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FDA Drug information

Trazodone Hydrochloride

Read time: 2 mins
Marketing start date: 27 May 2024

Summary of product characteristics


Adverse Reactions

6 ADVERSE REACTIONS The following serious adverse reactions are described elsewhere in the labeling: Suicidal Thoughts and Behavior in Children, Adolescents and Young Adults [see Boxed Warning and Warnings and Precautions ( 5.1 )] Serotonin Syndrome [see Warnings and Precautions ( 5.2 )] Cardiac Arrythmias [see Warnings and Precautions ( 5.3 )] Orthostatic Hypotension and Syncope [see Warnings and Precautions ( 5.4 )] Increased Risk of Bleeding [see Warnings and Precautions ( 5.5 )] Priapism [see Warnings and Precautions ( 5.6 )] Activation of Mania or Hypomania [see Warnings and Precautions ( 5.7 )] Discontinuation Syndrome [see Warnings and Precautions ( 5.8 )] Potential for Cognitive and Motor Impairment [see Warnings and Precautions ( 5.9 )] Angle-Closure Glaucoma [see Warnings and Precautions ( 5.10 )] Hyponatremia [see Warnings and Precautions ( 5.11 )] Most common adverse reactions (incidence ≥ 5% and twice that of placebo) are: edema, blurred vision, syncope, drowsiness, fatigue, diarrhea, nasal congestion, weight loss ( 6 ). To report SUSPECTED ADVERSE REACTIONS, contact Accord Healthcare Inc. at 1-866-941-7875 or www.accordhealthcare.us or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch . 6.1 Clinical Trials Experience 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. Table 2: Common Adverse Reactions Occurring in ≥ 2% of Trazodone Hydrochloride -treated Patients and Greater than the Rate of Placebo-Treated Patients as Observed in Controled Clinical Studies Inpatients Outpatients Trazodone Hydrochloride N=142 Placebo N=95 Trazodone Hydrochloride N=157 Placebo 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. 6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of trazodone hydrochloride tablets. 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

Contraindications

4 CONTRAINDICATIONS Trazodone hydrochloride tablets are contraindicated in: Patients taking, or within 14 days of stopping, monoamine oxidase inhibitors (MAOIs), including MAOIs such as linezolid or intravenous methylene blue, because of an increased risk of serotonin syndrome [see Warnings and Precautions ( 5.2 ), Drug Interactions ( 7.1 )]. Concomitant use of monoamine oxidase inhibitors (MAOIs), or use within 14 days of stopping MAOIs ( 4 ).

Description

11 DESCRIPTION Trazodone hydrochloride tablets, USP for oral administration contain trazodone hydrochloride, a selective serotonin reuptake inhibitor and 5HT 2 receptor antagonist. 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(2 H )-one hydrochloride. It is a white odorless crystalline powder which is freely soluble in water. The structural formula is represented as follows: Each tablet, 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 (maize), and sodium starch glycolate.

Dosage And Administration

2 DOSAGE AND ADMINISTRATION Starting dose: 150 mg in divided doses daily. May be increased by 50 mg per day every three to four days. Maximum dose: 400 mg per day in divided doses ( 2 ). Trazodone hydrochloride tablets should be taken shortly after a meal or light snack ( 2 ). Tablets should be swallowed whole or broken in half along the score line, and should not be chewed or crushed( 2 ). When discontinued, gradual dose reduction is recommended ( 2 ). 2.1 Dose Selection 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. 2.2 Important Administration Instructions 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. 2.3 Screen for Bipolar Disorder Prior to Starting Trazodone Hydrochloride Tablets 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 )]. 2.4 Switching to or from Monoamine Oxidase Inhibitor Antidepressant 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 )]. 2.5 Dosage Recommendations for Concomitant Use with Strong CYP3A4 Inhibitors or Inducers Coadministration with Strong CYP3A4 Inhibitors Consider reducing trazodone hydrochloride tablets dose based on tolerability when trazodone hydrochloride tablets are coadministered with a strong CYP3A4 inhibitor [see Drug Interactions ( 7.1 )]. Coadministration with Strong CYP3A4 Inducers Consider increasing trazodone hydrochloride tablets dose based on therapeutic response when trazodone hydrochloride tablets are coadministered with a strong CYP3A4 inducer [see Drug Interactions ( 7.1 )]. 2.6 Discontinuation of Treatment with Trazodone Hydrochloride Tablets Adverse reactions may occur upon discontinuation of trazodone hydrochloride tablets [See Warnings and Precautions ( 5.8 )]. Gradually reduce the dosage rather than stopping trazodone hydrochloride tablets abruptly whenever possible.

Indications And Usage

1 INDICATIONS AND USAGE Trazodone hydrochloride tablets are indicated for the treatment of major depressive disorder (MDD) in adults. Trazodone hydrochloride is a selective serotonin reuptake inhibitor indicated for the treatment of major depressive disorder (MDD) ( 1 ).

Drug Abuse And Dependence

9 DRUG ABUSE AND DEPENDENCE 9.1 Controlled Substance Trazodone hydrochloride is not a controlled substance. 9.2 Abuse 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.

Overdosage

10 OVERDOSAGE Death from overdose has occurred in patients ingesting trazodone hydrochloride 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 hydrochloride 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 ).

Adverse Reactions Table

Table 2: Common Adverse Reactions Occurring in ≥ 2% of Trazodone Hydrochloride -treated Patients and Greater than the Rate of Placebo-Treated Patients as Observed in Controled Clinical Studies
Inpatients Outpatients
Trazodone Hydrochloride N=142 Placebo N=95 Trazodone Hydrochloride N=157 Placebo N=158
Allergic
Skin Condition/Edema3%1%7%1%
Autonomic
Blurred Vision6%4%15%4%
Constipation7%4%8%6%
Dry Mouth15%8%34%20%
Cardiovascular
Hypertension20%1%1%*
Hypotension7%1%4%0
Syncope3%2%5%1%
CNS
Confusion5%06%8%
Decreased Concentration3%2%1%0
Disorientation2%0*0
Dizziness/Light-Headedness20%5%28%15%
Drowsiness24%6%41%20%
Fatigue11%4%6%3%
Headache10%5%20%16%
Nervousness15%11%6%8%
Gastrointestinal
Abdominal/Gastric Disorder4%4%6%4%
Diarrhea01%5%1%
Nausea/Vomiting10%1%13%10%
Musculoskeletal
Aches/Pains6%3%5%3%
Neurological
Incoordination5%02%*
Tremors3%1%5%4%
Other
Eyes Red/Tired/Itching3%000
Head Full-Heavy3%000
Malaise3%000
Nasal/Sinus Congestion3%06%3%
Weight Gain1%05%2%
Weight Loss*3%6%3%

Drug Interactions

7 DRUG INTERACTIONS CNS Depressants: Trazodone hydrochloride may enhance effects of alcohol, barbiturates, or other CNS depressants ( 7 ). CYP3A4 Inhibitors: Consider trazodone hydrochloride tablets dose reduction based on tolerability ( 2.5 , 7 ). CYP3A4 Inducers: Increase in trazodone hydrochloride tablets dosage may be necessary ( 2.5 , 7 ). Digoxin or Phenytoin: Monitor for increased digoxin or phenytoin serum levels ( 7 ). Warfarin: Monitor for increased or decreased prothrombin time ( 7 ). 7.1 Drugs Having Clinically Important Interactions with Trazodone Hydrochloride Table 3: Clinically Important Drug Interactions with Trazodone Hydrochloride Monoamine Oxidase Inhibitors (MAOIs) Clinical Impact: The concomitant use of MAOIs and serotonergic drugs including trazodone hydrochloride increases the risk of serotonin syndrome. Intervention: Trazodone hydrochloride 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 hydrochloride and other serotonergic drugs increases the risk of serotonin syndrome. Intervention: Monitor patients for signs and symptoms of serotonin syndrome, particularly during trazodone hydrochloride initiation. If serotonin syndrome occurs, consider discontinuation of trazodone hydrochloride 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 hydrochloride may potentiate the risk of bleeding. Intervention: Inform patients of the increased risk of bleeding with the concomitant use of trazodone hydrochloride and antiplatelet agents and anticoagulants. For patients taking warfarin, carefully monitor the international normalized ratio (INR) when initiating or discontinuing trazodone hydrochloride [see Warnings and Precautions ( 5.5 )]. Examples: warfarin, rivaroxaban, dabigatran, clopidogrel Strong CYP3A4 Inhibitors Clinical Impact: The concomitant use of trazodone hydrochloride and strong CYP3A4 inhibitors increased the exposure of trazodone compared to the use of trazodone hydrochloride alone. Intervention: If trazodone hydrochloride is used with a potent CYP3A4 inhibitor, the risk of adverse reactions, including cardiac arrhythmias, may be increased and a lower dose of trazodone hydrochloride 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 hydrochloride and strong CYP3A4 inducers decreased the exposure of trazodone compared to the use of trazodone hydrochloride alone. Intervention: Patients should be closely monitored to see if there is a need for an increased dose of trazodone hydrochloride 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 hydrochloride can increase digoxin or phenytoin concentrations. Intervention: Measure serum digoxin or phenytoin concentrations before initiating concomitant use of trazodone hydrochloride. Continue monitoring and reduce digoxin or phenytoin dose as necessary. Examples: digoxin, phenytoin Central Nervous System (CNS) Depressants Clinical Impact: Trazodone hydrochloride may enhance the response CNS depressants. Intervention: Patients should be counseled that trazodone hydrochloride 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 hydrochloride and increase the risk of cardiac arrhythmia. Intervention: Avoid the use of trazodone hydrochloride tablets 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

Drug Interactions Table

Table 3: Clinically Important Drug Interactions with Trazodone Hydrochloride
Monoamine Oxidase Inhibitors (MAOIs)
Clinical Impact:The concomitant use of MAOIs and serotonergic drugs including trazodone hydrochloride increases the risk of serotonin syndrome.
Intervention:Trazodone hydrochloride 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 hydrochloride and other serotonergic drugs increases the risk of serotonin syndrome.
Intervention:Monitor patients for signs and symptoms of serotonin syndrome, particularly during trazodone hydrochloride initiation. If serotonin syndrome occurs, consider discontinuation of trazodone hydrochloride 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 hydrochloride may potentiate the risk of bleeding.
Intervention:Inform patients of the increased risk of bleeding with the concomitant use of trazodone hydrochloride and antiplatelet agents and anticoagulants. For patients taking warfarin, carefully monitor the international normalized ratio (INR) when initiating or discontinuing trazodone hydrochloride [see Warnings and Precautions ( 5.5)].
Examples:warfarin, rivaroxaban, dabigatran, clopidogrel
Strong CYP3A4 Inhibitors
Clinical Impact:The concomitant use of trazodone hydrochloride and strong CYP3A4 inhibitors increased the exposure of trazodone compared to the use of trazodone hydrochloride alone.
Intervention:If trazodone hydrochloride is used with a potent CYP3A4 inhibitor, the risk of adverse reactions, including cardiac arrhythmias, may be increased and a lower dose of trazodone hydrochloride 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 hydrochloride and strong CYP3A4 inducers decreased the exposure of trazodone compared to the use of trazodone hydrochloride alone.
Intervention:Patients should be closely monitored to see if there is a need for an increased dose of trazodone hydrochloride 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 hydrochloride can increase digoxin or phenytoin concentrations.
Intervention:Measure serum digoxin or phenytoin concentrations before initiating concomitant use of trazodone hydrochloride. Continue monitoring and reduce digoxin or phenytoin dose as necessary.
Examples:digoxin, phenytoin
Central Nervous System (CNS) Depressants
Clinical Impact:Trazodone hydrochloride may enhance the response CNS depressants.
Intervention:Patients should be counseled that trazodone hydrochloride 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 hydrochloride and increase the risk of cardiac arrhythmia.
Intervention:Avoid the use of trazodone hydrochloride tablets 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

Clinical Pharmacology

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action 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 5HT 2 receptor antagonist and the net result of this action on serotonergic transmission and its role in trazodone’s antidepressant effect is unknown. 12.2 Pharmacodynamics 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-HT 2B (Ki = 78.4 nM), 5-HT 2C (Ki = 224 nM), α 1A (Ki = 153 nM), α 2C (Ki = 155 nM) receptors and it is a partial agonist at 5­ HT 1A (Ki = 118 nM) receptor. Trazodone antagonizes alpha 1-adrenergic receptors, a property which may be associated with postural hypotension. 12.3 Pharmacokinetics 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 vitro studies 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 vitro at concentrations attained with therapeutic doses in humans.

Effective Time

20231109

Version

102

Dosage Forms And Strengths

3 DOSAGE FORMS AND STRENGTHS Trazodone hydrochloride tablets, USP having functional scoring are available in the following strengths: 50 mg : white to off white, round, biconvex,uncoated tablets Engraved “IT” bisect “50” on one side and plain on the other side. 100 mg : white to off white, round, biconvex,uncoated tablets Engraved “IT” bisect “100” on one side and plain on the other side. 150 mg : white to off white, oval, flat faced bevelled edge uncoated tablets with full bisect and two partial trisects. engraved “IT” and “150” on one side and two trisect engraved “50 50 50” on each part with middle “50” perpendicular to the other on other side. 300 mg : white to off white, oval, flat faced bevelled edge uncoated tablets with full bisect and two partial trisects. engraved “IT” and “300” on one side and two trisect engraved “100 100 100” on each part with middle “100” perpendicular to the other on other side. Bisectable tablets having functional scoring of 50 mg, 100 mg, 150 mg and 300 mg ( 3 ).

Spl Product Data Elements

Trazodone Hydrochloride Trazodone Hydrochloride SILICON DIOXIDE MAGNESIUM STEARATE MICROCRYSTALLINE CELLULOSE STARCH, CORN SODIUM STARCH GLYCOLATE TYPE A POTATO TRAZODONE HYDROCHLORIDE TRAZODONE white to off white biconvex IT;50 structure

Nonclinical Toxicology

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 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 adult on mg/m 2 basis. 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 mg/m 2 basis in adolescents.

Application Number

ANDA206923

Brand Name

Trazodone Hydrochloride

Generic Name

Trazodone Hydrochloride

Product Ndc

71335-1575

Product Type

HUMAN PRESCRIPTION DRUG

Route

ORAL

Package Label Principal Display Panel

Trazodone HCI 50mg Tablet Label

Information For Patients

17 PATIENT COUNSELING INFORMATION 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, amphetamines, 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. Advise patients that there is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to trazodone during pregnancy [see Use in Special Populations ( 8.1 )]. Manufactured For: Accord Healthcare, Inc., 1009 Slater Road, Suite 210-B Durham, NC 27703, USA. Manufactured By: Intas Pharmaceuticals Limited, Plot No. : 5 to 14, Pharmez, Nr. Village Matoda, Bavla Road, Ta.- Sanand, Dist.- Ahmedabad – 382 213, India. 51 2487 1 718000 Issued November 2018

Spl Medguide

MEDICATION GUIDE Trazodone Hydrochloride Tablets (traz-oh-done hye-droe-klor-ide) 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: All risks and benefits of treatment with antidepressant medicines All treatment choices for depression or other serious mental illnesses 1. Antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, and young adults within the first few months of treatment . 2. Depression and other serious mental illnesses are the most important causes of suicidal thoughts and actions . Some people may have a higher risk of having suicidal thoughts or actions . These include people who have or have a family history of bipolar illness (also called manic- depressive illness) or suicidal thoughts or actions. 3. How can I watch for and try to prevent suicidal thoughts and actions? Pay close attention to any changes, especially sudden changes in mood, behaviors, thoughts, or feelings. This is very important when an antidepressant medicine is started or when the dose is changed. Call your healthcare provider right away to report new or sudden changes in mood, behavior, thoughts or feelings. Keep all follow-up visits with your healthcare provider as scheduled. Call your healthcare provider between visits as needed, especially if you are worried about symptoms. Call a healthcare provider right away if you have any of the following symptoms, especially if they are new, worse, or worry you: Thoughts about suicide or dying Attempts to commit suicide New or worse depression New or worse anxiety Feeling very agitated or restless Panic attacks Trouble sleeping (insomnia) New or worse irritability Acting aggressive, being angry or violent Acting on dangerous impulses An extreme increase in activity and talking (mania) Other unusual changes in behavior or mood What else do I need to know about antidepressant medicines? Never stop an antidepressant medicine without first talking to a healthcare provider. . Stopping an antidepressant medicine suddenly can cause other symptoms. Antidepressants are medicines used to treat depression and other illnesses. It is important to discuss all the risks of treating depression and also the risks of not treating it. You should discuss all treatment choices with your healthcare provider, not just the use of antidepressants. Antidepressant medicines have other side effects . Talk to your healthcare provider about the side effects of your medicines. Antidepressant medicines can interact with other medicines. Know all of the medicines that you take. Keep a list of all medicines to show your healthcare provider. Do not start new medicines without first checking with your healthcare provider. It is not known if trazodone hydrochloride tablets are safe and effective in children. What are trazodone hydrochloride tablets? Trazodone hydrochloride tablets are a prescription medicine used in adults to treat major depressive disorder (MDD). Trazodone hydrochloride belongs to a class of medicines known as SSRIs (or selective serotonin reuptake inhibitors). Do not take trazodone hydrochloride tablets: If you take a monoamine oxidase inhibitor (MAOI). Ask your healthcare provider or pharmacist if you are not sure if you take an MAOI, including the antibiotic linezolid, and intravenous methylene blue. Do not take an MAOI within 2 weeks of stopping trazodone hydrochloride tablets unless directed to do so by your healthcare provider. Do not start trazodone hydrochloride tablets if you stopped taking an MAOI in the last 2 weeks unless directed to do so by your healthcare provider. Before you take trazodone hydrochloride tablets tell your healthcare provider about all of your medical conditions, including if you: have heart problems, including QT prolongation or a family history of it have ever had a heart attack have bipolar disorder have liver or kidney problems have other serious medical conditions are pregnant or plan to become pregnant. It is not known if trazodone hydrochloride tablets will harm your unborn baby. Talk to your healthcare provider about the risk to your unborn baby if you take trazodone hydrochloride tablets. If you become pregnant during treatment with trazodone hydrochloride tablets, talk to your healthcare provider about registering with the National Pregnancy Registry for Antidepressants. You can register by calling 1-844-405-6185. are breastfeeding or plan to breastfeed. Trazodone hydrochloride passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby if you take trazodone hydrochloride tablets. have taken a Monoamine Oxidase Inhibitor (MAOI) or if you have stopped taking an MAOI in the last 2 weeks. Tell your healthcare provider about all the medicines you take , including prescription and over-the-counter medicines, vitamins, and herbal supplements. Using trazodone hydrochloride tablets with certain other medicines can affect each other causing serious side effects. Especially tell your healthcare provider if you take: triptans used to treat migraine headache medicines used to treat mood, anxiety, psychotic or thought disorders, including tricyclics, lithium, SSRIs, SNRIs, buspirone, or antipsychotics tramadol over-the-counter supplements such as tryptophan or St. John’s Wort nonsteroidal anti-inflammatory drugs (NSAIDS) aspirin warfarin (Coumadin, Jantoven) phenytoin (Mesantoin) diuretics Know the medicines you take. Keep a list of them and show it to your healthcare provider and pharmacist when you get a new medicine. How should I take trazodone hydrochloride tablets? Take trazodone hydrochloride tablets exactly as your healthcare provider tells you. Trazodone hydrochloride tablets should be taken shortly after a meal or light snack. If you feel drowsy after taking trazodone hydrochloride tablets, talk to your healthcare provider. Your healthcare provider may change your dose or the time of day you take your trazodone hydrochloride tablets. Do not stop taking trazodone hydrochloride tablets without talking to your healthcare provider. Trazodone hydrochloride tablets should be swallowed whole or broken in half along the score line. Do not chew or crush trazodone hydrochloride tablets. Tell your healthcare provider if you cannot swallow trazodone either whole or as a half tablet. If you take too much trazodone hydrochloride tablets, call your healthcare provider, your Poison Control Center at 1-800-222-1222, or go to the nearest emergency room right away. What should I avoid while taking trazodone hydrochloride tablets? Do not drive, operate heavy machinery, or do other dangerous activities until you know how trazodone hydrochloride tablets affects you. Trazodone hydrochloride tablets can slow your thinking and motor skills. Do not drink alcohol or take other medicines that make you sleepy or dizzy while taking trazodone hydrochloride tablets until you talk with your healthcare provider. Trazodone hydrochloride tablets may make your sleepiness or dizziness worse if you take it with alcohol or other medicines that cause sleepiness or dizziness. What are the possible side effects of trazodone hydrochloride tablets? Trazodone hydrochloride tablets can cause serious side effects or death, including: See “What is the most important information I should know about trazodone hydrochloride tablets?” Serotonin syndrome. Symptoms of serotonin syndrome include: agitation, hallucinations, problems with coordination, fast heartbeat, tight muscles, trouble walking, sweating, fever, nausea, vomiting, and diarrhea. Irregular or fast heartbeat or faint (QT prolongation) Low blood pressure. You feel dizzy or faint when you change positions (go from sitting to standing) Unusual bruising or bleeding Erection lasting for more than 6 hours (priapism) Feeling high or in a very good mood, then becoming irritable, or having too much energy, feeling like you have to keep talking or do not sleep (mania). Withdrawal symptoms. Symptoms of withdrawal can include anxiety, agitation, and sleep problems. Do not stop taking trazodone hydrochloride tablets without talking to your healthcare provider. Visual problems eye pain changes in vision swelling or redness in or around the eye Only some people are at risk for these problems. You may want to undergo an eye examination to see if you are at risk and receive preventative treatment if you are. Low sodium in your blood (hyponatremia). Symptoms of hyponatremia include: headache, feeling weak, feeling confused, trouble concentrating, memory problems and feeling unsteady when you walk. Get medical help right away, if you have any of the symptoms listed above. The most common side effects of trazodone hydrochloride tablets include: swelling blurred vision dizziness sleepiness tiredness diarrhea stuffy nose weight loss These are not all the possible side effects of trazodone hydrochloride tablets. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store trazodone hydrochloride tablets? Store trazodone hydrochloride tablets at room temperature between 68°F to 77°F (20°C to 25°C). Keep in tight container Keep out of the light Safely throw away medicine that is out of date or no longer needed. Keep trazodone hydrochloride tablets and all medicines out of the reach of children. 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. For more information, go to www.accordhealthcare.us or call Accord Healthcare Inc. at 1-866-941-7875. What are the ingredients in trazodone hydrochloride tablets? Active ingredient: trazodone hydrochloride, USP Inactive ingredients: colloidal silicon dioxide, magnesium stearate, microcrystalline cellulose, pregelatinized starch (maize) and sodium starch glycolate. This Medication Guide has been approved by the U.S. Food and Drug Administration. Medication guide available at www.accordhealthcare.us/medication-guides Manufactured For: Accord Healthcare, Inc., 1009 Slater Road, Suite 210-B Durham, NC 27703, USA. Manufactured By: Intas Pharmaceuticals Limited, Plot No. : 5 to 14, Pharmez, Nr. Village Matoda, Bavla Road, Ta.- Sanand, Dist.- Ahmedabad – 382 213, India. 51 2487 1 718000 Issued November 2018

Clinical Studies

14 CLINICAL STUDIES 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.

Use In Specific Populations

8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 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 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 to 11 times the maximum recommended human dose (MRHD) of 400 mg/day in adults on a mg/m 2 basis. There was also an increase in congenital anomalies in the rabbit at approximately 7.3 to 22 times the MRHD on a mg/m 2 basis (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 and 22 times, in rats and rabbits, respectively, the maximum recommended human dose (MRHD) of 400 mg/day in adults on a mg/m 2 basis. Increased fetal resorption and other adverse effects on the fetus in rats at 7.3 to 11 times the MRHD and increase in congenital anomalies in rabbits at 7.3 to 22 times the MRHD on a mg/m 2 basis were observed. No further details on these studies are available. 8.2 Lactation 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 and any potential adverse effects on the breastfed child from trazodone or from the underlying maternal condition. 8.4 Pediatric Use 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 )]. 8.5 Geriatric Use 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 ) ]. 8.6 Renal Impairment Trazodone has not been studied in patients with renal impairment. Trazodone should be used with caution in this population. 8.7 Hepatic Impairment Trazodone has not been studied in patients with hepatic impairment. Trazodone should be used with caution in this population.

How Supplied

16 HOW SUPPLIED/STORAGE AND HANDLING Trazodone hydrochloride tablets, USP 50 mg having functional scoring are available for oral administration as white to off white, round, biconvex, uncoated tablets Engraved “IT” bisect “50” on one side and plain on the other side. NDC: 71335-1575-1: 20 Tablets in a BOTTLE NDC: 71335-1575-2: 30 Tablets in a BOTTLE NDC: 71335-1575-3: 60 Tablets in a BOTTLE NDC: 71335-1575-4: 90 Tablets in a BOTTLE NDC: 71335-1575-5: 45 Tablets in a BOTTLE NDC: 71335-1575-6: 100 Tablets in a BOTTLE NDC: 71335-1575-7: 25 Tablets in a BOTTLE NDC: 71335-1575-8: 120 Tablets in a BOTTLE NDC: 71335-1575-9: 28 Tablets in a BOTTLE NDC: 71335-1575-0: 14 Tablets in a BOTTLE Repackaged/Relabeled by: Bryant Ranch Prepack, Inc. Burbank, CA 91504

Boxed Warning

WARNING: SUICIDAL THOUGHTS and BEHAVIORS 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 hydrochloride tablet is not approved for use in pediatric patients [see Use in Specific Populations ( 8.4 )]. WARNING: SUICIDAL THOUGHTS and BEHAVIORS See full prescribing information for complete boxed warning. Antidepresants increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients ( 5.1 ) Closely monitor for clinical worsening and emergence of suicidal thoughts and behaviors ( 5.1 ) Trazodone hydrochloride tablet is not approved for use in pediatric patients ( 8.4 )

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