Tricyclic and related antidepressant drugs

Tricyclic and related antidepressants block the re-uptake of both serotonin and noradrenaline, although to different extents. Tricyclic and related antidepressants also show varying degrees of antimuscarinic side-effects and cardiotoxicity in overdosage, which may be important in individual patients. Evidence of the efficacy of tricyclic antidepressants for depression in children has not been established.

Tricyclic Antidepressant Drugs:

AMITRIPTYLINE HYDROCHLORIDE:

Indications: depressive illness, nocturnal enuresis in children, neuropathic pain and migraine prophylaxis.

Contraindications: Recovery Phase Following Myocardial Infarct, Alcoholism, Chronic Idiopathic Constipation, Conduction Disorder of the Heart, Congenital Long QT Syndrome, Epilepsy, Fainting, Hyperthyroidism, Manic Bipolar Disorder, Narrow Angle Glaucoma, Paralytic Ileus, Prolonged QT Interval, Suicidal Ideation, Torsades de Pointes, Urinary Retention.

Dose and Administration: Depression (but not recommended, see notes above), initially 75 mg (elderly and adolescents 30–75 mg) daily in divided doses or as a single dose at bedtime increased gradually as necessary to 150–200 mg; child under 16 years not recommended for depression. Nocturnal enuresis, child 7–10 years 10–20 mg, 11–16 years 25–50 mg at night; max. period of treatment (including gradual withdrawal) 3 months—full physical examination before further course. Neuropathic pain [unlicensed indication], initially 10–25 mg daily at night, increased if necessary to 75 mg daily; higher doses under specialist supervision. Migraine prophylaxis initially 10 mg at night, increased if necessary to maintenance of 50–75 mg at night.

CLOMIPRAMINE HYDROCHLORIDE:

Indications: Obsessive-Compulsive Disorder, Anxiety, Cataplexy Syndrome, Depression, and Panic Disorder.

ContraindicationsMalignant Hyperthermia, Recovery Phase Following Myocardial Infarct, Epilepsy, Glaucoma, Severe Renal Disease, And Suicidal Ideation.

Dose and AdministrationDepressive illness, initially 10 mg daily, increased gradually as necessary to 30–150 mg daily in divided doses or as a single dose at bedtime; max. 250 mg daily; elderly initially 10 mg daily increased carefully over approx. 10 days to 30–75 mg daily; child and adolescent under 18 years not recommended. Phobic and obsessional states, initially 25 mg daily (elderly 10 mg daily) increased over 2 weeks to 100–150 mg daily; max. 250 mg daily; child and adolescent under 18 years not recommended. Adjunctive treatment of cataplexy associated with narcolepsy, initially 10 mg daily, gradually increased until satisfactory response (range 10–75 mg daily); child and adolescent under 18 years not recommended.

IMIPRAMINE HYDROCHLORIDE:

Indications: Depression, Nocturnal Enuresis, Anxiety, Attention-Deficit Hyperactivity Disorder, Bulimia Nervosa, Cataplexy Syndrome, Narcolepsy Syndrome, Neuropathic Pain, Panic Disorder.

Contraindications: Malignant Hyperthermia, Recovery Phase Following Myocardial Infarct, Epilepsy, Glaucoma, Severe Renal Disease, And Suicidal Ideation.

Dose and Administration: Depression, initially up to 75 mg daily in divided doses increased gradually to 150–200 mg (up to 300 mg in hospital patients); up to 150 mg may be given as a single dose at bedtime; elderly initially 10 mg daily, increased gradually to 30–50 mg daily; child not recommended for depression. Nocturnal enuresis, child 7–8 years 25 mg, 8–11 years 25–50 mg, over 11 years 50–75 mg at bedtime; max. period of treatment (including gradual withdrawal) 3 months—full physical examination before further course.

MAPROTILINE:

Indications: Anxiety with Depression, Depression and Neuralgia.

Contraindications: Abnormal ECG, Epilepsy, Myocardial Infarction, Alcoholism, Bipolar Disorder, Blood Dyscrasias, Bronchial Asthma, Disease of Cardiovascular System, Disease of Liver, Glaucoma, Hyperthyroidism, Narrow Angle Glaucoma, Schizophrenia, Suicidal Ideation, Urinary Retention.

Dose and Administration: initially 25-75mg daily. Elderly initially 30mg as a single dose at bedtime daily or in 3 divided doses, increased as necessary to 150mg.

Related Antidepressant Drugs:

Tricyclic-related drugs have a lower incidence of antimuscarinic side-effects compared with older tricyclics. The tricyclic-related drugs may also be associated with a lower risk of cardiotoxicity in overdosage.

TRAZODONE HYDROCHLORIDE:

Indications: depressive illness, particularly where sedation is required; anxiety.

Contraindications: Myocardial Infarction, Non Q-Wave Myocardial Infarction, Priapism, Cardiac Disease, Conduction Disorder of the Heart, Suicidal Ideation.

Dose and Administration: Depression, initially 150 mg (elderly 100 mg) daily in divided doses after food or as a single dose at bedtime; may be increased to 300 mg daily; hospital patients up to max. 600 mg daily in divided doses; child not recommended. Anxiety, 75 mg daily, increasing if necessary to 300 mg daily; child not recommended.​

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