Doxepin (Sinequan/Silenor)
Tricyclic antidepressant (3-6 mg: histamine H1 antagonist; Over 25 mg: norepinephrine, serotonin reuptake inhibitor, receptor antagonist (5-HT2))
- Major Depression
- Insomnia (safe in elderly)
- For sleep, mainly improves early morning awakening
- Although approved in adolescent depression (≥12 years), this is an historic approval it isn’t clearly effective there.
Features
Dosing
150-300 mg/d, start 25 mg/d.
Insomnia: use 3-6 mg or (if unaffordable in that size) generic liquid 10mg/ml 0.3-0.6ml qhs prn insomnia.
Adolescents: ≥12 years for depression start: 25-50 mg po qd; may gradually increase if needed to 100 mg/day po qd or divided q8-12hr; No more than 150 mg/day
Serum level optional (target 120-250).
Management
Doxepin improves early morning awakening but is not very effective for initiation insomnia. It is safe in the elderly in the low dose range used for insomnia.
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
Doxepin use based on FDA approval in major depressive disorder.
Doxepin side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.
Insomnia
Low-dose doxepin use based on FDA approval in insomnia.
Doxepin side effects, including cardiac/hypotension, reviewed with patient.