Amitriptyline HCL (Elavil®)
Based on "Essential Psychopharmacology"
written by Stephen M. Stahl, MD, PhD
- Generic name : Amitriptyline hydrochloride
- Brand names: Elavil®, Amitrol®, Endep®, Levate®, Laroxyl®, Saroten®
- Therapeutic class: Antidepressant
- Pharmacologic class: Tricyclic antidepressant (Tertiary amine)
- FDA Approved: May 1983
- Chemical Formula: C20H23N
- Pregnancy Category: C (Teratogenic effects have been observed in animal studies)
- Habit forming? No
- Originally discovered: 1950s, Merck Sharp and Dohme
FDA approved indications
- Depression (endogenous depression is more likely to be alleviated than are other depressive states)
Amitriptyline has been frequently used as an active comparator in clinical trials on newer antidepressants.
Off-label & Investigational uses
- chronic pain management 7, 9, 10
- post-herpetic neuralgia 17, 18, 19
- diabetic peripheral neuropathy 15, 16
- fibromyalgia 21, 22
- migraine headaches prophylaxis 25, 26
- childhood headaches 28
- chronic tension headache 3, 5, 29, 30
- drug-induced headache 6
- irritable bowel syndrome (IBS) with diarrhea 14, 38
- depressed phase of bipolar affective disorder
- somatoform pain disorder 32
- post traumatic stress disorder 33
- panic/anxiety disorders
- insomnia 34
- vulvodynia 35
- interstitial cystitis (painful bladder syndrome) 36, 37
- functional dyspepsia26
- sleep bruxism (teeth grinding) 41
- burning mouth syndrome 42
Clinical trials demonstrate that amitriptyline achieves at least a good or moderate response in up to 65% of patients with post-herpetic neuralgia and 75% of patients with painful diabetic neuropathy, and other neurogenic pain syndromes that are often unresponsive to narcotic analgesics. Amitriptyline has also demonstrated efficacy in patients with chronic non-malignant pain 7, 9, 10.
In the study a dose of 20 mg/kg of amitriptyline reduced pain in the second phase of the formalin test (an animal model of long-lasting pain in humans). Since the analgesic effect was produced by a single dose, which is insufficient to produce an antidepressant effect, these results indicate that amitriptyline has analgesic properties that are independent of its antidepressant properties 8.
Amitriptyline reduces the pain caused by peripheral-nerve disease 16. Blockade of norepinephrine reuptake is likely to mediate the analgesic effect of amitriptyline in diabetic neuropathy.
Controlled clinical trials and extensive clinical experience have shown that amitriptyline reduces the severity of post-herpetic neuralgia. It is a reasonable first choice for PHN.
Amitriptyline is useful in treating postherpetic neuralgia. It may provide significant pain relief with the dose 75 mg 18. The alleviant effect of amitriptyline in postherpetic neuralgia appears not to be primarily linked with its serotoninergic effects and is also independent of its effects on depression 19.
Amitriptyline therapy can provide improvements in general health, pain, sleep quality and quantity, and fatigue in the treatment of fibromyalgia 22. Clinical study demonstrated that amitriptyline 25 mg at night is an effective therapeutic regimen for patients with fibromyalgia and is associated with significant improvement in pain, sleep difficulties, and fatigue on awakening. Also, amitriptyline increases blood flow to the affected sites in fibromyalgia patients21.
Amitriptyline (with maximum dosage 100 mg) appears to be safe and effective for treating interstitial cystitis. Amitriptyline can improve pain, urgency intensity, frequency and functional bladder capacity 37.
Amitriptyline "pros" and "cons"
- Potent antidepressant effective for various mental disorders
- Well researched
- The only documented and most widely used prophylactic therapy for chronic tension-type headache 31
- Small efficacy advantage over other tricyclic antidepressants
- Proven analgesic effects 8
- Relatively early onset of antidepressive effect 12
- Drug of choice for patients with insomnia, anxiety, or chronic pain syndromes.
- Risk of fatality in overdose
- Narrow therapeutic index
- Strong anticholingergic properties, and as a result severe anticholingergic side effects (such as sedation, dry mouth, constipation, urinary hesitancy)
- Sedation, hypersomnia, and mental/motor impairment. Also, amitriptyline may significantly impair driving performance27. The drug is especially poorly tolerated by those working in jobs demanding intense concentration.
- Can lower the seizure threshold; contraindicated in persons with epilepsy. Amitriptyline is reputed to be the most proconvulsive TCA40.
- Cardiotoxicity, which involves the impairment of the cardiac conduction system.
- Weight gain (greater increase in weight than with nortriptyline, desipramine, zimelidine, and imipramine) 39, 24
- Possible decreased amount of REM sleep 23
Mechanism of action
Amitriptyline hydrochloride is an antidepressant with sedative effects.
Amitriptyline inhibits the reuptake of noradrenaline at the noradrenergic nerve endings and the reuptake of serotonin (5-hydroxy tryptamine) at the serotoninergic nerve endings in the central nervous system. These two effects are considered to be the likely base of the antidepressant effect. Amitriptyline also has a strong anticholinergic effect 20. In fact, amitriptyline is the most anticholinergic of all antidepressants.
Amitriptyline has ability to antagonize histamine H1 receptors and appears to be a potent antihistamine 11.
Time for Amitriptyline to clear out the system
Elimination half-life varies from 24 to 46 hours. The mean elimination half-life is about 36 hours 2.
Within 24 hours, approximately 25 to 50% of a dose of amitriptyline is excreted in the urine as inactive metabolites; small amounts are excreted in the bile.
Onset of action
- Antidepressant effect: 4-6 weeks, it is recommended to reduce dosage to lowest effective level. However, antidepressive effect may be noticed as early as after 1 week of therapy 12.
- Migraine prophylaxis: 6 weeks, higher dosage may be required in heavy smokers because of increased metabolism.
The first tricyclic antidepressant discovered was imipramine, which was discovered accidentally in a search for a new antipsychotic in the late 1950s.
The therapeutic and commercial success of N-aminoalkylphenothiazines such as promethazine, promazine, and chlorpromazine, initiated an enormous effort in the molecular modification of the polycyclic phenothiazine ring structure and its N-aminoalkyl side chain.
Hafliger and Schinder, in 1951 US Patent 2,554,736, replaced the sulfur bridge of the phenothiazine ring of promethazine with an ethylene bridge to synthesize imipramine, a weak antihistaminic and mild anticholinergic with sedative properties in normal human volunteers. Kuhn, a clinical psychiatrist in Swiss psychiatric hospital, discovered that of some 500 patients with various psychiatric disorders that were treated, only those with endogenous depression with mental and motor retardation showed a remarkable improvement after about 1 to 6 weeks of daily imipramine therapy.
Thus, the first clinically useful tricyclic antidepressant was discovered. Amitriptyline was synthesized shortly after imipramine discovery and it became another tricyclic antidepressant widely used in clinical practice 4.
- Amitriptyline (Elavil) versus other medications
- Amitriptyline for migraine & headache
- Amitriptyline vs Fluoxetine
- Amitriptyline vs Nortriptyline
- Amitriptyline vs Venlafaxine
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Published: August 26, 2008
Last updated: September 01, 2017
- Nortriptyline (marketed under brand name Pamelor) is an intermediate active metabolite of amitriptyline.
- Amitriptyline is the only documented and most widely used antidepressant for tension headache prophylaxis.
- The first tricyclic antidepressant discovered was imipramine, which was discovered accidentally in a search for a new antipsychotic medicine in the late 1950s.