Amitriptyline is the name of an antidepressant drug that we use to treat some types of chronic
pain, like fibromyalgia and neuropathic pain.
In this video, I will answer the 10 most common questions that people ask me about amitriptyline:
How amitriptyline works?
Will amitriptyline help me to sleep?
Is there any contra-indication to take amitritptyline?
Can amitriptyline cause weight gain?
What to do when amitriptyline doesn’t work for my pain?
Does amitriptyline cause any damage to the liver or kidneys?
Can you use amitriptyline during pregnancy and breastfeeding?
Can you drive or can you take alcohol with amitriptyline?
Is amitriptyline good for anxiety?
Is amitriptyline addictive?
So, let’s talk about amitriptyline today.
1.
How amitriptyline works?
Amitriptyline was one of the very first medications developed to treat depression in the 1960s.
It increases serotonin and norepinephrine in the synapses by blocking the enzymes that
removes these neurotransmitters.
If you block the removal of serotonin and norepinephrine, there will be more of them
available for a longer time.
Well, serotonin and norepinephrine are neurotransmitters that regulates mood.
They are also important in the descending pain pathways.
In theory, if you can have more serotonin and norepinephrine in the brain, the mood
is better and your brain will be able to block pain sensations coming from the periphery.
However, the scientific evidence from randomized controlled trials of amitriptyline for pain
is not too convincing.
The two most recent Cochrane Reviews of amitriptyline for pain in adults concluded that:
Amitriptyline has been a first-line treatment for fibromyalgia for many years.
The fact that there is no supportive unbiased evidence for a beneficial effect is disappointing
but has to be balanced against years of successful treatment in many patients with fibromyalgia.
There is no good evidence of a lack of effect; rather our concern should be of overestimation
of treatment effect.
Amitriptyline will be one option in the treatment of fibromyalgia, while recognising that only
a minority of patients will achieve satisfactory pain relief.
It is unlikely that any large, randomised trials of amitriptyline will be conducted
in fibromyalgia to establish efficacy statistically or measure the size of the effect.
And very similar conclusion for neuropathic pain:
Amitriptyline has been a first-line treatment for neuropathic pain for many years.
The fact that there is no supportive unbiased evidence for a beneficial effect is disappointing
but has to be balanced against decades of successful treatment in many people with neuropathic
pain.
There is no good evidence of a lack of effect; rather our concern should be of overestimation
of treatment effect.
Amitriptyline should continue to be used as part of the treatment of neuropathic pain,
but only a minority of people will achieve satisfactory pain relief.
Limited information suggests that failure with one antidepressant does not mean failure
with all.
We know that the pain relief effect is independent from the antidepressant effects.
This is to say that some people may improve mood and not pain, other people may improve
pain and not mood, others will improve both, and some will improve none.
Before I continue, let me remind you that this video is not intended to replace medical
advice.
It is for educational purposes only.
You should contact your doctor for a proper diagnosis and treatment plan for you.
In case of emergency, go to the nearest emergency department or call an ambulance.
2.
Will amitriptyline help me to sleep?
It is quite possible that you will sleep faster, longer and better with amitriptyline.
In many patients with chronic pain, this is a good side effect, as they don’t sleep
well.
In patients with myofascial pain syndrome, this side effect is quite useful, because
patients need to relax their muscles at night, and amitriptyline will help them to achieve
this goal.
However, this side effect is what makes some people stop amitriptyline, as they can’t
get up from bed in the morning.
They say they are too fatigued and groggy in the morning.
In this case, I tell them to take the amitriptyline earlier in the evening.
Maybe 2 hours before their bedtime.
This usually helps them to feel more alert when they wake up.
3.
Is there any contra-indication or precautions to take amitriptyline?
Yes
Amitriptyline may cause a condition that affects the heart rhythm, including people with QT
prolongation
Amitriptyline may make the you more sensitive to the sun.
You have to limit your time in the sun.
Avoid tanning booths and sunlamps.
Use sunscreen and wear protective clothing when outdoors.
Older adults may be more sensitive to the side effects of this drug, especially dry
mouth, dizziness, drowsiness, confusion, constipation, difficulty urinating, and QT prolongation.
They may have an increase in the risk of falling.
People with narrow-angle glaucoma should not take amitriptyline
And men with prostate hypertrophy should be careful as it may cause urinary retention.
People with bipolar depression should not take amitriptyline because it may precipitate
hypomanic episodes.
People who use a MAO inhibitor should not take amitriptyline.
It should not be given to people with history of epilepsy or seizures because it decreases
the seizure threshold
4.
Can amitriptyline cause weight gain?
Yes, that is a common side effect of amitriptyline because it increases appetite.
On average people may gain 5 to 10 pounds but the good news is that they loose that
when they stop the medication.
5.
What to do when amitriptyline doesn’t work for my pain?
It might be that the dose you are taking is not high enough, or you didn’t try for longer
enough, or you are not taking every day.
For amitriptyline to work, the person needs to take it everyday, for at least 2 months.
If they tried a few days here and there, they would not notice any benefit, either for depression
or pain.
For depression they may start to feel better after 1 to 2 weeks but it can take 4 to 6
weeks for amitriptyline to work fully.
For pain, they may notice some benefit after 4 weeks.
The dose for depression is usually higher than the doses for pain.
We start with 10 mg at night, then increase slowly, every 2 weeks to 20 mg, then 50 mg
and then 75 mg.
We stop at 75 mg for pain management.
For depression the person may need to go up to 150 mg per day.
Most people stop taking amitriptyline because of the side effects.
The most common are: Dry mouth
Constipation Fatigue
Weight gain Orthostatic hypotension, which is a drop in
blood pressure when you go from sitting to standing position.
You may feel dizzy for a few seconds and fall.
6.
Does amitriptyline cause any damage to the liver or kidneys?
We are usually not concerned that this drug will be toxic to the liver of kidneys, even
if the person will have to use it for the rest of their lives.
But it is important to know, before we give the first prescription, if the person has
any liver or kidney function problem because we may need to reduce the dose.
7.
Can you use amitriptyline during pregnancy and breastfeeding?
During pregnancy, this medication should be used only when clearly needed.
Since untreated depression and anxiety can be a serious condition, do not stop using
amitriptyline during pregancy unless directed by your doctor.
If you are planning to become pregnant, or think you may be pregnant, immediately discuss
with your doctor the benefits and risks of using this medication during pregnancy.
This medication passes into breast milk and the effect on a nursing infant is unknown.
Consult your doctor before breast-feeding.
8.
Can you drive or can you take alcohol with amitriptyline?
The short answer is no.
If you feel that you are dizzy and sleepy you should not be driving a car or operating
any heavy equipment.
You could cause injury to yourself and others.
Taking with alcohol makes you sleepier and dizzier.
9.
Is amitriptyline good for anxiety?
Amitriptyline has sedating and anti-anxiety effects, and those can be helpful to people
who suffer form anxiety disorders, especially anxiety that is on top of depression.
However, it is important to remember that if you stop taking your daily amitriptyline
your body will have withdrawal symptoms.
Those abstinence symptoms may include nausea, anxiety, insomnia and headache.
10.
Is amitriptyline addictive?
There is no such thing as addiction to amitriptyline.
Physical dependence is not the same thing as being addicted.
It is expected that the person will develop some physical dependence if they use antidepressants
every day for a long period, the same way that people can develop physical dependence
on thyroid hormones or blood pressure medications.
If they stop any of those medications abruptly, they have withdrawal symptoms.
It does not mean they are addicted to their thyroid hormones or blood pressure medications.
When the person uses amitriptyline for a prolonged time, they cannot stop abruptly, they need
to reduce the dose slowly, this will avoid withdrawal symptoms.
There are people who abuse amitriptyline, and that is mainly because of the sedative
effects.
Overdose of amitriptyline is a very serious condition.
It does not mean the person is addicted to it.
People may also abuse acetaminophen, ibuprofen, or steroids.
The person needs education that they cannot increase the dose too quickly.
So, I hope these answered your 10 top questions about amitriptyline.
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