Can a patient using Anoro Ellipta (umeclidinium and vilanterol) take amitriptyline?

Amitriptyline Use with Anoro Ellipta (Umeclidinium/Vilanterol)

Yes, patients using Anoro Ellipta (umeclidinium/vilanterol) can take amitriptyline, but caution is advised due to potential anticholinergic side effect overlap.

Medication Overview

Anoro Ellipta

• Anoro Ellipta is a fixed-dose combination of umeclidinium (a LAMA) and vilanterol (a LABA) used for maintenance treatment of COPD 1
• It works through bronchodilation via two complementary mechanisms: muscarinic receptor antagonism and β2-adrenoceptor agonism 2
• Administered once daily via the Ellipta dry powder inhaler 3

Amitriptyline

• Tricyclic antidepressant (TCA) with multiple mechanisms of action including:
  • Inhibition of serotonin and noradrenergic reuptake
  • Blockade of muscarinic-1 receptors (anticholinergic effects)
  • Blockade of α1-adrenergic and histamine-1 receptors 4
• Commonly used at lower doses (10-75 mg/day) for chronic pain conditions including neuropathic pain, rather than the higher doses used for depression 4, 5

Potential Interaction Considerations

Anticholinergic Burden

• Both medications have anticholinergic properties that could theoretically be additive:
  • Amitriptyline has significant anticholinergic effects 4
  • Umeclidinium is a muscarinic antagonist with anticholinergic properties 2
• Potential overlapping side effects include:
  • Dry mouth
  • Constipation
  • Urinary retention
  • Blurred vision 4

Cardiovascular Considerations

• Amitriptyline may cause:
  • Orthostatic hypotension
  • Tachycardia
  • QT interval prolongation at doses >100 mg/day 4
• Anoro Ellipta contains vilanterol (LABA) which may affect heart rate, but clinical trials showed no clinically relevant increased risk of cardiovascular adverse events 1

Clinical Recommendations

Dosing Considerations

• Start amitriptyline at a low dose (10-25 mg at bedtime) and titrate slowly based on response and tolerability 4
• Lower starting doses are particularly important in elderly patients 4
• Maximum recommended dose of amitriptyline should not exceed 75 mg/day for pain management 4

Monitoring Recommendations

• Monitor for exacerbation of anticholinergic side effects:
  • Dry mouth
  • Constipation
  • Urinary hesitancy
  • Blurred vision 4
• Consider baseline ECG in patients with cardiovascular disease history before starting amitriptyline 4
• If QT interval prolongation or PR prolongation is present, consider alternative agents 4

Alternative Options

• If anticholinergic side effects become problematic:
  • Secondary amine TCAs (nortriptyline, desipramine) have fewer anticholinergic effects than tertiary amines like amitriptyline 4
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) like duloxetine may be considered as alternatives with less anticholinergic burden 4

Special Considerations

Elderly Patients

• Greater caution is needed in elderly patients due to:
  • Increased sensitivity to anticholinergic effects
  • Higher risk of orthostatic hypotension
  • Greater risk of cognitive effects 4, 5
• Start with very low doses (10 mg/day) in elderly patients 4

Patients with Constipation-Predominant Conditions

• Amitriptyline's anticholinergic effects may worsen constipation
• For patients with IBS-C, secondary amine TCAs (desipramine, nortriptyline) may be better tolerated due to lower anticholinergic effects 4

Pain Management Context

• Amitriptyline is effective for neuropathic pain conditions with an NNT of 1.5-3.5 4
• Low-dose amitriptyline (10 mg at bedtime) has shown efficacy for pain management 4
• Analgesic effects are independent of antidepressant effects and may be achieved at lower doses 4