Amitriptyline (Elavil)
Tricyclic antidepressant (10-50 mg: histamine H1 and serotonin 5-HT2 receptor antagonist; 150-300 mg: norepinephrine, serotonin reuptake inhibitor, receptor antagonist (5-HT2))
- Major Depression3
- Higher side effects than other tricyclics
- Deepens sleep quality
- Chronic Pain2
- Migraine prevention
- Although approved in teen depression, this is an historic approval it isn’t clearly effective there.
Features
Dosing
150-300 mg/d, start 25-50 mg/d.
Dose by serum level (target 100-250).
Teen depression (≥ 13): Start 25-50 mg/day in divided doses; increase gradually to 100 mg/day in divided doses.
Management
TCA with highest anticholinergic burden and sedation. But may have strongest benefits in pain.
TOLERABILITY: ANTICHOLINERGIC: Constipation (treat docusate 100 mg BID + sennosides 8.6 mg; bethanechol 10-25 mg tid if severe), urinary retention (treat bethanechol 25mg tid), dry mouth (treat spry gum tid, biotene; or pilocarpine swish), blurry vision, confusion.
RISKS: HEART: Orthostatic hypotension (treat elastic abdominal binders or support stockings; if severe, fludrocortisone 0.1-0.2 mg qd or midrodine 0.5 mg tid), falls, cardiac arrhythmias; HEPATOTOXICITY: Extremely rare (4 per 100,000 patient-years).
EMR Text
Depression
Amitriptyline use based on FDA approval in major depressive disorder.
Amitriptyline side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.