Amitriptyline

Therapeutic Indications

Amitriptyline is part of the tricyclic antidepressant class of medicines. These medicines are oral tablets available in generic form, employed to treat symptoms of anxiety & depression. In addition, this drug is effective in relieving mood disorders.

Because of the drug’s proven efficacy in pain management, amitriptyline is widely used to treat/prevent migraine. The medicine is beneficial in reducing chronic pain from rheumatic diseases. Statistics show that this medicine effectively treats pain associated with cancer. Injections of Amitriptyline are also available, although healthcare providers do not prescribe it for long-term use.

Although Amitriptyline is an antidepressant, in recent years healthcare providers are using it more as a pain reliever. Briefly, Amitriptyline can treat:

• Anxiety and depression
• Chronic pain
• Mental problems
• Tension
• Low energy levels
• Sleep problems
• Postherpetic neuralgia

Amitriptyline is available as a generic version. Astra Zeneca earlier manufactured this drug, formerly available under brand name Elavil.  However, the company has stopped manufacturing this drug.

Do I Need a Prescription?

Amitriptyline is not available over the counter. Only a qualified healthcare professional can prescribe this medicine. For refills of this medication, one does not need a new prescription; the healthcare professional usually mentions the number of refills on the initial prescription itself.

Dosage

Amitriptyline is available in the generic form as an oral tablet in strengths of 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, and 150 mg. Healthcare professionals fix the dosage after considering key factors of age, symptoms, severity of the condition, the presence of other medical ailments/ conditions and reactions to the initial dose.

To Treat Depression

Adult dosage (ages 18–64 years): Specialists fix the initial dosage at 75 mg per day for oral intake. Doctors split this dose equally throughout the day. Doctors prescribe bedtime doses too. After follow up, the doctor may increase the dosage. The upper limit of dosage is 150 mg per day and it is advisable not to exceed this limit.

Child dosage (ages 0–17 years): Doctors do not prescribe Amitriptyline for children below 17 years, as the safety of this drug for this age group needs more evidence.

Senior dosage (ages 65 years and older): Health care providers usually fix the initial dosage for senior adults at a reduced dose or adopt a modified dosing schedule. This is because the kidneys of senior adults may not be in a position to process the drugs adequately. The risk of side effects looms large if the drugs remain longer in the system.

Dosage for Pain management: Adult dosage for pain management begins at a reduced dose and gets upgraded depending upon the need and response. The dosage for this age group is usually between 10 mg to 150 mg. It is advisable to consume the dosage at bedtime. This also ensures the patient sleeps well.

For this drug to be effective

• Take the right dosage as per schedule
• Regular follow up as recommended by the healthcare provider
• Do not stop Amitriptyline suddenly, especially if you have been taking it for a long time.
• Doing so increases your risk of severe withdrawal symptoms. Specialists taper the dose gradually and over time the body adjusts to the reduction in medication or no medication at all.
• If you do not take the drug on schedule consistently: Your medication may not work as well or may stop working completely.

Chemical Composition

Amitriptyline HCL is a derivative of dibenzocycloheptadiene and is a crystalline white compound. This odorless compound is also soluble in water. Each tablet of Amitriptyline contains lactose monohydrate, hypromellose, colloidal silicon dioxide, magnesium stearate, polyethylene glycol, polysorbate, microcrystalline cellulose, sodium starch glycolate, and titanium dioxide.

Mechanism of Action

Amitriptyline improves mood and depressive symptoms by targeting the central nervous system. Here the drug works on enhancing levels of key brain chemicals that are concerned with mood and behavior.

Contraindications

It is quite possible that Amitriptyline could react with other medications and have adverse reactions. The interactions may drop the efficiency of the drug too. The healthcare provider can take care of these drug interactions easily. For this, the patient must inform about the intake of all vitamins, medicines or herbs.

Amytriptyline facts

• Amitriptyline, as well as the other drugs that belong to the class of tricyclic antidepressants effectively, treat depression. Yet, novel drugs called selective serotonin reuptake inhibitors (SSRIs) have replaced tricyclic antidepressants, as they are more effective.
• An overdose of amitriptyline may lead to a condition called serotonin syndrome. Serotonin that is required by the brain to function well can have the opposite effect if serotonin accumulates in excess. Serotonin syndrome is the medical name of this condition.
• Serotonin syndrome can happen on the introduction of new drugs or if the dosage of the existing antidepressant increases.
• Some of the symptoms of serotonin syndrome manifest as any of these symptoms -seizures, muscle rigidity, goosebumps, intense perspiration, restlessness, and irregular heartbeat.
• Amitriptyline has a back box warning from the FDA. This is an alert to healthcare professionals and patients regarding precaution and monitoring. The side effects of amitriptyline can be life-threatening.
• A 2017 insight found that the fatalities and grave outcomes from overdose or poisoning from drugs used to treat depression have doubled in the last 15 years. Amitriptylinetopped the list of the drugs that caused death.  The fatalities due to antidepressants went up by 32% and amitriptyline caused 2 out of 5 deaths.
• Ironically, the medicines to treat depression sometimes increase the risk of suicide. Therefore, patients need to be monitored carefully especially in the initial days following drug administration

Drug interactions with amitriptyline

Consuming certain drugs with amitriptyline triggers serious side effects. This means you should avoid taking these drugs and amitriptyline at the same time. Examples of these drugs include:

• Drugs such as Tranylcypromine, Phenelzine and Selegiline are Monoamine oxidase inhibitors (MAOIs). Do not take amitriptyline if you are on any of these drugs as it can cause seizures. The combo is potentially life-threatening; doctors may prescribe Amitriptyline only after a gap of few weeks after stopping MAOIs.
• Quinidine and Amitriptyline interact adversely. The result can increased amitriptyline amounts in the body with alarming side effects
• This is the case with drugs Fluoxetine, Topiramate, paroxetine, and sertraline Cimetidine. Taking amitriptyline with the above drugs could lead to dangerous effects as this combo causes amitriptyline in large amounts to linger in the body. Healthcare providers usually adjust the dosage of amitriptyline to offset the risk of side effects
• Exercise caution while taking Anticholinergic drugs. For instance drugs such as oxybutynin, olanzapine, diphenhydramine, solifenacin, react badly with amitriptyline and can cause a high fever.
• Amitriptyline and antipsychotics are contraindicated; this can also result in high fever.
• Neuroleptic drugs such as haloperidol, clozapine, and risperidone can elevate the chances of grave side effects.

Alcohol

Alcohol interaction with amitriptyline is a reality, which causes serious side effects. This combo can cause extreme drowsiness, which can lead to accidents.

Health Conditions

Patients of the following health conditions must take note of interactions with amitriptyline.

• Victims of heart disorders or for those that are recovering from a heart attack must not take this drug as it could increase the risk of stroke.
• Those suffering from bipolar disorder need to check with their healthcare provider. The risk of major depressive episode looms large with amitriptyline. Therefore, Doctors do not prescribe this drug for bipolar disorder patients.
• Amitriptyline increases the risk of seizures for those who already have a history of seizures. Moreover, it is better to stop consuming the drug in case a seizure occurs after taking this medicine.
• Glaucoma patients need to watch out as amitriptyline can increase the pressure in the eyes. Healthcare providers need to monitor patients with increased eye pressure.
• Pregnant women need to exercise caution while taking amitriptyline. Animal studies have pointed to amitriptyline causing deleterious effects on the fetus. The link is still unclear so researchers need to prove this connection in depth to prove the claim.
• Breastfeeding mothers must speak to the specialist regarding the continuation of amitriptyline. Studies have proved that the drug passes through the milk to the baby. Depending on the health condition of the mother, doctors can decide whether to withdraw the drug or discontinue breastfeeding the child.
• Senior adults are not in a position to process this drug efficiently which may lead to a range of side effects such as blurred vision, dry mouth, problems with urination or even a faster heart rate making the victims uncomfortable.
• Specialists do not prescribe this drug for children below 18, as there are doubts about the safety and effectiveness of its use. Healthcare providers evaluate the absolute need for this drug by weighing the degree of symptoms with the potential risk of side effects before recommending this drug.

Side Effects

The side effects of amitriptyline are categorized as common ones, which could be relatively innocuous. There are also serious side effects and warnings associated with amitriptyline that is dangerous to ignore. Additionally, once you start taking Amitriptyline, you could experience a worsening of depressive symptoms. This could last until the drug actually begins to work which is a couple of weeks.

The commonly occurring side effects are:

• Sudden weight gain or loss
• Rashes on the skin
• Headache
• Constipation
• Diarrhea
• Numbness and tingling sensation in limbs
• Blurred vision
• Confusion
• Nausea

Usually, these symptoms vanish within a couple of weeks. In case they persist, seek the advice of your health care provider immediately.

Serious side effects

The following serious side effects could turn life-threatening if you do not seek immediate medical assistance.

• Chest pain
• Breathlessness
• Heart attack which could also occur with the above symptoms
• Stroke- symptoms can be numbness in one part of the body or slurring of speech.
• Inflammation of the face
• Swelling of tongue
• Allergic reaction – skin rash
• Suicide risk

The FDA has issued a grave warning for users of amitriptyline of the risk of suicidal thoughts and behavior. The advisory warns that those on amitriptyline especially young adults, adolescents, and children require close monitoring for alteration n in behavior or worsening of depressive symptoms. Research has pointed out that this drug can trigger effects similar to those caused by drugs called anticholinergics. This can raise your risk of dementia.

What to Do If You Skip a Dose

If you happen to miss a dose, take it as soon as it crosses your mind. However, if it is too close to the schedule of the next dose, refrain from taking it. Instead, just take the next scheduled dosage. Double dosage is certainly harmful and can lead to overdose.

Overdose: Overdosing on amitriptyline could lead to alarming levels of the drug in the body. This can manifest as low heart rate, irregular heartbeat, muscle stiffness, seizures, and even hallucinations.

Consult the emergency immediately in case of overdose as it could turn life-threatening.

Generic Brand Names of the Drug

Brand names: Elavil, Vanatrip, Endepcontain amitriptyline

Multi-ingredient medications containing amitriptyline:

Brand names: Limbitrol, Limbitrol DS are amitriptyline/chlordiazepoxide systemic drugs

Etrafon, Etrafon Forte, Duo-Vil, Triavil are amitriptyline/perphenazine systemic drugs

Different Brands and Manufacturing Companies of the Drug

Nearly 64 companies produce generic amitriptyline. Listed below are some of the brands of the drug:

Substitutes for the Drug Amitriptyline

• Pamelor (nortriptyline)
• Norpramin (desipramine)
• Tofranil (imipramine hydrochloride)
• Neurontin (gabapentin)
• Paxil (paroxetine)
• Zoloft (sertraline)
• Cymbalta (duloxetine)
• Effexor (venlafaxine)

References

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