What to Know About Amitriptyline

Amitriptyline is an oral anti-depressant medication that is also sometimes prescribed off-label for the management of certain types of pain, including migraines and neuropathic pain. It prolongs the action of epinephrine and serotonin, neurotransmitters that play a role in modulating pain and mood. Specifically, amitriptyline prevents termination of the action of these neurotransmitters by preventing their uptake into membrane receptors.

Currently only available in the generic form, amitriptyline had previously been manufactured by AstraZeneca under the brand name Elavil, which has been discontinued.

Uses

This medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression, and it is more effective for the treatment of endogenous depression (that which is caused by a genetic or biological factor) than for depression caused by external factors. It is taken every day for the prevention of depressive symptoms and it does not immediately alleviate the effects of depression.

Off-Label Uses

There are a number of off label-uses for which amitriptyline is commonly used without FDA approval. These are generally chronic conditions that require consistent, long-term management.

Conditions that are often treated with amitriptyline include:

• Anxiety
• Pain from neuropathy, fibromyalgia, postherpetic neuralgia, or central nervous system disorders
• Migraine prophylaxis
• Insomnia
• Post-traumatic stress disorder (PTSD)
• Sialorrhea (excessive drooling)

Before Taking

Amitriptyline is a first-line agent for the treatment of depression, which means that you can be prescribed this medication even if you have not tried any other treatments. It also isn't necessary that you try any other prescriptions before using amitriptyline off-label.

Precautions and Contraindications

Amitriptyline is not FDA-approved for children under age 12.

There are other cases in which use of amitriptyline is either not advised or must be considered carefully.

Amitriptyline should not be used if you:

• Have had an adverse reaction to it in the past
• Are recovering from a heart attack
• Have cardiac arrhythmia or QT prolongation on your electrocardiogram (EKG)
• Have bipolar disorder (the drug increases the risk of manic episodes)

Your doctor will weigh the pros and cons of this medication before prescribing it to you if you:

• Are pregnant, plan to be pregnant, or are nursing (safety has not been verified)
• Have wide-angle glaucoma: The drug can exacerbate this condition; if you haven't been diagnosed with this, you may be checked for it in advance given the risks.
• Have a history of suicidal ideation or a suicide attempt, as amitriptyline has been associated with a risk of suicide ideation
• Have schizophrenia (due to a related worsening of symptoms)

Other Tricyclic Antidepressants

Due to its molecular structure, amitriptyline is described as a tricyclic antidepressant.

Some other tricyclic antidepressants include:

• Nortriptyline
• Imipramine
• Desipramine
• Doxepin
• Amoxapine

Other Antidepressants

Other antidepressant classes include monoamine oxidase (MAO) inhibitors, such as selegiline and rasagiline, and selective serotonin reuptake inhibitors (SSRIs), such as sertraline and paroxetine.

Dosage

Amitriptyline comes in tablet form and is available in doses of 10 milligrams (mg), 25 mg, 50 mg, 75 mg, 100 mg, and 150 mg. For depression, the medication is usually started at a relatively low dose (between 50 mg and 100 mg per day).

If necessary, this may be increased by 25 mg every three to seven days to a total of 150 mg per day.

Modifications

According to the package label, hospitalized patients may require 100 mg a day initially. This can be increased gradually to 200 mg or 300 mg per day if necessary.

Adolescents and elderly adults should start at a lower dose of approximately 30 mg per day. If you have liver disease, your doctor may prescribe a lower dose of amitriptyline for you.

Follow your prescriber's instructions and never alter your dose on your own.

Off-Label Dose

When used off-label for pain, amitriptyline is started at a lower dose than when it is used as an antidepressant—typically at a dose of 10 mg or 20 mg per day. If needed, this dose can be slowly increased under the guidance of your physician.

How to Take and Store

This medicine is taken by mouth, initially in divided doses, but can be taken once per day when the target dose is established. One of the divided doses should be taken at bedtime; the same is recommended if you are taking your entire dose of amitriptyline at once.

Amitriptyline should be stored in the original container at 68 to 77 degrees F. If necessary, you can place your medication in a pillbox to help you manage your medication schedule.

Side Effects

Sleepiness or drowsiness can occur when taking this amitriptyline. Using it at night may alleviate this side effect, but some people continue to feel drowsy during the day, even after a full night's sleep.

Amitriptyline can cause mood changes and suicidal ideation. It may cause dizziness, lightheadedness, or orthostatic hypotension (low blood pressure when standing).

It may also increase appetite and cause weight gain. The weight gain can be more than what you would expect from the increased appetite.

Warnings and Interactions

Amytriptyline can interact with more than 2,000 drugs. It is imperative that you discuss your other medications with your doctor.

A major drug interaction is defined as one in which the risk of taking both medications outweighs the benefits of doing so. The most common medications that have the potential for such an interaction when combined with amitriptyline include:

Moderate drug interactions are generally allowed only in special circumstances. The most common medications that have the potential for these interactions when combined with amitriptyline include: