Tricyclic Antidepressants
Tricyclic antidepressants (TCAs) are used in low doses to treat chronic pain conditions and in high doses to treat mood disorders such as depression. TCAs may also be used as migraine and chronic tension headache prophylaxis.
- PDF / 133,852 Bytes
- 2 Pages / 504.567 x 720 pts Page_size
- 77 Downloads / 189 Views
Tricyclic Antidepressants R. Jason Yong and Mohammed Issa
Tricyclic Antidepressants Tricyclic antidepressants (TCAs) are used in low doses to treat chronic pain conditions and in high doses to treat mood disorders such as depression. TCAs may also be used as migraine and chronic tension headache prophylaxis.
Examples: Generic Amitriptyline Desipramine Nortriptyline
Brand name Elavil Norpramin Pamelor
Starting dose 10–25 mg 10 mg 25 mg
Side effects: Common Dry mouth Mechanism of Action Blurred vision Tricyclics primary work as serotonin- Constipation Urinary retention norepinephrine reuptake inhibitors (SNRIs) by Drowsiness blocking serotonin and norepinephrine transportOrthostasis ers. TCAs do not block dopamine reuptake. Weight gain
Rare Disorientation Tremor Arrhythmia Seizures
Drug Interactions R.J. Yong, MD, MBA (*) Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA Department of Anesthesiology, Brigham and Women’s Faulkner Hospital, 1153 Centre Street, Boston, MA 02130, USA e-mail: [email protected] M. Issa, MD Department of Anesthesiology and Psychiatry, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected]
Caution with high doses and when combined with other serotonergic agents such as SNRIs, SSRIs, MAOIs, lithium, triptans, St. John’s wort, and illicit substances.
Clinical Clinical Indications Neuropathic pain, fibromyalgia, generalized pain with comorbid depression/anxiety.
© Springer International Publishing Switzerland 2017 R.J. Yong et al. (eds.), Pain Medicine, DOI 10.1007/978-3-319-43133-8_42
165
R.J. Yong and M. Issa
166
I nitiation (Using Amitriptyline as an Example) Typical starting dose is 10–25 mg at bedtime. Every 2 weeks, the dose can be increased by 10–25 mg with a usual maximum dose of 150 mg. Approximately 6–8 weeks are required for an adequate trial.
Weaning Abrupt discontinuation can lead to withdrawal symptoms such as anxiety, insomnia, headaches, nausea, and motor disturbances. TCAs should be gradually weaned over weeks to months.
Special Considerations • Avoid in elderly secondary to exacerbation of cognitive impairment and increased falls. • Most TCAs are also beneficial for insomnia.
Clinical Pearls In general practice, TCAs are a second-line treatment after neuroleptics such as gabapentin/pregabalin for neuropathic pain. Nortriptyline has a better side-effect profile than amitriptyline and has equal efficacy. If patients can tolerate the TCAs, I will increase to maximum effective dose before considering lack of effect a failure. If limited by side effects, I will consider splitting doses. Nortriptyline has been found to be the most weight neutral when comparing antidepressants for pain.
Literature Review A Cochrane review of 13 placebo-controlled trials showed TCAs were significantly more efficacious than placebo for neuropathic pain conditions. Additionally, studies comparing one TCA to another showed no difference among the TC
Data Loading...
