From the Guidelines
Common tricyclic antidepressant (TCA) medications include amitriptyline, nortriptyline, imipramine, desipramine, doxepin, and clomipramine. These medications work by increasing the levels of serotonin and norepinephrine in the brain by blocking their reuptake at nerve terminals. TCAs are typically prescribed at starting doses of 10-25mg daily, often taken at bedtime due to their sedating effects, with gradual increases to therapeutic ranges of 75-300mg daily depending on the specific medication and patient response, as seen in studies such as 1. Treatment duration is usually several months to years, with continuation recommended for 6-12 months after symptom resolution to prevent relapse. While effective for depression, TCAs are also used for conditions like neuropathic pain, migraine prevention, and anxiety disorders. Some key points to consider when prescribing TCAs include:
- Starting with low doses, especially in older patients, and gradually increasing as needed and tolerated, as recommended in 1
- Being aware of common side effects including dry mouth, constipation, blurred vision, urinary retention, and drowsiness, which result from the anticholinergic properties of these medications
- Careful monitoring due to potential cardiac effects and toxicity in overdose, and tapering gradually under medical supervision if discontinuation is necessary, as noted in 1 and 1
- Considering the differences between tertiary-amine TCAs (e.g., amitriptyline, imipramine) and secondary-amine TCAs (e.g., nortriptyline, desipramine), with the latter thought to be safer due to lower affinity for muscarinic receptor antagonism, as discussed in 1.
From the FDA Drug Label
The biochemical activity of the drug metabolizing isozyme cytochrome P450 2D6 (debrisoquin hydroxylase) is reduced in a subset of the Caucasian population (about 7% to 10% of Caucasians are so-called "poor metabolizers"); reliable estimates of the prevalence of reduced P450 2D6 isozyme activity among Asian, African, and other populations are not yet available. Poor metabolizers have higher than expected plasma concentrations of tricyclic antidepressants (TCAs) when given usual doses. Drugs Metabolized by P450 2D6 ... Poor metabolizers have higher than expected plasma concentrations of tricyclic antidepressants (TCAs) when given usual doses.
Common TCA medications include:
- Amitriptyline 2
- Imipramine 3 These are examples of tricyclic antidepressants (TCAs) mentioned in the provided drug labels.
From the Research
Common Tricyclic Antidepressant (TCA) Medications
- Amitriptyline: commonly used for migraine prevention 4 and neuropathic pain management 5, 6
- Nortriptyline: alternative to amitriptyline for patients who may not tolerate it 4, used for neuropathic pain management 5, 6
- Imipramine: used for neuropathic pain management 5, 7
- Desipramine: used for chronic orofacial pain management 8
- Doxepin: used for chronic orofacial pain management 8
Uses of TCAs
- Migraine prevention 4
- Neuropathic pain management 5, 6
- Chronic orofacial pain management 8
- Treatment of depression 5