Amitriptyline hydrochloride

CLASSIFICATION(S): Antidepressant, tricyclic PREGNANCY CATEGORY: C WRx: Apo-Amitriptyline.

SEE ALSO ANTIDEPRESSANTS, TRICYCLIC.

(ah -m e- TR IP - t ih - le e n )

USES (1) Relief of symptoms of depression, including depression accompanied by anxiety and insomnia. (2) Chronic pain due to cancer or other pain syndromes. (3) Prophylaxis of cluster and migraine headaches. Investigational: Pathologic laughing and crying secondary to forebrain disease, bulimia nervosa, antiulcer agent, enuresis. Adjunct analgesic for phantom limb pain, migraine, chronic tension headaches, diabetic neuropathy, tic douloureux, cancer pain, peripheral neuropathy with pain, postherpetic neuralgia, arthritic pain. Dermatologic disorders (chronic urticaria and angioedema, nocturnal pruritus in atopic eczema). ACTION/KINETICS Action Amitriptyline is metabolized to an active metabolite, nortriptyline. Has significant anticholinergic and sedative effects with moderate orthostatic hypotension. Very high ability to block serotonin uptake and moderate activity with respect to norepinephrine uptake. Pharmacokinetics Effective plasma levels of amitriptyline and nortriptyline: Approximately 110250 ng/mL. Time to reach steady 1 state: 410 days. t /2: 3146 hr. Up to 1 month may be required for beneficial effects to be manifested. CONTRAINDICATIONS Use in children less than 12 years old SPECIAL CONCERNS Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive dis-

orders and other psychiatric disorders. Anyone considering the use of amitriptyline or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Clients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Amitriptyline is not approved for use in pediatric clients. Analysis of short-term (416 weeks) placebo-controlled trials in children and adolescents with major depressive disorder, obsessive-compulsive disorder, or other psychiatric disorders have revealed a greater risk of adverse reactions representing suicidal thinking or behavior during the first few months of treatment in those receiving antidepressants. The average risk of such reactions in such clients receiving antidepressants was 4%, twice the placebo risk of 2%. No suicides occurred in these trials. SIDE EFFECTS Most Common Sedation, dry mouth, blurred vision, constipation, mydriasis, urinary retention, disturbance of accommodation. See Antidepressants, Tricyclic for a complete list of possible side effects. ADDITIONAL DRUG INTERACTIONS Guanethidine and similar drugs / Antihypertensive effect may be blocked H St. Johns Wort / Blood levels of amitriptyline and its metabolite Smoking / Amitriptyline levels R/T hepatic metabolism; possible efficacy Valproic acid / Amitriptyline levels HOW SUPPLIED Tablets: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg. DOSAGE TABLETS Antidepressant. Adults (outpatients): 75 mg/day in divided doses; may be increased to 150 mg/day. Alternate dosage: Initial, 50100 mg at bedtime; then, increase by 2550 mg, if necessary, up to 150
IV = Intravenous

C = see color insert

H = Herbal

E = sound alike drug

AMITRIPTYLINE HYDROCHLORIDE
3. Take dose right after food or fluid and in late afternoon or at bedtime if sedative effects a problem. Tablets may be crushed. 4. Do not stop taking drug abruptly without provider approval. 5. Report if blurred vision, sore throat, fever, increased heart rate, impaired coordination, difficult urination, excessive sedation, or seizures occur. 6. Rise slowly from lying to sitting position to reduce low BP drug effects. 7. Wear sunscreen; avoid prolonged sun exposure. 8. Urine may appear blue-green in color; harmless. May experience dry mouth. Report urinary retention or constipation; increase fluids/bulk in diet to offset. 9. Encourage regular dental care; oral dryness can increase risk for dental caries. 10. Beneficial antidepressant effects may not be noted for 4 to 6 wk but side effects may be noted earlier. 11. Elderly clients may be at increased risk for falls; start low doses, use precautions, and observe closely. 12. Avoid intake of alcohol or other CNS depressants. Keep F/U visits to evaluate response and adverse SE. OUTCOMES/EVALUATE Symptoms of depression Control of incontinence Chronic pain control with migraine, tension headache, phantom limb pain, tic douloureux, diabetic neuropathy, peripheral neuropathy, cancer or arthritis, treatment of panic and eating disorders (unlabeled) Relief of insomnia/itching

mg/day. Hospitalized clients: initial, 100 mg/day; may be increased to 200300 mg/day. Maintenance: usual, 40100 mg/day (may be given as a single dose at bedtime). Adolescent and geriatric: 10 mg 3 times per day and 20 mg at bedtime up to a maximum of 100 mg/day. Chronic pain. 50100 mg/day. Analgesic adjunct. 75300 mg/day. Dermatologic disorders. 1050 mg/day.

NURSING CONSIDERATIONS
E Do not confuse amitriptyline with nortriptyline (also a tricyclic antidepressant). ADMINISTRATION/STORAGE 1. Initiate dosage increases late in afternoon or bedtime. 2. Sedative effects may be manifested before antidepressant effects. 3. When satisfactory improvement is noted, reduce the dose to the lowest effective amount. Continue three or more months to lessen the possibility of relapse. ASSESSMENT 1. Note indications, onset, characteristics/extent of S&S; list other agents trialed, outcome. 2. Monitor mental status, CBC, electrolytes, EKG, renal and LFTs. 3. Assess I&O, weights, VS, and bowel elimination patterns. CLIENT/FAMILY TEACHING 1. Take with food; minimizes gastric upset. May increase appetite and cause some weight gain. 2. Do not drive or operate hazardous machinery until drug effects realized; causes high degree of sedation.

Bold Italic = life threatening side effect

= black box warning

W = Available in Canada