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Updated: Feb 7 2022

Tricyclic Antidepressants (TCAs)

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(10)

  • 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, flushing, dry membranes, fever, mydriasis
        • 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 = NaHCO3
        • 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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