Amitriptyline

Amitriptyline, sold under the brand name Elavil among others, is a medicine primarily used to treat a number of mental illnesses.[2] These include major depressive disorder and anxiety disorders, and less commonly attention deficit hyperactivity disorder (ADHD) and bipolar disorder.[2][3] Other uses include prevention of migraines, treatment of neuropathic pain such as fibromyalgia and postherpetic neuralgia, and less commonly insomnia.[2][4] It is in the tricyclic antidepressant (TCA) class and its exact mechanism of action is unclear.[2] Amitriptyline is taken by mouth.[2]

For the song, see Life and Death of an American Fourtracker.

Amitriptyline
Clinical data
Pronunciation/ˌæmɪˈtrɪptɪliːn/[1]
Trade namesElavil, others
Other namesAmitryptyline; Amytriptyline; Amitryptiline; Amitriptiline; MK-230; N-750; Ro 4-1575
AHFS/Drugs.comMonograph
MedlinePlusa682388
License data
Pregnancy
category
  • AU: C
  • US: C (Risk not ruled out)
    Routes of
    administration    		By mouth, intramuscular injection
    Drug classTricyclic antidepressant (TCA)
    ATC code
    Legal status
    Legal status
    Pharmacokinetic data
    Bioavailability30–60%
    Protein binding96%[2]
    MetabolismLiver[2] (CYP2D6, CYP2C19)
    Metabolitesnortriptyline
    Elimination half-life10–50 hours[2]
    ExcretionUrine[2]
    Identifiers
    CAS Number
    PubChem CID
    IUPHAR/BPS
    DrugBank
    ChemSpider
    UNII
    KEGG
    ChEBI
    ChEMBL
    CompTox Dashboard (EPA)
    ECHA InfoCard100.000.038
    Chemical and physical data
    FormulaC20H23N
    Molar mass277.411 g·mol−1
    3D model (JSmol)
    Melting point188 °C (370 °F)
      (verify)

    Common side effects include blurred vision, dry mouth, low blood pressure on standing, sleepiness, and constipation.[2] Serious side effects may include seizures, an increased risk of suicide in those less than 25 years of age, urinary retention, glaucoma, and a number of heart issues.[2] It should not be taken with MAO inhibitors or the medication cisapride.[2] Amitriptyline may cause problems if taken during pregnancy.[2][5] Use during breastfeeding appears to be relatively safe.[6]

    Amitriptyline was discovered in 1960[7] and approved by the US Food and Drug Administration (FDA) in 1961.[8] It is on the World Health Organization's List of Essential Medicines.[9] It is available as a generic medication.[2] In 2017, it was the 87th most commonly prescribed medication in the United States, with more than nine million prescriptions.[10][11]

    Medical uses

    Amitriptyline is used for a number of medical conditions including major depressive disorder (MDD).[12][13][14] Some evidence suggests amitriptyline may be more effective than other antidepressants,[15][16] including selective serotonin reuptake inhibitors (SSRIs),[17] although it is rarely used as a first-line antidepressant due to its higher toxicity in overdose and generally poorer tolerability,[13] so is used as a second-line treatment when SSRIs do not work.[18] It is used in addition to other medications for pain.[19] A 2001 review called it "the gold-standard antidepressant".[15]

    It is TGA-labeled in Australia for migraine prevention, also in cases of neuropathic pain disorders,[13] fibromyalgia[4] and nocturnal enuresis.[13][20] Amitriptyline is a popular off-label treatment for irritable bowel syndrome (IBS),[21] although it is most frequently reserved for severe cases of abdominal pain in patients with IBS because it needs to be taken regularly to work and has a generally poor tolerability profile, although a firm evidence base supports its efficacy in this indication.[21] Amitriptyline can also be used as an anticholinergic drug in the treatment of early-stage Parkinson's disease if depression also needs to be treated.[22] Amitriptyline is the most widely researched agent for prevention of frequent tension headaches.[23]

    Contraindications

    The known contraindications of amitriptyline are:[24]

    • Hypersensitivity to TCAs or to any of its excipients
    • History of myocardial infarction
    • History of arrhythmias, particularly heart block to any degree
    • Congestive heart failure
    • Coronary artery insufficiency
    • Mania
    • Severe liver disease
    • Being under seven years of age
    • Breast feeding
    • Patients who are taking monoamine oxidase inhibitors (MAOIs) or have taken them within the last 14 days.

    Side effects

    Common side effects, occurring in more than 1% of users, include dizziness, headache, and weight gain. Side effects common to anticholinergics occur more often than with other TCAs such as imipramine. Cognitive side effects include delirium and confusion, as well as mood disturbances such as anxiety and agitation. Cardiovascular side effects may include orthostatic hypotension, sinus tachycardia, and QT-interval prolongation.[25] Sexual side effects include loss of libido and impotence, while sleep disturbances may include drowsiness, insomnia, and nightmares.[12][13][14][24][26][27] Of the TCAs, amitriptyline is said to have the most anticholinergic side effects and to be the most likely to produce delirium.[28]

    Overdose
    Main article: Tricyclic antidepressant overdose

    The symptoms and the treatment of an overdose are largely the same as for the other TCAs, including the presentation of serotonin syndrome and adverse cardiac effects. The British National Formulary notes that amitriptyline can be particularly dangerous in overdose,[14] thus it and other TCAs are no longer recommended as first-line therapy for depression. Alternative agents, SSRIs and SNRIs, are safer in overdose, though they are no more efficacious than TCAs. English folk singer Nick Drake died from an overdose of Tryptizol in 1974.[29]

    The possible symptoms of amitriptyline overdose include:[27]

    • Drowsiness
    • Hypothermia (low body temperature)
    • Tachycardia (high heart rate)
    • Other arrhythmic abnormalities, such as bundle branch block
    • ECG evidence of impaired conduction
    • Congestive heart failure
    • Dilated pupils
    • Convulsions (e.g. seizures, myoclonus)
    • Severe hypotension (very low blood pressure)
    • Stupor
    • Coma
    • Death
    • Polyradiculoneuropathy
    • Changes in the electrocardiogram, particularly QT-interval prolongation[25] and change in QRS axis or width
    • Agitation
    • Hyperactive reflexes
    • Muscle rigidity
    • Vomiting

    The treatment of overdose is mostly supportive as no specific antidote for amitriptyline overdose is available.[27] Activated charcoal may reduce absorption if given within 1–2 hours of ingestion.[27] If the affected person is unconscious or has an impaired gag reflex, a nasogastric tube may be used to deliver the activated charcoal into the stomach.[27] ECG monitoring for cardiac conduction abnormalities is essential and if one is found close monitoring of cardiac function is advised.[27] Body temperature should be regulated with measures such as heating blankets if necessary.[27] Cardiac monitoring is advised for at least five days after the overdose.[27] Benzodiazepines are recommended for control of seizures.[27] Dialysis is of no use due to the high degree of protein binding with amitriptyline.[27]

    Interactions

    Amitriptyline is known to interact with:[27]

    • Monoamine oxidase inhibitors as it can potentially induce a serotonin syndrome
    • CYP2D6 inhibitors and substrates such as fluoxetine due to the potential for an increase in plasma concentrations of the drug to be seen
    • Guanethidine as it can reduce the antihypertensive effects of this drug
    • Anticholinergic agents such as benztropine, hyoscine (scopolamine) and atropine, because the two might exacerbate each other's anticholinergic effects, including paralytic ileus and tachycardia
    • Antipsychotics due to the potential for them to exacerbate the sedative, anticholinergic, epileptogenic and pyrexic (fever-promoting) effects. Also increases the risk of neuroleptic malignant syndrome
    • Cimetidine due to the potential for it to interfere with hepatic metabolism of amitriptyline and hence increasing steady-state concentrations of the drug
    • Disulfiram due to the potential for the development of delirium
    • ECT may increase the risks associated with this treatment
    • Antithyroid medications may increase the risk of agranulocytosis
    • Thyroid hormones have a potential for increased adverse effects such as CNS stimulation and arrhythmias.
    • Analgesics, such as tramadol and pethidine due to the potential for an increase in seizure risk and serotonin syndrome.
    • Medications subject to gastric inactivation (e.g. levodopa) due to the potential for amitriptyline to delay gastric emptying and reduce intestinal motility
    • Medications subject to increased absorption given more time in the small intestine (e.g. anticoagulants)
    • Serotonergic agents such as the SSRIs and triptans due to the potential for serotonin syndrome.

    Pharmacology

    Pharmacodynamics
    See also: Pharmacology of antidepressants and Tricyclic antidepressant § Binding profiles
    Amitriptyline (and metabolite)[30]
    SiteAMINTISpeciesRef
    SERT2.8–4.315–18Human[31][32]
    NET19–351.8–4.4Human[31][32]
    DAT3,2501,140Human[31]
    5-HT1A450–1,800294Human[33][34]
    5-HT1B840NDRat[35]
    5-HT2A18–235.0–41Human/rat[33][34]
    5-HT2B174
    13.4 (KB)    		NDHuman[36]
    5-HT2C4.08.5Human/rat[37][38]
    5-HT34301,400Rat[39]
    5-HT665–141148Human/rat[40][41][42]
    5-HT792.8–123NDRat[43]
    α14.4–2455Human[32][33]
    α2114–6902,030Human[32][33]
    β>10,000>10,000Rat[44][45]
    D189NDHuman[46]
    D2196–1,4602,570Human[33][46]
    D3206NDHuman[46]
    D4NDNDNDND
    D5170NDHuman[46]
    H10.5–1.13.0–15Human[46][47][48]
    H266646Human[47]
    H375,90045,700Human[46][47]
    H426,3006,920Human[47][49]
    mACh9.637Human[33]
      M111.0–14.740Human[50][51]
      M211.8110Human[50]
      M312.8–3950Human[50][51]
      M47.284Human[50]
      M515.7–2497Human[50][51]
    σ13002,000Guinea pig[52]
    σ2NDNDNDND
    hERG>3,000NDHuman[53]
    Values are Ki (nM), unless otherwise noted. The smaller the value, the more strongly the drug binds to the site.

    Amitriptyline is classified as a tricyclic antidepressant (TCA), with strong actions on the serotonin transporter (SERT) and moderate effects on the norepinephrine transporter (NET).[31][54] It has negligible influence on the dopamine transporter (DAT) and therefore does not affect dopamine reuptake, being nearly 1,000 times weaker on inhibition of the reuptake of this neurotransmitter than on serotonin.[31] It is metabolized to nortriptyline, a more potent and selective norepinephrine reuptake inhibitor, and this may serve to complement its effects on norepinephrine reuptake.[27]

    Amitriptyline additionally acts as an antagonist or inverse agonist of the serotonin 5-HT2A, 5-HT2C, 5-HT3, 5-HT6, and 5-HT7 receptors, the α1-adrenergic receptor, the histamine H1 and H2 receptors,[55] and the muscarinic acetylcholine receptors, and as an agonist of the sigma σ1 receptor.[32][56][57][58] It has also been shown to be a relatively weak NMDA receptor antagonist via the dizocilpine (MK-801)/phencyclidine (PCP) site.[59] Amitriptyline inhibits sodium channels, L-type calcium channels, and Kv1.1, Kv7.2, and Kv7.3 voltage-gated potassium channels, and therefore acts as a sodium, calcium, and potassium channel blocker as well.[60][61]

    Amitriptyline has been demonstrated to act as an agonist of the TrkA and TrkB receptors.[62] It promotes the heterodimerization of these proteins in the absence of NGF and has potent neurotrophic activity both in-vivo and in-vitro in mouse models.[62][63] These are the same receptors BDNF activates, an endogenous neurotrophin with powerful antidepressant effects, and as such this property may contribute significantly to its therapeutic efficacy against depression. Amitriptyline also acts as a functional inhibitor of acid sphingomyelinase,[64] and as a PARP1 inhibitor.[65]

    Mechanism of action

    Amitriptyline inhibits neuronal reuptake of serotonin and noradrenaline from the synapse in the central nervous system; this increases their availability in the synapse to cause neurotransmission on the post-synaptic neurone.[66] Amitriptyline is metabolised by cytochrome P450 enzymes in the liver to nortriptyline, which also acts as a noradrenaline reuptake inhibitor; this potentiates the antidepressant effects of amitriptyline.[67]

    Pharmacokinetics

    Amitriptyline is a highly lipophilic molecule having an octanol-water partition coefficient (pH 7.4) of 3.0,[68] while the log P of the free base was reported as 4.92.[69] Solubility in water is 9.71 mg/litre at 24 °C.[70]

    Amitriptyline is readily absorbed from the gastrointestinal tract and is extensively metabolized on first pass through the liver.[27] It is metabolized mostly by CYP2D6, CYP3A4, and CYP2C19-mediated N-demethylation into nortriptyline,[27] which is another TCA in its own right.[71] It is 96% bound to plasma proteins; nortriptyline is 93–95% bound to plasma proteins.[27][72] It is mostly excreted in the urine (around 30–50%) as metabolites either free or as glucuronide and sulfate conjugates within 24 hours.[27] 2% of the unchanged drug is excreted in the urine.[66] Small amounts are also excreted in feces.[26] Amitriptyline has an elimination half life of 25 hours an its volume of distribution is 10–50L/kg.[67]

    Therapeutic levels of amitriptyline range from 75 to 175 ng/mL (270–631 nM),[73] or 80–250 ng/mL of both amitriptyline and its metabolite nortriptyline.[74]

    Pharmacogenetics

    Since amitriptyline is primarily metabolized by CYP2D6 and CYP2C19, genetic variations within the genes coding for these enzymes can affect its metabolism, leading to changes in the concentrations of the drug in the body.[75] Increased concentrations of amitriptyline may increase the risk for side effects, including anticholinergic and nervous system adverse effects, while decreased concentrations may reduce the drug's efficacy.[76][77][78][79]

    Individuals can be categorized into different types of CYP2D6 or CYP2C19 metabolizers depending on which genetic variations they carry. These metabolizer types include poor, intermediate, extensive, and ultrarapid metabolizers. Most individuals (about 77–92%) are extensive metabolizers,[78] and have "normal" metabolism of amitriptyline. Poor and intermediate metabolizers have reduced metabolism of the drug as compared to extensive metabolizers; patients with these metabolizer types may have an increased probability of experiencing side effects. Ultrarapid metabolizers use amitriptyline much faster than extensive metabolizers; patients with this metabolizer type may have a greater chance of experiencing pharmacological failure.[76][77][78][79]

    The Clinical Pharmacogenetics Implementation Consortium recommends avoiding amitriptyline in patients who are CYP2D6 ultrarapid or poor metabolizers, due to the risk for a lack of efficacy and side effects, respectively. The consortium also recommends considering an alternative drug not metabolized by CYP2C19 in patients who are CYP2C19 ultrarapid metabolizers. A reduction in starting dose is recommended for patients who are CYP2D6 intermediate metabolizers and CYP2C19 poor metabolizers. If use of amitriptyline is warranted, therapeutic drug monitoring is recommended to guide dose adjustments.[78] The Dutch Pharmacogenetics Working Group also recommends selecting an alternative drug or monitoring plasma concentrations of amitriptyline in patients who are CYP2D6 poor or ultrarapid metabolizers, and selecting an alternative drug or reducing initial dose in patients who are CYP2D6 intermediate metabolizers.[80]

    Chemistry

    Amitriptyline is a tricyclic compound, specifically a dibenzocycloheptadiene, and possesses three rings fused together with a side chain attached in its chemical structure.[81] Other dibenzocycloheptadiene TCAs include nortriptyline (noramitriptyline, N-desmethylamitriptyline), protriptyline, and butriptyline.[81] Amitriptyline is a tertiary amine TCA, with its side chain-demethylated metabolite nortriptyline being a secondary amine.[82][83] Other tertiary amine TCAs include imipramine, clomipramine, dosulepin (dothiepin), doxepin, and trimipramine.[84][85] The chemical name of amitriptyline is 3-(10,11-dihydro-5H-dibenzo[a,d]cycloheptene-5-ylidene)-N,N-dimethylpropan-1-amine and its free base form has a chemical formula of C20H23N with a molecular weight of 277.403 g/mol.[86] The drug is used commercially mostly as the hydrochloride salt; the free base form is used rarely and the embonate (pamoate) salt is used for intramuscular administration.[86][87] The CAS Registry Number of the free base is 50-48-6, of the hydrochloride is 549-18-8, and of the embonate is 17086-03-2.[86][87]

    History

    Amitriptyline was first synthesized in 1960 and was introduced for medical use in United States in 1961 and in the United Kingdom in 1962, in both countries under the brand name Elavil.[88][89][90][91] It was the second TCA to be introduced, following the introduction of imipramine in 1957.[89][90]

    Society and culture
    Two boxes of amitriptyline (Endep) in 10 and 25 mg doses

    Generic names

    Amitriptyline is the English and French generic name of the drug and its INN, BAN, and DCF, while amitriptyline hydrochloride is its USAN, USP, BANM, and JAN.[86][87][92][93] Its generic name in Spanish and Italian and its DCIT are amitriptilina, in German is Amitriptylin, and in Latin is amitriptylinum.[87][93] The embonate salt is known as amitriptyline embonate, which is its BANM, or as amitriptyline pamoate unofficially.[87]

    Brand names

    As of September 2018, amitriptyline was marketed under many brand names worldwide alone and as a combination drug with each of chlordiazepoxide, perphenazine, and medazepam.[94]

    Brands include Adepril, ADT, Ambival, Amicon, Amilavil, Amilin, Amiline, Amineurin, Amiplin, Amirol, Amit, Amitin, Amitone, Amitrac, Amitrip, Amitriptilina, Amitriptilino, Amitriptilins, Amitriptine, Amitriptylin, Amitriptyline, Amitriptylinhydrochlorid, Amitriptylini, Amitriptylinum, Amitryp, Amotrip, Amyline, Amypres, Amytril, Amyzol, Anapsique, Arpidox, Deprelio, Elatrol, Elatrolet, Elavil, Endep, Fiorda, Laroxyl, Latilin, Levate, Maxitrip, Maxivalet, Mitryp, Modup, Normaln, Odep, Pinsaun, Polytanol, Protanol, Qualitriptine, Redomex, Saroten, Sarotex, Stelminal, Syneudon, Teperin, Trepiline, Triamyl, Trilin, Trip, Tripta, Triptiline, Triptizol, Triptric, Triptyl, Triptyline, Tripyline, Trynol, Tryptalgin, Tryptanol, Tryptin, Tryptizol, Tryptomer, and Vanatrip.[94]

    Brands as of that date for the combination with chlordiazepoxide included Amicon Forte, Amitrac-CZ, Amypres-C, Antalin, Antalin Forte, Arpidox-CP, Axeptyl, Diapatol, Diaztric-A, Emotrip, Klotriptyl, Libotryp, Limbatril, Limbitrol, Limbitryl, Limbival, Limbritol, Maxitrip-CZ, Mitryp Forte, Morelin, Ristryl, and Sedans.[94]

    Brands as of that date for the combination with perphenazine included Levazine, Minitran, Mutabase, Mutabon, Pertriptyl, Triavil, and Triptafen.[94]

    Brands as of that date for the combination with medazepam included Nobritol.[94]

    Research

    Amitriptyline has been studied in several disorders:

    • Eating disorders:[26] The few randomized controlled trials investigating its efficacy in eating disorders have been discouraging.[95]
    • Insomnia: As of 2004, amitriptyline was the most commonly prescribed off-label prescription sleep aid in the United States.[96] Owing to the development of tolerance and the potential for adverse effects such as constipation, its use in the elderly for this indication is recommended against.[13]
    • Urinary incontinence. An accepted use for amitriptyline in Australia is the treatment of urinary urge incontinence.[13]
    • Cyclic vomiting syndrome[97][98]
    • Preventive treatment for patients with recurring biliary dyskinesia (sphincter of Oddi dysfunction)[99]
    • Attention deficit/hyperactivity disorder (in addition to, or sometimes in place of ADHD stimulant drugs)[100]
    • Retching/dry heaving, especially after the anti-reflux procedure Nissen fundoplication[101]
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    Further reading
    • "Amitriptyline". Drug Information Portal. U.S. National Library of Medicine.
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