Starting Dose of Amitriptyline

Start amitriptyline at 10-25 mg at bedtime for most adult patients, with 10 mg being the preferred initial dose in clinical practice. 1, 2

Standard Adult Dosing

Initial dose: 10-25 mg at bedtime is recommended across multiple guidelines for neuropathic pain conditions 1
The FDA label indicates that for outpatients, therapy can be initiated with 50-100 mg at bedtime, though this represents traditional antidepressant dosing rather than the lower doses used for pain management 2
Most patients in specialty practice are started on 10 mg daily, which has been shown to be effective and well-tolerated in real-world headache treatment 3

Increase by 10-25 mg every 3-7 days as tolerated to reach a target dose of 25-100 mg at bedtime 1
For neuropathic pain, the therapeutic range is typically 25-150 mg daily, which is lower than antidepressant dosing 1
The FDA label allows increases preferably in the late afternoon and/or bedtime doses, with outpatients potentially requiring up to 150 mg per day 2

Start with 10 mg three times daily with 20 mg at bedtime for those who do not tolerate higher dosages 2
Lower doses are generally recommended due to increased plasma levels from decreased hepatic metabolism in elderly patients 2
Elderly patients should be monitored carefully with quantitative serum levels obtained as clinically appropriate 2

Use caution and consider lower starting doses (10 mg) in patients with cardiac disease or dysrhythmia history 1
Amitriptyline can prolong QTc interval and increase heart rate, with mean increases of 16 beats per minute observed in clinical studies 4

A sedative effect may appear before the antidepressant or analgesic effect, which is noted within the first few weeks 2
Adequate therapeutic effect may take up to 30 days to develop, so patience is required during initial titration 2
In post-herpetic neuralgia, significant pain reduction was demonstrated in 66% of patients within 3 weeks at doses of 25-150 mg daily 1

Dry mouth, constipation, and sedation are the most common anticholinergic effects 1
Orthostatic hypotension can occur, particularly in elderly patients 1
Weight gain may develop with continued use 1
Daytime fatigue was reported in 11% of headache patients in specialty practice 3

Avoid starting at traditional antidepressant doses (75-150 mg) for pain management, as lower doses (10-25 mg) are equally effective and better tolerated 3
Do not use in pediatric patients under 12 years of age due to lack of experience and safety data 2
Risk of serotonin syndrome exists when combined with other serotonergic agents 1
Nearly half of patients prescribed amitriptyline may have contraindications or precautions for its use, requiring careful screening before initiation 5

Screen for contraindications: cardiac disease, recent MI, concurrent MAO inhibitor use, urinary retention, narrow-angle glaucoma 1, 2
Start 10 mg at bedtime for most patients, or 25 mg if younger and healthy 1, 3
Increase by 10-25 mg every 3-7 days based on tolerability 1
Target dose: 25-100 mg at bedtime for neuropathic pain 1
Reassess at 3-4 weeks for therapeutic benefit, as full effect may take up to 30 days 2
Once stable, continue maintenance therapy for at least 3 months to prevent relapse 2

Most patients (58%) in specialty practice take 10-25 mg as their maximum dose, which is substantially lower than traditional dosing 3
Approximately 75% of headache patients report improvement with low-dose amitriptyline 3
85% of patients persist with treatment when started at low doses, suggesting better tolerability 3