Neuropathic pain | Migraine prophylaxis | Chronic tensiontype headache prophylaxis
▶ Adult: Initially 10–25 mg daily, dose to be taken in the
evening, then increased, if tolerated, in steps of
10–25 mg every 3–7 days in 1–2 divided doses; usual
dose 25–75 mg daily, dose to be taken in the evening,
doses above 100 mg should be used with caution (doses
above 75 mg should be used with caution in the elderly
and in patients with cardiovascular disease); maximum
l UNLICENSED USE Not licensed for use in abdominal pain
or discomfort in patients who have not responded to
laxatives, loperamide, or antispasmodics.
l CONTRA-INDICATIONS Arrhythmias . during manic phase
of bipolar disorder. heart block . immediate recovery
period after myocardial infarction
CAUTIONS, FURTHER INFORMATION Treatment should be
stopped if the patient enters a manic phase.
Elderly patients are particularly susceptible to many of
the side-effects of tricyclic antidepressants; low initial
doses should be used, with close monitoring, particularly
for psychiatric and cardiac side-effects.
l INTERACTIONS → Appendix 1: tricyclic antidepressants
▶ Common or very common Anticholinergic syndrome . drowsiness . QT interval prolongation
depression . breast enlargement. cardiac conduction
disorders . stroke . sudden cardiac death . suicidal
effective dose (every 2–3 days). Consider using a lower
starting dose in elderly patients.
Overdose Overdosage with amitriptyline is associated with
a relatively high rate of fatality. Symptoms of overdosage
may include dry mouth, coma of varying degree,
hypotension, hypothermia, hyperreflexia, extensor plantar
responses, convulsions, respiratory failure, cardiac
conduction defects, and arrhythmias. Dilated pupils and
urinary retention also occur. For details on the
management of poisoning, see Tricyclic and related
antidepressants, under Emergency treatment of poisoning
l PREGNANCY Use only if potential benefit outweighs risk.
l BREAST FEEDING The amount secreted into breast milk is
l HEPATIC IMPAIRMENT Manufacturer advises use with
caution in mild-to-moderate impairment; avoid in severe
l TREATMENT CESSATION Withdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge (6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
l PRESCRIBING AND DISPENSING INFORMATION Limited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
Driving and skilled tasks Drowsiness may affect the
performance of skilled tasks (e.g. driving).
l LESS SUITABLE FOR PRESCRIBING Amitriptyline
hydrochloride is less suitable for prescribing, see Tricyclic
and related antidepressant drugs in Antidepressant drugs
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Amitriptyline hydrochloride (Non-proprietary)
Amitriptyline hydrochloride 2 mg per 1 ml Amitriptyline 10mg/5ml
oral solution sugar free sugar-free | 150 ml P £131.90 DT =
Amitriptyline hydrochloride 5 mg per 1 ml Amitriptyline 25mg/5ml
oral solution sugar free sugar-free | 150 ml P £18.00 DT = £18.00
Amitriptyline hydrochloride 10 mg per 1 ml Amitriptyline
50mg/5ml oral solution sugar free sugar-free | 150 ml P £24.00
CAUTIONARY AND ADVISORY LABELS 2
▶ Amitriptyline hydrochloride (Non-proprietary)
Amitriptyline hydrochloride 10 mg Amitriptyline 10mg tablets | 28 tablet P £1.50 DT = £0.87
Amitriptyline hydrochloride 25 mg Amitriptyline 25mg tablets |
Amitriptyline hydrochloride 50 mg Amitriptyline 50mg tablets | 28 tablet P £5.99 DT = £2.04
Clomipramine hydrochloride 02-Jul-2018
▶ Adult: Initially 10 mg daily, then increased if necessary
to 30–150 mg daily in divided doses, dose to be
increased gradually, alternatively increased if
necessary to 30–150 mg once daily, dose to be taken at
bedtime; maximum 250 mg per day
▶ Elderly: Initially 10 mg daily, then increased to
30–75 mg daily, dose to be increased carefully over
▶ Adult: Initially 25 mg daily, then increased to
100–150 mg daily, dose to be increased gradually over
2 weeks; maximum 250 mg per day continued→
▶ Elderly: Initially 10 mg daily, then increased to
100–150 mg daily, dose to be increased gradually over
2 weeks; maximum 250 mg per day
Adjunctive treatment of cataplexy associated with
▶ Adult: Initially 10 mg daily, dose to be gradually
increased until satisfactory response; increased if
CAUTIONS, FURTHER INFORMATION Treatment should be
stopped if the patient enters a manic phase.
Elderly patients are particularly susceptible to many of
the side-effects of tricyclic antidepressants; low initial
doses should be used, with close monitoring, particularly
for psychiatric and cardiac side-effects.
l INTERACTIONS → Appendix 1: tricyclic antidepressants
▶ Uncommon Psychosis . seizure
▶ Rare or very rare Agranulocytosis . alopecia . cardiac
conduction disorders . eosinophilia . glaucoma . hepatic
disorders . hyperpyrexia . leucopenia . neuroleptic
▶ Frequency not known Rhabdomyolysis . serotonin
syndrome . suicidal tendencies . withdrawal syndrome
SIDE-EFFECTS, FURTHER INFORMATION The patient should
be encouraged to persist with treatment as some tolerance
to these side-effects seems to develop.
The risk of side-effects is reduced by titrating slowly to
the minimum effective dose (every 2–3 days). Consider
using a lower starting dose in elderly patients.
Overdose Tricyclic and related antidepressants cause dry
mouth, coma of varying degree, hypotension,
hypothermia, hyperreflexia, extensor plantar responses,
convulsions, respiratory failure, cardiac conduction
defects, and arrhythmias. Dilated pupils and urinary
retention also occur. For details on the management of
poisoning see Tricyclic and related antidepressants under
Emergency treatment of poisoning p. 1359.
l PREGNANCY Neonatal withdrawal symptoms reported if
l BREAST FEEDING The amount secreted into breast milk is
l HEPATIC IMPAIRMENT Manufacturer advises caution; avoid
in severe impairment (risk of hypertensive crisis).
l MONITORING REQUIREMENTS Manufacturer advises
monitor cardiac and hepatic function during long-term
l TREATMENT CESSATION Withdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge (6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
l PRESCRIBING AND DISPENSING INFORMATION Limited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
Driving and skilled tasks Drowsiness may affect the
performance of skilled tasks (e.g. driving).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: modified-release
tablet, oral suspension, oral solution
CAUTIONARY AND ADVISORY LABELS 2
▶ Clomipramine hydrochloride (Non-proprietary)
Clomipramine hydrochloride 10 mg Clomipramine 10mg capsules
| 28 capsule P £6.72 DT = £1.47
Clomipramine hydrochloride 25 mg Clomipramine 25mg capsules
| 28 capsule P £9.36 DT = £1.62
Clomipramine hydrochloride 50 mg Clomipramine 50mg capsules
| 28 capsule P £11.76 DT = £3.66
Depressive illness, particularly where sedation is required
(not recommended—increased risk of fatality in
overdose) (initiated by a specialist)
▶ Adult: Initially 75 mg daily in divided doses,
alternatively initially 75 mg once daily, dose to be
taken at bedtime, increased if necessary to 150 mg
daily, doses to be increased gradually; up to 225 mg
daily in some circumstances (e.g. hospital use)
▶ Elderly: Initially 50–75 mg daily in divided doses,
alternatively initially 50–75 mg once daily, dose to be
taken at bedtime, increased if necessary to 75–150 mg
daily, doses to be increased gradually; up to 225 mg
daily in some circumstances (e.g. hospital use)
CAUTIONS, FURTHER INFORMATION Treatment should be
stopped if the patient enters a manic phase.
374 Mental health disorders BNF 78
Elderly patients are particularly susceptible to many of
the side-effects of tricyclic antidepressants; low initial
doses should be used, with close monitoring, particularly
for psychiatric and cardiac side-effects.
l INTERACTIONS → Appendix 1: tricyclic antidepressants
effective dose (every 2–3 days). Consider using a lower
starting dose in elderly patients.
Overdose Overdosage with dosulepin is associated with a
relatively high rate of fatality.
Tricyclic and related antidepressants cause dry mouth,
coma of varying degree, hypotension, hypothermia,
hyperreflexia, extensor plantar responses, convulsions,
respiratory failure, cardiac conduction defects, and
arrhythmias. Dilated pupils and urinary retention also
occur. For details on the management of poisoning see
Tricyclic and related antidepressants under Emergency
l PREGNANCY Use only if potential benefit outweighs risk.
l BREAST FEEDING The amount secreted into breast milk is
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild to moderate impairment; avoid in severe impairment.
l TREATMENT CESSATION Withdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge. (6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
l PRESCRIBING AND DISPENSING INFORMATION Limited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
A maximum prescription equivalent to 2 weeks’ supply
of 75 mg daily should be considered in patients with
increased risk factors for suicide at initiation of treatment,
during any dose adjustment, and until improvement
Driving and skilled tasks Drowsiness may affect the
performance of skilled tasks (e.g. driving).
l LESS SUITABLE FOR PRESCRIBING Dosulepin
hydrochloride is less suitable for prescribing, see Tricyclic
and related antidepressant drugs in Antidepressant drugs
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Dosulepin hydrochloride (Non-proprietary)
Dosulepin hydrochloride 75 mg Dosulepin 75mg tablets | 28 tablet P £18.38 DT = £4.88
Dosulepin hydrochloride 75 mg Prothiaden 75mg tablets | 28 tablet P £2.97 DT = £4.88
CAUTIONARY AND ADVISORY LABELS 2
▶ Dosulepin hydrochloride (Non-proprietary)
Dosulepin hydrochloride 25 mg Dosulepin 25mg capsules | 28 capsule P £3.50 DT = £1.61
Dosulepin hydrochloride 25 mg Prothiaden 25mg capsules | 28 capsule P £1.70 DT = £1.61
Depressive illness (particularly where sedation is
▶ Adult: Initially 75 mg daily in divided doses,
alternatively 75 mg once daily, adjusted according to
response, dose to taken at bedtime; maintenance
25–300 mg daily, doses above 100 mg given in
▶ Elderly: Start with lower doses and adjust according to
CAUTIONS, FURTHER INFORMATION Treatment should be
stopped if the patient enters a manic phase.
▶ Elderly Elderly patients are particularly susceptible to
many of the side-effects of tricyclic antidepressants; low
initial doses should be used, with close monitoring,
particularly for psychiatric and cardiac side-effects.
l INTERACTIONS → Appendix 1: tricyclic antidepressants
delusions . photosensitivity reaction . postural
effective dose (every 2–3 days). Consider using a lower
starting dose in elderly patients.
Overdose Tricyclic and related antidepressants cause dry
mouth, coma of varying degree, hypotension,
hypothermia, hyperreflexia, extensor plantar responses,
convulsions, respiratory failure, cardiac conduction
defects, and arrhythmias. Dilated pupils and urinary
retention also occur. For details on the management of
poisoning see Tricyclic and related antidepressants under
Emergency treatment of poisoning p. 1359.
l PREGNANCY Use with caution—limited information
l BREAST FEEDING The amount secreted into breast milk is
too small to be harmful. Accumulation of metabolite may
cause sedation and respiratory depression in neonate.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild to moderate impairment; avoid in severe impairment.
Dose adjustments Manufacturer advises consider dose
reduction in mild to moderate impairment.
l RENAL IMPAIRMENT Use with caution.
l TREATMENT CESSATION Withdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge (6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
l PRESCRIBING AND DISPENSING INFORMATION Limited
quantities of tricyclic antidepressants should be prescribed
at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
Driving and skilled tasks Drowsiness may affect
performance of skilled tasks (e.g. driving). Effects of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule, oral
CAUTIONARY AND ADVISORY LABELS 2
Doxepin (as Doxepin hydrochloride) 25 mg Doxepin 25mg capsules
| 28 capsule P £97.00 DT = £97.00
Doxepin (as Doxepin hydrochloride) 50 mg Doxepin 50mg capsules
| 28 capsule P £154.00 DT = £154.00
Imipramine hydrochloride 30-Mar-2017
▶ Adult: Initially up to 75 mg daily in divided doses, then
increased to 150–200 mg daily, up to 150 mg may be
given as a single dose at bedtime, dose to be increased
▶ Elderly: Initially 10 mg daily, increased to 30–50 mg
daily, dose to be increased gradually
Depressive illness in hospital patients
▶ Adult: Initially up to 75 mg daily in divided doses, dose
to be increased gradually, increased to up to 300 mg
▶ Child 6–7 years: 25 mg once daily, to be taken at
bedtime, initial period of treatment (including gradual
withdrawal) 3 months—full physical examination
▶ Child 8–10 years: 25–50 mg once daily, to be taken at
bedtime, initial period of treatment (including gradual
withdrawal) 3 months—full physical examination
▶ Child 11–17 years: 50–75 mg once daily, to be taken at
bedtime, initial period of treatment (including gradual
withdrawal) 3 months—full physical examination
l CONTRA-INDICATIONS Immediate recovery period after
myocardial infarction (in adults). Acute porphyrias
p. 1058 . arrhythmia . during the manic phase of bipolar
significant risk of suicide . phaeochromocytoma (risk of
arrhythmias). prostatic hypertrophy (in adults). susceptibility to angle-closure glaucoma . urinary
CAUTIONS, FURTHER INFORMATION Treatment should be
stopped if the patient enters a manic phase.
Elderly patients are particularly susceptible to many of
the side-effects of tricyclic antidepressants; low initial
doses should be used, with close monitoring, particularly
for psychiatric and cardiac side-effects.
l INTERACTIONS → Appendix 1: tricyclic antidepressants
disorder.tremor. vomiting . weight changes
delusions exacerbated . psychiatric disorder. suicidal
tendencies .tinnitus . urinary disorder. withdrawal
effective dose (every 2–3 days). Consider using a lower
starting dose in elderly patients.
Overdose Tricyclic and related antidepressants cause dry
mouth, coma of varying degree, hypotension,
hypothermia, hyperreflexia, extensor plantar responses,
convulsions, respiratory failure, cardiac conduction
defects, and arrhythmias. Dilated pupils and urinary
retention also occur. For details on the management of
poisoning see Tricyclic and related antidepressants under
Emergency treatment of poisoning p. 1359.
l PREGNANCY Colic, tachycardia, dyspnoea, irritability,
muscle spasms, respiratory depression and withdrawal
376 Mental health disorders BNF 78
symptoms reported in neonates when used in the third
l BREAST FEEDING The amount secreted into breast milk is
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild to moderate impairment; avoid in severe impairment.
l RENAL IMPAIRMENT Use with caution in severe
l TREATMENT CESSATION Withdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge (6 months in
patients who have been on long-term maintenance
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