriction, the seizures and hyponatremia resolved over a 3-day-period (Vanpee et al, 1999).
• 4. CASE SERIES - In a review of 88 unpublished overdoses reported to the manufacturer, seizures were seen in two cases (trazodone alone 3 grams in one case and trazodone 750 mg plus alprazolam 13 mg in the other) (Gamble & Peterson, 1986).
• 5. CASE REPORT - Generalized seizures have been described in a 50-year-old patient with a pre-existing abnormal EEG but no history of seizures following trazodone therapy with 50 mg per day for 18 days (Lefkowitz et al, 1985).
• 6. The manufacturer had received approximately 30 reports of seizures, the majority in patients with a history of seizures, focal CNS lesions, or concomitant use of other medications.
• 7. CASE REPORT - Another report described a 47-year-old man who developed complex partial seizures after treatment with trazodone 150 mg/day for 3 weeks. EEG findings were abnormal after discontinuation of trazodone and it was speculated that trazodone unmasked an underlying seizure disorder (Tasini, 1986).
• B. MYOCLONUS
• 1. CASE REPORT - Myoclonus was reported in a 38-year-old woman receiving 300 mg/ day (Patel et al, 1988). This may be related to serotonergic activity.
• C. SOMNOLENCE
• 1. Somnolence is common following acute overdoses.
• 2. CASE SERIES - Drowsiness was reported in 11 of 22 adult patients who overdosed on trazodone alone (Henry et al, 1984).
• D. COMA
• 1. CASE SERIES - The most common manifestation of overdose is CNS depression, ranging from lethargy to coma. In 22 adult patients with sole ingestions of trazodone, two were comatose (grade 2 to 3 on the Edinburgh scale) (mean dose 1.4 grams) (Henry et al, 1984).
• 2. The prolonged duration of coma (20 hours) in one case may indicate involvement of an active metabolite, possibly m-chlorophenylpiperazine (Caccia et al, 1982)
• E. ATAXIA
• 1. CASE SERIES - Ataxia was reported in 5 of 22 adults who overdosed as trazodone alone (Henry et al, 1984).
• F. LACK OF EFFECT
• 1. Seizures were not reported in a series of 44 adult patients who overdosed on trazodone (Ali & Henry, 1986). Seizures were also not found in a series of 26 trazodone overdoses (Wedin et al, 1986).
• 3.8 GASTROINTESTINAL
• 3.8.1 SUMMARY
• A. Nausea and vomiting are relatively common.
• 3.8.2 CLINICAL EFFECTS
• A. NAUSEA VOMITING
• 1. Nausea and vomiting are relatively common after overdose.
• B. ANOREXIA
• 1. CASE REPORT - Anorexia and hypomania were reported in a patient given 100 mg trazodone and 500 mg of tryptophan three times a week. Appetite returned when trazodone was discontinued (Patterson & Srisopark, 1989).
• 3.9 HEPATIC
• 3.9.1 SUMMARY
• A. Liver damage has been reported following therapeutic trazodone doses.
• 3.9.2 CLINICAL EFFECTS
• A. HEPATITIS
• 1. CASE REPORT - A 75-year-old female presented to ED with jaundice, dark urine, pale stools, nausea and anorexia. Liver function and serologic tests revealed a chronic active hepatitis. The patient was taking no other medication and had no history of alcohol or intravenous drug use or blood transfusions. Prothrombin and thromboplastin times were elevated and remained elevated despite 3 days of vitamin K therapy (Beck et al, 1993).
• a. Within one week of discontinuing trazodone, the patients nausea and anorexia resolved. 10 days later, aminotransferase enzyme levels were markedly decreased, and subsequently returned to normal within 4 weeks. Bilirubin and GGTP levels gradually returned to normal after 6 months.
• 2. CASE REPORT - Acute reversible hepatic damage after 18 months of trazodone and corticosteroid therapy was reported in a 38-year-old female. Liver biopsy revealed a cholestatic process. All medications were stopped and her liver enzyme tests started to improve. Following an inadvertent re-challenge with trazodone, liver enzyme levels immediately began to increase. Trazodone was again stopped and the patient's liver function returned to normal (Fernandes et al, 2000).
• 3.10 GENITOURINARY
• 3.10.1 SUMMARY
• A. Priapism has been noted in at least 1 overdose and in many other instances after therapeutic doses. This may be a very serious side effect requiring surgery.
• 3.10.2 CLINICAL EFFECTS
• A. PRIAPISM
• 1. Priapism has been seen as an adverse effect from therapeutic doses (Scher et al, 1983; Hanno et al, 1988; Carson & Mino, 1988), and also rarely after overdose.
• 2. CASE REPORT - A 24-year-old male who took 3.5 grams of trazodone developed priapism (Gamble & Peterson, 1986).
• 3. CASE SERIES - Surgery was required in 26 of 84 cases reported to the manufacturer and permanent impotence has been a sequela (Hayes & Kristoff, 1986).
• 4. CASE REPORT - A 34-year-old female presented with priapism of the clitoris after taking trazodone for 5 days while withdrawing from fluoxetine. Both medications were discontinued and an alpha-adrenergic agonist (phenylpropranolamine) was administered. Within 24 hours the clitoral priapism had resolved (Pescatori et al, 1993).
• 5. Prolonged or inappropriate erections should be referred to a physician after immediately discontinuing the drug.
• 3.12 FLUID-ELECTROLYTE
• 3.12.1 SUMMARY
• A. Peripheral edema has been reported in 10% of patients receiving therapeutic doses.
• B. Hyponatremia and marked hypokalemia have been reported following overdose.
• 3.12.2 CLINICAL EFFECTS
• A. EDEMA PERIPHERAL
• 1. CASE SERIES - Peripheral edema was described during therapeutic use in 10 of 100 patients receiving a mean dose of 370 mg/day (range 150 to 600 mg/day). Dose reduction or discontinuation resulted in prompt resolution (Barrnett et al, 1985).
• 2. Peripheral edema, with an onset within 24 hours of initiation of trazodone therapy, was attributed to an allergic response in one case, but no immunologic evidence was presented (Maguire & Singh, 1987),
• B. HYPONATREMIA
• 1. Rarely, hyponatremia may result following trazodone overdoses. It has been suggested that inappropriate secretion of antidiuretic hormone due to the overdose results in the hyponatremia (Vanpee et al, 1999).
• 2. CASE REPORT - Vanpee et al (1999) reported profound hyponatremia (sodium 106 mmol/L) and seizures in a 60-year-old female approximately 40 hours after a 1200 mg overdose. Hyponatremia and seizures resolved over a 3-day-period following fluid restriction and clonazepam therapy (Vanpee et al, 1999).
• 3. CASE REPORT - Hyponatremia was reported in a 72-year-old female following an overdose of 350 mg trazodone. Approximately 30 hours after the reported overdose, and 10 hours after ED admission, her serum sodium concentration was reported to be 118 mmol/L. It should be noted that this patient had been hydrated during the previous 20 hours and no sodium levels were reported at the time of patient admission. The hyponatremia resolved within 72 hours following fluid restriction (Balestrieri et al, 1992).
• C. HYPOKALEMIA
• 1. CASE REPORT - A marked hypokalemia (2.7 mmol/L) was reported in a 37-year-old woman following an overdose of 20 trazodone tablets and ethanol. Laboratory data revealed no other disturbances. Concurrently, she experienced hypotension and torsades de pointe. The patient recovered following symptomatic therapy (Wittebole et al, 2000).
• 3.13 HEMATOLOGIC
• 3.13.1 SUMMARY
• A. Leukopenia has been reported following therapeutic trazodone doses.
• 3.13.2 CLINICAL EFFECTS
• A. AGRANULOCYTOSIS
• 1. CASE REPORT - A 40-year-old male had been using trazodone for one month prior to admission, with no history of any other concurrent drug or chemical use. He was admitted for perianal furuncles. Hematology laboratory values were normal with the exception of an elevated ESR and decreased leukocyte count of 3.7 x 10(9) (normal range of 4.0 - 10.0). Differential cell count was reported to be 74% lymphocytes, 25% monocytes, and 1% eosinophils (absolute neutrophil count 0). Pus from his furuncles yielded Staphylococcus aureus. Treatment was begun with flucloxacillin. Trazodone therapy was discontinued. Four days later, his leukocyte count had increased and ESR had decreased. 11 days after admission, laboratory values had returned to normal (Van der Klauw et al, 1993).