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drug adverse effects of tricyclic antidepressants

Adverse effects: 1) anticholinergic effects a) tinnitus b) constipation c) confusion d) mydriasis e) tachycardia - amitriptyline > doxepin > nortriptyline > desipramine f) in general, NOT a good class of agents for the elderly 2) arrhythmic effects a) overdose results in prolongation of the QT interval b) patients with a bundle branch block are at higher risk c) risk of torsades de pointes d) avoid use within 6 months of coronary syndrome e) avoid in patients with cardiovascular disease, arrhythmias [3] - risk of arrhythmias, heart block, & sudden death [3] 3) cholinergic symptoms with abrupt withdrawal - abdominal cramping & diarrhea 4) increased risk of seizures [3] 5) orthostatic hypotension - doxepin = amitriptyline > imipramine = nortriptyline > desipramine 6) galactorrhea, hyperprolactinemia 7) may trigger manic attack in patients with a) bipolar affective disorder b) schizoaffective disorder Overdose: 1) clinical manifestations - progressive somnolence, hypotension, widened QRS interval, seizures, & parasympatholytic signs (fever, tachycardia, mydriasis, diminished peristalsis) - case report of cardiac arrest in a young women [5] 2) management a) early endotracheal intubation, hyperventilation b) fluid resusitation c) gastric lavage followed by activated charcoal even with delayed presentation d) EKG monitoring: QRS complex > 100 msec predicts seizures e) bicarbonate - bolus 1-2 meq/kg every 3-5 minutes until QRS complex narrows or blood pressure improves - bicarbonate drip titrated to QRS width & blood pressure - monitor serum K+, signs of fluid overload f) norepinephrine for hypotension not responsive to bicarbonate g) lidocaine for ventricular arrhythmias h) benzodiazepines for seizures - avoid phenytoin - propofol or barbiturates for refractory seizures

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DRUGS: tricyclic antidepressant FORM: drug adverse effects tricyclic antidepressant

References

  1. Journal Watch 23(1):11, 2003 Furukawa TA et al, Meta-analysis of effects and side effects of low dosage tricyclic antidepressants in depression: systematic review BMJ 325:991, 2002 PMID: 12411354 http://bmj.com/cgi/content/full/325/7371/991
  2. Medications Can Cause Seizures Prescriber's Letter 10(3):16 2003 Detail-Document#: 190320 (subscription needed) http://www.prescribersletter.com
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 19 American College of Physicians, Philadelphia 2006, 2009, 2022
  4. The Washington Manual of Medical Therapeutics, 33rd edition Foster C et al (eds) Lippincott, Williams & Wilkins, Philadelphia, 2010, pg 957
  5. Goldstein JN, Dudzinski DM, Erickson TB, Linder G. Case 12-2018: A 30-Year-Old Woman with Cardiac Arrest. N Engl J Med 2018; 378:1538-1549. April 19, 2018 PMID: 29669228 http://www.nejm.org/doi/full/10.1056/NEJMcpc1800322