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Antidepressant-like effects of trazodone on a behavioral screen are mediated by trazodone, not the metabolite m-chlorophenylpiperazine.

Trazodone is an atypical antidepressant drug (i.e. blocks neither monoamine uptake nor monoamine oxidase) which tests as an antidepressant drug on the differential-reinforcement-of-low-rate 72-s (DRL 72-s) schedule of reinforcement by increasing the reinforcement rate and decreasing the response rate. m-Chlorophenylpiperazine (m-CPP) is a 5-HT1B and 5-HT1C agonist, weak 5-HT2 antagonist, and trazodone metabolite. It has been suggested that formation of m-CPP is responsible for the antidepressant action of trazodone. Administration of m-CPP (1-10 mg/kg i.p.) 60, 30 or 10 min before the behavioral session did not mimic the reinforcement rate-increasing effects of trazodone (10-20 mg/kg i.p.) on rats performing under the DRL 72-s schedule of water reinforcement. Pretreatment with proadifen (50 mg/kg i.p.), an inhibitor of trazodone metabolism, caused a greater than 30-fold leftward shift in the dose-response curve for both the reinforcement rate and the response rate. These results suggest that the parent compound and not the trazodone metabolite m-CPP, mediates the antidepressant-like effects of trazodone on DRL 72-s behavior.

Animals

Pathophysiology of prolonged penile erection associated with trazodone use.

Treatment with the antidepressant trazodone has been associated with the occurrence of prolonged penile erection and priapism. To evaluate the effect of trazodone on erection we monitored the periodic physiological sleep-related erections in 6 healthy volunteers in a double-blind crossover study comparing the effect of trazodone, trimipramine (a tricyclic antidepressant) and placebo. In addition, to determine the effects of trazodone on the neurovascular control of penile smooth muscle we performed in vitro studies on corpus cavernosum tissue obtained from patients undergoing penile prosthesis implantation. Trazodone significantly increased the total interval of nocturnal erectile activity, while trimipramine had no effect. During the high dose treatment (nights 4 and 5) the average duration of erectile activity per night with placebo was 158 +/- 41 minutes (mean +/- standard deviation) for night 4 and 177 +/- 21 minutes for night 5. During trazodone treatment the erectile activity per night was significantly prolonged to 285 +/- 115 minutes during night 4 and 232 +/- 86 during night 5 (p less than 0.01). Analysis of the erectile activity in relation to the rapid eye movement sleep period during which erectile activity usually occurs revealed that the detumescence phase of erection, under sympathetic control, was significantly prolonged an average of 2.4 times by trazodone compared to placebo (p less than 0.05). In vitro, trazodone at concentrations comparable to those reached in plasma significantly impaired corporeal smooth muscle contractions elicited by electrical stimulation of adrenergic nerves and antagonized contractions induced by exogenous norepinephrine. We conclude that trazodone can enhance penile erection in man and propose a mechanism related to the alpha-adrenoceptor blocking properties of trazodone by interference with the sympathetic control of penile detumescence.

Adolescent

Single dose pharmacokinetics of trazodone in healthy subjects.

Eight healthy subjects were administered trazodone-HCl orally (100 mg) with and without food and by infusion in a three way cross-over study. Unchanged trazodone was determined in serum and urine by high performance liquid chromatography after an alkaline extraction. Absorption of trazodone was irregular in fasting subjects and improved after food intake. Food intake significantly decreased the maximum serum concentrations of trazodone from 1.88 +/- 0.42 to 1.47 +/- 0.16 micrograms/ml, and increased the time for reaching maximum concentration from 1.3 +/- 0.8 hr to 2.0 +/- 1.5 hr. No differences were observed in the total amount of trazodone absorbed with or without food with bioavailability values of 65 +/- 6 and 63 +/- 4 per cent, respectively. The apparent volume of distribution and total body clearance for trazodone were estimated to 0.84 +/- 0.16 l/kg and 5.3 +/- 0.9 l/hr, respectively. The terminal elimination half-life of 7.3 +/- 0.8 hr showed no significant differences between the different ways of administration. Urinary excretion of unchanged trazodone during 26 hr was less than 0.13 per cent of the administered dose, suggesting a high degree of trazodone metabolism. Earlier statements of enterohepatic circulation of trazodone and pharmacokinetic differences between males and females were not confirmed by the present study. Due to the irregular absorption in fasting subjects, trazodone should preferably be administered after food.

Absorption

[Effect of trazodone (KB-831) and its metabolites on brain monoamines in rat].

The effects of trazodone (KB-831) and its metabolites on the uptake, turnover and contents of monoamines in rats were studied in comparison with those of imipramine and mianserin. Trazodone exhibited a more potent inhibitory effect on the uptake of [3H] 5-hydroxytryptamine (5-HT) into brain synaptosomes than on the uptake of [3H]norepinephrine (NE). Trazodone at 10-30 mg/kg, p.o., also inhibited the p-chloramphetamine-induced depletion of 5-HT in rat brain, but not the 6-hydroxydopamine-induced NE depletion in rat heart. Trazodone was the most selective 5-HT uptake inhibitor among the drugs tested in vitro. Its metabolite, m-chlorophenyl-piperazine (m-CPP), inhibited 5-HT and NE uptake in vitro, but not in vivo. Trazodone (100 mg/kg) and imipramine (30-100 mg/kg) inhibited the depletion of NE induced by alpha-methyl-p-tyrosine, whereas mianserin (100 mg/kg) facilitated it. At 1 hr after a single administration of each drug, an increase in 5-HT content and a decrease in 5-hydroxyindole-3-acetic acid (5-HIAA) content were observed when 30 mg/kg trazodone was used. At 100 mg/kg, trazodone increased the levels of dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) and decreased the NE content. m-CPP (10-30 mg/kg) produced similar effects on monoamine contents to those of trazodone. Imipramine and mianserin had no effect on monoamine contents even at a dose of 100 mg/kg. After 3 weeks of successive administration, an increase in 5-HT and a decrease in 5-HIAA were induced by trazodone and m-CPP at 1 hr, but not at 17 hr, after the final administration. Imipramine decreased the contents of NE and 5-HIAA, and its effects lasted for 17 hr. These results suggest that trazodone is a selective 5-HT uptake inhibitor and that its neurochemical profile is different from those of imipramine and mianserin.

Animals

A drug utilization review of prescribing patterns for trazodone versus amitriptyline.

The second-generation antidepressant trazodone has been thought by some clinicians to exert a less robust antidepressant effect than do tricyclic agents. This impression differs from the findings of numerous published clinical trials. In an effort to determine whether this discrepancy may be due to possible inappropriate dosing or use of trazodone for different patient subtypes, a retrospective chart review of 138 depressed inpatients treated with amitriptyline and of 42 depressed inpatients treated with trazodone was performed to compare their respective prescribing patterns. While these two groups did not differ with regard to most demographic variables, results revealed that patient prescribed trazodone were older (trazodone, mean +/- SD age = 54.5 +/- 8.8 years versus amitriptyline, 43.2 +/- 12.9 years; p less than .001), more often had a recurrent depressive disorder (trazodone = 57.1%, amitriptyline = 39.1%, p less than .06), and more frequently had a history of unresponsiveness to other antidepressants (trazodone = 47.6%, amitriptyline = 11.6%; p less than .001). In addition, initially prescribed daily doses of trazodone were below the recommended starting dose of 150 mg/day (mean +/- SD starting dose = 113.7 +/- 42.1 mg/day), while starting daily doses for amitriptyline (mean +/- SD = 69.8 +/- 20.1 mg/day) were judged to be more adequate relative to the recommended daily dose of 75 mg/day. Final trazodone dosage (mean +/- SD final dose = 217.9 +/- 87.5 mg/day) could be judged to have been far short of optimal levels of 250 to 350 mg/day and of up to 600 mg/day for inpatients and 400 mg/day for outpatient.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult

Post-mortem toxico-kinetics of trazodone.

Trazodone is a structurally unique bicyclic anti-depressant, said to be significantly less toxic than other anti-depressants following an acute overdose. We studied the tissue distribution and post-mortem redistribution of trazodone in two fatalities, one of which allowed comparison with trimipramine, a typical tricyclic anti-depressant. Case 1, a 53-year-old female weighing 72 kg, had femoral vein concentrations of trimipramine 5.5 micrograms/ml, trazodone 14.4 micrograms/ml and alcohol 107 mg%. Case 2, a 48-year-old female of 70 kg, had a femoral vein trazodone of 15.5 micrograms/ml and alcohol 34 mg%, with no other drugs detected. For case 1 and case 2 respectively, trazodone tissue concentrations were: skeletal muscle 7.3 and 9.0 micrograms/g; left and right lungs 13.3, 12.9 and 35.3, 40.1; myocardium, 30.9 and 28.9; kidneys 34.7 and 39.6; liver 73.7 and 82.4; fat 18.5 and 16.5; brain 48.6 and 20.9. For case 1 and 2, respectively, blood trazodone concentrations in 10 initial autopsy samples ranged from 13.7-17.3 and 14.4-16.9 micrograms/ml. Twenty-four and forty-eight hours later the respective ranges were 12.8-18.0 and 12.4-19.9 for case 1, 12.5-20.1 and 12.7-27.0 for case 2. By contrast, for trimipramine, blood concentrations at 0 time, 24 h and 48 hours ranged from 5.5-11.4, 5.2-14.3, and 4.2-18.2, respectively. We conclude that trazodone shows little preferential concentration in solid organs and consequently has relatively stable post-mortem blood concentrations with little drug redistribution artefact. Both the clinical pharmacokinetics and post-mortem toxicokinetics of trazodone differ significantly from the tricyclic anti-depressants.

Female

Experimental examination of trazodone.

To establish the differential indication of trazodone and to find the predictors of its efficacy, we conducted a study in which 45 patients with major depressive disorder and 75 patients with acute schizophrenia were randomly assigned under double-blind conditions to either 400 mg trazodone daily, 150 mg amitriptyline daily, 20 mg haloperidol daily, or placebo daily. At the beginning of the investigations, numerous variables (basic data, MMPI, AMDP, HAM-A, HAM-D) were documented and evaluated on days 3, 7, 14, and 21. In our study, trazodone proved to be as effective an antidepressant drug as amitriptyline. In group comparison, no antipsychotic action of trazodone in schizophrenic patients could be proved. Yet the trazodone treatment was clearly of less risk than the amitriptyline treatment. Under trazodone, provocation of schizophrenic symptoms, which occurred numerously under amitriptyline, was found only in one patient out of 17 schizophrenics. Related to anamnesis and characteristics of the schizophrenic patient, a predictor-variable concerning the antipsychotic effect was not found. It can be assured, however, that patients with depressive symptoms (regarding the entity classification) respond to trazodone. After only 7 days of trazodone treatment, a relatively reliable decision can be established as to whether a therapeutical success can be expected if treatment is continued.

Adult

Quantitative analysis of trazodone hydrochloride in tablets by an ion-selective electrode.

A simple assay procedure for the quantitation of trazodone hydrochloride in tablets, without prior separation, has been developed using a trazodone-selective electrode. The electrode was based on a trazodone:tetrakis(p-chlorophenyl)borate ion-pair complex, dioctyl phthalate, and polyvinyl chloride matrix that were mounted on a PTFE membrane. The electrode showed a near-Nernstian response in the range of 10(-2) to 5 x 10(-6) M trazodone over the pH range of 2.5 to 5.0, with a cationic slope of 58 mV/concentration decade. The durability of the electrode and the reproducibility of the performance among the electrodes were sufficient. The electrode was used for the determination of the pKa value of trazodone. The selectivity of the electrode to a number of interferences was investigated. Many inorganic cations (alkali and alkaline earth metals) and pharmaceutical excipients did not interfere, but some organic ammonium compounds interfered according to their extractability. Determination of 10 to 3000 micrograms/mL of trazodone hydrochloride in aqueous solution showed an average recovery of 100.6% (mean standard deviation 0.4%) by direct potentiometry. This assay was applied to determine trazodone hydrochloride in tablets and the results compared favorably with those obtained by high-performance liquid chromatography.

Chromatography, High Pressure Liquid

Effects of repeated trazodone administrations on serotonergic neurotransmission: biochemical studies.

1. Repeated administrations of trazodone as well as imipramine or mianserin (10 mg/kg i.p. twice daily for 3 weeks) attenuated the norepinephrine (NE) stimulation of adenylate cyclase studied in brain minces. Therefore trazodone shares with "tricyclic" (imipramine) and "atypic" (mianserin) antidepressants the capability to modulate the beta-adrenergic function. 2. Daily treatments with imipramine or trazodone enhanced the Vmax of neural uptake of serotonin (5HT) in minces prepared from rat frontal cortex; in contrast mianserin failed to modify the [3H]-5HT uptake. 3. Repeated administrations of imipramine but not of trazodone or mianserin reduced the maximum number of [3H]-imipramine recognition sites which are located on serotonergic axon terminals. 4. Differently, only repeated administration of trazodone decreased Bmax values of [3H]-mianserin binding sites which are located on membranes innervated by serotonergic neurons. Moreover trazodone did not change the number or affinity of 5HT2 receptors either after single or repeated administrations; in contrast even a single administration with mianserin or repeated administrations with imipramine down-regulated [3H]-ketanserin specific binding in membranes prepared from the frontal cortex. 5. Our observations therefore suggest that trazodone, imipramine or mianserin exerts similar effects on the adenylate cyclase system, by acting on a interneuronal loop which links serotonergic and noradrenergic transmission function. However, its exact mechanism of action, in part resembling both tricyclic and atypic depressants, requires further examination.

Animals

A double-blind, placebo controlled study of trazodone in patients with obsessive-compulsive disorder.

Patients with obsessive-compulsive disorder (OCD) have been shown to be preferentially responsive to serotonin (5-HT) uptake-inhibiting antidepressants including clomipramine, fluoxetine, fluvoxamine, and sertraline. The nontricyclic antidepressant, trazodone, also possesses serotonin reuptake inhibiting properties and has been reported to be efficacious in OCD in several case reports and open trials. In order to investigate trazodone's potential antiobsessive efficacy in a controlled fashion, 21 patients with OCD were entered into a double-blind, parallel design comparison of trazodone and placebo. There were no significant differences in baseline rating scores of OCD or depressive symptoms between those who entered the trazodone phase (N = 13) versus those who entered the placebo phase (N = 8). As measured by standardized OCD and depression rating scales, there was no significant difference in OCD or depressive symptoms in the 17 patients who completed 10 weeks of trazodone (N = 11, mean daily dose, 235 +/- 10 mg) versus 10 weeks of placebo (N = 6) administration. In comparison to clomipramine and fluoxetine treatment which we have found to be associated with greater than 95% reduction in platelet 5-HT concentration, there was only a 26% mean reduction in platelet 5-HT concentration after 10 weeks of trazodone administration. These results indicate that trazodone lacks substantial antiobsessive effects and is associated with only modest reductions in platelet 5-HT concentrations.

Adolescent

A comparison of trazodone and fluoxetine: implications for a serotonergic mechanism of antidepressant action.

Trazodone is an atypical antidepressant drug that is commonly referred to as a serotonin (5-hydroxytryptamine; 5-HT) uptake inhibitor. However, the most potent pharmacological effect of trazodone appears to be antagonist action at 5-HT2/1C receptors. This is in contrast to fluoxetine, for which inhibition of 5-HT uptake is the most potent pharmacological action. The effects of trazodone and fluoxetine on several antidepressant drug screens are mediated by antagonist action at 5-HT2 receptors and inhibition of 5-HT uptake, respectively. While fluoxetine is an effective agent for the treatment of major depression, obsessive-compulsive disorder (OCD) and panic disorder, trazodone does not appear to be effective in the treatment of OCD and panic disorder. In addition, trazodone and fluoxetine differ in humans with respect to their effects on sleep and weight. Taken together, the preclinical and clinical data suggest that trazodone acts as an antidepressant via antagonist action at 5-HT2/1C receptors, while fluoxetine likely acts as an antidepressant via inhibition of 5-HT uptake.

Animals

Effects of intracavernosal trazodone hydrochloride: animal and human studies.

Trazodone hydrochloride is an oral antidepressant agent which has been associated with the improvement of erections in impotent men and the development of prolonged erections or priapism in potent men. An in vivo study in animal and human subjects was performed to gain experience with the effect of intracavernosal trazodone. In the anesthetized New Zealand White rabbit, intracavernosal trazodone or its major metabolite m-chlorophenylpiperazine (m-CPP) produced full penile erection in 76% and 84% of animals studied respectively with doses ranging from one to 15 mg. On the other hand, intracavernosal administration of five mg. papaverine resulted in a prolonged erection in 90% of animals studied. In 13 selected volunteer patients, intracavernosal trazodone caused tumescence but not full penile erection with corporal body pressures of 28.2 +/- 5.8 mm. Hg. Intracavernosal papaverine or papaverine and phentolamine in these subjects resulted in significantly higher corporal body pressures of 58 +/- 18 mm. Hg (p less than .05). Intracavernosal administration of alpha adrenoceptor agonists but not normal saline resulted in complete detumescence of trazodone- or m-CPP-induced prolonged erection in the animal studies. Intracavernosal trazodone results in erectile activity that appears in part based on its local alpha blocking activity but like other intracavernosal alpha-blocking agents is not as effective in initiating penile erections as are intracavernosal agents that directly induce smooth muscle relaxation.

Adrenergic alpha-Antagonists

Efficacy and tolerability of controlled-release trazodone in depression: a large multicentre study in general practice.

A double-blind, parallel-group study was carried out to compare the efficacy and tolerability of a controlled-release tablet formulation of trazodone with the standard trazodone tablet. Three hundred and forty-seven general practice patients with depressive symptoms were recruited into the trial. Patients were randomly allocated to receive either 1 controlled-release trazodone (150 mg) tablet at night or 1 standard trazodone (150 mg) tablet at night for a period of 6 weeks. Assessments of efficacy, tolerability and compliance were made at study entry and after 1, 2, 4 and 6 weeks of study medication. Seventy-seven patients withdrew from the study of whom 44 were in the standard trazodone tablet group and 33 were in the controlled-release trazodone tablet group. There were no statistically significant differences between treatment groups in any of the measures of efficacy (global severity, global improvement and Hamilton Depression Rating Scales 17- and 21-item). Major improvements in patients' condition were shown in all efficacy measures by the end of the study in comparison with study entry. Treatment differences were small but were numerically in favour of the controlled-release tablet formulation. As expected, a greater proportion of side-effects were reported during the first 2 weeks of treatment in both groups. Treatment differences, revealed in a five symptom adverse event checklist used throughout the study, were small, although in favour of the controlled-release tablet in the majority of cases, but not statistically significant.

Adolescent

Acute and chronic administration of trazodone in the treatment of disruptive behavior disorders in children.

We report the results of an open trial of trazodone in the treatment of severe behavioral disturbances in a sample of 22 hospitalized children previously found to be unresponsive to other treatments. Response to treatment was assessed by overall clinical criteria and improvements in individual symptom dimensions during the inpatient hospitalization. Thirteen children (67%) were found to benefit from the introduction of trazodone. Aggressive, impulsive behaviors were symptoms most frequently improved by this agent. Three of those found to be nonresponders actually worsened in symptomatology. A follow-up interview of the parents was conducted 3-14 months after discharge from the inpatient unit, for those children who initially responded to trazodone administration. The results of this interview suggest that the effect of trazodone was persistent for a prolonged period of time after the initial inpatient trial. Trazodone appears to be of value in the management of severe behavioral disturbances in children. The possible mechanism of action of trazodone is discussed.

Aggression

Etoperidone, trazodone and MCPP: in vitro and in vivo identification of serotonin 5-HT1A (antagonistic) activity.

The Ki values for etoperidone, trazodone and MCPP (m-chlorophenylpiperazine dihydrochloride) at 5-HT1A sites (using rat cerebral cortical synaptosomes and [3H]8-OH-DPAT) were determined to be 20.2, 23.6 and 18.9 nM, respectively. In an effort to elucidate the functional nature of the interaction at 5-HT1A sites in vivo, the ability of each compound to elicit reciprocal forepaw treading (RFT) or to block the RFT induced by 8-OH-DPAT in reserpinized rats was tested. Specifically, 8-OH-DPAT (1.0 mg/kg SC)-challenged or non-challenged (control) reserpinized (1.0 mg/kg SC) rats were administered etoperidone, trazodone or MCPP (IP) and scored for the elicitation of RFT (indicative of 5-HT1A agonistic activity) or for block of RFT induced by 8-OH-DPAT (indicative of 5-HT1A antagonistic activity). Reference compounds confirmed the specificity of the test. We report that etoperidone, trazodone and MCPP inhibited 8-OH-DPAT-induced RFT (ID50 = 17.4, 23.8 and 13.4 mg/kg, respectively). Only marginal RFT was produced in non-challenged animals by etoperidone and trazodone at a high dose (40 mg/kg). Taken together, the results suggest a predominant antagonistic activity of etoperidone, trazodone and MCPP at 5-HT1A receptor sites in rat central nervous system. However, one cannot rule out the possibility that these compounds are weak partial agonists. This activity may be relevant to the antidepressant action of these compounds.

8-Hydroxy-2-(di-n-propylamino)tetralin

Acute cardiovascular toxicity of trazodone, etoperidone and imipramine in rats.

The cardiovascular effects of trazodone, a broad-spectrum antidepressant and its analogue etoperidone, were compared with imipramine, following intravenous infusion in rats. Their effects on electrocardiogram and blood pressure were simultaneously recorded until cardiac arrest. Hypotension was the primary effect of trazodone and etoperidone. ECG changes, i.e. lengthening of the PR interval, were observed only when the blood pressure reached very low values. On the other hand, imipramine produced first the well known ECG changes and then a drop in blood pressure. As far as mortality was concerned, trazodone was the least toxic drug, followed by etoperidone, whereas imipramine was most toxic; these differences being in agreement with the LD50 values reported in rats by the i.v. route. It is concluded that trazodone and etoperidone produce in rats cardiovascular effects, which are different from those of imipramine. Moreover these differences are consistent with their pharmacological properties, particularly their interaction with catecholamines, which are inhibited by trazodone or etoperidone and potentiated by imipramine.

Animals

United States experience and perspectives with trazodone.

In the United States, trazodone has shown efficacy comparable with tricyclic antidepressants. Trazodone's side-effect profile, however, is vastly superior to the older drugs. In cases of overdose, trazodone alone has not caused a single death. For depressed patients, starting with 150 mg/day of trazodone, preferably at night, produces best results. Preliminary data suggest good safety and efficacy for patients with chronic depression when used up to 5 1/2 years. New uses for trazodone include treatment of insomnia, chronic pain, obsessive-compulsive disorder (OCD), bulimia nervosa, and psychogeriatrics.

Aged

Evidence for a linear relationship between plasma trazodone levels and clinical response in depression in the elderly.

To investigate a possible relationship between plasma levels of trazodone and its clinical antidepressant effects, 11 elderly depressed patients underwent a 5-week treatment with 150 mg/day trazodone in three oral administrations. Clinical antidepressant response was assessed with two different clinical improvement criteria and plasma trazodone concentrations were determined by high-performance liquid chromatography. A significant correlation was found between steady-state plasma trazodone levels and its antidepressant efficacy, but not between plasma drug levels and the incidence of side effects. Moreover, the steady-state plasma trazodone concentration of 650 ng/ml was identified as threshold value for a greater occurrence of good antidepressant responses.

Administration, Oral