Imipramine (Tofranil)

Tricyclic antidepressant (serotonin, norepinephrine reuptake inhibitor; metabolized to desipramine)

  • Major depression3
  • Treatment resistant depression4
  • Generalized anxiety3
  • Binge eating3
  • Anxious depression3
  • Panic3
  • Irritable bowel syndrome

Features

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Handout

Dosing

Start 25-50 mg qhs, target 150-300 mg qhs.

Dose by serum level (target 150-300 ng/mL).

Two forms: Hydrochloride (instant release) and Pamoate (better tolerated sustained release, generic but more expensive).

Management

Best studied TCA for panic disorder and anxious depression. Approved for childhood enuresis.

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

Imipramine use based on FDA approval in major depressive disorder.

Imipramine side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.

Panic Disorder

Imipramine use based on controlled trials in panic disorder (Barlow DH et al, JAMA. 2000;283(19):2529-2536)

Imipramine side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.

Generalized Anxiety Disorder

Imipramine use based on controlled trials in generalized anxiety disorder (Rickels K et al, Arch Gen Psychiatry. 1993;50(11):884-895)

Imipramine side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.

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