Trimipramine (Surmontil) is a tricyclic antidepressant drug that is used for the symptomatic treatment of depression. It is also used as an off-label medicine for anxiety and as a sedative and hypnotic drug.
Trimipramine Uses:
-
Depression:
- Symptomatic relief of depression
Trimipramine dose in Adults
Trimipramine dose in the treatment of Depression:
- P/O: Initial:
- 25 to 50 mg one tablet H.S or in divided doses
- Initial doses of 100 mg daily may be considered in admitted patients.
- Based on the response and tolerability gradually increase the dose to 75 to 300 mg once daily.
- Maintenance:
- Lowest effective dose at bedtime.
Discontinuation of therapy:
- When discontinuing antidepressant therapy that has lasted for >3 weeks, taper the dose gradually (eg, over 2 to 4 weeks) to minimize withdrawal symptoms & detect re-emerging symptoms.
Reasons for a slower titration (eg, over 4 weeks) include:
- use of a drug with a half-life <24 hours (eg, paroxetine, venlafaxine)
- history of prior antidepressant withdrawal symptoms
- high doses of antidepressants.
- Resume the previously prescribed dose and/or decrease dose at a more gradual rate, If intolerable withdrawal symptoms occur.
- Selective patients (eg, those with a history of discontinuation syndrome) on long-term treatment (more than 6 months) might benefit from tapering over more than 3 months.
- There is limited evidence supporting ideal taper rates.
MAO inhibitor recommendations:
Switching to or from an MAO inhibitor intended to treat psychiatric disorders:
- 14 days should be allowed to elapse between discontinuing an MAO inhibitor intended to treat psychiatric disorders and initiation of trimipramine.
- Similarly, 14 days should be allowed to elapse between discontinuing trimipramine and initiation of an MAO inhibitor intended to treat psychiatric disorders.
Trimipramine dose in Childrens
Trimipramine dose in the treatment of Depression:
-
Adolescents:
- A reduced dose of up to 50 mg daily should be used initially.
- Based on the response and tolerability gradually increase the dose to 100 mg daily.
- Maintenance dose: The lowest effective dose should be used at bedtime.
Discontinuation of therapy: Refer to adult dosing.
MAO inhibitor recommendations: Refer to adult dosing.
Trimipramine pregnancy risk category: C
- Negative events have been reported in animal reproduction studies.
- Tricyclic antidepressants can cause irritability, convulsions, and jitteriness in neonates.
- ACOG (2008) recommends that treatment for depression during pregnancy should be individualized and include the clinical expertise of the mental healthcare provider, obstetrician or primary care provider, as well as the pediatrician.
- The American Psychiatric Association states that medication treatment is not a good option for treating depression.
- Women who have stopped taking antidepressant medication during pregnancy or who are at high risk of developing postpartum depression can have their medications reintroduced.
- Treatment algorithms have been developed by the ACOG and APA for women with depression during pregnancy and before conception.
Dose in Kidney Disease:
Use with caution, no dosage adjustment provided in the manufacturer’s labeling.
Trimipramine dose in Liver disease:
Use with caution, no dosage adjustment provided in the manufacturer’s labeling.
Side effects of Trimipramine:
-
Cardiovascular:
- Cardiac Arrhythmia
- Cerebrovascular Accident
- Facial Edema
- Flushing
- Heart Block
- Hypertension
- Hypotension
- Myocardial Infarction
- Palpitations
- Tachycardia
-
Central Nervous System:
- Abnormal Electroencephalogram
- Agitation
- Anxiety
- Ataxia
- Confusion
- Delusions
- Disorientation
- Dizziness
- Drowsiness
- Exacerbation Of Psychosis
- Extrapyramidal Reaction
- Fatigue
- Hallucination
- Headache
- Hypomania
- Insomnia
- Nightmares
- Numbness
- Paresthesia
- Peripheral Neuropathy
- Restlessness
- Seizure
- Tingling Sensation
- Withdrawal Syndrome
-
Dermatologic:
- Alopecia
- Diaphoresis
- Pruritus
- Skin Photosensitivity
- Skin Rash
- Urticaria
-
Endocrine & Metabolic:
- Change In Libido
- Galactorrhea
- Gynecomastia
- Hyperglycemia
- Hypoglycemia
- SIADH
- Weight Gain
- Weight Loss
-
Gastrointestinal:
- Abdominal Cramps
- Anorexia
- Constipation
- Diarrhea
- Epigastric Distress
- Melanoglossia
- Nausea
- Paralytic Ileus
- Parotid Gland Enlargement
- Stomatitis
- Unpleasant Taste
- Vomiting
- Xerostomia
-
Genitourinary:
- Breast Hypertrophy
- Difficulty In Micturition
- Impotence
- Testicular Swelling
- Urinary Retention
-
Hematologic & Oncologic:
- Agranulocytosis
- Eosinophilia
- Petechia
- Purpura
- Thrombocytopenia
-
Hepatic:
- Cholestatic Jaundice
- Increased Liver Enzymes
-
Hypersensitivity:
- Tongue Edema
-
Neuromuscular & Skeletal:
- Tremor
- Weakness
-
Ophthalmic:
- Accommodation Disturbance
- Angle-Closure Glaucoma
- Blurred Vision
- Mydriasis
-
Otic:
- Tinnitus
-
Renal:
- Polyuria
Contraindications to Trimipramine:
- Hypersensitivity to trimipramine and any other components of the formulation, or other TCAs
- Use in the acute recovery phase during MI
- MAO inhibitors are used to treat psychiatric disorders. They can be used concurrently or within 14-days of stopping either trimipramine nor the MAO inhibitor.
- Initiation to trimipramine for a patient who has received linezolid intravenous methyleneblue
Warnings and precautions
-
Anticholinergic effects
- Anticholinergic effects may include constipation, dry and blurred vision, urinary retention, and dry mouth.
- Patients with reduced gastrointestinal motility, paralytic and ileus, urinary retentions, BPH, xerostomias, narrow-angle or other visual impairments should be cautious.
- This agent is more effective than other antidepressants in causing a high level of anticholinergic blockade.
-
Depression in the CNS:
- CNS depression can lead to impairment of mental or physical abilities. Patients should be cautious about driving or operating machinery that requires mental alertness.
- The level of sedation is much higher than other antidepressants.
-
Fractures
- Antidepressant treatment is often associated with bone fractures.
- Unexplained bone pain, tenderness, swelling or bruising in an antidepressant-treated person may indicate a fragility fracture.
-
Orthostatic hypotension
- Orthostatic hypotension may occur (risk is higher than other antidepressants).
- Patients at higher risk for this effect and those who cannot tolerate transient hypotensive episodes (CVAs, cardiovascular disease, hypovolemia or concurrent use medication that may lead to hypotension/bradycardia) should be used with caution.
-
Serotonin syndrome
- Serotonin syndrome (SS), which can be life-threatening, is caused by serotonergic drugs (eg SSRIs, SNRIs), especially when combined with other serotonergic medications (eg triptans TCAs, fentanyl and buspirone, lithium, tramadol or buspirone, St John's wort. tryptophan) and agents that impair serotonin metabolism (eg MAO inhibitors to treat psychia, intravenous methyleneblue blue, intravenous methyleneblue blue, linezolid, intravenous methylene, methylene blue]
- You should monitor your patients closely for any signs of SS, such as
- Mental status changes (eg. agitation, hallucinations and delirium, coma).
- Autonomic instability (eg tachycardia or labile blood pressure, diaphoresis)
- Neuromuscular changes (eg tremors, rigidity, myoclonus, etc.)
- GI symptoms include nausea, vomiting, diarrhea, and/or seizures.
- Stop taking any serotonergic agents or treatment if you notice signs and symptoms.
-
Hyponatremia and inappropriate antidiuretic hormone production:
- Antidepressant drugs have been linked to the development of SIADH (syndromes of inappropriate antidiuretic hormonal hormone secretion), and hyponatremia.
- This is a condition that primarily affects the elderly.
- Other risk factors include volume loss, concurrent diuretics use, female gender and low body weight.
- TCAs are less likely to cause hyponatremia than SSRIs.
-
Cardiovascular disease
- Patients with a history or cardiovascular disease, such as stroke, MI, or conduction abnormalities, should be cautious.
- This agent has a high risk of conduction abnormalities relative to other antidepressants.
- The American Heart Association has stated that trimipramine may be an agent that can exacerbate underlying myocardial dysfunction.
-
Diabetes:
- It may affect glucose regulation so be careful.
-
Hepatic impairment
- Be careful
-
Hypomania and mania:
- It can lead to hypomania or mania in patients with bipolar disorder.
- Patients with bipolar disorder should avoid monotherapy
- Patients with depressive symptoms should be screened for bipolar disorder. This includes details about family history, suicide attempts, and bipolar disorder.
- Trimipramine has not been approved by the FDA for treatment of bipolar disorder.
-
Renal impairment
- Be careful.
-
Seizure disorder
- Patients at high risk of seizures should be treated with caution, especially those who have had seizures in the past, brain damage, head trauma or alcoholism, and patients receiving concurrent treatment with medication that could lower their seizure threshold.
Trimipramine: Drug Interaction
|
Acetylcholinesterase Inhibitors |
May diminish the therapeutic effect of Anticholinergic Agents. Anticholinergic Agents may diminish the therapeutic effect of Acetylcholinesterase Inhibitors. |
|
Ajmaline |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Alcohol (Ethyl) |
CNS Depressants may enhance the CNS depressant effect of Alcohol (Ethyl). |
|
Alizapride |
May enhance the CNS depressant effect of CNS Depressants. |
|
Alpha1-Agonists |
Tricyclic Antidepressants may enhance the therapeutic effect of Alpha1Agonists. Tricyclic Antidepressants may diminish the therapeutic effect of Alpha1-Agonists. |
|
Alpha2-Agonists (Ophthalmic) |
Tricyclic Antidepressants may diminish the therapeutic effect of Alpha2-Agonists (Ophthalmic). |
|
Altretamine |
May enhance the orthostatic hypotensive effect of Tricyclic Antidepressants. |
|
Amantadine |
May enhance the anticholinergic effect of Anticholinergic Agents. |
|
Amezinium |
May enhance the adverse/toxic effect of Tricyclic Antidepressants. |
|
Amifampridine |
Agents With Seizure Threshold Lowering Potential may enhance the neuroexcitatory and/or seizure-potentiating effect of Amifampridine. |
|
Amphetamines |
Tricyclic Antidepressants may enhance the stimulatory effect of Amphetamines. Tricyclic Antidepressants may also potentiate the cardiovascular effects of Amphetamines. |
|
Anticholinergic Agents |
May enhance the adverse/toxic effect of other Anticholinergic Agents. |
|
Antiemetics (5HT3 Antagonists) |
May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. |
|
Antipsychotic Agents |
Serotonin Modulators may enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. |
|
Aspirin |
Tricyclic Antidepressants (Tertiary Amine) may enhance the antiplatelet effect of Aspirin. |
|
Beta2-Agonists |
Tricyclic Antidepressants may enhance the adverse/toxic effect of Beta2Agonists. |
|
Botulinum Toxin-Containing Products |
May enhance the anticholinergic effect of Anticholinergic Agents. |
|
Brexanolone |
CNS Depressants may enhance the CNS depressant effect of Brexanolone. |
|
Brimonidine (Topical) |
May enhance the CNS depressant effect of CNS Depressants. |
|
Cannabidiol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Cannabis |
May enhance the CNS depressant effect of CNS Depressants. |
|
CarBAMazepine |
May decrease the serum concentration of Tricyclic Antidepressants. |
|
Chloral Betaine |
May enhance the adverse/toxic effect of Anticholinergic Agents. |
|
Chlorphenesin Carbamate |
May enhance the adverse/toxic effect of CNS Depressants. |
|
Cimetidine |
May decrease the metabolism of Tricyclic Antidepressants. |
|
Citalopram |
Tricyclic Antidepressants may enhance the serotonergic effect of Citalopram. Tricyclic Antidepressants may increase the serum concentration of Citalopram. Citalopram may increase the serum concentration of Tricyclic Antidepressants. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and increased TCA and citalopram concentrations/effects. |
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CloBAZam |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
CNS Depressants |
May enhance the adverse/toxic effect of other CNS Depressants. |
|
Cobicistat |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
CYP2C19 Inducers (Moderate) |
May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). |
|
CYP2C19 Inhibitors (Moderate) |
May decrease the metabolism of CYP2C19 Substrates (High risk with Inhibitors). |
|
CYP2D6 Inhibitors (Moderate) |
May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors). |
|
Darunavir |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Desmopressin |
Tricyclic Antidepressants may enhance the adverse/toxic effect of Desmopressin. |
|
Dexmethylphenidate |
May enhance the adverse/toxic effect of Tricyclic Antidepressants. Dexmethylphenidate may increase the serum concentration of Tricyclic Antidepressants. |
|
Dimethindene (Topical) |
May enhance the CNS depressant effect of CNS Depressants. |
|
Doxylamine |
May enhance the CNS depressant effect of CNS Depressants. Management: The manufacturer of Diclegis (doxylamine/pyridoxine), intended for use in pregnancy, specifically states that use with other CNS depressants is not recommended. |
|
Dronabinol |
May enhance the CNS depressant effect of CNS Depressants. |
|
DULoxetine |
May enhance the serotonergic effect of Tricyclic Antidepressants. This could result in serotonin syndrome. DULoxetine may decrease the metabolism of Tricyclic Antidepressants. |
|
Escitalopram |
Tricyclic Antidepressants may enhance the serotonergic effect of Escitalopram. Escitalopram may increase the serum concentration of Tricyclic Antidepressants. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and increased TCA concentrations/effects if these agents are combined. |
|
Esketamine |
May enhance the CNS depressant effect of CNS Depressants. |
|
FluvoxaMINE |
May enhance the serotonergic effect of Tricyclic Antidepressants. FluvoxaMINE may increase the serum concentration of Tricyclic Antidepressants. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and increased TCA concentrations/effects if these agents are combined. |
|
Gastrointestinal Agents (Prokinetic) |
Anticholinergic Agents may diminish the therapeutic effect of Gastrointestinal Agents (Prokinetic). |
|
Glucagon |
Anticholinergic Agents may enhance the adverse/toxic effect of Glucagon. Specifically, the risk of gastrointestinal adverse effects may be increased. |
|
Guanethidine |
Tricyclic Antidepressants may diminish the therapeutic effect of Guanethidine. |
|
HydrOXYzine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Imatinib |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Itopride |
Anticholinergic Agents may diminish the therapeutic effect of Itopride. |
|
Kava Kava |
May enhance the adverse/toxic effect of CNS Depressants. |
|
Lumacaftor |
May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). |
|
Lumefantrine |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Magnesium Sulfate |
May enhance the CNS depressant effect of CNS Depressants. |
|
Metaxalone |
May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. |
|
Methylphenidate |
May enhance the adverse/toxic effect of Tricyclic Antidepressants. Methylphenidate may increase the serum concentration of Tricyclic Antidepressants. |
|
Methylphenidate |
May enhance the adverse/toxic effect of Serotonin Modulators. Specifically, the risk of serotonin syndrome or serotonin toxicity may be increased. |
|
MetyroSINE |
CNS Depressants may enhance the sedative effect of MetyroSINE. |
|
MetyroSINE |
May enhance the adverse/toxic effect of Tricyclic Antidepressants. |
|
Mianserin |
May enhance the anticholinergic effect of Anticholinergic Agents. |
|
Minocycline |
May enhance the CNS depressant effect of CNS Depressants. |
|
Mirabegron |
Anticholinergic Agents may enhance the adverse/toxic effect of Mirabegron. |
|
Mirtazapine |
CNS Depressants may enhance the CNS depressant effect of Mirtazapine. |
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Nabilone |
May enhance the CNS depressant effect of CNS Depressants. |
|
Nicorandil |
Tricyclic Antidepressants may enhance the hypotensive effect of Nicorandil. |
|
Nitroglycerin |
Anticholinergic Agents may decrease the absorption of Nitroglycerin. Specifically, anticholinergic agents may decrease the dissolution of sublingual nitroglycerin tablets, possibly impairing or slowing nitroglycerin absorption. |
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Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective) |
Tricyclic Antidepressants (Tertiary Amine) may enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). |
|
Nonsteroidal Anti-Inflammatory Agents (Nonselective) |
Tricyclic Antidepressants (Tertiary Amine) may enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective). |
|
Panobinostat |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Peginterferon Alfa-2b |
May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Perhexiline |
CYP2D6 Substrates (High risk with Inhibitors) may increase the serum concentration of Perhexiline. Perhexiline may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Piribedil |
CNS Depressants may enhance the CNS depressant effect of Piribedil. |
|
Pramipexole |
CNS Depressants may enhance the sedative effect of Pramipexole. |
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Protease Inhibitors |
May increase the serum concentration of Tricyclic Antidepressants. |
|
QuiNINE |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Ramosetron |
Anticholinergic Agents may enhance the constipating effect of Ramosetron. |
|
ROPINIRole |
CNS Depressants may enhance the sedative effect of ROPINIRole. |
|
Rotigotine |
CNS Depressants may enhance the sedative effect of Rotigotine. |
|
Rufinamide |
May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. |
|
Selective Serotonin Reuptake Inhibitors |
CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. |
|
Serotonin Modulators |
May enhance the adverse/toxic effect of other Serotonin Modulators. The development of serotonin syndrome may occur. Exceptions: Nicergoline; Tedizolid. |
|
Sertraline |
May enhance the serotonergic effect of Tricyclic Antidepressants. Sertraline may increase the serum concentration of Tricyclic Antidepressants. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and increased TCA concentrations/effects if these agents are combined. |
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Sodium Phosphates |
Tricyclic Antidepressants may enhance the adverse/toxic effect of Sodium Phosphates. Specifically, the risk of seizure and/or loss of consciousness may be increased in patients with significant sodium phosphate induced fluid/electrolyte abnormalities. |
|
Sulfonylureas |
Cyclic Antidepressants may enhance the hypoglycemic effect of Sulfonylureas. |
|
Tedizolid |
May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. |
|
Tetrahydrocannabinol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Tetrahydrocannabinol and Cannabidiol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Thiazide and Thiazide-Like Diuretics |
Anticholinergic Agents may increase the serum concentration of Thiazide and Thiazide-Like Diuretics. |
|
Thyroid Products |
May enhance the arrhythmogenic effect of Tricyclic Antidepressants. Thyroid Products may enhance the stimulatory effect of Tricyclic Antidepressants. |
|
Topiramate |
Anticholinergic Agents may enhance the adverse/toxic effect of Topiramate. |
|
Trimeprazine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Valproate Products |
May increase the serum concentration of Tricyclic Antidepressants. |
|
Vitamin K Antagonists (eg, warfarin) |
Tricyclic Antidepressants may enhance the anticoagulant effect of Vitamin K Antagonists. |
|
Yohimbine |
Tricyclic Antidepressants may increase the serum concentration of Yohimbine. |
|
Risk Factor D (Consider therapy modification) |
|
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Abiraterone Acetate |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of abiraterone with CYP2D6 substrates that have a narrow therapeutic index whenever possible. When concurrent use is not avoidable, monitor patients closely for signs/symptoms of toxicity. |
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Alpha-/Beta-Agonists (Direct-Acting) |
|
|
Alpha2-Agonists |
Tricyclic Antidepressants may diminish the antihypertensive effect of Alpha2Agonists. Management: Consider avoiding this combination. If used, monitor for decreased effects of the alpha2-agonist. Exercise great caution if discontinuing an alpha2-agonist in a patient receiving a TCA. Exceptions: Apraclonidine; Brimonidine (Ophthalmic); Lofexidine. |
|
Asunaprevir |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). |
|
Barbiturates |
May increase the metabolism of Tricyclic Antidepressants. |
|
Blonanserin |
CNS Depressants may enhance the CNS depressant effect of Blonanserin. |
|
Buprenorphine |
CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants. |
|
Chlormethiazole |
May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. |
|
Cinacalcet |
May increase the serum concentration of Tricyclic Antidepressants. Management: Seek alternatives when possible. If these combinations are used, monitor closely for increased effects/toxicity and/or elevated serum concentrations (when testing is available) of the tricyclic antidepressant. |
|
CYP2C19 Inducers (Strong) |
May increase the metabolism of CYP2C19 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. |
|
CYP2C19 Inhibitors (Strong) |
May decrease the metabolism of CYP2C19 Substrates (High risk with Inhibitors). |
|
CYP2D6 Inhibitors (Strong) |
May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors). |
|
Dabrafenib |
May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP2C19 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). |
|
Dacomitinib |
May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of dacomitinib with CYP2D6 subtrates that have a narrow therapeutic index. |
|
Droperidol |
May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Exceptions to this monograph are discussed in further detail in separate drug interaction monographs. |
|
Enzalutamide |
May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). Conversely, concentrations of active metabolites may be increased for those drugs activated by CYP2C19. Management: Concurrent use of enzalutamide with CYP2C19 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP2C19 substrate should be performed with caution and close monitoring. |
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Flunitrazepam |
CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. |
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HYDROcodone |
CNS Depressants may enhance the CNS depressant effect of HYDROcodone. Management: Avoid concomitant use of hydrocodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
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Iohexol |
Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iohexol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iohexol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. |
|
Iomeprol |
Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iomeprol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iomeprol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. |
|
Iopamidol |
Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iopamidol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iopamidol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. |
|
Linezolid |
May enhance the serotonergic effect of Tricyclic Antidepressants. This could result in serotonin syndrome. Management: Consider alternatives to this combination whenever possible. If clinically acceptable, wait at least 2 weeks after tricyclic antidepressants (TCA) discontinuation to initiate linezolid. |
|
Linezolid |
May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Management: Due to a risk of serotonin syndrome/serotonin toxicity, discontinue serotonin modulators 2 weeks prior to the administration of linezolid. If urgent initiation of linezolid is needed, discontinue serotonin modulators immediately and monitor closely. |
|
Lithium |
May enhance the neurotoxic effect of Tricyclic Antidepressants. Management: This combination should be undertaken with great caution. When combined treatment is clinically indicated, monitor closely for signs of serotonin toxicity/serotonin syndrome. |
|
Lofexidine |
Tricyclic Antidepressants may diminish the therapeutic effect of Lofexidine. Management: Consider avoiding this combination. If used, monitor for decreased effects of the alpha2-agonist. Exercise great caution if discontinuing an alpha2-agonist in a patient receiving a TCA. |
|
Methotrimeprazine |
CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce adult dose of CNS depressant agents by 50% with initiation of concomitant methotrimeprazine therapy. Further CNS depressant dosage adjustments should be initiated only after clinically effective methotrimeprazine dose is established. |
|
Metoclopramide |
May enhance the adverse/toxic effect of Tricyclic Antidepressants. Management: Seek alternatives to this combination when possible. Monitor patients receiving metoclopramide with tricyclic antidepressants for signs of extrapyramidal symptoms, neuroleptic malignant syndrome, and serotonin syndrome. |
|
Opioid Agonists |
CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
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OxyCODONE |
CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
Perampanel |
May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination. |
|
Pramlintide |
May enhance the anticholinergic effect of Anticholinergic Agents. These effects are specific to the GI tract. |
|
QuiNIDine |
Tricyclic Antidepressants may enhance the QTc-prolonging effect of QuiNIDine. QuiNIDine may increase the serum concentration of Tricyclic Antidepressants. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs. |
|
Secretin |
Anticholinergic Agents may diminish the therapeutic effect of Secretin. Management: Avoid concomitant use of anticholinergic agents and secretin. Discontinue anticholinergic agents at least 5 half-lives prior to administration of secretin. |
|
Sodium Oxybate |
May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to combined use. When combined use is needed, consider minimizing doses of one or more drugs. Use of sodium oxybate with alcohol or sedative hypnotics is contraindicated. |
|
St John's Wort |
May increase the metabolism of Tricyclic Antidepressants. The risk of serotonin syndrome may theoretically be increased. |
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Suvorexant |
CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. |
|
Tapentadol |
May enhance the CNS depressant effect of CNS Depressants. Management: Avoid concomitant use of tapentadol and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
Zolpidem |
CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. |
|
Risk Factor X (Avoid combination) |
|
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Aclidinium |
May enhance the anticholinergic effect of Anticholinergic Agents. |
|
Azelastine (Nasal) |
CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal). |
|
Bromopride |
May enhance the adverse/toxic effect of Tricyclic Antidepressants. |
|
Bromperidol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Cimetropium |
Anticholinergic Agents may enhance the anticholinergic effect of Cimetropium. |
|
Dapoxetine |
May enhance the adverse/toxic effect of Serotonin Modulators. |
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Dronedarone |
Tricyclic Antidepressants may enhance the arrhythmogenic effect of Dronedarone. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs. |
|
Eluxadoline |
Anticholinergic Agents may enhance the constipating effect of Eluxadoline. |
|
Glycopyrrolate (Oral Inhalation) |
Anticholinergic Agents may enhance the anticholinergic effect of Glycopyrrolate (Oral Inhalation). |
|
Glycopyrronium (Topical) |
May enhance the anticholinergic effect of Anticholinergic Agents. |
|
Iobenguane Radiopharmaceutical Products |
Tricyclic Antidepressants may diminish the therapeutic effect of Iobenguane Radiopharmaceutical Products. Management: Discontinue all drugs that may inhibit or interfere with catecholamine transport or uptake for at least 5 biological half-lives before iobenguane administration. Do not administer these drugs until at least 7 days after each iobenguane dose. |
|
Ipratropium (Oral Inhalation) |
May enhance the anticholinergic effect of Anticholinergic Agents. |
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Levosulpiride |
Anticholinergic Agents may diminish the therapeutic effect of Levosulpiride. |
|
Methylene Blue |
Tricyclic Antidepressants may enhance the serotonergic effect of Methylene Blue. This could result in serotonin syndrome. |
|
Methylene Blue |
May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. |
|
Monoamine Oxidase Inhibitors |
May enhance the serotonergic effect of Tricyclic Antidepressants. This may cause serotonin syndrome. While methylene blue and linezolid are expected to interact via this mechanism, management recommendations differ from other monoamine oxidase inhibitors. Refer to monographs specific to those agents for details. Exceptions: Linezolid; Methylene Blue; Tedizolid. |
|
Orphenadrine |
CNS Depressants may enhance the CNS depressant effect of Orphenadrine. |
|
Oxatomide |
May enhance the anticholinergic effect of Anticholinergic Agents. |
|
Oxomemazine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Paraldehyde |
CNS Depressants may enhance the CNS depressant effect of Paraldehyde. |
|
Pitolisant |
Tricyclic Antidepressants may diminish the therapeutic effect of Pitolisant. |
|
Potassium Chloride |
Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Chloride. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium chloride. |
|
Potassium Citrate |
Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Citrate. |
|
Revefenacin |
Anticholinergic Agents may enhance the anticholinergic effect of Revefenacin. |
|
Thalidomide |
CNS Depressants may enhance the CNS depressant effect of Thalidomide. |
|
Tiotropium |
Anticholinergic Agents may enhance the anticholinergic effect of Tiotropium. |
|
Umeclidinium |
May enhance the anticholinergic effect of Anticholinergic Agents. |
Monitoring parameters:
- Clinically indicated, serum Na+ for populations at-risk
- Before and after initial therapy, blood pressure and pulse rate
- Assess mental health, suicide thoughts (especially when therapy is just starting or when the doses are increasing or decreasing).
- Anxiety, social functioning and panic attacks, as well as mania and mania, are all signs of unusual behavior.
- Blood glucose levels
- BMI and weight
- ECG for patients with cardiac disease and older adults
How to administer Trimipramine?
- No relation to food.
- Give initial doses in divided doses & maintenance doses as a single dose at bedtime.
Mechanism of action of Trimipramine:
Antidepressant effects are proposed to result from postsynaptic sensitization to serotonin.
Metabolism:
- Hepatic with significant first-pass metabolicm
Bioavailability:
- 18% - 63%.
Half-life elimination:
- 7 - 40 hrs.
Time to peak serum concentration:
- 1 - 6 hrs.
Excretion:
- Urinary
International Brands of Trimipramine:
- Surmontil
- APO-Trimipramine
- NOVO-Tripramine
- Apo-Trimip
- Herphonal
- Sapilent
- Stangyl
- Sumontil
- Surmontil
- Trimin
- Tydamine
Trimipramine Brand Names in Pakistan:
No Brands Available in Pakistan.
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