Drug DataClassificationMechanism of ActionIndicationContraindicationsAdverse ReactionNursing Responsibilities

Generic Name: AMITRIPTYLINETrade/Brand Name: Apo- Imipramine, Tofranil, Impril, Norfranil, Novopramine, Tipramine, Tofranil PM

Minimum Dose:

Depression

Adult: 50 mg daily

Child: Adolescents(>16yr): 30 mg daily

Elderly: 30 mg daily

Nocturnal enuresis

Child: >11 yr: 25mg at bedtime; 6-10 yr: 10 mg at bedtime. *Treatment should not continue >3 mth.Neuropathic pain- Adult: 10 mg at nightProphylaxis of migraine

Adult: 10 mg daily

Maximum Dose:

Depression

Adult: 300 mg daily

Child: Adolescents(>16yr): 7 5mg daily

Elderly: 75 mg daily

Nocturnal enuresis

Child: >11 yr: 50mg at bedtime; 6-10 yr: 20 mg at bedtime. *Treatment should not continue >3 mth.Neuropathic pain- Adult: 25 mg at nightProphylaxis of migraine

Adult: 75 mg daily

Availability:

Tablets, Capsules

Route(s) of Administration:

Oral

Source: Karch Am 2011: Lippincotts Nursing Drug Guide; Lippincott William and Wilkins: pp. 117-119Therapeutic:

AntidepressantPharmacologic Class:

Tricyclic Antidepressant

Pregnancy Risk Category: C - Either studies in animals have revealed adverse effects on the foetus (teratogenic or embryocidal or other) and there are no controlled studies in women or studies in women and animals are not available.Source: Karch Am 2011: Lippincotts Nursing Drug Guide; Lippincott William and Wilkins: pp. 117-119Amitriptyline is a TCA that exerts its action by blocking neuronal re-uptake of noradrenaline and serotonin thus increasing synaptic concentration of serotonin and/or norepinephrine in the CNS.

Absorption: Readily absorbed from the GI tract (oral).Distribution: Widely distributed; crosses the placenta; enters breast milk. Protein-binding: Extensive.Metabolism: Extensively 1st-pass effect; demethylated hepatically to nortriptyline (active metabolite).Excretion: Urine (as metabolites in free or conjugated form); 9-25 hr (elimination half-life).

Pharmacokinetics

Route Onset Peak Duration

PO Varies 2-4 hr 2-4 wk

Source: Karch Am 2011: Lippincotts Nursing Drug Guide; Lippincott William and Wilkins: pp. 117-119General Indication:

Relief of symptoms of depression (endogenous depression most responsive); sedative effects may help when depression is associated with anxiety and sleep disturbance

Unlabeled Use: Control of chronic pain (e.g. intractable pain of cancer, central pain syndromes, peripheral neuropathies, postherpetic neuralgia, tic douloureux); prevention of onset of cluster and migraine headaches; treatment of pathologic weeping and laughing secondary to forebrain disease (due to MS); insomnia, fibromyalgia

Source: Karch Am 2011: Lippincotts Nursing Drug Guide; Lippincott William and Wilkins: pp. 117-119

Hypersensitivity, use of MAO inhibitors within the last 14 days; acute recovery phase post-MI. Concurrent usage with cisapride.

Precautions

Bipolar illness, pregnancy, lactation elderly, CVS disease, renal or liver impairment, epilepsy, thyroid dysfunction, DM. Avoid abrupt withdrawal; urinary retention, prostatic hyperplasia; chronic constipation; angle-closure glaucoma; phaeochromocytoma. Monitor for signs of clinical worsening, suicidality or behavioural changes. May increase risks associated with electro-convulsive therapy. May affect ability to drive or operate machinery.

Drug-drug Interaction

Reduced effect of antihypertensives. Potentiates hypertensive effects of sympathomimetics. Concurrent use with altretamine may cause orthostatic hypotension. May increase adverse CV effects when used with amphetamines. May increase serum levels of carbamazepine. Increased risk of cardiac arrhythmias when used with -agonists. Absorption may be reduced when used with cholestyramine, colestipol or sucralfate. Additive sedative effects when used with CNS depressants. Concurrent use with CYP2D6 inhibtors (e.g. chlorpromazine, delavirdine, fluoxetine, miconazole, paroxetine) may increase serum levels of amitriptyline. May increase antidiabetic effect of tolazamide, chlorpropamide or insulin. May reduce absorption of levodopa. Increased risk of neurotoxicity when used with lithium. Increased risk of seizures when used with tramadol. May increase anticoagulant effect of warfarin. May cause QT prolongation and fatal arrhythmias when used with drugs that prolong QT interval.

Drug-Food Interaction

Alcohol may enhance adverse effects.Source: Karch Am 2011: Lippincotts Nursing Drug Guide; Lippincott William and Wilkins: pp. 117-119CNS: Disturbed concentration, sedation and anticholinergic (atropine-like) effects; confusion (especially in elderly), hallucinations, disorientation, decreased memory, insomnia, nightmares, hypomania, mania, exacerbation of psychosis, drowsiness, paresthesias of extremities, incoordination, motor hyperactivity, akisthisia, ataxia, tremors, peripheral neuropathy, EPS, seizures, speech blockage, dysarthria, tinnititus, altered ECG

CV: Orthostatic hypotension, hypertension, syncope, palpitayions, MI, arythmias, heart block, precipitation of Heart Failure, CVA

Endocrine: Elevated or depressed blood sugar, elevated prolactin levels, inappropriate ADH Secretion

GI: Dry mouth, constipation, paralytic ileus, nausea, vomiting, epigastric distress

GU: Urinary retention, delayed micturition, dilation of the urinary tract, gynecomastia, testicular swelling, breast enlargement, menstrual irregularity and galctorrhea; increased or decreased libido, impotence

Hematologic: Bone marrow depression, purpura, lekopenia

Source: Karch Am 2011: Lippincotts Nursing Drug Guide; Lippincott William and Wilkins: pp. 117-119Before:

1.) Verify order on Patients Chart

2.) Know Reason for giving drug

3.) Obtain baseline Vital Signs

4.) Check for Hypersensitivity to the drug

5.) Check for Pregnancy/ Lactation

During:

1.) Verify clients identity

2.) Inform Client about purpose of the drug

3.) Administer major portion of dose at bedtime if drowsiness, severe anticholinergic effects occur

4.) Reduce dosage as ordered if minor side effects develop; discontinue if serious side effects occur

5.) Check Vital Signs

After:

1.) Document appropriately

2.) Dispose of used materials

3.) Restrict drug access for depressed and potentially suicidal patients

4.) Arrange for CBC if patient develops fever, sore throat or other sign of infection

5.) Note that drugs sedative effects may take place before antidepressant effects

6.) Instruct to avoid prolonged exposure to sunlight or sunlamps; use sunscreen or protective garments

7.) Instruct not to consume considerable amounts of alcohol while on this drug

8.) Instruct to call nurse/physician if adverse effects occur

9.) Arrange to taper drug when discontinuing

10.) Check Vital Signs

Source: Karch Am 2011: Lippincotts Nursing Drug Guide; Lippincott William and Wilkins: pp. 117-119

Source:

Deglin, J. et. Al. 2009. Daviss Drug Guide for Nurses. 12th ed. F.A. Davis. pp 349-351