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All About Amitriptyline

Jay-Sheree Allen, MD and Neda Frayha, MD
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What is the deal with amitriptyline? Is it a panacea? Or a pariah? PC RAP’s own Dr. Jay-Sheree Allen and Dr. Neda Frayha break it all down for us in this medication deep dive.

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Alan R., M.D. -

Is the incidence of QTc prolongation less in those without heart disease/arrhythmias? Do you check a baseline ECG in everyone or check an ECG periodically to assess for QTc prolongation?

Neda F., MD -

Hi Alan. Here is Jay's response: "Yes it is, but though heart disease is a major factor the majority of patients who develop drug-induced QT prolongation have multiple risk factors including but not limited to heart disease, age >65 years, female sex, multiple offending drugs, and hypokalemia. Females are at higher risk than males since testosterone shortens the QT interval. Hypokalemia is a risk factor owing to the role of the potassium channels in QT prolongation. In our prep for this segment we found that a baseline EKG is recommended for patients >50. It's also recommended that we recheck with each dose increase. In addition to QTc prolongation, it is also important to note that this drug can cause heart rate variability, slow intracardiac conduction and induce various arrhythmias."

Joshua Y. -

Suggestions comparing nortriptyline to amitriptyline? I remember learning nortriptyline has less side effects than amitriptyline. I think efficacy is similar?

Neda F., MD -

Hi Joshua. Great question. Here is Jay's response: "A 2017 publication in Canadaian Family Physician reports the following:
'When prescribing TCAs [tricyclic antidepressants], secondary amines (nortriptyline, desipramine) are usually better tolerated in terms of sedation, postural hypotension, and anticholinergic effects when compared with tertiary amines (amitriptyline and imipramine) with comparable analgesic efficacy.' This is from a review of the Canadian Pain Society’s recent consensus statement on chronic neuropathic pain." Thanks for writing in!

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Hippo Primary Care Written Summary February 2021 480 KB - PDF

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