MEDICINES INFORMATION TRICYCLIC antidepressants Pronounced: try-sigh-click

What are tricyclic antidepressants (TCAs) used for? Tricyclic antidepressants (TCAs) are a group of medicines usually used to help treat people with depression. Medicines are often used to treat more than one condition, so if you are not sure why you have been prescribed a TCA, you should discuss this with your doctor. Types of TCAs are amitryptyline, clomipramine, dosulepin (dothiepin), imipramine, lofepramine, nortriptyline and trimipramine. Your medicine may also have a trade or brand name. This is the name that the manufacturer gives to the medicine, for example Anafranil is a brand name for clomipramine. What are the benefits of taking TCAs? People with depression may feel fed up, unhappy and miserable most of the time, and this usually interferes with their everyday life. This feeling of depression is worse than short periods of unhappiness that people can experience from time to time. Restlessness, agitation and tiredness are common, as well as difficulty in sleeping and loss of appetite. People with depression may also feel hopeless and inadequate, and find it difficult to enjoy life. They may also have thoughts of harming themselves or committing suicide. TCAs can help to treat these symptoms in people who are unwell, and may also help to keep people well in the longer term. They may also help people to cope better so that they can enjoy life and be able to deal with any problems they may have. How quickly do TCAs work? TCAs work over a period of weeks. Some symptoms may start to improve before others, but it may take up to four weeks until they have their full effect. Not everybody benefits from TCAs, but most people do. If you do not feel any benefit after four to six weeks, you should discuss this with you doctor or healthcare worker. Occasionally, thoughts of suicide or self-harm may increase in the first few weeks of treatment until your medicine has taken its full effect. If this happens to you tell your doctor immediately or go to the nearest hospital. What are the usual doses of TCAs and how should I take them? Refer to the manufacturers patient information leaflet for the TCA that you have been given. TCAs are usually started at low doses that are gradually increased, depending on how you respond to the treatment. The usual doses of some TCAs are given below, but do not change your dose of medication without checking with your doctor, as doing so may affect your response to the medication or be harmful. The usual dose of amitriptyline is between 150milligrams (mg) and 200mg daily. The usual dose of clomipramine is between 10mg and 150mg daily. The maximum dose is 250mg daily. The usual dose of imipramine is between 150mg and 200mg daily. The maximum dose is 300mg daily. The usual dose of lofepramine is between 140mg and 210mg daily usually given in two doses. The usual dose of nortriptyline is between 75mg and 100mg daily. The maximum dose is 150mg daily. The usual dose of trimipramine is between 150mg and 300mg daily. What should I do if I miss a dose? You will get the most out of your medication when taken correctly and regularly. If you miss, or forget to take a dose at your usual time, but remember within an hour or two then take it straight away. If it is longer than this just leave out the missed dose. Take the next dose at the usual time. If you miss a few doses you may experience discontinuation symptoms (see below). Never take extra medication at the next dose. If you find it difficult to remember taking medication speak to your pharmacist or healthcare worker. For how long should I take TCAs? Your doctor will discuss with you the length of treatment, which will vary depending on the type of illness you have. It may be for a few months or
longer. TCAs are usually taken for at least six months after you start to feel better. Taking medication regularly may prevent you from becoming unwell again. Your doctor should regularly review your medication to make sure that you do not take medicines for longer than needed. If you stop taking TCAs suddenly you may get unpleasant symptoms called discontinuation or withdrawal. These are usually mild and disappear by themselves, but occasionally can cause problems. TCAs are not addictive.

What are the side effects of TCAs? As with all medicines there is a risk of unwanted effects (side effects). Some can occur soon after starting treatment so you may experience these before you feel better. Most are temporary and should go away after a few days or weeks. Not everyone will get side effects and many people experience them to different degrees. If you feel that you have side effects that are causing you discomfort, discuss this with your doctor, pharmacist, nurse or healthcare worker. The table on the following page lists some of the main recognised side effects of TCAs but the chance of experiencing each of these side effects will depend on the individual TCA that you have been prescribed. What about alcohol or street drugs? Both alcohol and TCAs can affect the brain so it is not recommended that you drink alcohol while taking TCAs. Drinking alcohol can cause drowsiness and in combination with TCAs can cause severe drowsiness. Once you are used to taking medication, and know the effects of taking alcohol you may be able to drink occasionally and in small amounts. It is good to be cautious because alcohol affects people in different ways, especially when taking medication. Do not stop taking your medication because you feel like drinking alcohol. If you drink alcohol, drink only small amounts. Never drink alcohol and drive while taking medication. Street drugs (for example, cannabis, ecstasy, speed, heroin and cocaine) may affect your antidepressant treatment. Taking amphetamines, ecstasy and cocaine whilst taking TCAs may increase their toxicity and can cause an abnormal heart rhythm, which potentially can be very serious. Taking cannabis whilst on TCAs can cause tachycardia (a rapid heart beat). There is very little information on taking TCAs with other street drugs and so the effect and safety of doing this is unknown. It is best if you do not take any street drugs whilst taking TCAs. You may need to get advice and support to help you do this. What about other medicines? If you take any other medicines or herbal remedies including any that have been newly prescribed or bought, it is important to check with your doctor or pharmacist that they are safe with TCAs. When I should be cautious? It is usually safe to take TCAs regularly, as prescribed by your doctor, but they are not suitable for everyone. If any of the following situations apply to you, you should tell your doctor immediately: 1 If you are allergic to TCAs (if you have taken one before and developed a rash, itching, swollen mouth or throat); 2 If you are taking or have recently been taking medicines called monoamine oxidase inhibitors (MAOIs), used to treat depression; 3 If you have previously had thoughts about harming yourself or committing suicide; 4 If you have diabetes, epilepsy (or have had a fit in the past), suffer from kidney, thyroid or liver disease or heart problems; 5 If you have an eye condition known as glaucoma; 6 If you have phaeochromocytoma (a tumour of the adrenal gland); 7 If you have difficulty passing urine or have an enlarged prostate; 8 If you have episodes of mania (overactive behaviour or thoughts); 9 If you are having electro-convulsive therapy (ECT); 10 If you are an older person and have a history of falls; 11 If you are pregnant, or are planning to become pregnant; or 12 If you are breastfeeding.

Side effect Drowsiness

What is it?
Feeling sleepy or sluggish.

Dry mouth Blurred vision Constipation Urinary retention Weight gain Headache Nausea Loss of appetite

Lack of saliva in the mouth. Things look blurry and you cant focus properly. Difficulty going to the toilet or opening the bowels. Difficulty in passing urine. Eating more and putting on weight. Your head is pounding or painful. Feeling sick. Feeling less hungry than you normally would or eating less than normal. Change in sex drive or sexual ability, for example lack of orgasm, abnormal erection and ejaculation. Sweat much more than normal, especially at night. Awareness of your own heartbeat. It may seem irregular, or unusually fast, or just different to normal. A drop in your blood pressure when you sit or stand up. It can make you feel faint or dizzy. Feeling shaky. Your muscles may feel stiff. Yellowing of skin and eyes. A fit, funny turn or blackout.

What should I do if it happens to me? Do not drive or use machinery. This is most common at the start of treatment, and if your medicine is taken once a day it may help to take it at bedtime. If this continues for more than a couple of weeks speak to your doctor over the next few days. Frequent sips of water, sugar-free boiled sweets, chewing gum or citrus fruits will often help. If this continues or becomes a problem speak to your doctor at your next appointment. Do not drive. Speak to your doctor over the next few days if this continues or gets worse. Make sure you drink plenty of fluid. Eat more fibre for example bran, fruit and vegetables and take regular exercise. If this does not help speak to your doctor over the next few days. Speak to your doctor over the next few days. Avoid fatty and sugary foods. Try to eat plenty of fruit, vegetables and fibre. Take regular exercise. If your weight becomes a problem or you are worried speak to your doctor at your next appointment. Try a mild painkiller such as paracetamol. If it does not help, speak to your doctor at your next appointment. Try taking your dose with or after food. This is most common at the start of treatment and if this continues after a couple of weeks speak to your doctor over the next few days.
If this continues or you are worried about it speak to your doctor at your next appointment. Speak to your doctor at your next appointment. Speak to your doctor at your next appointment if this becomes a problem. Cut down on caffeine, for example, coffee, tea and cola. Speak to your doctor over the next few days. Try to sit or stand up slowly. If you feel dizzy, do not drive. Speak to your doctor over the next few days if this does not stop. Your doctor may be able to give you something for this, or change your medication to one that is less likely to cause tremors. Speak to your doctor at your next appointment. Contact your doctor immediately. If you think you have had a seizure, contact your doctor immediately.
of any inaccuracy or error contained in this leaflet, including (for the avoidance of doubt) in relation to breach of contract, misrepresentation or negligence whether of CNWL or any other person; but nothing in this leaflet shall exclude or restrict liability for death or personal injury resulting from negligence. The information given in this leaflet is current as at the publication date. This leaflet has been written by Central and North West London NHS Foundation Trust, Greater London House, Hampstead Road, London NW1 7QY. Tel: 020 3214 5700 Publication Number: CNWL/MM004 Publication Date: May 2007 Copyright 2007

Sexual dysfunction Excessive sweating Palpitations

Postural hypotension Tremor Jaundice Seizures

Please r efer to the manufacturers patient information leaflet that comes with your medicine for more information and the full list of side effects and precautions. If you have any questions or concerns about your medicines, or if you are worried about anything you think might be a side effect, ask your doctor, pharmacist or nurse. This leaflet gives you some information about this medicine. It does not replace the expertise or judgement of a doctor, pharmacist or other healthcare professional. It is not a manufac turers patient information leaflet and is not to be taken as a substitute for, or an endorsement of, the manufacturers information or advice in respect of any medicine referred to in this leaflet. You might find more information in other leaflets or books, or on the internet but remember, the internet is not always accurate. Whilst every care has been taken in the compilation of this leaflet, CNWL is not responsible for any loss or damage howsoever caused as a result