Amitriptyline, formerly sold under the brand name Elavil among others, is a tricyclic antidepressant primarily used to treat major depressive disorder, and a variety of pain syndromes such as neuropathic pain, fibromyalgia, migraine and tension headaches. Due to the frequency and prominence of side effects, amitriptyline is generally considered a second-line therapy for these indications. and amitriptyline interacts with many other medications potentially aggravating its side effects.
Amitriptyline was discovered in the late 1950s by scientists at Merck and approved by the US Food and Drug Administration (FDA) in 1961. It is on the World Health Organization's List of Essential Medicines. It is available as a generic medication. In 2023, it was the 90th most commonly prescribed medication in the United States, with more than 7million prescriptions.
Medical uses
Amitriptyline is indicated for the treatment of major depressive disorder, neuropathic pain, and for the prevention of migraine and chronic tension headache. It can be used for the treatment of nocturnal enuresis in children older than 6 after other treatments have failed. It can be tried for depression as a second-line therapy, after the failure of other treatments. For treatment-resistant adolescent depression or for cancer-related depression amitriptyline is no better than placebo; however, the number of treated patients in both studies was small. It is sometimes used for the treatment of depression in Parkinson's disease, but supporting evidence for its effectiveness in that respect is lacking.
Pain
Amitriptyline alleviates painful diabetic neuropathy. It is recommended by a variety of guidelines as a first or second-line treatment. It is as effective for this indication as gabapentin or pregabalin but less well tolerated. Amitriptyline is as effective at relieving pain as duloxetine. Combination treatment of amitriptyline and pregabalin offers additional pain relief for people whose pain is not adequately controlled with one medication and is usually safe. Amitriptyline in certain formulations may also induce the level of sciatic-nerve blockade needed for local anesthesia therein. Here, it has been demonstrated to be of superior potency to bupivacaine, a customary long-acting local anesthetic.
Low doses of amitriptyline moderately improve sleep disturbances and reduce pain and fatigue associated with fibromyalgia. and as a second-line option for fibromyalgia, with exercise being the first line option, by European League Against Rheumatism. Combinations of amitriptyline and fluoxetine or melatonin may reduce fibromyalgia pain better than either medication alone.
There is some (low-quality) evidence that amitriptyline may reduce pain in cancer patients. It is recommended only as a second-line therapy for non-chemotherapy-induced neuropathic or mixed neuropathic pain if opioids did not provide the desired effect.
Moderate evidence exists in favor of amitriptyline use for atypical facial pain. Amitriptyline is ineffective for HIV-associated neuropathy.
Central post-stroke pain
Amitriptyline has also been reported to be effective in treating central post-stroke pain following lateral medullary infarction (Wallenberg Syndrome), particularly in patients with thermal dysesthesia. In a long-term observational study of 63 patients with brainstem stroke, 16 developed central pain, and all responded to amitriptyline, often relapsing when treatment was discontinued.
Headache
Amitriptyline is probably effective for the prevention of periodic migraine in adults. Amitriptyline is similar in efficacy to venlafaxine and topiramate but carries a higher burden of adverse effects than topiramate. For many patients, even very small doses of amitriptyline are helpful, which may allow for minimization of side effects. Amitriptyline is not significantly different from placebo when used for the prevention of migraine in children.
Amitriptyline may reduce the frequency and duration of chronic tension headache, but it is associated with worse adverse effects than mirtazapine. Overall, amitriptyline is recommended for tension headache prophylaxis, along with lifestyle advice, which should include avoidance of analgesia and caffeine.
Other indications
Amitriptyline is effective for the treatment of irritable bowel syndrome (IBS); however, because of its side effects, it should be reserved for select patients for whom other agents do not work. Still, the results on side effects of low-dose amitriptyline for treating IBS are mixed: a large 2023 trial in IBS patients compared titrated low-dose amitriptyline (10–30 mg/day over 3 weeks) with placebo—discontinuations were 20% versus 26% (13% vs. 9% due to adverse events), with five serious reactions (two amitriptyline, three placebo) and five unrelated serious events, demonstrating that amitriptyline outperformed placebo across multiple outcomes. In a 2009 study IBS patients received 25 mg daily titrated to 50 mg if needed. After 12 weeks, 74% experienced improvement in symptoms, and symptom relief correlated with reduced visceral hypersensitivity to stress-induced neuronal stimulation (e.g., cold pressor test); the benefit was not explained by changes in autonomic tone, suggesting a neuromodulatory (sensory nerve or neuroimmune) mechanism rather than purely psychological improvement. Amitriptyline is supposed to have effect on reducing mast cell degranulation, thus reducing pain and the symptoms associated with mast cell activation, such as IBS pain; people with IBS exhibit increased mucosal mast cells, elevated tryptase/histamine, and enhanced proximity of degranulating mast cells to enteric nerves, each correlating with subjective pain scores. The ability of amitriptyline to have mast-cell stabilizing effects and to reduce subjective pain score are believed to help not simply by altering mood, but by reducing visceral afferent firing, possibly through attenuation of nerve-mast cell crosstalk.
Amitriptyline may improve pain and urgency intensity associated with bladder pain syndrome and can be used in the management of this syndrome. Amitriptyline can be used in the treatment of nocturnal enuresis in children. However, its effect is not sustained after the treatment ends. Alarm therapy gives better short- and long-term results.
In the US, amitriptyline is commonly used in children with ADHD as an adjunct to stimulant medications without any evidence or guideline supporting this practice. Many physicians in the UK (and the US also) commonly prescribe amitriptyline for insomnia; however, Cochrane reviewers were not able to find any randomized controlled studies that would support or refute this practice. Similarly, a major systematic review and network meta-analysis of medications for the treatment of insomnia published in 2022 found little evidence to inform the use of amitriptyline for insomnia. The well-known sedating effects of amitriptyline, however, bear understanding on and arguable justification for this practice. It may function similarly to doxepin in this regard, although the evidence for doxepin is more robust. Trimipramine may be a more novel alternative given its tendency to not suppress but brighten R.E.M. sleep.
Contraindications and precautions
The known contraindications of amitriptyline are:
CYP2D6 poor metabolizers should avoid amitriptyline due to increased side effects. If it is necessary to use it, half dose is recommended. Amitriptyline can be used during pregnancy and lactation when SSRIs have been shown not to work.
Side effects
The most frequent side effects, occurring in 20% or more of users, are dry mouth, drowsiness, dizziness, constipation, and weight gain (on average 1.8 kg). Other common side effects are headache problems (amblyopia, blurred vision), tachycardia, increased appetite, tremor, fatigue/asthenia/feeling slowed down, and dyspepsia. Amitriptyline-associated sexual dysfunction (occurring at a frequency of 6.9%) seems to be mostly confined to males with depression and is expressed predominantly as erectile dysfunction and low libido disorder, with lesser frequency of ejaculatory and orgasmic problems. The rate of sexual dysfunction in males treated for indications other than depression and in females is not significantly different from placebo.
Liver test abnormalities occur in 10–12% of patients on amitriptyline, but are usually mild, asymptomatic, and transient, The increases of the enzymes above the 3-fold threshold of liver toxicity are uncommon, and cases of clinically apparent liver toxicity are rare; nevertheless, amitriptyline is placed in the group of antidepressants with greater risks of hepatic toxicity. This prolongation is relatively small at therapeutic doses but becomes severe in overdose.
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, thus it and other TCAs are no longer recommended as first-line therapy for depression. The treatment of overdose is mostly supportive as no specific antidote for amitriptyline overdose is available. Activated charcoal may reduce absorption if given within 1–2 hours of ingestion. 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. ECG monitoring for cardiac conduction abnormalities is essential and if one is found close monitoring of cardiac function is advised. Body temperature should be regulated with measures such as heating blankets if necessary. Cardiac monitoring is advised for at least five days after the overdose. Benzodiazepines are recommended to control seizures. Dialysis is of no use due to the high degree of protein binding with amitriptyline.
Interactions
Since amitriptyline and its active metabolite nortriptyline are primarily metabolized by cytochromes CYP2D6 and CYP2C19 (see its pharmacology), the inhibitors of these enzymes are expected to exhibit pharmacokinetic interactions with amitriptyline. According to the prescribing information, the interaction with CYP2D6 inhibitors may increase the plasma level of amitriptyline. the co-administration of amitriptyline with a potent CYP2D6 inhibitor paroxetine does increase the plasma levels of amitriptyline two-fold and of the main active metabolite nortriptyline 1.5-fold, but combination with less potent CYP2D6 inhibitors thioridazine or levomepromazine does not affect the levels of amitriptyline and increases nortriptyline by about 1.5-fold; A case of clinically significant interaction with potent CYP2D6 inhibitor terbinafine has been reported.
A potent inhibitor of CYP2C19 and other cytochromes fluvoxamine increases the level of amitriptyline two-fold while slightly decreasing the level of nortriptyline. Similar changes occur with a moderate inhibitor of CYP2C19 and other cytochromes cimetidine: amitriptyline level increases by about 70%, while nortriptyline decreases by 50%. CYP3A4 inhibitor ketoconazole elevates amitriptyline level by about a quarter. On the other hand, cytochrome P450 inducers such as carbamazepine and St. John's Wort decrease the levels of both amitriptyline and nortriptyline
Oral contraceptives may increase the blood level of amitriptyline by as high as 90%. Valproate moderately increases the levels of amitriptyline and nortriptyline through an unclear mechanism.
The prescribing information warns that the combination of amitriptyline with monoamine oxidase inhibitors may cause potentially lethal serotonin syndrome; The prescribing information cautions that some patients may experience a large increase in amitriptyline concentration in the presence of topiramate.
Amitriptyline counteracts the antihypertensive action of guanethidine. When given with amitriptyline, other anticholinergic agents may result in hyperpyrexia or paralytic ileus. Co-administration of amitriptyline and disulfiram is not recommended due to the potential for the development of toxic delirium. Amitriptyline causes an unusual type of interaction with the anticoagulant phenprocoumon during which great fluctuations of the prothrombin time have been observed.
Pharmacology
Pharmacodynamics
{| class="wikitable floatright" style="font-size:small;"
|+ Molecular targets of amitriptyline (AMI) and main active metabolite nortriptyline (NTI)
|-
! Site !! !! !! Species !! Ref
|-
| || 2.8–36 || 15–279 || Human ||
|-
| || 19–102 || 1.8–21 || Human ||
|-
| 5-HT<sub>1B</sub> || 840 || || Rat ||
|-
| 5-HT<sub>2A</sub> || 18–23 || 41 || Human ||
|-
| 5-HT<sub>2C</sub> || 4-8 || 8.5 || Rat ||
|-
| 5-HT<sub>3</sub> || 430 || 1,400 || Rat ||
|-
| 5-HT<sub>6</sub> || 65–141 || 148 || Human/rat ||
|-
| 5-HT<sub>7</sub> || 92.8–123 || || Rat ||
|-
| α<sub>1A</sub> || 6.5–25 || 18–37 || Human ||
|-
| α<sub>1B</sub> || 600–1700|| 850–1300|| Human ||
|-
| α<sub>2B</sub> || 76–1000 || || Human ||
|-
| α<sub>2C</sub> || 120 || || Human ||
|-
| H<sub>2</sub> || 66 || 646 || Human ||
|-
| M<sub>1</sub> || 11.0–14.7 || 40 || Human ||
|-
| M<sub>2</sub> || 11.8 || 110 || Human ||
|-
| || 3,260 || 31,600 || Human ||
|-
| PARP1 || 1650 || || Human ||
|-
| TrkA || 3,000<br />(agonist) || || Human ||
|-
| TrkB || 14,000<br />(agonist) || || Human || voltage-gated potassium channels K<sub>v</sub>7.2/ K<sub>v</sub>7.3, K<sub>v</sub>7.1, K<sub>v</sub>7.1/KCNE1, and hERG.
Amitriptyline also acts as NMDA receptor blocker, but the precise mechanism of this blockade remains unclear . Amitriptyline's blockade of various types ion channels may explain the high efficacy regarding Neuropathic pain.
Pharmacokinetics
Amitriptyline is readily absorbed from the gastrointestinal tract (90–95%). Extensive metabolism on the first pass through the liver leads to average bioavailability of about 50% (45%
Blood levels of amitriptyline and nortriptyline and pharmacokinetics of amitriptyline in general, with clearance difference of up to 10-fold, vary widely between individuals. Variability of the area under the curve in steady state is also high, which makes a slow upward titration of the dose necessary. and (E)-10-hydroxynortiptyline − 8–10 hours. 2% of the unchanged drug is excreted in the urine. Elimination in the feces, apparently, have not been studied.
Therapeutic levels of amitriptyline range from 75 to 175 ng/mL (270–631 nM), or 80–250 ng/mL of both amitriptyline and its metabolite nortriptyline.
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. 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.
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,
Chemistry
class=skin-invert-image|thumb|right|upright=1.6|Chemical synthesis of amitriptyline.
Amitriptyline is a highly lipophilic molecule having an octanol-water partition coefficient (pH 7.4) of 3.0, while the log P of the free base was reported as 4.92. Solubility of the free base amitriptyline in water is 14 mg/L. Amitriptyline is prepared by reacting dibenzosuberone with 3-(dimethylamino)propylmagnesium chloride and then heating the resulting intermediate product with hydrochloric acid to eliminate water. Following this, the US Food and Drug Administration approved amitriptyline for depression in 1961.
According to research by a historian of psychopharmacology David Healy, amitriptyline became a much bigger selling drug than its precursor imipramine because of two factors. First, amitriptyline has a much stronger anxiolytic effect. Second, Merck conducted a marketing campaign raising clinicians' awareness of depression as a clinical entity.
Society and culture
thumb|Two boxes of amitriptyline (Endep; produced by [[Alphapharm, Australian market) in 10 and 25 mg doses]]
Amitriptyline (formerly referred to by the brand name Elavil) is part of the plot line of the 2021 film The Many Saints of Newark.
Names
Amitriptyline is the English and French generic name of the drug and its , , and , while amitriptyline hydrochloride is its , , , and . Its generic name in Spanish and Italian and its are , in German is , and in Latin is .
Prescription trends
Between 1998 and 2017, along with imipramine, amitriptyline was the most commonly prescribed first antidepressant for children aged 5–11 years in England. It was also the most prescribed antidepressant (along with fluoxetine) for 12- to 17-year-olds.
Research
The few randomized controlled trials investigating amitriptyline efficacy in eating disorder have been discouraging.
See also
- List of antidepressants