Q:Should amitriptyline be used in the elderly? – DS, Sausalito, CA
Amitriptyline is classified as a “tricyclic” antidepressant. It has been available for decades and was commonly used under the brand name “Elavil®” as an antidepressant in the 1970’s and into the 1980’s and 1990’s. It has demonstrated efficacy for depression but has largely been replaced by the newer antidepressants that are considered to be of at least equal efficacy, but far safer. Amitriptyline and other tricyclics have also been used in low doses to treat neuropathic pain, such as that associated with diabetic neuropathy. Tricyclic antidepressants as a class are associated with significant adverse side effects, predominantly anticholinergic in nature. This means they reduce the effect of the important neurotransmitter, acetylcholine, which results in some serious side effects. Within the class, amitriptyline is an agent that is more likely to exhibit anticholinergic activity including dry mouth, and constipation. It is also associated with cardiovascular side effects and impairment of cognitive skills and may cause confusion and even psychosis. As stated in the Nursing Home Surveyor Guidelines on “unnecessary drugs”, Tag F-329, Table 1 Medication Issues of Particular Relevance, nortriptyline and desipramine are less likely to cause adverse side effects than are the other tricyclic antidepressants, such as amitriptyline. Amitriptyline is associated with causing sedation, especially after the initial dose. Because of that, and because it is an inexpensive generically available medication, some prescribers use it as a sleep aide. However, in my opinion, the potential risks of this medication to induce sleep outweigh the potential benefit. A dosage of 25 mg. daily is sometimes used to treat neuropathic pain, and, while that dose is fairly small, it is still capable of causing adverse effects. In my opinion, the use of larger doses in the elderly, such as 50 – 100 mg. would be very hard to justify due to the chance of adverse effects. As with any medication, the risk v. benefit of amitriptyline must be considered prior to initiating therapy and while a patient is taking the medication. While its use in the elderly is not completely contraindicated, its use has dwindled compared to previous years, largely due to concerns for its adverse side effects, and due to the availability of newer, safer agents. In my experience, most contemporary geriatric clinicians avoid the use of amitriptyline.