plantar responses, convulsions, respiratory failure, cardiac
conduction defects, and arrhythmias. Dilated pupils and
urinary retention also occur. For details on the
management of poisoning, see Tricyclic and related
antidepressants, under Emergency treatment of poisoning
p. 832.lPREGNANCYUse only if potential benefit outweighs risk.
lBREAST FEEDINGThe amount secreted into breast milk is
too small to be harmful.
lHEPATIC IMPAIRMENTSedative effects are increased in
hepatic impairment. Avoid in severe liver disease.
lTREATMENT CESSATIONWithdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge ( 6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
should be withdrawn slowly.
lPRESCRIBING AND DISPENSING INFORMATIONLimited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
lPATIENT AND CARER ADVICE
Medicines for Children leaflet: Amitriptyline for neuropathic
painwww.medicinesforchildren.org.uk/amitriptyline-for-
neuropathic-pain
Driving and skilled tasksDrowsiness may affect the
performance of skilled tasks (e.g. driving).
Effects of alcohol enhanced.
lLESS SUITABLE FOR PRESCRIBINGAmitriptyline
hydrochloride is less suitable for prescribing, see Tricyclic
and related antidepressant drugs in Antidepressant drugs
p. 235.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug. Forms available from special-order
manufacturers include: oral suspension, oral solution
Oral solution
CAUTIONARY AND ADVISORY LABELS 2
▶Amitriptyline hydrochloride (Non-proprietary)
Amitriptyline hydrochloride 2 mg per 1 mlAmitriptyline 10 mg/ 5 ml
oral solution sugar free sugar-free| 150 mlP£ 122. 76 DT =
£ 111. 96
Amitriptyline hydrochloride 5 mg per 1 mlAmitriptyline 25 mg/ 5 ml
oral solution sugar free sugar-free| 150 mlP£ 18. 00 DT = £ 18. 00
Amitriptyline hydrochloride 10 mg per 1 mlAmitriptyline
50 mg/ 5 ml oral solution sugar free sugar-free| 150 mlP£ 24. 00
DT = £ 19. 20
Tablet
CAUTIONARY AND ADVISORY LABELS 2
▶Amitriptyline hydrochloride (Non-proprietary)
Amitriptyline hydrochloride 10 mgAmitriptyline 10 mg tablets|
28 tabletP£ 1. 50 DT = £ 0. 97
Amitriptyline hydrochloride 25 mgAmitriptyline 25 mg tablets|
28 tabletP£ 1. 75 DT = £ 0. 74
Amitriptyline hydrochloride 50 mgAmitriptyline 50 mg tablets|
28 tabletP£ 5. 99 DT = £ 2. 46
Doxepin
lINDICATIONS AND DOSE
Depressive illness (particularly where sedation is
required)
▶BY MOUTH
▶Child 12–17 years:Initially 75 mg daily in divided doses,
alternatively 75 mg once daily, adjusted according toresponse, dose to taken at bedtime; maintenance
25 – 300 mg daily, doses above 100 mg given in
3 divided doseslCONTRA-INDICATIONSAcute porphyrias p. 603.
arrhythmias.during manic phase of bipolar disorder.
heart block
lCAUTIONSCardiovascular disease.chronic constipation.
diabetes.epilepsy.history of bipolar disorder.history of
psychosis.hyperthyroidism (risk of arrhythmias).patients
with significant risk of suicide.phaeochromocytoma (risk
of arrhythmias).susceptibility to angle-closure glaucoma.
urinary retention
CAUTIONS, FURTHER INFORMATIONTreatment should be
stopped if the patient enters a manic phase.
lINTERACTIONS→Appendix 1 : tricyclic antidepressants
lSIDE-EFFECTSAgitation.agranulocytosis.alopecia.
anticholinergic syndrome.appetite decreased.asthenia.
asthma exacerbated.bone marrow depression.breast
enlargement.cardiovascular effects.chills.confusion.
constipation.diarrhoea.dizziness.drowsiness.dry
mouth.dyspepsia.eosinophilia.face oedema.flushing.
galactorrhoea.gynaecomastia.haemolytic anaemia.
hallucination.headache.hyperhidrosis.hyperpyrexia.
increased risk of fracture.jaundice.leucopenia.mania.
movement disorders.nausea.oral ulceration.paranoid
delusions.photosensitivity reaction.postural
hypotension.psychosis.seizure.sensation abnormal.
sexual dysfunction.SIADH.skin reactions.sleep
disorders.suicidal tendencies.tachycardia.taste altered.
testicular swelling.thrombocytopenia.tinnitus.tremor.
urinary retention.vision blurred.vomiting.weight
increased.withdrawal syndrome (in neonates)
SIDE-EFFECTS, FURTHER INFORMATIONThe risk of side-
effects is reduced by titrating slowly to the minimum
effective dose (every 2 – 3 days).
OverdoseTricyclic and related antidepressants cause dry
mouth, coma of varying degree, hypotension,
hypothermia, hyperreflexia, extensor plantar responses,
convulsions, respiratory failure, cardiac conduction
defects, and arrhythmias. Dilated pupils and urinary
retention also occur. For details on the management of
poisoning see Tricyclic and related antidepressants under
Emergency treatment of poisoning p. 832.
lPREGNANCYUse with caution—limited information
available.
lBREAST FEEDINGThe amount secreted into breast milk is
too small to be harmful. Accumulation of metabolite may
cause sedation and respiratory depression in neonate.
lHEPATIC IMPAIRMENTSedative effects are increased in
hepatic impairment. Avoid in severe liver disease.
lRENAL IMPAIRMENTUse with caution.
lTREATMENT CESSATIONWithdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge ( 6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
should be withdrawn slowly.
lPRESCRIBING AND DISPENSING INFORMATIONLimited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.BNFC 2018 – 2019 Depression 239
Nervous system4