Amitriptyline Dosing

[Paddington]

I favor Amitriptyline for neuropathic pain. I usually start and pretty much stay at 25 mg QHS. On rare occasions I've gone up to 50 mg QHS. My understanding is that it works for pain (and maybe slightly for mood) at the lower doses and at higher doses (100+) it's an antidepressant. Mainly, I don't want them to get anticholinergic side effects, cardiac effects, and too much sedation so I try to stick with 25 mg.

I was perusing some scholarly articles today, and it seems like many folks recommend going to even higher doses 75 mg or even 150 mg QHS.

I was wondering what has been the experience of folks here. Does 25 mg QHS do much of anything, or should I be more aggressively titrating upwards towards a higher dose?

---

Members don't see this ad.

 

[Paddington]

Also, Tramadol + Amitriptyline interaction? I came across that in some articles, but at my current practice we use them together all the time (and so do other docs). Tramadol we're using maybe 100mg BID.

 

[Aether2000]

I frequently start at 10mg amitriptryline. The sedating properties with this drug are pronounced, over 40% report sedation at 25mg. But they do seem to become tolerant to the sedative effects.
For a monograph on interactions between antidepressants and sedating drugs see
http://www.indianapainsociety.org/index.php/opioidcalc/2013-01-07-02-39-11/antidepressants

 

[Pain Applicant1]

Why not go to nortriptyline, side effects tend to be lower, particularly in the elderly

 

[drf]

Or desipramine.

 

[Jcm800]

Why not go to nortriptyline, side effects tend to be lower, particularly in the elderly

Agree

 

[michaelrack]

Also, Tramadol + Amitriptyline interaction? I came across that in some articles, but at my current practice we use them together all the time (and so do other docs). Tramadol we're using maybe 100mg BID.

Usually ok to use the 2 together, but there is an increased risk of seizures. Also the theoretical possibility of serotonin syndrome

 

[michaelrack]

I favor Amitriptyline for neuropathic pain. I usually start and pretty much stay at 25 mg QHS. On rare occasions I've gone up to 50 mg QHS. ?

Make sure and check drug levels if you go above 50 (even at 50 it would be reasonable to check a level).

A 12 lead EKG is also reasonable to monitor effects on cardiac conduction/QTc

 

[bedrock]

Why not go to nortriptyline, side effects tend to be lower, particularly in the elderly

Seems like I have to use a higher dose of nortriptyline to achieve the same clinical effect I see with a lower dose of amitriptyline, and the patient ends up with the same amount of sedation.

 

[Tenesma]

i much prefer nortript... a lot less side-effects...

 

[emd123]

Are you guys seeing good pain reduction in your TCA patients?

 

[Tenesma]

i see less complaints of neuropathic complaints ---

 

[Paddington]

I have seen Nortriptyline used, but I've seen Amitriptyline used much more commonly.

Seems like I have to use a higher dose of nortriptyline to achieve the same clinical effect I see with a lower dose of amitriptyline, and the patient ends up with the same amount of sedation.

That's kind of what I've seen. I've stopped Nortriptyline in a few patients who got anticholinergic effects on it. I don't remember off hand what doses they were on. The 25 mg of Amitriptyline seems quite well tolerated.