Are Tricyclics bad?

[PierreC]

Why do Tricyclics have such a bad reputation?

[panic_down_under]

Why do Tricyclics have such a bad reputation?

Ignorance, mostly.

[KK77]

Tricyclics are dangerous to OD on and at therapeutic levels have some unpleasant side effects, especially cognitive dysfunction. They're now mainly used in low doses for pain conditions and/or sleep disorders.

[panic_down_under]

Tricyclics are dangerous to OD on

So are two SSRIs, one SNRI and a noradrenaline-dopamine reuptake inhibitor. However, relatively few choose their antidepressant to OD on.

and at therapeutic levels have some unpleasant side effects, especially cognitive dysfunction.

All antidepressants may impede cognitive function, but not as much as anxiety disorders and depression do.

Given that TCAs are not as homogeneous a group as the SSRI which all have basically the same effects on the brain, but differ considerably in the way they work ranging from almost pure antihistamines, through to serotonin reuptake inhibitors, noradrenaline reuptake inhibitors and both serotonin and noradrenaline reuptake inhibitors, blanket conclusions really shouldn't be drawn about them as a class.

[KK77]

Are you a doctor Panic? You seem to get angry when contradicted.

Even cit which has now been shown to cause prolonged QT interval at high doses is nowhere near as dangerous as amit/nortrip. My GP explained that even below therapeutic levels many TCAs can cause dangerous tachycardia and sudden cardiac death, esp amit and imipramine. As I said, it's why many are relegated to pain management use at far below therapeutic levels.

And at >50mg amit's cognitive dysfunction compared to SSRIs is marked and significant. Look it up before you jump up and down and try to blind people with selective info. Do you take TCAs for your anxiety/ depression?

https://www.ncbi.nlm.nih.gov/pubmed/15345781

---------- Post added at 14:23 ---------- Previous post was at 13:40 ----------

I've been battling panic disorder, mostly successfully, for almost 30 years and been participating in anxiety forums for nearly as long, most recently in AZ.

Along the way I've picked up a few clues on how to manage these disorders which might help others, and hopefully I'll get new ideas here too.

Ian

30 years of armchair pharmacology Ian?

[MyNameIsTerry]

Ian,

You are a much respected member of the forum, as can be seen from all the positive feedback you get on here. You've clearly got the most knowledge on here about meds by far.

I always appreciate your knowledge.

You've never once tried to mislead anyone about being the same as everyone else here and your posts have never been emotional.

You are a credit to this place. I wouldn't hesitate advising someone to post a thread on here and looking out for your response, as I have done a few times.

[panic_down_under]

Are you a doctor Panic?

No

You seem to get angry when contradicted.

How do you draw that conclusion?

Even cit which has now been shown to cause prolonged QT interval at high doses is nowhere near as dangerous as amit/nortrip.

As I said earlier is this thread, there is a lot of ignorance about tricyclics. Credible Meds maintains the QTc drug data base for the FDA.

Their advice for amitriptyline is:

Conditional Risk of TdP - These drugs are associated with TdP BUT only under certain conditions of their use (e.g. excessive dose, in patients with conditions such as hypokalemia, or when taken with interacting drugs) OR by creating conditions that facilitate or induce TdP (e.g. by inhibiting metabolism of a QT-prolonging drug or by causing an electrolyte disturbance that induces TdP).

For nortriptyline:

Possible Risk of TdP - These drugs can cause QT prolongation BUT currently lack evidence for a risk of TdP when taken as recommended.

This is the same rating as for fluoxetine, fluvoxamine, paroxetine and sertraline.

OTOH, citalopram (and escitalopram) has the more serious warning:

Known Risk of TdP - These drugs prolong the QT interval AND are clearly associated with a known risk of TdP, even when taken as recommended

My GP explained that even below therapeutic levels many TCAs can cause dangerous tachycardia and sudden cardiac death, esp amit and imipramine.

The CredibleMeds lists imipramine as:

Possible Risk of TdP - These drugs can cause QT prolongation BUT currently lack evidence for a risk of TdP when taken as recommended.

which, as above, puts it on par with most of the SSRIs and much better than citalopram and escitalopram.

And at >50mg amit's cognitive dysfunction compared to SSRIs is marked and significant. Look it up before you jump up and down and try to blind people with selective info.

So challenging a claim which seems incorrect is "jump[ing] up and down"?

And here's some more selected info:

Carrière I, 2017, Antidepressant use and cognitive decline in community-dwelling elderly people"

Compared to non-users, the TCA users showed lower baseline performances of 9% for verbal fluency, 5% for visual memory (BVRT) and 9% for psychomotor speed (TMTA), and the SSRI users of 3% for verbal fluency and 7% for psychomotor speed. On the other hand, no significant differences were found at baseline for global cognitive performances (MMSE) or executive function (TMTB) irrespective of the treatment groups.

...However, the effect of TCAs on baseline cognitive visual memory may be more related to psychological comorbidity as it became statistically non-significant when participants with a history of MDE [major depression episode] were excluded.

...Hence, our study indicates that TCAs and SSRIs are principally associated with relatively weak cognitive impairment at baseline, mainly related to verbal fluency, visual memory and psychomotor skills, but the question remains as to whether this occurred before or at treatment initiation.

...CONCLUSIONS:
In this large elderly general population cohort, we found no evidence for an association between antidepressant use and post-treatment cognitive decline over 10 years of follow-up in various cognitive domains.

Podewils LJ, 2002, "Tricyclic antidepressants and cognitive decline.":

These findings failed to support the concept that TCA use is related to concurrent measurable cognitive deficits, and TCA use does not appear to significantly compromise memory over a substantial time span.

OTOH, there is some evidence TCAs reduce dementia risk.

Do you take TCAs for your anxiety/ depression?

Yes, mostly imipramine for the first 10 years at doses of 300-350mg/day for most of that period, the last 21 years I've continually been on 225mg dosulpin, aka dotheipin, which is the most cardio toxic antidepressant by a considerable margin. Despite being under greater than normal pressure as a result of having had a lung removed, my almost 70yo heart remains fine. Nor has 30 years of TCA use at very high doses addled my brain.

---------- Post added at 11:50 ---------- Previous post was at 09:50 ----------

You are a credit to this place.

Thank you for the vote of confidence. I don't take these things personally. I've been around support groups long enough to know that things can be misinterpreted, even with the use of emoticons, etc. All just part of the rich tapestry of life.

[MyNameIsTerry]

Ian,

Here is one of our local NHS trust's prescribing guidelines:

https://www.google.co.uk/url?sa=t&so...Yj9JHCy3RejRkw

TCA's being third line may mean a hand off to a psychiatrist but plenty of GP's play around with Mirt & Ven so it's difficult to say.

But it's very clear in these current guidelines that several TCA's are on the menu. And NICE guidelines for OCD also include the use of Clomipramine where SSRI/SNRI's have failed.

As can be seen, there are requirements set to ensure patient safety.

The NHS clearly aren't against using them.

[panic_down_under]

The NHS clearly aren't against using them.

And I don't have a problem with the guidelines generally, though I remain unconvinced by mirtazapine and agomelatine for anxiety. The next person to tell me how great agomelatine is working for him/her will be the first.

Mine default suggestion is to try citalopram/escitalopram first as they generally have the best side-effects profile, although as with everything about antidepressants, that isn't a guarantee. Switching to sertraline is second, and then, given NHS restrictions, duloxetine or a TCA as the third option.

Outside the NHS framework, I think adding some nortriptyline to the sertraline to create a bespoke SNRI would be worth a shot ahead of a SNRI/TCA switch if there is even a small positive response from the sertraline as this might produce the fastest outcome with the least trauma.

BTW-I was shocked at the price premium quoted for duloxetine and venlafaxine compared to most of the SSRIs. The TCAs seem to be at a considerable premium too, especially clomipramine.

Though perhaps I shouldn't be. I was discussing MAOIs with a British psycho pharmacologist a while back and he explained they are pretty much off the table because of cost. Apparently, the NHS is paying more than £200 for a box of 28 tablets. That is <expletive> outrageous for drugs which have been out of patent for 50 years and probably cost only pennies to make!! But with only one or two companies still making them they can charge whatever they want. Dick Turpin had nothing on these guys!!

[lliiaamm0099]

So are two SSRIs, one SNRI and a noradrenaline-dopamine reuptake inhibitor. However, relatively few choose their antidepressant to OD on.

I am a doctor and have been a doctor for 12 years, mainly as a neurologist, and whilst studying Medicine I worked part time as what is now known as an anatomical pathology technician (morgue technician) carrying out post mortem examinations and I can say plenty of people who were depressed would overdose on their antidepressants with intentions of killing themselves. I can also say the ones who were successful in ending their lives were the ones on tricyclics and many of the times they were the only drugs in their system. I never did and autopsy were just an SSRI or SNRI was the only drug to contribute to someone's death that is almost unheard of. I have also worked in A&E in my job and plenty of people to this day still overdose on just antidepressants alone.