Evidence-Based Reviews

Tricyclics: Still solid performers for the savvy psychiatrist

Current Psychiatry. 2002 June;1(6):30-39

References

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TCA metabolism is affected by age and interaction with other drugs. Closely monitor serum levels in elderly and medically compromised patients, especially during dosage increases. Pay particular attention to other medications that may affect serum levels²³ (Table 4). SSRIs, particularly fluoxetine and paroxetine, may affect TCA plasma levels because of their potent inhibition of CYP2D6.

Individualize dosing and serum level monitoring. For example, the patient who is clinically tolerating a TCA and has a normal ECG does not require a serum level measurement, unless medically indicated.

Discontinuing tricyclics

When discontinuing a TCA, taper the dosage no more rapidly than 25 to 50 mg every 2 to 3 days. Abrupt discontinuation can cause cholinergic rebound, with symptoms such as nausea, cramping, headache, vomiting, and sweating. “Rebound hypomania” or “mania” have been reported with abrupt cessation of TCAs,²⁴ especially in patients with bipolar disorder. If the etiology of rebound symptoms is unclear (i.e., medical versus psychiatric), re-administering the discontinued TCA should relieve the symptoms and confirm a diagnosis of discontinuation.

Related resources

Schatzberg AF, Cole JO, DeBattista C. Antidepressants. Manual of clinical psychopharmacology (3rd ed). Washington, DC: American Psychiatric Press, 1997.
Janicak PG, Davis JM, Preskorn SH, Ayd Jr. FJ. Principles and practice of psychopharmacotherapy (2nd ed). Baltimore: Lippincott Williams & Wilkins, 1997.
PDR Psychotropic Prescribing Guide (2nd ed). Montvale, NJ: Medical Economics, 1999.
National Library of Medicine, MedlinePlus Health Information: Antidepressants, tricyclics (http://www.nlm.nih.gov/medlineplus/druginfo/antidepressantstricyclicsystem202055.html)

Drug brand names

See table 1 for tricyclic drug brand names. Others mentioned in this article include:

Bupropion • Wellbutrin
Cimetidine • Tagamet
Citalopram • Celexa
Disulfiram • Antabuse
Fluoxetine • Prozac
Fluvoxamine • Luvox
Guanethidine • Ismelin
Methylphenidate • Concerta, Ritalin
Mirtazapine • Remeron
Nefazodone • Serzone
Paroxetine • Paxil
Phenytoin • Dilantin

Disclosure

Dr. Zajecka reports that he receives grant/research support from, serves as a consultant to, and is on the speaker’s bureau of Bristol-Myers Squibb and Eli Lilly and Co.; receives grant/research support from Cephalon Inc., GlaxoSmithKline, Lichtwer Pharma, Merck and Co., MIICRO Inc., Otsuka Pharmaceuticals, Parke-Davis, Pfizer Inc., and Wyeth-Ayerst Pharmaceuticals; serves as a consultant to Abbott Laboratories; and is on the speaker’s bureau of Abbott Laboratories, Pfizer/Roerig, GlaxoSmithKline, Pharmacia, and Wyeth-Ayerst Pharmaceuticals.

Dr. Tummala reports no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.