Amitriptyline (Oral)

Amitriptyline is a tricyclic antidepressant which is primarily used to treat mental illnesses, but it is also prescribed for arthritis and chronic pain disorders.

Overview

Commonly known under the brand name ELAVIL (amitriptyline), is a serotonin and norepinephrine reuptake inhibitors (SNRIs). This type of drug increases the levels of two naturally-occurring chemicals in the brain - serotonin and norepinephrine. These chemicals are known to be related to mood, and people suffering from mood disorders like depression often have low levels of these chemicals in their brain. Therefore increasing the amounts of these chemicals available in the brain is how amitriptyline is thought to help people suffering from these conditions.

In addition to depression, there is evidence suggesting that amitriptyline can help people with other mental disorders, such as anxiety, eating disorders, insomnia, and attention deficit hyperactivity disorder. The drug is also used as a treatment for people suffering from disorders which cause chronic pain. These include neuropathic pain (damage or disease which affects the nervous system), fibromyalgia, and arthritis.

Although amitriptyline increases serotonin and norepinephrine levels fairly quickly, its effects on mood and pain generally do not come until you have been taking the drug for two to four weeks. It is therefore important to continue taking the medication even if you do not immediately see any improvement in your condition.

Studies have shown amitriptyline to be an effective treatment for the above conditions, and although it is generally well-tolerated, it is associated with more undesired side effects than other drugs that are available for the same conditions. It is therefore not typically used as a “front line” treatment but is more often given to patients who were resistant to other treatments.

Conditions Treated

  • Anxiety
  • Attention deficit hyperactivity disorder
  • Arthritis
  • Bipolar disorder
  • Chronic pain
  • Depression
  • Eating disorders
  • Fibromyalgia
  • Insomnia
  • Migraine headaches
  • Post-herpetic neuralgia (pain following a shingles infection)

Type of Medicine

  • Tricyclic antidepressant (TCA)
  • Serotonin–norepinephrine reuptake inhibitor (SNRI)

Side Effects

Although amitriptyline is considered safe when used within prescribed limits, it is less well-tolerated than other antidepressant drugs and more side effects are reported by the people who use it. Serious side effects are rare, but they have been reported. Contact your doctor immediately if you experience any of the following:

  • Bleeding or bruising
  • Chest pain
  • Difficulty speaking, including slurred speech or slow speech
  • Faintness or fainting
  • Hallucinations (seeing or hearing things that aren't there)
  • Heart issues, including rapid or irregular heartbeat
  • Weakness or numbness in one part of the body

Other side effects may occur that are less serious, but you may still wish to speak to your doctor about. These include:

  • Dry mouth
  • Drowsiness
  • Changes in appetite
  • Changes in weight (both gain and loss)
  • Changes to sex drive
  • Constipation
  • Difficulty urinating
  • Headaches
  • Nausea
  • Sweating

This list is not exhaustive and amitriptyline might trigger other side effects. Pay attention to your body and how you feel, and if you notice any side effects that are unusual, bothersome, or that cause you any concern, discuss them with your doctor or pharmacist. It may be that your dosage has to be altered, or you may be given another drug or product to help you manage the side effects.

Sometimes amitriptyline can have unexpected impacts on your mood or the type of thoughts that you think, especially when you first start taking the medication. This can include thoughts of self-harm or suicide and is more common in younger individuals taking the drug. Because of this, your doctor may want to check up on you regularly, and you should inform your family or caregivers that you are taking the drug and that this response is possible. They can then keep an eye out for any changes in your behavior. If you do notice such thoughts, consult your doctor promptly.

People tend to experience fewer side effects from amitriptyline if they start with a lower dose and build up to their required clinical dose over a period of a few weeks. This gives the body the time to adapt to the presence of the drug. Also, people often find that many side effects that do occur initially tend to disappear within a few weeks.

Overdose

Always take the dosage as prescribed by your doctor, because there are potentially serious consequences if you take an overdose of amitriptyline. If you notice any of the symptoms below, seek emergency medical assistance immediately:

  • Clumsiness, lack of coordination
  • Coma (loss of consciousness)
  • Confusion and disorientation
  • Drowsiness, tiredness, or sleepiness
  • Irregular heartbeat
  • Reduced body temperature or difficulty staying warm
  • Rigid muscles
  • Muscle aches, weakness or spasms
  • Vomiting
  • Weak pulse
  • Allergic reaction
  • Allergic reactions to amitriptyline are rare, but they can occur. Seek emergency medical assistance if you experience any of the following symptoms:
  • Rash, hives or redness of the skin
  • Itching or swelling particularly when occurring in the face, tongue, or throat
  • Severe dizziness, drowsiness, or fatigue
  • Any difficulty in breathing, including wheezing

Dosage

The dosage of amitriptyline that you are prescribed will be based on your demographics and the type and severity of your condition. You should always take amitriptyline exactly as prescribed to do so by your doctor. With that said, here are the doses that are typically prescribed:

Outpatient dosages

The typical dose is 75 mg, although this may be adjusted depending on your clinical response to the drug. Amitriptyline is most commonly taken in divided doses throughout the day, although some individuals may be told to take the entire dose at bedtime. The maximum outpatient dose of amitriptyline to be taken daily is 150 mg.

Inpatient dosages

These dosages are typically a little higher than outpatient doses, both because the severity of symptoms displayed by inpatients tends to be higher, and because they can be monitored more carefully to ensure no adverse effects to amitriptyline are occurring. Inpatients typically take around 100 mg per day, and the maximum dose is 300 mg.

Older patients (depression)

Geriatric patients usually receive around 50 mg per day, with one larger dose taken at bedtime (for example, 20 mg), and the remainder taken in divided doses throughout the day. Generally speaking, because older patients are more likely to have liver problems and are at a higher risk of developing them, they will usually receive a lower dose than younger individuals.

Arthritis and chronic pain

For these conditions, the dose is generally much lower than the dose given for depression and other mental health issues. Usually, you will begin by taking 5-10 mg a day, and this dose will gradually increase to around 20 mg per day. If the pain you experience as a result of your arthritis is particularly intense, you may be prescribed a dose of up to 75 mg.

If you are unable or forget to take one of your scheduled doses of amitriptyline, take it as soon as you remember. The exception is when you are close to the time at which you would take your next dose. In that case, just skip the dose you missed and carry on with your schedule as normal. Do not double up your next dose because you missed a previous one - it is not necessary to do so and may be harmful.

When the time comes for you to stop taking amitriptyline, you will normally be advised to “taper off” the dosage. That is to say, you will gradually reduce your dosage over a period of several weeks, rather than simply discontinuing the use of the drug immediately. This is because amitriptyline can cause withdrawal effects including headaches and disturbances to sleep patterns if you stop taking it abruptly.

Interactions

Before you take amitriptyline, it is important to discuss with your doctor any medications, vitamins, herbal products or any other supplements that you are already taking. This is because certain other medications and products can cause adverse medical effects when taken with amitriptyline.

Some drugs are of particular concern due to their interaction with amitriptyline. These include the following:

Cisapride

This is a drug used to treat heartburn in people who have proven resistant to other treatments. It is known to sometimes cause irregularities with the heart, and when taken at the same time as amitriptyline the results can be very serious. You should not take amitriptyline and cisapride concurrently.

Monoamine Oxidase (MAO) Inhibitors

This is another form of drug used primarily to treat depression. Amitriptyline and MAO inhibitors are dangerous when they are taken together. In some cases, the combination can cause convulsions, high blood pressure, high temperatures or stomach pain. Furthermore, MAO inhibitors can remain in your system for around 14 days, so you will be advised not to start taking amitriptyline until at least two weeks after you have finished your course of the MAO inhibitor.

Other drug classes of concern include:

  • Anticholinergics
  • Antipsychotics
  • Antithyroid medications
  • Cimetidine
  • Disulfiram
  • Guanethidine

Painkillers, particularly opiate-based drugs such as tramadol (Ultram)

Selective serotonin reuptake inhibitors such as fluoxetine (prozac)

Thyroid hormones

Amitriptyline can cause negative side effects when taken at the same time as certain anaesthetic and other medications that are given during surgery. If you are due to have any form of surgery during the time period for which you expect to be taking amitriptyline, make sure that your usual doctor and the doctor in charge of your surgery are aware of this. This also applies to certain anaesthetics used during dental procedures, so if you need to see your dentist, inform them that you are taking amitriptyline.

If you consume alcohol while you are taking a course of amitriptyline this may make the side effects worse or reduce the effect that the drug has on your condition. Amitriptyline also significantly increases the effects of alcohol in the body. You should, therefore, avoid consuming alcohol while taking a course of amitriptyline. If you feel you will have difficulty abstaining, be sure to inform your doctor of this. If you do drink alcohol, seek medical assistance if you experience any unusual symptoms, including:

  • Confusion or mental fogginess
  • Drowsiness
  • Lightheadedness
  • Nausea or vomiting
  • Seizures
  • Sweating
  • Vision problems

As well as alcohol, amitriptyline will add to the effects of some other central nervous system depressants, including:

  • Antihistamines and other medication normally prescribed to treat allergies like hay fever
  • Barbiturates
  • Muscle relaxants
  • Sedatives or any medication given to help you sleep
  • Some prescription painkillers
  • Tranquilizers
  • Amitriptyline may stay in your system for several days after you discontinue usage, so you should continue to avoid the above substances for at least a few days after you finish your course of amitriptyline.

Warnings

Amitriptyline is considered to be safe when taken as prescribed by a doctor. However, there are some people for whom amitriptyline may not be an appropriate choice of medication. If you meet any of the criteria below, make sure you discuss this with your doctor before you take amitriptyline:

If you have had a heart attack, amitriptyline may not be suitable for you. Inform your doctor if you have ever suffered a heart attack.

Do not take amitriptyline if you have taken a monoamine oxidase (MAO) inhibitor in the previous two weeks. MOI inhibitors are typically prescribed for depression or Parkinson's disease, so if you suffer from and take medication for these conditions, let your doctor know.

If you are taking cisapride, a heartburn medication.

Amitriptyline may make the symptoms of some other conditions more intense. See your doctor if you suffer from another condition and its symptoms have worsened since you started taking amitriptyline. Conditions that are at particularly high risk of being affected by amitriptyline include:

Diabetes - Amitriptyline can affect your blood sugar levels in unpredictable ways. If your blood glucose level changes while you are taking this medication, discuss the matter with your doctor, as changes to your medication dosage may need to be made in order to compensate for this.

Epilepsy - you may experience more seizures while taking amitriptyline.

Heart problems - amitriptyline may cause an irregular heartbeat in people with existing heart problems.

Glaucoma - you should undergo more frequent eye tests with your optician if you suffer from glaucoma.

You should also let your doctor know if you have previously suffered from any of the conditions on the above list. If you no longer suffer from the condition, you may still be able to take amitriptyline, but your doctor may adjust the dose or monitor your response to the drug more closely. You should also let your doctor know if you have previously suffered from:

Any mental illness, including bipolar disorder, schizophrenia or psychosis

Enlarged prostate

Liver disease or any other problems with your liver

Problems or difficulty urinating

At present it is not known whether taking amitriptyline while you are pregnant will be harmful to the developing baby. If you are pregnant or planning to become pregnant, inform your doctor who will be able to advise you on the latest information in this regard. It is known, however, that amitriptyline finds its way into breast milk and therefore can be passed on to your baby via breastfeeding, albeit in small amounts. If you plan to breastfeed while you are taking amitriptyline, you should discuss this with your doctor first.

Amitriptyline is not considered to be safe for children younger than 12 years of age, and should not be taken by this age group.

You may experience some drowsiness when you are taking amitriptyline, particularly when you first start taking it. So you should not drive, operate machinery, or engage in any task that requires focused attention until you have been taking the drug for a little while and can see how it affects you. It is also advisable not to drive or use machinery whenever the dosage of your medication is adjusted, as you are more prone to experience side effects for a short time as your body adapts to the new dose.

Because of the unpredictable effects that amitriptyline can have on your physical and emotional health, your doctor may wish to see you for regular check ups, particularly in the initial phases of your treatment, or whenever the dosage is altered. Ensure that you attend all of these appointments.

People over the age of 65 are usually not prescribed amitriptyline, because they are at a greater risk of experiencing side effects, and there are other medications available that are potentially safer for this age group. However, if you are prescribed amitriptyline, pay close attention to the effects of the drug in your body, and maintain regular contact with your doctor in order to monitor your condition.

Storage

Improper storage of amitriptyline may affect the strength of the medication, and may also make it more dangerous for you to take. Observe the following instructions when storing your medicine:

Room temperature -- Excessive heat or cold can damage your medication, so always store the tablets at room temperature. Keep the medication away from sources of heat, away from heaters, radiators, the stove or any other cooking devices, and your glove compartment. Do not store the medication in a medicine cabinet in the bathroom, because the heat produced by the shower and the hot water faucet can also be damaging to the tablets. You should also avoid storing your medication in the refrigerator or the freezer. This can also damage the tablets.

Dry location -- Tablets should be stored in a dry location -- another reason that the kitchen and bathroom are not good places to store medication. If the bottle that your medication came in contains cotton wool, dispose of this rather than leave it in the bottle, as it can bring moisture into the bottle.

Avoid sunlight -- Do not store your medication near a window or any other location in which they will be exposed to direct sunlight.

Child safe -- Amitriptyline should be kept in a safe location that is inaccessible by children. Use the “up and away” rule -- all medication should be stored “up” in a location that children cannot reach, and “away” from their line of sight. On top of this, keep the medication in a child-resistant container.

Signs of damage -- Check your medication for any signs of damage. Such signs include a change in color, chips or cracks, an odor, crumbling, or tablets being stuck together. If you see any of these signs, do not take the tablets.

Shelf life -- You should dispose of any medication that has exceeded its expiration date. Such medication may not be as potent anymore, or it may be dangerous to take.

Safe disposal: If any of your tablets are expired or if they have passed their expiry date, dispose of them safely. Ideally, locate a “take back” scheme operating in your area -- your pharmacist will be able to advise you on whether such a scheme is in operation near where you live, and if not, they can offer further advice on how to dispose of your medication.

Summary

Amitriptyline is considered an effective treatment for major depressive disorder, and some studies suggest that it is one of the most effective drug treatments available, showing better results in experiments than other tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs).

In addition to depression, amitriptyline is also used to treat some other conditions, including chronic pain disorders, insomnia, and other mental health issues such as anxiety and attention deficit hyperactivity disorder (ADHD).

Despite being an effective treatment, amitriptyline is generally less well-tolerated and more people report side effects. Many of these side effects are unpleasant, but they can generally either be managed with other drugs, or they will disappear after a short period of usage. However, other side effects are more serious, for example some younger individuals report suicidal thoughts in the initial period of taking the drug.

There are some important drug interactions to be aware of, as side effects of varying severity have been reported when amitriptyline is taken alongside other drugs. In particular, cisapride and MAO inhibitors can have serious consequences when taken at the same time as amitriptyline. It is very important to discuss all medication, nutritional supplements and herbal products with your doctor before you start taking amitriptyline.