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Psychotropic Use during Pregnancy
Published in “Bert” Bertis Britt Little, Drugs and Pregnancy, 2022
A national study, Collaborative Perinatal Project, included 21 infants whose mothers were treated with amitriptyline during the first trimester. The rate of birth defects was not increased in the exposed offspring (Heinonen et al., 1977). Another large multinational study included 118 first-trimester exposures to amitriptyline among whom there was no increased frequency of congenital anomalies (McElhatton et al., 1996). Transient central nervous system depression was reported in a newborn whose mother was exposed to amitriptyline throughout gestation (Vree and Zwart, 1985). However, maternal levels were high, with serum levels in the moderately toxic range; and the infant’s levels were in the severely toxic range.
Neurologic disorders in pregnancy
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Robert Burger, Terry Rolan, David Lardizabal, Upinder Dhand, Aarti Sarwal, Pradeep Sahota
Lateral femoral cutaneous nerve is prone to entrapment or stretch during third trimester due to expanding abdominal wall and lordosis (23,29). Symptoms of pain, tingling, and numbness over lateral aspect of thigh may be unilateral or bilateral. Compression may also occur due to thigh flexion during delivery or pressure from the retractor during caesarian section. Treatment consists of reassurance for spontaneous resolution, and topical Lidoderm patches or local anesthetic injection in severe cases (24). Use of GBP or amitriptyline is preferably avoided during pregnancy. Intercostal neuralgias may also occur due to stretch injury and lead to chest or abdominal wall pain in a dermatomal pattern (23).
Nonopioid and Adjuvant Analgesic Agents
Published in Pamela E. Macintyre, Stephan A. Schug, Acute Pain Management, 2021
Pamela E. Macintyre, Stephan A. Schug
Adverse effects of TCAs are common but dose dependent (Pryor & Storer, 2019). As tolerance develops to both the anticholinergic and sedative effects of TCAs (see later), it is better to start with low, single daily doses that can be increased every few days as tolerated and needed. Recommended starting doses for amitriptyline are 5–25 mg (it is best to commence older patients on the lower dose), and these may be increased every three to seven days if required and if no unacceptable adverse effects develop (Bates et al, 2019). A satisfactory response usually occurs at levels between 25–150 mg. Benefits may be seen within a few days, but TCAs should be continued for six to eight weeks at the maximum tolerated dose before a definitive decision is made about their effectiveness. As TCAs may cause drowsiness, especially in the early stages of treatment, doses are best given at night. This may also help to “normalize” sleep patterns, which are often disturbed in patients with pain.
Fatal self-poisoning with amitriptyline: a case report and brief review of literature
Published in Journal of Substance Use, 2023
Qing Gao, Bin Lv, Weisheng Huang, Tianying Sun, Hongmei Dong
Amitriptyline can treat various forms of depression. This drug has been also used as an adjunct to analgesics for certain chronic and neuropathic pain syndromes. Following oral administration, amitriptyline is rapidly absorbed from the gastrointestinal tract and binds strongly to plasma albumin. The bound form accounts for 90% to 95% of total amitriptyline in plasma (Gillman, 2007). Subsequently, the drug is transported to the extravascular tissues via blood circulation. The detoxification of amitriptyline occurs in the liver via CYP-mediated metabolism. Initially, this compound undergoes oxidative metabolism on the side chain to produce N-oxide amitriptylinoxide (AT-NO). The metabolite AT-NO can either be excreted by the kidneys or reduced to the parent compound amitriptyline. Secondly, amitriptyline can further be demethylated to nortriptyline (NT). Subsequently, hydroxylation of amitriptyline or NT results in the production of numerous isomeric alcohols (Breyer-Pfaff, 2004). These compounds are finally degraded into inactive metabolites, which are excreted by the kidney. Amitriptyline and its metabolite, namely NT and AT-NO, exert toxic effects. Among amitriptyline overdose case, the toxicity may primarily correlate to the concentration of amitriptyline in the blood as described previously (Kerr et al., 2001).
Considerations for single- versus multiple-drug pharmacotherapy in the management of painful diabetic neuropathy
Published in Expert Opinion on Pharmacotherapy, 2021
Kalliopi Pafili, Nikolaos Papanas
Amitriptyline is a tricyclic antidepressant [15]. It is formally licensed by the US Food and Drug Administration for the treatment of neuropathic pain. The drug is available as tablets (10, 25, and 50 mg) and oral solutions [15]. Its main untoward effects relate to its anticholinergic activity, but they tend to wean after 2–3 weeks, namely at the onset of its analgesic effects [15]. Sedation is a further limitation, rendering the administration at night time unavoidable [15]. Its mechanism of action to reduce neuropathic pain remains obscure, although it is known to inhibit both serotonin and noradrenaline re-uptake [15,16]. Importantly, the analgesic and anti-depressive effects of amitriptyline potentially rely on different mechanisms, given that pain relief is achieved at lower dosages and that antidepressants produce analgesia in people with and without depression [16].
Contemporary management of unipolar depression in the perinatal period
Published in Expert Review of Neurotherapeutics, 2021
Bhuvaneshwari Sethuraman, Susan Thomas, Krishnamachari Srinivasan
Most protocols recommend the use of sertraline and citalopram as the first line of treatment for antenatal depression [3,10,84]. Paroxetine is to be avoided during pregnancy as its use during pregnancy is associated with an increased risk of cardiac malformations in the newborn [112]. Similarly, it is better to avoid clomipramine during pregnancy as in some studies it has been associated with an increased risk of congenital malformations such as cleft palate, open eyelids, ear defects and neck defects [114]. UK Teratology body recommends the use of amitriptyline and imipramine as the first line options for treatment of depression during pregnancy [10]. Benzodiazepines as a class of drugs should be avoided as some studies have noted its use to be associated with an increased risk for floppy infant syndrome, withdrawal signs in the newborn, congenital malformations such as esophageal atresia, microphthalmia and pulmonary valve stenosis [115] and impaired cognitive development in children [116]. There is limited evidence for safe and efficacious use of other antidepressant medications during pregnancy.