Amitriptyline Hydrochloride

Amitriptyline Hydrochloride

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Questions & Answers

Side Effects & Adverse Reactions

Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. There has been a long-standing concern, however, that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18 to 24) with major depressive disorder (MDD) and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction with antidepressants compared to placebo in adults aged 65 and older.

The pooled analyses of placebo-controlled trials in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders included a total of 24 short-term trials of 9 antidepressant drugs in over 4400 patients. The pooled analyses of placebo-controlled trials in adults with MDD or other psychiatric disorders included a total of 295 short-term trials (median duration of 2 months) of 11 antidepressant drugs in over 77,000 patients. There was considerable variation in risk of suicidality among drugs, but a tendency toward an increase in the younger patients for almost all drugs studied. There were differences in absolute risk of suicidality across the different indications, with the highest incidence in MDD. The risk differences (drug vs placebo), however, were relatively stable within age strata and across indications. These risk differences (drug-placebo difference in the number of cases of suicidality per 1000 patients treated) are provided in Table 1.

Table 1
Age Range

Drug-Placebo Difference in

Number of Cases of Suicidality

per 1000 Patients Treated
Increases Compared to Placebo
<1814 additional cases
18 to 245 additional cases
Decreases Compared to Placebo
25 to 641 fewer case
≥656 fewer cases

No suicides occurred in any of the pediatric trials. There were suicides in the adult trials, but the number was not sufficient to reach any conclusion about drug effect on suicide.

It is unknown whether the suicidality risk extends to longer-term use, i.e., beyond several months. However, there is substantial evidence from placebo-controlled maintenance trials in adults with depression that the use of antidepressants can delay the recurrence of depression.

All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric. Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.

Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms.

Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to health care providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for amitriptyline hydrochloride should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.

 

A major depressive episode may be the initial presentation of bipolar disorder. It is generally believed (though not established in controlled trials) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such a conversion is unknown. However, prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. It should be noted that amitriptyline hydrochloride is not approved for use in treating bipolar depression.

Amitriptyline hydrochloride may block the antihypertensive action of guanethidine or similarly acting compounds.

It should be used with caution in patients with a history of seizures and, because of its atropine-like action, in patients with a history of urinary retention, angle-closure glaucoma or increased intraocular pressure. In patients with angle-closure glaucoma, even average doses may precipitate an attack.

Patients with cardiovascular disorders should be watched closely. Tricyclic antidepressant drugs, including amitriptyline hydrochloride, particularly when given in high doses, have been reported to produce arrhythmias, sinus tachycardia, and prolongation of the conduction time. Myocardial infarction and stroke have been reported with drugs of this class.

Close supervision is required when amitriptyline hydrochloride is given to hyperthyroid patients or those receiving thyroid medication.

Amitriptyline may enhance the response to alcohol and the effects of barbiturates and other CNS depressants. In patients who may use alcohol excessively, it should be borne in mind that the potentiation may increase the danger inherent in any suicide attempt or overdosage. Delirium has been reported with concurrent administration of amitriptyline and disulfiram.

 

Teratogenic effects were not observed in mice, rats, or rabbits when amitriptyline was given orally at doses of 2 to 40 mg/kg/day (up to 13 times the maximum recommended human dose 1). Studies in literature have shown amitriptyline to be teratogenic in mice and hamsters when given by various routes of administration at doses of 28 to 100 mg/kg/day (9 to 33 times the maximum recommended human dose), producing multiple malformations. Another study in the rat reported that an oral dose of 25 mg/kg/day (8 times the maximum recommended human dose) produced delays in ossification of fetal vertebral bodies without other signs of embryotoxicity. In rabbits, an oral dose of 60 mg/kg/day (20 times the maximum recommended human dose) was reported to cause incomplete ossification of cranial bones.

Amitriptyline has been shown to cross the placenta. Although a causal relationship has not been established, there have been a few reports of adverse events, including CNS effects, limb deformities, or developmental delay, in infants whose mothers had taken amitriptyline during pregnancy.

There are no adequate and well-controlled studies in pregnant women. Amitriptyline hydrochloride should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus.

1

 

Amitriptyline is excreted into breast milk. In one report in which a patient received amitriptyline 100 mg/day while nursing her infant, levels of 83 to 141 ng/mL were detected in the mother’s serum. Levels of 135 to 151 ng/mL were found in the breast milk, but no trace of the drug could be detected in the infant’s serum.

Because of the potential for serious adverse reactions in nursing infants from amitriptyline, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

 

In view of the lack of experience with the use of this drug in pediatric patients, it is not recommended at the present time for patients under 12 years of age.

 

1 Based on a maximum recommended amitriptyline dose of 150 mg/day or 3 mg/kg/day for a 50 kg patient.

Legal Issues

There is currently no legal information available for this drug.

FDA Safety Alerts

There are currently no FDA safety alerts available for this drug.

Manufacturer Warnings

There is currently no manufacturer warning information available for this drug.

FDA Labeling Changes

There are currently no FDA labeling changes available for this drug.

Uses

For the relief of symptoms of depression. Endogenous depression is more likely to be alleviated than are other depressive states.

 

History

There is currently no drug history available for this drug.

Other Information

Amitriptyline HCl, a dibenzocycloheptadiene derivative, is a white, or practically white, odorless, crystalline compound which is freely soluble in water and alcohol.

It is designated chemically as 10,11-Dihydro-N,N-dimethyl-5 H-dibenzo[a,d] cycloheptene-Δ 5, γ-propylamine hydrochloride. It has the following structural formula:

MM1

Each tablet for oral administration contains 10, 25, 50, 75, 100, or 150 mg amitriptyline hydrochloride. Inactive ingredients include colloidal anhydrous silica, croscarmellose sodium, lactose (monohydrate), lecithin, magnesium stearate, microcrystalline cellulose, polyvinyl alcohol, iron oxide red, talc, titanium dioxide and xanthan gum.

 

Amitriptyline Hydrochloride Manufacturers


  • Remedyrepack Inc.
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  • Remedyrepack Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Remedyrepack Inc. ]
  • Sun Pharmaceutical Industries, Inc.
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  • Proficient Rx Lp
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  • American Health Packaging
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  • Direct Rx
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  • Blenheim Pharmacal, Inc.
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    Amitriptyline Hydrochloride Tablet, Film Coated [Proficient Rx Lp]
  • Remedyrepack Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Remedyrepack Inc. ]
  • Remedyrepack Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Remedyrepack Inc. ]
  • Blenheim Pharmacal, Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Blenheim Pharmacal, Inc.]
  • A-s Medication Solutions Llc
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  • Contract Pharmacy Services-pa
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  • Rebel Distributors Corp.
    Amitriptyline Hydrochloride Tablet, Film Coated [Rebel Distributors Corp.]
  • St. Mary’s Medical Park Pharmacy
    Amitriptyline Hydrochloride Tablet [St. Mary’s Medical Park Pharmacy]
  • Blenheim Pharmacal, Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Blenheim Pharmacal, Inc.]
  • Stat Rx Usa Llc
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  • Blenheim Pharmacal, Inc.
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  • Physicians Total Care, Inc.
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    Amitriptyline Hydrochloride (Amitriptyline Hydrochloride) Tablet [Remedyrepack Inc. ]
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    Amitriptyline Hydrochloride (Amitriptyline Hydrochloride) Tablet [Remedyrepack Inc. ]
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    Amitriptyline Hydrochloride (Amitriptyline Hydrochloride) Tablet [Remedyrepack Inc. ]
  • Pd-rx Pharmaceuticals, Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Pd-rx Pharmaceuticals, Inc.]
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    Amitriptyline Hydrochloride Tablet, Film Coated [Pd-rx Pharmaceuticals, Inc.]
  • Lake Erie Medical & Surgical Supply Dba Quality Care Products Llc
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  • Lake Erie Medical Dba Quality Care Products Llc
    Amitriptyline Hydrochloride Tablet, Film Coated [Lake Erie Medical Dba Quality Care Products Llc]
  • Pd-rx Pharmaceuticals, Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Pd-rx Pharmaceuticals, Inc.]
  • Lake Erie Medical Dba Quality Care Products Llc
    Amitriptyline Hydrochloride Tablet, Film Coated [Lake Erie Medical Dba Quality Care Products Llc]
  • Remedyrepack Inc.
    Amitriptyline Hydrochloride Tablet [Remedyrepack Inc. ]
  • H.j. Harkins Company, Inc.
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  • Pd-rx Pharmaceuticals, Inc.
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  • Lake Erie Medical Dba Quality Care Products Llc
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  • Pd-rx Pharmaceuticals, Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Pd-rx Pharmaceuticals, Inc.]
  • Unit Dose Services
    Amitriptyline Hydrochloride Tablet, Film Coated [Unit Dose Services]
  • Stat Rx Usa Llc
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  • Lake Erie Medical & Surgical Supply Dba Quality Care Products Llc
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    Amitriptyline Hydrochloride Tablet, Film Coated [Lake Erie Medical & Surgical Supply Dba Quality Care Products Llc]
  • Bryant Ranch Prepack
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  • Major Pharmaceuticals
    Amitriptyline Hydrochloride Tablet, Film Coated [Major Pharmaceuticals]
  • Remedyrepack Inc.
    Amitriptyline Hydrochloride (Amitriptyline Hydrochloride ) Tablet [Remedyrepack Inc. ]
  • Lake Erie Medical Dba Quality Care Products Llc
    Amitriptyline Hydrochloride Tablet, Film Coated [Lake Erie Medical Dba Quality Care Products Llc]
  • Mylan Institutional Inc.
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  • Remedyrepack Inc.
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  • Clinical Solutions Wholesale
    Amitriptyline Hydrochloride Tablet, Film Coated [Clinical Solutions Wholesale]
  • Lake Erie Medical Dba Quality Care Products Llc
    Amitriptyline Hydrochloride Tablet, Film Coated [Lake Erie Medical Dba Quality Care Products Llc]
  • A-s Medication Solutions Llc
    Amitriptyline Hydrochloride Tablet, Film Coated [A-s Medication Solutions Llc]
  • Dispensing Solutions, Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Dispensing Solutions, Inc.]
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    Amitriptyline Hydrochloride Tablet, Film Coated [Dispensing Solutions, Inc.]
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    Amitriptyline Hydrochloride Tablet, Film Coated [Dispensing Solutions, Inc.]
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    Amitriptyline Hydrochloride Tablet, Film Coated [Dispensing Solutions, Inc.]
  • Remedyrepack Inc.
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  • Aidarex Pharmaceuticals Llc
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  • Clinical Solutions Wholesale
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  • Medvantx, Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Medvantx, Inc.]
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  • Direct Rx
    Amitriptyline Hydrochloride Tablet [Direct Rx]
  • Cardinal Health
    Amitriptyline Hydrochloride Tablet, Film Coated [Cardinal Health]
  • Direct Rx
    Amitriptyline Hydrochloride Tablet [Direct Rx]
  • Aphena Pharma Solutions – Tennessee, Llc
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  • C.o. Truxton, Inc.
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  • Mylan Pharmaceuticals Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Mylan Pharmaceuticals Inc.]
  • Bryant Ranch Prepack
    Amitriptyline Hydrochloride Tablet, Film Coated [Bryant Ranch Prepack]
  • Bryant Ranch Prepack
    Amitriptyline Hydrochloride Tablet, Film Coated [Bryant Ranch Prepack]
  • Ncs Healthcare Of Ky, Inc Dba Vangard Labs
    Amitriptyline Hydrochloride Tablet, Film Coated [Ncs Healthcare Of Ky, Inc Dba Vangard Labs]
  • Qualitest Pharmaceuticals
    Amitriptyline Hydrochloride Tablet, Film Coated [Qualitest Pharmaceuticals]
  • Glenview Pharma Inc.
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  • Proficient Rx Lp
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  • Tya Pharmaceuticals
    Amitriptyline Hydrochloride Tablet, Film Coated [Tya Pharmaceuticals]
  • Preferred Pharmaceuticals, Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Preferred Pharmaceuticals, Inc.]
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  • Accord Healthcare Inc.
    Amitriptyline Hydrochloride Tablet, Film Coated [Accord Healthcare Inc. ]
  • Sandoz Inc
    Amitriptyline Hydrochloride Tablet, Film Coated [Sandoz Inc]
  • Medsource Pharmaceuticals
    Amitriptyline Hydrochloride Tablet, Film Coated [Medsource Pharmaceuticals]

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