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Pretreatment screening and counseling on prolonged erections for patients prescribed trazodone

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Purpose: We examined whether patients are appropriately screened for previous prolonged erections or priapism and counseled about trazodone complications, specifically prolonged erections and priapism, prior to trazodone treatment. Materials and methods: We identified patients under the age of 50 on trazodone as of February 27, 2019 at the VA New Jersey Health Care System. Patients were asked about information provided to them prior to medication initiation, occurrence of prolonged erections/priapism, and reporting rate of side effects. Results: Two hundred and twenty nine out of five hundred and twenty four male patients agreed to participate in the study. Forty three out of two hundred and twenty nine of patients were informed about the side effects of prolonged erections and 37/229 of patients were informed of risk of priapism prior to treatment. Only 17/229 of patients were asked if they had had any episodes of prolonged erection or priapism in the past. Eighteen patients developed prolonged erection while taking trazodone. Only 5/18 patients who had developed prolonged erections informed their physicians. Conclusions: Only a fraction of patients were properly screened for previous prolonged erections or priapism and properly informed about the side effects of trazodone. Urologist should better educate trazodone prescribers, such as family medicine and psychiatric colleagues, regarding the side effects of trazodone. It is imperative that prescribing physicians appropriately screen and educate patients prior to trazodone initiation and instruct patients to report any treatment side effects to avoid potential long-term adverse outcomes.
85
Pretreatment screening and counseling on
prolonged erections for patients prescribed
trazodone
Tejash Shah , Juhi Deolanker , Thaiphi Luu , Hossein Sadeghi-Nejad
Department of Urology, Rutgers New Jersey Medical School, Newark, NJ, USA
Purpose: We examined whether patients are appropriately screened for previous prolonged erections or priapism and counseled
about trazodone complications, specifically prolonged erections and priapism, prior to trazodone treatment.
Materials and Methods: We identified patients under the age of 50 on trazodone as of February 27, 2019 at the VA New Jersey
Health Care System. Patients were asked about information provided to them prior to medication initiation, occurrence of pro-
longed erections/priapism, and reporting rate of side effects.
Results: Two hundred and twenty nine out of five hundred and twenty four male patients agreed to participate in the study. Forty
three out of two hundred and twenty nine of patients were informed about the side effects of prolonged erections and 37/229 of
patients were informed of risk of priapism prior to treatment. Only 17/229 of patients were asked if they had had any episodes of
prolonged erection or priapism in the past. Eighteen patients developed prolonged erection while taking trazodone. Only 5/18 pa-
tients who had developed prolonged erections informed their physicians.
Conclusions: Only a fraction of patients were properly screened for previous prolonged erections or priapism and properly in-
formed about the side effects of trazodone. Urologist should better educate trazodone prescribers, such as family medicine and
psychiatric colleagues, regarding the side effects of trazodone. It is imperative that prescribing physicians appropriately screen and
educate patients prior to trazodone initiation and instruct patients to report any treatment side effects to avoid potential long-
term adverse outcomes.
Keywords: Antipsychotic agents; Drug-related side effects and adverse reactions; Priapism
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Original Article - Sexual Dysfunction/Infertility
Received: 12 May, 2020 Revised: 22 June, 2020 Accepted: 2 September, 2020 Published online: 10 December, 2020
Corresponding Author: Tejash Shah https://orcid.org/0000-0002-5301-8103
Department of Urology, Rutgers New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, USA
TEL: +1-917-804-6745, FAX: +1-973-972-3892, E-mail: shahtt@njms.rutgers.edu
The Korean Urological Association www.icurology.org
Investig Clin Urol 2021;62:85-89.
https://doi.org/10.4111/icu.20200195
pISSN 2466-0493 • eISSN 2466-054X
INTRODUCTION
Priapism is a urologic emergency defined as a prolonged,
painful erection lasting greater than 4 hours, not usually
initiated by sexual stimuli or desire. It has been established
that there are a variety of risk factors f or priapism, includ-
ing the use of antipsychotics such as trazodone, and having
a history of prolonged erections. There are several reports
in the literature of trazodone use leading to both prolonged
erections and priapism, but patients are often not counseled
on these well-known side ef f ects [1]. If patients are not aware
of such side effects, it is highly likely that they may delay
seeking care for priapism/prolonged erections, which ulti-
mately may lead to irreversible complications of ischemic
86 www.icurology.org
Shah et al
https://doi.org/10.4111/icu.20200195
penile f ibrosis and subsequent erectile dysfunction.
Medications, including antidepressants, antihyperten-
sives, anticoagulants, alpha-blockers and some psychoactive
substances such as alcohol and cocaine, are responsible f or
the onset of 25% to 40% of cases of priapism. However, about
50% of all drugs related priapism is due to antipsychotics
usage [2]. It is the prescri bing physicians’ duty to inf orm
patients about all risks prior to initiating therapy, especially
in this population who may be on an extensive pharmaco-
logic regimen. It has been noted that all patients should be
questioned about previous episodes of prolonged erections as
a past significant history of delayed detumescence is present
in approximately 50% of any subsequent cases of priapism [1].
Previous data also suggests that priapism is most likely to
occur within the first 28 days of treatment initiation with
a majority of the patients taking a dosage of 150 mg/day or
less [3]. While medication side ef f ects are never desired, if
patients are aware of them, it is only intuitive that they can
seek side ef f ect management sooner and avoid long term
conseq ue nces.
The veterans af fairs (VA ) system is the one of the larg-
est health care systems in the United States, with almost
over 8 million veterans enrolled and about 5 million receiv-
ing care. It is critical to investigate all adverse events re-
lated to antipsychotic medication use, particularly in view
of studies indicating usage as high as 47.5% in the nursing
home population and veteran af fairs health care system [4].
Furthermore, off-label use of antipsychotic medications is
extremely prevalent in the VA population, as almost 60% of
patients had no record of a diagnosis for which these drugs
were off icially approved. The most common mental illnesses
receiving antipsychotic prescriptions were post-traumatic
stress disorder (41.8%), minor depression (39.5%), major de-
pression (23.4%), and anxiety disorder (20.0%) [5]. Male veter-
ans, especially those with suicidal ideation and psychiatric
comorbidities, are more likely to receive antipsychotics than
any other types of psychiatric medications [6]. With this
high percentage of use, providers should be cautious when
prescribing these medications.
In our clinical practice at the East Orange Veterans Af-
fairs Hospital, we recently came across two patients with
priapism in the emergency room that were on trazodone,
but were never informed about the medication side ef fects.
We therefore set out to evaluate whether the larger cohort
of patients on trazodone were appropriately counseled about
prolonged erections and priapism prior to starting the medi-
cation. We also sought to identify the incidence of prolonged
erections in those taking trazodone, as well as the rate of pa-
tient reported events of prolonged erection to the prescribing
physicians.
MATERIALS AND METHODS
Institutional Board Review of VA New Jersey Health
Care System approval was obtained (approval number:
00001450) and su bsequently a pharmacy search was per-
formed at the V A New Jersey Health Care System (VAN-
JHS), to identify all male patients under the age of 50 cur-
rently taking trazodone as of February 27, 2019. Patients
previously on trazodone or those who discontinued it prior
to this date for any reason, including priapism, were not in-
cluded. Patients were contacted via telephone, informed con-
sent about study participation was obtained, and were asked
about information provided prior to medication initiation,
whether history of prolonged erection or priapism was elic-
ited prior to medication initiation, occurrence of prolonged
erections/priapism while on trazodone therapy, and commu-
nication with prescribing physicians in case these adverse
events had been encountered. We defined prolonged erec-
tions as erections lasting anywhere from one to f our hours.
RESULTS
Two hundred and twenty nine out of a total of 524 male
patients on trazodone at the V ANJHS participated in the
study, with an average age of 38.57±6.88 years. Indications
for prescribing trazodone were insomnia, depression or post-
traumatic stress disorder in all cases. Dosages of trazodone
administered ranged from 50–100 mg, two to three times
a day (Table 1). Prior to prescribing trazodone, only 43/229
(18.78%) of patients were informed about the side ef fects of
prolonged erections. Even fewer numbers of patients were
inf orm ed abo ut t he r isk of p r iapism, 37 /229 (16.16%).
Table 1. Patient demographics
Patient characteristic Result (n=229)
Age (y) 38.57 (25–50)
Sex
Male 229 (100.0)
Female 0 (0.0)
Trazodone dosage (mg)
50 138 (60.3)
100 91 (39.7)
Indications Insomnia; depression; PTSD
Values are presented as mean (range) or number (%).
PTSD, post-traumatic stress disorder.
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Investig Clin Urol 2021;62:85-89. www.icurology.org
Trazodone screening and side effect counseling
Only 17/229 (7.42%) of patients were asked if they previ-
ously had any episodes of prolonged erection. Similarly, only
17/229 (7.42%) of patients were asked if they ever had pria-
pism in the past. Af ter the initiation of trazodone therapy,
18/229 (7.86%) of patients developed prolonged erection and
only 2/18 were informed about the risk of prolonged erec-
tions prior to initiation of therapy. Only 5/18 of those who
developed prolonged erections told their physicians. Patients
did not report these events to physicians due to embarrass-
ment and/or lack of awareness that this side ef f ect was pos-
sibly associated with trazodone. None of the patients who
were actively taking trazodone had an episode of priapism
requiring an emergency room visit while on the medication
(Table 2 ).
DISCUSSION
Priapism is a true urologic emergency as a delay in care
can lead to deleterious long-term consequences. There are
a variety of risk factors for priapism, including the use of
antipsychotics such as trazodone as there are several reports
in the literature of trazodone use leading to both prolonged
erections and priapism. Initially, priapism was only noted to
be associated with the use of the more typical first genera-
tion antipsychotic medications and trazodone, but now there
have been some reports of the newer atypical antipsychot-
ics causing priapism as well [7]. Trazodone is U.S. Food and
Drug Administration-approved f or treating major depres-
sive disorder, but it can also be used for of f-label purposes
such as insomnia, post-traumatic stress disorder, anxiety,
Alzheimer’s, personality disorders, and cocaine/alcohol with-
drawal. The medication can be orally dosed in 50, 100, 150,
and 300 mg tablets with 300 mg/day being the maximum
dosage for outpatient and 600 mg/day f or inpatient usage.
Priapism is considered as an adverse effect occurring in
less than 1% of patients on trazodone. This is more likely to
occur in male who have multiple myeloma, sickle cell ane-
mia, leukemia, autonomic dysfunction, or those who have
a penile anatomic variation such as cavernosal fibrosis,
angulation, or Peyronie’s disease [8]. One study by Haria et
al. [9] reported a priapism incidence ra te of 1:1,000 to 1:10,000
for male on trazodone, while the incidence of priapism in
the general population has been reported to significantly
lower at 1.5:10,000 [10]. Psychotropic-induced priapism is
thought to be caused by the alpha1-adrenergic antagonism
of these medications within the corpora cavernosa which
inhibits detumescence [11,12]. It has been shown that during
the rapid eye movement sleep period, during which spon-
taneous erectile activity usually occurs, the detumescence
phase of erection which is under sympathetic control, was
signif icantly prolonged 2.4 times by trazodone compared to
placebo.
In vitro
, trazodone at similar concentrations to those
that are achieved in plasma considerably af fected corporeal
smooth muscle contractions that were induced by electrical
stimulation of adrenergic nerves and antagonized contrac-
tions caused by exogenous norepinephrine [13]. With all the
studies perf ormed to understand the mechanism of action
of trazodone and other antipsychotics, the most widely ac-
cepted mechanism involves a decrease in local sympathetic
tone with respect to the local parasympathetic tone [14]. In
addition to the alpha1-adrenergic antagonism with which
priapism is caused by, trazodone also inhibits the neuronal
uptake of serotonin and is a histamine antagonist [15].
Multiple case reports have established a connection
between the use of a combination of trazodone and other
antipsychotics with priapism occurrence [16]. A particular
case report of a military veteran receiving treatment f or
PTSD (post-traumatic stress disorder) with trazodone and
three other antipsychotic medications notes the patient hav-
ing recurrent priapism with the f irst episode being three
months after initiation of treatment. At that time, he was
instructed to stop trazodone. The second episode presented
one month af ter discontinuation, at which he then discon-
tinued prazosin, and after 6 weeks he did not experience
recurrence [17]. Several cases with the use of other antipsy-
chotics such as quetiapine, carbamazepine, olanzapine, and
clozapine have also been reported, signifying the prevalence
of priapism when on these medications. Olanzapine and que-
tiapine, specif ically, have been implicated numerous times.
A case report of an individual with schizoaf fective disorder
discusses recurrent priapism over a three year period, each
time related to the ingestion of quetiapine [18]. More recent-
ly, a case series f rom the AMSP ( Arzneimittelsicherheit in
der Psychiatrie) database reviews 19 case reports of priapism
Table 2. Rates of screening, side effect counseling and side effect reporting
Asked about previous
prolonged
erection/priapism
Informed about risk of
prolonged erection
Informed about
risk of priapism
Incidence of
prolonged
erections
Incidence of
priapism
Reporting rate to
physician about
side effect
17/229 (7.42) 43/229 (18.78) 37/229 (16.16) 18/229 (7.86) 0 5/18 (27.78)
Values are presented as number (%).
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Shah et al
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that are likely caused by typical and atypical antipsychotics,
as well as trazodone. Common amongst the reports was the
introduction of a psychotropic drug causing the immediate
development of priapism and a shif t in drug plasma concen-
tration due to a change in drug dosage or due to co-adminis-
tration of specific selective serotonin reuptake inhibitors [19].
Physicians should also be aware that there are reports of
priapism occurring even in children under the age of 6 who
are on trazodone [20].
Patients on trazodone or other antipsychotics should be
made aware of such side effects prior to initiating treatment
as the lack of awareness of the side effects may lead to a
delay in patients seeking medical attention and thus lead-
ing to irreversible damage and poor erectile f unction. The
prescribing physicians must inf orm patients about all risks
prior to initiating therapy. When patients taking trazodone
or other antipsychotics present with priapism, the treatment
algorithm is the same as for ischemic, low f low priapism
[21]. The main goals of medical therapy are decompression
of the corporal bodies and restoration of arterial blood f low
to reduce ischemia and the potential risk of tissue necrosis.
Prompt treatment within 4 to 6 hours of onset has been
shown to reduce long term ef f ects and decrease the need for
surgical intervention.
In the present study, patients were not appropriately
counseled as only 43/229 (18.78%) of patients were inf ormed
about the side effects of prolonged erections and even f ewer
numbers of patients were informed about the risk of pria-
pism, 37/229 (16.16%). It is also concerning that prior to tra-
zodone initiation, only 17/229 (7.42%) of patients were asked
if they previously had any episodes of prolonged erection
and priapism. A change in the prescribing algorithm must
be made to include clear disclosure of trazodone side effects.
While medication side ef fects are never desired, if patients
are aware of potential adverse ef f ects, then they can get
seek medical care and side effect management sooner to
hopefully avoid long term consequences. Interestingly, in
the past 2 years at various private and academic hospitals
covered by Rutgers New Jersey Medical School urology
residents, in addition to the two patients on trazodone who
developed priapism at the VANJHS there have been three
cases of patients with priapism on trazodone, all who were
never counseled on this side effect. While anecdotal, this
suggests that there is not proper discussion of trazodone side
ef f ects regarding prolonged erection and priapism in the
community as well.
This study f ocuses on veteran patients, a population
that has a high percentage of usage of trazodone and other
antipsychotic medication. Given the patient population and
the complex psychotropic regimen, the study population may
be at higher risk for priapism and prolonged erections. It is
noteworthy that despite multiple episodes of prolonged erec-
tions, none of the patients in the study required an emer-
gency room visit f or priapism during the study. This is likely
because patients who did have priapism while taking trazo-
done, the medication was discontinued and not captured in
our study. Based on our f indings, it is clear that patient edu-
cation and counseling needs to be drastically improved prior
to starting trazodone. Providing the proper inf ormation to
patients can f oster a more communicati ve and well-inf ormed
patient-doctor relationship that allows patients with compli-
cations to f eel comfortable discussing adverse ef f ects with
their physician.
Limitations of the study include the study population
as we only included patients who were on trazodone at the
time of our study, and did not account for patients who
may have discontinued trazodone for priapism or any other
adverse ef f ect. We defined prolonged erections as lasting
between one to f our hours but did not obtain more detailed
inf ormation as to the specif ic length of each patients pro-
longed erections. Additionally, our study only looked at the
practice patterns at one veterans af f air system. Further in-
vestigation needs to be done regarding the true incidence of
prolonged erections and priapism in patients in the general
population taking trazodone, other antipsychotics, or a com-
bination of antipsychotic medications.
CONCLUSIONS
Patients taking trazodone are known to have an in-
creased risk of prolonged erections and priapism. Only a
fraction of patients were properly screened for previous pro-
longed erections or priapism and properly informed about
the side effects of trazodone treatment prior to receiving the
medication. Urologist should better educate trazodone pre-
scribers, such as family medicine and psychiatric colleagues,
regarding the side ef f ects of trazodone. It is imperative that
physicians appropriately screen patients prior to trazodone
initiation, educate patients about the risks of prolonged erec-
tions and priapism and instruct patients to report any treat-
ment side e f fec ts.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
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Investig Clin Urol 2021;62:85-89. www.icurology.org
Trazodone screening and side effect counseling
AUTHORS’ CONTRIBUTIONS
Research conception and design: Thaiphi Luu and Hos-
sein Sadeghi-Nejad. Data acquisition: Thaiphi Luu and Juhi
Deolanker. Statistical analysis: Tejash Shah and Juhi Deo-
lanker. Data analysis and interpretation: Tejash Shah. Draf t-
ing of the manuscript: Tejash Shah and Juhi Deolanker.
Critical revision of the manuscript: Tejash Shah and Hossein
Sadeghi-Nejad. Supervision: Hossein Sadeghi-Nejad. Approval
of the f inal manuscript: Tejash Shah, Hossein Sadeghi-Nejad,
and Juhi Deolanker.
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... Based on these premises, it appears that, among the high-risk list of drugs here analysed, trazodone generated indeed the strongest SDR, whilst olanzapine and tadalafil seemed somewhat more prone to cause priapism vs. the other drugs of the database (except for trazodone). The propensity of trazodone to elicit priapism is already well documented in the literature [19][20][21]. Although a number of medications identified in this list may be prescribed by sexual medicine specialists, most of these drugs are typically prescribed by psychiatrists and primary care doctors. ...
... Although a number of medications identified in this list may be prescribed by sexual medicine specialists, most of these drugs are typically prescribed by psychiatrists and primary care doctors. It is of outmost importance that physicians prescribing trazodone are aware and prepared to face this possible detrimental side effect [20], as this medication is still prescribed to more than 27 million Americans [17]. To this respect, some 229 male patients younger than 50 years taking trazodone were surveyed regarding their pretreatment counselling: only less than 20% of the patients were informed about the possible risk of prolonged erections and priapism [20]. ...
... It is of outmost importance that physicians prescribing trazodone are aware and prepared to face this possible detrimental side effect [20], as this medication is still prescribed to more than 27 million Americans [17]. To this respect, some 229 male patients younger than 50 years taking trazodone were surveyed regarding their pretreatment counselling: only less than 20% of the patients were informed about the possible risk of prolonged erections and priapism [20]. The concomitant use/abuse of other legal and/or illegal drugs known to cause priapism may increase the risk of trazodone-induced priapism, due to a synergistic effect [6]. ...
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Priapism is rarely related to use of non-erectile related medications. The objective was to educate about the multiple possible causes of priapism and to provide treatment recommendations for the different types of priapism. We present the case of a 43-year-old African American male with a history of schizoaffective disorder who presented to our emergency department multiple times over a three year period with priapism, each episode related to the ingestion of quetiapine. Following penile aspiration and intercavernosal injection of phenylephrine, this patient had resolution of his priapism. This case demonstrates an unusual case of recurrent priapism.
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Purpose A case report of multiple episodes of priapism associated with the use of 4 different psychotropic medications. Summary A 34-year-old African American male with treatment-refractory schizoaffective disorder suffered priapism on 6 separate occasions. His medical history is relatively unremarkable, with the exception of possible undiagnosed thalassemia. All incidences were potentially attributable to psychotropic medications, with chlorpromazine, risperidone, trazodone, and quetiapine being the most likely culprits. The onset of priapism ranged from hours after a single injection of chlorpromazine, to years after multiple injections of risperidone, with nothing to indicate a medication dose or duration relationship to priapism. While on clozapine, fluphenazine, haloperidol, lurasidone, and olanzapine at varying times, the patient did not appear to develop priapism. The commonality of high-affinity alpha-1 antagonism with these psychotropics may be to blame. No pharmacokinetic or pharmacodynamic interactions were noted, which would have produced elevations in the levels of these psychotropics, nor was the patient on any phosphodiesterase type 5 (PDE-5) inhibitors or antihypertensives known to cause priapism. Depending on the offending agent, the Naranjo et al’s Adverse-Reaction Probability Scale scores ranged from 5 to 8 (probable). Conclusion A man suffered from multiple episodes of priapism attributed to psychotropic medications. This is not the first case to describe this effect, but will give clinicians a timeline of events and medications that did and did not appear to elicit priapism in a patient with treatment-refractory schizoaffective disorder. Knowledge of which psychotropic medications may be more likely to induce priapism is crucial to preventing long-term penile damage.
Article
Priapism is a rare adverse effect of several psychotropics. Both, typical and atypical antipsychotics, as well as trazodone are known to cause priapism. The mechanism is still not fully understood, however, the most common assumption is that priapism occurs due to the α-adrenergic blocking effects of the drugs. Here we present from the AMSP database 19 cases of priapism being likely caused by a variety of psychotropics. We further reviewed case reports in order to find similaritie and to identify risk factors. Several patterns emerged: Common was the introduction of a specific drug to a patient resulting into the immediate development of priapism, as well as a change in drug plasma concentration due to a change of drug dosage or due to comedication with certain SSRIs. However, priapism can occur at nearly any age and with any dose. Clinicians must be aware of the risk and reports of early signs, such as prolonged erections, should be taken seriously. https://www.tandfonline.com/eprint/crrEmhczNpdQwUXT3RA7/full
Chapter
This chapter addresses the following FDA-approved medications for the treatment of major depressive disorder available for use in the United States including bupropion, mirtazapine, trazodone, vortioxetine, and vilazodone. These medications do not belong to one of the previously featured classes of antidepressants discussed in the preceding chapters. Each medication featured in this chapter has a unique structure and properties that target diverse receptors in the central nervous system. These diverse targets are distinct from other classes of medications used to treat major depressive disorder. This chapter will provide an overview of each medication’s indication for use, history of development, pharmacology, metabolism, dosing recommendations, onset of action, use in special populations, safety and tolerability, adverse effects, potential interactions with additional medications, and data regarding possible overdose with available treatments.
Article
Trazodone is a drug that was introduced in the clinic almost 40 years ago. It is licensed to treat depression, but it is also commonly used off-label to treat insomnia. A recent study shows that it could be promising in preventing neurodegeneration in mice, and clinical trials to assess its possible beneficial effects on dementia and Alzheimer’s disease are expected to start soon in humans. In this study, we describe the dose-dependent pharmacology of trazodone by carrying out pharmacokinetic simulations aiming to predict the brain concentrations of trazodone for different drug-dosing regimens and calculating occupancy for 28 different targets for which published trazodone-binding data are available. Our study indicates that low doses of trazodone (typically 50 mg daily) should suffice to block specific receptors responsible for the hypnotic effect, and to provide the protective effect against neuroinflammation and neurodegeneration that could be beneficial in dementia. Higher doses are required for an antidepressant effect. The occupancy of specific receptors at therapeutic doses also explains peculiar side effects reported by patients treated with trazodone (e.g. dry-mouth, hypotension and priapism).
Article
Introduction: For veterans struggling with post-traumatic stress disorder (PTSD), symptomatic control often requires multiple psychotropic agents. We describe a case in which a young veteran experienced recurrent priapism while receiving treatment for PTSD with several medications, most notably trazodone and prazosin. Case description: Our patient presented to the emergency department with priapism, approximately 3 months after beginning a pharmacologic regimen of escitalopram, prazosin, trazodone, and methylphenidate for PTSD. Detumescence was achieved, and he was instructed to discontinue trazodone. Approximately 1 month after discontinuation, he presented to the emergency department with recurrent priapism. Our patient had no obvious risk factors, including sickle cell disease, cocaine use, or utilization of phosphodiesterase type 5 inhibitors. After his second episode, our patient discontinued prazosin, and after 6 weeks had not experienced recurrence. Discussion: Food and Drug Administration-approved medications alone are often inadequate to treat-specific symptoms, especially those related to sleep. Consequently, trazodone and prazosin are frequently used off-label. Although priapism has been associated with these medications, there are currently no data available regarding the incidence of priapism related to dose or combination with other agents. Combat veterans may represent a population at higher risk for priapism given their often complex psychotropic regimens.
Article
Antipsychotic medications have been increasingly prescribed for off-label uses, including treatment of posttraumatic stress disorder (PTSD). Given limited knowledge about their use in returning Iraq and Afghanistan veterans with PTSD, we explored rates of antipsychotic use in this population and correlations with sociodemographic, military service, and psychiatric factors. Iraq and Afghanistan veterans with a PTSD diagnosis based on ICD-9-CM codes enrolled in Veterans Administration care between January 1, 2007, and September 30, 2011, were followed through September 30, 2012. Patients with a comorbid diagnosis of schizophrenia or bipolar disorder were excluded. Poisson regression models evaluated factors associated with prescriptions for antipsychotic versus other psychiatric medications (primary outcome). The mean age of our study population was 29.3 years, and 9.4% were women. Of 186,460 veterans with PTSD diagnoses examined, 19.9% received no psychiatric medications, and the remainder received psychiatric medications that excluded (61.2%) or included (18.9%) antipsychotics. In adjusted models, several factors were independently associated with antipsychotic use, including male sex (adjusted relative risk = 1.25; 95% CI, 1.20-1.30) and enlisted rank (1.44; 95% CI, 1.35-1.53). Increased likelihood of antipsychotic prescribing was associated with suicidal ideation (4.77; 95% CI, 4.59-4.95) and comorbid psychiatric diagnoses including personality disorder (4.27; 95% CI, 4.09-4.46), drug use disorder (3.56; 95% CI, 3.43-3.69), and alcohol use disorder (2.75; 95% CI, 2.65-2.84). A substantial minority of Iraq and Afghanistan veterans diagnosed with PTSD received antipsychotics. Male veterans, those of enlisted rank, and those with suicidal ideation and psychiatric comorbidities were more likely to receive antipsychotics than other types of psychiatric medications. Providers should be cautious about antipsychotic use, given their known metabolic risks and questionable benefits for PTSD. © Copyright 2015 Physicians Postgraduate Press, Inc.
Article
Priapism is a persistent, and often painful, penile erection, lasting more than 3hours, not usually associated with sexual stimuli. It is a urological emergency that can cause serious complications. Drugs are responsible of the onset of 25 to 40% of cases of priapism. Several classes of medication are involved: antidepressants, antihypertensives, anticoagulants, alpha-blockers and some psychoactive substances (alcohol, cocaine, cannabis…). However, about 50% of drug related priapism is due to antipsychotics (AP). Clinicians should be aware of this rare side effect because of the severity of its complications and the difficulty of its management, especially in non-stabilized psychotic patients. We report a case of a 22-year-old male Moroccan patient, diagnosed with schizophrenia, who had been admitted for the first time to a psychiatric hospital for management of a psychotic episode. First, he received 15mg per day of haloperidol, and seven days later he developed priapism. The patient was immediately referred for urological care. Aspiration and irrigation of the corpora cavernosa was proposed, but could not be performed because of patient refusal, and the erection resolved spontaneously after 10hours. Haloperidol was stopped, and four days later the patient was switched to 10mg per day of olanzapine. After 10days of treatment, he developed a second episode of priapism, and olanzapine was also stopped. A cavernosal aspiration-irrigation was performed in emergency; which resulted in the partial detumescence of the penis. Two days later, and despite therapeutic abstention, the patient presented another episode of priapism. The indication of a revascularization of the corpora cavernosa was proposed, but again the patient refused the surgery. Finally, the patient was administered 400mg/day of amisulpride, with a favorable outcome. Priapism disappeared after a month with the installation of fibrosis and partial loss of erectile function. The precise mechanisms of the role of AP in the occurrence of priapism are not all known and a multifactor etiology seems the most likely. Neuromuscular hypothesis is the most mentioned, involving the blocking action of alpha1-adrenergic receptors of the corpora cavernosa for which most of AP have an affinity. The occurrence of priapism in a psychotic patient, especially during periods of decompensation, raises a number of challenges for the medical staff. First, the non-recognition by the patient of this side effect, and its potentially severe consequences. Second, the absence of link between dose and duration of AP treatment on one side, and the onset of priapism on the other, which makes it hard to predict. The third challenge is the choice and initiation of another AP. The literature reveals many cases of priapism in both conventional and atypical AP, the presence of a predisposition to this type of incident has been reported. However, few authors have focused on alternatives to provide for these patients. Amisulpride is currently the only molecule that does not have alpha-adrenergic affinity and is therefore preferred in these cases. Priapism is a rare but serious adverse event of AP medication. Informing patient about the risk of priapism would help to report it early and prevent erectile dysfunction. Switching to another AP with less alpha1-blocking properties is generally recommended.
Article
To examine prevalence and resident- and site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants in older Veterans Affairs (VA) Community Living Center (CLC) residents. Longitudinal study. One hundred thirty-three VA CLCs. Three thousand six hundred ninety-two veterans aged 65 and older admitted between January 1, 2004, and June 3, 2005, with long stays (≥ 90 days). Prevalence of potential underuse, inappropriate use, and overuse of antidepressants in residents with and without depression (as documented according to International Classification of Diseases, Ninth Revision, Clinical Modification, codes or Depression Rating Scale). Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressant. Of the 877 residents with depression, 25.4% did not receive an antidepressant, suggesting potential underuse. Of residents with depression who received antidepressants, 57.5% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. Of the 2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants; only 48 (4.0%) of these had a Food and Drug Administration-approved labeled indication, suggesting potential overuse. Overall, only 17.6% of antidepressant use was appropriate (324/1,844). The only consistent resident factor associated with potential underuse and overuse use was taking an antipsychotic without evidence of schizophrenia (underuse: adjusted relative risk ratio (ARRR)=0.56, 95% confidence interval (CI)=0.33-0.94; overuse: adjusted odds ratio=1.52, 95% CI=1.21-1.91). Having moderate to severe pain (ARRR=1.54, 95% CI=1.08-2.20) and the prescribing of an anxiolytic or hypnotic (ARRR=1.33, 95% CI=1.02-1.74) increased the risk of potential inappropriate antidepressant use. Potential problems with the use of antidepressants were frequently observed in older U.S. veteran CLC residents. Future studies are needed to examine the true risks and benefits of antidepressant use in CLC and non-VA nursing homes.