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ELAVIL (Amitriptyline)

Elavil is a classified as a tricyclic antidepressant (TCA) used as one of the initial medications for neuropathic pain, preceded the Lyrica and Cymbalta medications and found benefit in reducing the painful symptoms of diabetic neuropathy sometimes with undesired sedative effects, so should be used in the elderly with caution.

An early norepinephrine and serotonin reuptake inhibitor it functions at the receptors to potentiate the effects of the two transmitters thus terminating activity transmitting the neuropathic pain. This mode of action is also responsible for its antidepressant activity.

CONTRAINDICATIONS



Amitriptyline should not be used in patients taking MAIO (monoamine oxidase inhibitors) a drug class of medications for hypertension and depression/anxiety, as a combination may induce convulsion or death with hyperpyretic ( elevated body temperature) or coma. Patients with a history of seizures, difficulty, hyperthyroid patients, schizophrenic or manic/depressant patients should avoid taking amitriptyline. It is not recommended in patients younger than 12 years of age, pregnant or nursing mothers.

Amitriptyline interacts with alcohol, CNS (central nervous system) depressants, Disulfiram ( a medication used to treat alcohol addiction by blocking an enzyme to metabolize alcohol-causing nausea, vomiting, gastric pain “Disulfiram reaction") Cimetidine (Tagamet-a medication now over the counter for treating excessive stomach acid symptoms as it blocks histamine-a compound similar to serotonin). The drug also blocks the activity of guanethidine, an antihypertensive medication. Since the drug exerts atropine-like action, it should be administered cautiously in patients with a urinary –retention (difficulty urinating) history, or narrow-angle glaucoma (eye disease with fluid pressure accumulation). Patients taking thyroid medication should also be monitored or those patients diagnosed with hyperthyroidism

Those patients that have been diagnosed as schizophrenic or paranoia may develop increased psychosis with exaggeration of symptoms if given Amitriptyline, and it may enhance may become hypomania in the manic-depressed patient. Due to the drugs mechanism of metabolism(break down in the body), certain drugs may potentiate the effects of amitriptyline such as quinidine-a heart medicine, certain antiarrthymics(drugs that control heart rate) and various other antidepressant the SSRIs- serotonin selective re-uptake inhibitors.

Patients while taking amitriptyline should use extreme caution operating automobiles or other equipment and should determine if the drug causes excessive drowsiness which would alter their ability to perform these tacks.

Alcohol should not be taken while on amitriptyline, and it can potentiate the sedative effects of barbiturates and other central nervous system depressants.

SIDE EFFECTS



Adverse reactions affect the cardiovascular system causing arrhythmias (irregular heartbeats), tachycardia (rapid heartbeats), myocardial infarctions (heart attacks),abnormal lowering of blood pressure, and palpitations, CVA (strokes or cerebral vascular accidents), and the nervous system with disturbed concentration, weakness, fatigue, restlessness, nightmares, tinnitus(ringing in the ears) coma, seizure, elevated body temperature (hyperpyrexia), and gastrointestinal causing paralytic ileus. (Slowing of the intestines) hepatitis, nausea, vomiting diarrhea, abnormal taste in the oral cavity, and urinary retention. Patients may experience weight gain or loss, increased perspiration testicular swelling, altering of blood sugar levels.

DOSING



The drug is available in 10mg, 25mg, 50mg, 75mg, 100mg, 150mg, and injectable form as 10mg/cc. The dosing usually is initiated at 25 mg. at bedtime, increasing to 75 mg. gradually as tolerated or deemed necessary. As with all medication, the smallest dose producing the desired effect is always the goal. The elderly should be started at 10 mg. at bedtime gradually increasing to 25 or 30 mg. The medication is used for psychiatric disorders in higher doses for depression symptoms, and those patients may experience some of the dose related side effects of dry mouth eyes, and GI (stomach) disturbances due to digestive changes.

REFERENCES

PODIATRIC THERAPEUTIC DIGEST -PTD- FIRST EDITION, 1996.

PHYSICIANS DESK REFERENCE, PDR 53 1999

DRUGS.COM, AMITRIPTYLINE

COMMENTS

My personal experience as a podiatrist in treating peripheral neuropathy associated with diabetes and various nerve entrapments has been favorable, with occasional dryness of the mouth or eyes. However with the newer mediations, I have deviated from amtriptyline and have reserved its use for those patients perhaps desiring to avoid Cymbalta or Lyrica and are still fairly symptomatic after a six month course with Metanx. The doses for my patients ranged from 10-25mg orally at bedtime which generally provided some relief without the sedative effects.



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