Tricyclic Antidepressants - Uses and Precautions

Type of drug:

Antidepressants; mood-elevating agents.

How the Drug Works:

Tricyclic antidepressants (TCAs) appear to adjust or rebalance the brain's own natural chemicals (neurotransmitters), which control mood, feelings, and behaviors. The effect may take a few weeks (1 to 4) to be noticed.

Uses:

For the relief of symptoms of depression (except clomipramine).

Clomipramine: Only for the treatment of obsessive-compulsive disorder.

Doxepin: To treat anxiety.

Imipramine: For the treatment of bedwetting in children 6 years of age and older after possible organic causes have been excluded by appropriate tests.

Unlabeled Uses: Occasionally doctors may prescribe doxepin, clomipramine, imipramine, or amitriptyline to control chronic pain and to treat bulimia. Imipramine, clomipramine, nortriptyline, and other tricyclic anti­depressants have also been used to treat panic disorder. Amitriptyline has been used to prevent the onset of cluster and migraine headaches and to treat pathologic weeping and laughing secondary to forebrain disease. Protriptyline has been used in the treatment of obstructive sleep apnea. Trimipramine and doxepin have been studied in the treatment of peptic ulcer disease and to treat skin disorders. Desipramine has been used to facilitate cocaine withdrawal and to treat bulimia. Clomipramine and nortriptyline have been used to treat panic disorder. Nortriptyline has also been used to treat skin disorders and premenstrual depression.

Precautions:

Tardive Dyskinesia: Involuntary and uncontrollable movements may develop in patients treated with these drugs. Occurrence is highest among the elderly, especially women. The risk of developing these involuntary movements and the likelihood that they will become permanent are increased as the length of treatment and the total amount of drug given increases. However, it is possible to develop these symptoms after short-term treatment at low doses.

Neuroleptic Malignant Syndrome (NMS) Is a potentially fatal syndrome associated with use of tricyclic antidepressants. Symptoms include increased body heat, muscle rigidity, altered mental abilities including catatonia, irregular pulse or irregular blood pressure, increased heart rate, sweating, and irregular heart rhythm.

Withdrawal Symptoms: Stopping abruptly after prolonged therapy may pro­duce nausea, headache, dizziness, nightmares, and malaise. Clomipramine may also cause vomiting, sleep disturbances, hyperthermia (abnormally high temperature), and irritability. Gradual dose reduction may produce, within 2 weeks, transient symptoms including irritability, restlessness, dreams, and sleep disturbances.

Sensitivity to sunlight: May occur. Avoid prolonged exposure to the sun. Use sunscreens and wear protective clothing until tolerance is determined. These drugs may reduce tolerance to hot weather.

Pregnancy: Adequate studies have not been done in pregnant women. Use only if clearly needed and potential benefits outweigh the possible hazards to the fetus. There have been a few reports of birth defects associated with use of imipramine and amitriptyline. Withdrawal symptoms have been seen in newborns of mothers who have taken clomipramine, desipramine, or imipramine until delivery.

Breastfeeding: Tricyclic antidepressants appear in breast milk. Because of the potential for adverse reactions, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother. Consult your doctor before you begin breastfeeding.

Children: Amitriptyline and doxepin are not recommended for patients younger than 12 years of age. Safety and effectiveness have not been established for amoxapine in children younger than 16 years of age. Imipramine HCI use in bed wetting should be limited to children 6 years of age or older. The safety and effectiveness of imipramine HCI in children with conditions other than bed wetting have not been established. Safety and effectiveness have not been established for clomipramine in children younger than 10 years of age. Trimipramine, nortriptyline, desipramine, imipramine pamoate, and protriptyline are not recommended for use in children.

Elderly: Elderly patients are particularly sensitive to the anticholinergic effects (eg, constipation; difficulty urinating; confusion) of tricyclic antideprossants and may be at increased risk for falls. Lower than normal adult doses are generally used when starting therapy.