Formulary
Amitriptyline hydrochloride: Indications, Dosing, Side Effects and Interactions
Amitriptyline hydrochloride clinical drug profile including indications, dosing, side effects, cautions and interactions.
MedNext Academy | 5 min read
Amitriptyline hydrochloride: Indications, Dosing, Side Effects and Interactions
Amitriptyline hydrochloride clinical drug profile including indications, dosing, side effects, cautions and interactions.
Indications and dose
**Abdominal pain or discomfort (in patients who have not responded to laxatives, loperamide, or antispasmodics)**
- **Adult** (By Mouth): Initially 5-10 mg daily, to be taken at night; increased in steps of 10 mg at least every 2 weeks as required; maximum 30 mg per day.
**Major depressive disorder [not recommended-increased risk of fatality in overdose]**
- **Adult** (By Mouth): Initially 50 mg daily in 2 divided doses, then increased in steps of 25 mg once daily on alternate days if required, maximum 150 mg daily in 2 divided doses.
- **Elderly** (By Mouth): Initially 10-25 mg daily, increased if necessary up to 100-150 mg daily in 2 divided doses, dose increases dependent on individual patient response and tolerability-doses above 100 mg should be used with caution.
**Major depressive disorder in patients with cardiovascular disease [not recommended-increased risk of fatality in overdose]**
- **Adult** (By Mouth): Initially 10-25 mg daily, increased if necessary up to 100-150 mg daily in 2 divided doses, dose increases dependent on individual patient response and tolerability-doses above 100 mg should be used with caution.
**Neuropathic pain,Migraine prophylaxis,Chronic tension-type headache prophylaxis**
- **Adult** (By Mouth): Initially 10-25 mg daily, dose to be taken in the evening, then increased, if tolerated, in steps of 10-25 mg every 3-7 days in 1-2 divided doses; usual dose 25-75 mg daily, dose to be taken in the evening, doses above 100 mg should be used with caution (doses above 75 mg should be used with caution in the elderly and in patients with cardiovascular disease); maximum per dose 75 mg.
**Emotional lability in multiple sclerosis**
- **Adult** (By Mouth): Initially 10-25 mg daily; increased, if tolerated, in steps of 10-25 mg every 1-7 days; maximum 75 mg per day.
**Neuropathic pain for amitriptyline hydrochloride**
- **Child 2-11 years** (By mouth): Initially 200-500 micrograms/kg once daily (max. per dose 10 mg), dose to be taken at night, increased if necessary; maximum 1 mg/kg twice daily on specialist advice.
- **Child 12-17 years** (By mouth): Initially 10 mg once daily, increased if necessary to 75 mg once daily, dose to be taken at night, dose to be increased gradually, higher doses to be given on specialist advice.
Cautions
Cardiovascular disease; chronic constipation; diabetes; epilepsy; history of bipolar disorder; history of psychosis; hyperthyroidism (risk of arrhythmias); increased intra-ocular pressure; patients with a significant risk of suicide; phaeochromocytoma (risk of arrhythmias); prostatic hypertrophy; pyloric stenosis; susceptibility to angle-closure glaucoma; urinary retention Cautions, further information Treatment should be stopped if the patient enters a manic phase. M Elderly patients are particularly susceptible to many of the side-effects of tricyclic antidepressants; low initial doses should be used, with close monitoring, particularly for psychiatric and cardiac side-effects. M
Contraindications
Arrhythmias; during manic phase of bipolar disorder; heart block; immediate recovery period after myocardial infarction
Side effects
Common or very common Accommodation disorder; anxiety; arrhythmias; behaviour abnormal; cardiac conduction disorders; concentration impaired; confusion; constipation; dizziness; drowsiness; dry mouth; fatigue; headache; hyperhidrosis; hyponatraemia; movement disorders; mydriasis; nasal congestion; nausea; palpitations; paraesthesia; postural hypotension; QT interval prolongation; sexual dysfunction; speech impairment; taste altered; thirst; tremor; urinary disorders; weight changes Uncommon Circulatory collapse; diarrhoea; face oedema; galactorrhoea; heart failure aggravated; hepatic disorders; hypertension; mood altered; oral disorders; seizure; skin reactions; sleep disorders; tinnitus; vomiting Rare or very rare Acute glaucoma; agranulocytosis; alopecia; appetite decreased; bone marrow depression; cardiomyopathy; delirium; eosinophilia; fever; gynaecomastia; hallucination; interstitial lung disease; leucopenia; paralytic ileus; photosensitivity reaction; polyneuropathy; pulmonary eosinophilia; suicidal behaviours; thrombocytopenia Frequency not known Angioedema; anticholinergic syndrome; dry eye; hypersensitivity myocarditis; hyperthermia; increased risk of fracture; severe cutaneous adverse reactions (SCARs) Side-effects, further information The risk of side-effects is reduced by titrating slowly to the minimum effective dose (every 2-3 days). Consider using a lower starting dose in elderly patients. Overdose Overdosage with amitriptyline is associated with a relatively high rate of fatality. Symptoms of overdosage may include dry mouth, coma of varying degree, hypotension, hypothermia, hyperreflexia, extensor plantar responses, convulsions, respiratory failure, cardiac conduction defects, and arrhythmias. Dilated pupils and urinary retention also occur. For details on the management of poisoning, see Tricyclic and related antidepressants, under Emergency treatment of poisoning .
Interactions
**Other interactions (19):**
- Combinations that are not recommended Sympathomimetic agents : Amitriptyline may potentiate the cardiovascular effects of adrenaline, ephedrine, isoprenaline, noradrenaline, phenylephrine, and...
- Adrenergic neurone blockers : Tricyclic antidepressants may counteract the antihypertensive effects of centrally acting antihypertensives such as guanethidine, betanidine, reserpine, clonidine and...
- It is advisable to review all antihypertensive therapy during treatment with tricyclic antidepressants.
- Anticholinergic agents: Tricyclic antidepressants may potentiate the effects of these drugs on the eye, central nervous system, bowel and bladder; concomitant use of these should be avoided due to...
- Drugs which prolong the QT-interval including antiarrhythmics such as quinidine, the antihistamines astemizole and terfenadine, some antipsychotics (notably pimozide and sertindole),...
- Caution is also advised for co-administration of amitriptyline and diuretics inducing hypokalaemia (e.g.
Pregnancy
Use only if potential benefit outweighs risk.
Breast feeding
The amount secreted into breast milk is too small to be harmful.
Hepatic impairment
Manufacturer advises use with caution in mild-to-moderate impairment; avoid in severe impairment.
Medicinal forms
Solution,Tablet,Solution
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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