Protriptyline (Vivactil)
Tricyclic antidepressant (norepinephrine reuptake inhibitor)
- Major Depression
- Least sedating tricyclic
- Treatment resistant depression
- Although approved in teen depression (≥ 12), this is an historic approval it isn’t clearly effective there
Features
Dosing
Start 5-10 mg qhs, target 15-60 mg qhs. Children 15-20 mg po qhs
Serum levels are optional but general target is 70-170.
Management
Least sedating TCA and may be activating.
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
Protriptyline use based on FDA approval in major depressive disorder.
Protriptyline side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.