Precautions

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Like all tricyclic antidepressants, trimipramine should be used cautiously and with close physician supervision in people, especially the elderly, who have benign prostatic hypertrophy, urinary retention, and glaucoma, especially angle-closure glaucoma (the most severe form). Before starting treatment, people with these conditions should discuss the relative risks and benefits of treatment with their doctors to help determine if trimipramine is the right antidepressant for them.

A common problem with tricyclic antidepressants is sedation (drowsiness, lack of physical and mental alert-

£ ness). This side effect is especially noticeable early in ther-£ apy. In most patients, sedation decreases or disappears ^ entirely with time, but until then patients taking trim-'jE ipramine should not perform hazardous activities requiring jE mental alertness or coordination. The sedative effect is increased when trimipramine is taken with other central nervous system depressants, such as alcoholic beverages, sleeping medications, other sedatives, or antihistamines. It may be dangerous to take trimipramine in combination with these substances. Trimipramine may increase the possibility of having seizures. Patients should tell their physician if they have a history of seizures, including seizures brought on by the abuse of drugs or alcohol. These people should use trimipramine only with caution and be closely monitored by their physician.

Trimipramine may increase heart rate and stress on the heart. It may be dangerous for people with cardiovascular disease, especially those who have recently had a heart attack, to take this drug or other antidepressants in the same pharmacological class. In rare cases where patients with cardiovascular disease must receive trim-ipramine, they should be monitored closely for cardiac rhythm disturbances and signs of cardiac stress or damage.

Side effects

Trimipramine shares side effects common to all tri-cyclic antidepressants. The most frequent of these are dry mouth, constipation, urinary retention, increased heart rate, sedation, irritability, dizziness, and decreased coordination. As with most side effects associated with tricyclic antidepressants, the intensity is highest at the beginning of therapy and tends to decrease with continued use.

Dry mouth, if severe to the point of causing difficulty speaking or swallowing, may be managed by dosage reduction or temporary discontinuation of the drug. Patients may also chew sugarless gum or suck on sugarless candy in order to increase the flow of saliva. Some artificial saliva products may give temporary relief.

Men with prostate enlargement who take trim-ipramine may be especially likely to have problems with urinary retention. Symptoms include having difficulty starting a urine flow and more difficulty than usual passing urine. In most cases, urinary retention is managed with dose reduction or by switching to another type of antidepressant. In extreme cases, patients may require treatment with bethanechol, a drug that reverses this particular side effect. People who think they may be experiencing any side effects from this or any other medication should tell their physicians.

Interactions

Dangerously high blood pressure has resulted from the combination of tricyclic antidepressants, such as trim-ipramine, and members of another class of antidepres-sants known as monoamine oxidase (MAO) inhibitors. Because of this, trimipramine should never be taken in combination with MAO inhibitors. Patient taking any MAO inhibitors, for example Nardil (phenelzine sulfate) or Parmate (tranylcypromine sulfate), should stop the MAO inhibitor then wait at least 14 days before starting trimipramine or any other tricyclic antidepressant. The same holds true when discontinuing trimipramine and starting an MAO inhibitor.

Trimipramine may decrease the blood pressure-lowering effects of clonidine. Patients who take both drugs should be monitored for loss of blood-pressure control and the dose of clonidine increased as needed.

The sedative effects of trimipramine are increased by other central nervous system depressants such as alcohol, sedatives, sleeping medications, or medications used for other mental disorders such as schizophrenia. The anticholinergic effects of trimipramine are additive with other anticholinergic drugs such as benztropine, biperi-den, trihexyphenidyl, and antihistamines.

See also Neurotransmitters

Resources BOOKS

American Society of Health-System Pharmacists. AHFS Drug

Information 2002. Bethesda: American Society of

Health-System Pharmacists, 2002. DeVane, C. Lindsay, Pharm.D. "Drug Therapy for Mood

Disorders." In Fundamentals of Monitoring Psychoactive

Drug Therapy. Baltimore: Williams and Wilkins, 1990.

Jack Raber, Pharm.D.

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