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Amitriptyline | Elavil is indicated for depressive illness, particularly with anxiety and nocturnal enuresis in children.

Therapeutic Class

Tricyclic Anti-depressant

Pharmacology

Amitriptyline/ Elavil HCl is an antidepressant with sedative effects. Its mechanism of action in man is not known. It is not a monoamine oxidase inhibitor and it does not act primarily by stimulation of the central nervous system.

Amitriptyline inhibits the membrane pump mechanism responsible for uptake of norepinephrine and serotonin in adrenergic and serotonergic neurons. Pharmacologically, this action may potentiate or prolong neuronal activity since reuptake of these biogenic amines is important physiologically in terminating transmitting activity.

This interference with reuptake of norepinephrine and/or serotonin is believed by some to underlie the antidepressant activity of Amitriptyline.

Dosage & Administration

Depression:

• Adults: Initially 50-70 mg a day in divided dose or as a single dose at night at bedtime.

• Elderly and adolescents: 25-50 mg daily in divided doses or as single dose at bedtime. Dose can be increased gradually as necessary to a maximum of 150-200 mg. Usual maintenance dose is 50-100 mg daily.

Nocturnal enuresis:

• 6-10 years: 10-20 mg at bedtime.

• 11-16 years: 25-50 mg at bedtime for up to 3 months and gradually withdrawn.

Interaction

Monoamine oxidase inhibitors can potentiate the effects of Amitriptyline.

Anticholinergic agents: Amitriptylin/ Elavil should not be given with symptomatic agents such as adrenaline, epinephrine, isoprenaline, noradrenaline.

CNS depressant: Amitriptyline/ Elavil may enhance the response to alcohol, barbiturates.

Cemitidine: Cemitidine is reported to reduce hepatic metabolism of certain tricyclic antidepressants.

Contraindications

Amitriptyline is contraindicated in myocardial infarction; arrythmias, particularly heartblock of any degree; mania; severe liver disease. Initially sedation may affect the ability to drive or operate machinery. It should be used with caution in patients

 with a history of epilepsy, glaucoma, urinary retention, prostatic hypertrophy, constipation, cardiac disease, diabetes, pregnancy, hepatic impairment, thyroid disease, increased intraoccular pressure, psychoses (may aggravate mania).

Side Effects

• Cardiovascular reactions: Hypotension, syncope, postural hypotension, hypertension, tachycardia, palpitations, myocardial infarction, arrythmias, and heart block stroke.

• CNS and neuromuscular: Confusional states, disturbed concentration disorientation, delusions, and hallucinations.

• Anticholinergic: Dry mouth, blurred vision, mydriasis, increased intraoccular pressure, hyperplasia.

• Allergic: Skin rash, urticaria, and photosensitization.

• Haematological: Bone-marrow depression including agranulocytosis, leukopenia, eosinophilia, and thrombocytopenia.

• Gastrointestinal: Nausea, epigastric distress, vomiting anorexia, diarrhoea.

• Endocrine: Testicular swelling, gynaecomastia; breast enlargement, galactorrhoea.

• Other reaction: Dizziness, weakness, fatigue, headache, weight loss

Pregnancy & Lactation

Pregnancy Category C. Amitriptyline is not recommended during pregnancy, especially during the first and third trimester because the safety of Amitriptyline/ Elavil has not been established yet.

Amitriptyline is detectable in breast milk. Because of the serious adverse reactions in infants from Amitriptyline, a decision should be made whether to continue breast feeding or discontinue the drug

Precautions & Warnings

Schizophrenic patients may develop increased symptoms of psychosis; patients with paranoid symptomatology may have an exaggeration of such symptoms. Depressed patients, particularly those with known manic-depressive illness, may experience a shift to mania or hypomania.

In these circumstances the dose of Amitriptyline may be reduced or a major tranquilizer such as perphenazine may be administered concurrently.

The possibility of suicide in depressed patients remains until significant remission occurs. Potentially suicidal patients should not have access to large quantities of this drug. Prescriptions should be written for the smallest amount feasible.

Concurrent administration of Amitriptyline hydrochloride and electroshock therapy may increase the hazards associated with such therapy. Such treatment should be limited to patients for whom it is essential.

When possible, the drug should be discontinued several days before elective surgery. Both elevation and lowering of blood sugar levels have been reported. Amitriptyline hydrochloride should be used with caution in patients with impaired liver function.

Storage Conditions

Keep containers well closed and stored below 25˚ C, protected from light.