Updated: 11/16/2019

Tricyclic Antidepressants (TCAs)

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Topic
Psychiatric Drug Introduction
  • Psychiatric medications can be broken down into the following categories
    • antidepressants
    • antipsychotics
    • bipolar medications
    • anxiolytics
Overview
  • Drugs
    • 3° TCAs
      • imipramine
      • amitriptyline
      • doxepin 
      • clomipramine
    • 2° TCAs
      • nortriptyline (most well tolerated)
      • desipramine (least histaminic)
      • protriptyline
  • Mechanism
    • block reuptake of NE and serotonin
  • Clinical use
    • major depression
    • enuresis (imipramine)
    • OCD (clomipramine)
    • fibromyalgia
    • painful diabetic neuropathy (amtitryptyline)
  • Side effects
    • anticholinergic 
      • tachycardia, urinary retention
      • 3° TCAs worse than 2° TCAs
    • anti-histaminic
      • sedation
        • desipramine is the least sedating
    • ↓ seizure threshold
  • Toxicity
    • do NOT mix with SSRIs and MAOIs → can be fatal
    • 3 C's of overdose 
      • Convulsions
      • Coma
      • Cardiotoxicity (arrhythmias) 
        • Brugada pattern (downsloping ST elevation with RBBB) 
    • respiratory depression, hyperpyrexia
    • confusion/hallucinations in the elderly
      • due to anticholinergic side effects
      • should use nortriptyline which has lesser SEs
    • Rx for overdose = NaHCO
      • sodium load treats CV toxicity (best answer for mechanism)
      • bicarbonate load could improve renal excretion and decrease TCA binding of sodium channels

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