The tricyclic antidepressants are often overlooked as they do have some real negative adverse effects and potential drug interactions.  I’ll give you 5 important clinical pearls below when considering using the tricyclic antidepressants.

Know Thy Indication.

Using tricyclic antidepressants (TCA) for fibromyalgia or other pain syndromes like neuropathy or possibly even migraine is sometimes useful.  In a condition like fibromyalgia and migraine which tend to present at a younger age, a tricyclic antidepressant may be a very viable option.  Using a TCA for something like sleep gets a little less exciting as these drugs can cause a significant number of side effects for a condition where we have a lot of other options.  Identifying what you are using the drug for will help you weigh the risk versus benefit of whether its appropriate or not.

Tricyclic Antidepressants have Anticholinergic Side Effects.

The tricyclic antidepressants are notorious for causing antichoinergic side effects.  You have to assess your patient for these concerns and make sure that we are not causing more harm than good.  Classic, common side effects with the TCA’s include constipation, urinary retention, dry eyes, and dry mouth.

Avoid in the Elderly.

With the above mentioned side effect profile, you could understand why you would want to try to avoid using this class of medication in the elderly.  Also add in the fact that these drugs can be sedating, cause confusion, and increase fall risk, and you can understand why we do what we can to try to avoid using these medications in the elderly.

Cardiac Concerns.

These drugs can potentially prolong the QT interval.  Be aware of patients who may have electrolyte imbalances, have preexisting conditions that place them at risk for QT prolongation or may be on medications that may exacerbate this like antiarrhthmics, antipsychotics, or quinolone antibiotics. This is also a major reason why they are typically more risky in a patient at risk for overdose.

Prescribing Cascade.

I talk more about this in the video below, but there are numerous examples of the prescribing cascade involving adverse effects from the tricyclic antidepressants.  Here’s a classic case from the past where amitriptyline led to an inappropriate order for a dementia medication!

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