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Amitriptyline-Chlordiazepoxide Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing

See also Warning section.

Drowsiness, dizziness, dry mouth, blurred vision, constipation, bloating, trouble urinating, and weight gain may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

To reduce the risk of dizziness and fainting, get up slowly when rising from a sitting or lying position.

To relieve dry mouth, suck on (sugarless) hard candy or ice chips, chew (sugarless) gum, drink water, or use a saliva substitute.

To prevent constipation, eat dietary fiber, drink enough water, and exercise. You may also need to take a laxative. Ask your pharmacist which type of laxative is right for you.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor right away if any of these unlikely but serious side effects occur: easy bruising/bleeding, loss of balance, persistent heartburn, mental/mood changes (such as confusion, excitement, memory problems, suicidal thoughts), shaking (tremor), decreased sexual ability/desire, signs of infection (such as fever, persistent sore throat), persistent nausea/vomiting, severe stomach/abdominal pain, dark urine, yellowing eyes/skin.

Get medical help right away if you have any very serious side effects, including: black stools, chest pain, severe dizziness, fainting, fast/irregular heartbeat, seizures, trouble speaking, weakness on one side of the body, eye pain/swelling/redness, widened pupils, vision changes (such as seeing rainbows around lights at night), vomit that looks like coffee grounds.

A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

In the US –

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.

In Canada – Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Amitriptyline and Chlordiazepoxide | Memorial Sloan Kettering Cancer Center

This information from Lexicomp® explains what you need to know about this medication, including what it’s used for, how to take it, its side effects, and when to call your healthcare provider.

Warning

  • Drugs like this one have raised the chance of suicidal thoughts or actions in children and young adults. The risk may be greater in people who have had these thoughts or actions in the past. All people who take this drug need to be watched closely. Call the doctor right away if signs like low mood (depression), nervousness, restlessness, grouchiness, panic attacks, or changes in mood or actions are new or worse. Call the doctor right away if any thoughts or actions of suicide occur.
  • This drug is not approved for use in children. Talk with the doctor.
  • This drug is a benzodiazepine. The use of a benzodiazepine drug along with opioid drugs has led to very bad side effects. Side effects that have happened include slowed or trouble breathing and death. Opioid drugs include drugs like codeine, oxycodone, and morphine. Opioid drugs are used to treat pain and some are used to treat cough. Talk with the doctor.
  • If you are taking this drug with an opioid drug, get medical help right away if you feel very sleepy or dizzy; if you have slow, shallow, or trouble breathing; or if you pass out. Caregivers or others need to get medical help right away if the patient does not respond, does not answer or react like normal, or will not wake up.
  • Benzodiazepines can put you at risk for addiction, abuse, and misuse. Misuse or abuse of this drug can lead to overdose or death, especially when used along with certain other drugs, alcohol, or street drugs. Addiction can happen even if you take this drug as your doctor has told you. Get medical help right away if you have changes in mood or behavior, suicidal thoughts or actions, seizures, or trouble breathing.
  • You will be watched closely to make sure you do not misuse, abuse, or become addicted to this drug.
  • Benzodiazepines may cause dependence. Lowering the dose or stopping this drug all of a sudden may cause withdrawal. This can be life-threatening. The risk of dependence and withdrawal are raised the longer you take this drug and the higher the dose. Talk to your doctor before you lower the dose or stop this drug. You will need to follow your doctor’s instructions. Get medical help right away if you have trouble controlling body movements, seizures, new or worse behavior or mood changes like depression or thoughts of suicide, thoughts of harming someone, hallucinations (seeing or hearing things that are not there), losing contact with reality, moving around or talking a lot, or any other bad effects.
  • Sometimes, withdrawal signs can last for several weeks to more than 12 months. Tell your doctor if you have anxiety; trouble with memory, learning, or focusing; trouble sleeping; burning, numbness, or tingling; weakness; shaking; muscle twitching; ringing in the ears; or any other bad effects.

What is this drug used for?

  • It is used to treat low mood (depression).
  • It is used to treat anxiety.

What do I need to tell my doctor BEFORE I take this drug?

  • If you are allergic to this drug; any part of this drug; or any other drugs, foods, or substances. Tell your doctor about the allergy and what signs you had.
  • If you have had a recent heart attack.
  • If you have taken certain drugs for depression or Parkinson’s disease in the last 14 days. This includes isocarboxazid, phenelzine, tranylcypromine, selegiline, or rasagiline. Very high blood pressure may happen.
  • If you are taking any of these drugs: Linezolid or methylene blue.
  • If you are breast-feeding. Do not breast-feed while you take this drug.

This is not a list of all drugs or health problems that interact with this drug.

Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take this drug with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.

What are some things I need to know or do while I take this drug?

  • Tell all of your health care providers that you take this drug. This includes your doctors, nurses, pharmacists, and dentists. This drug may need to be stopped before certain types of surgery as your doctor has told you. If this drug is stopped, your doctor will tell you when to start taking this drug again after your surgery or procedure.
  • Avoid driving and doing other tasks or actions that call for you to be alert until you see how this drug affects you.
  • Have your blood work checked if you are on this drug for a long time. Talk with your doctor.
  • Talk with your doctor before you use alcohol, marijuana or other forms of cannabis, or prescription or OTC drugs that may slow your actions.
  • This drug may make you sunburn more easily. Use care if you will be in the sun. Tell your doctor if you sunburn easily while taking this drug.
  • If you have high blood sugar (diabetes), you will need to watch your blood sugar closely.
  • Tell your doctor if you have signs of high or low blood sugar like breath that smells like fruit, dizziness, fast breathing, fast heartbeat, feeling confused, feeling sleepy, feeling weak, flushing, headache, more thirsty or hungry, passing urine more often, shaking, or sweating.
  • Some people may have a higher chance of eye problems with this drug. Your doctor may want you to have an eye exam to see if you have a higher chance of these eye problems. Call your doctor right away if you have eye pain, change in eyesight, or swelling or redness in or around the eye.
  • If you are 65 or older, use this drug with care. You could have more side effects.
  • This drug may cause harm to the unborn baby if you take it while you are pregnant, especially in the first trimester.
  • If you are pregnant or you get pregnant while taking this drug, call your doctor right away.

What are some side effects that I need to call my doctor about right away?

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Signs of high or low blood pressure like very bad headache or dizziness, passing out, or change in eyesight.
  • Hallucinations (seeing or hearing things that are not there).
  • Chest pain or pressure, a fast heartbeat, or an abnormal heartbeat.
  • Weakness on 1 side of the body, trouble speaking or thinking, change in balance, drooping on one side of the face, or blurred eyesight.
  • Change in sex interest.
  • A burning, numbness, or tingling feeling that is not normal.
  • Strange or odd dreams.
  • Feeling confused, not able to focus, or change in behavior.
  • Shakiness.
  • Trouble controlling body movements, twitching, change in balance, trouble swallowing or speaking.
  • Seizures.
  • Severe constipation or stomach pain. These may be signs of a severe bowel problem.
  • Trouble passing urine.
  • Not able to get or keep an erection.
  • Swelling of the testicles.
  • Enlarged breasts or nipple discharge.
  • Yellow skin or eyes.
  • Change in tongue color.
  • Sweating a lot.
  • Hair loss.
  • Period (menstrual) changes.
  • Low blood cell counts have happened with this drug. If blood cell counts get very low, this can lead to bleeding problems, infections, or anemia. Call your doctor right away if you have signs of infection like fever, chills, or sore throat; any unexplained bruising or bleeding; or if you feel very tired or weak.

What are some other side effects of this drug?

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

  • Feeling dizzy, sleepy, tired, or weak.
  • Dry mouth.
  • Constipation, diarrhea, stomach pain, upset stomach, throwing up, or feeling less hungry.
  • Bloating.
  • Restlessness.
  • Headache.
  • Change in taste.
  • Weight gain or loss.
  • Mouth sores.

These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.

You may report side effects to your national health agency.

You may report side effects to the FDA at 1-800-332-1088. You may also report side effects at https://www.fda.gov/medwatch.

How is this drug best taken?

Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely.

  • Keep taking this drug as you have been told by your doctor or other health care provider, even if you feel well.

What do I do if I miss a dose?

  • Take a missed dose as soon as you think about it.
  • If it is close to the time for your next dose, skip the missed dose and go back to your normal time.
  • Do not take 2 doses at the same time or extra doses.

How do I store and/or throw out this drug?

  • Store at room temperature protected from light. Store in a dry place. Do not store in a bathroom.
  • Store this drug in a safe place where children cannot see or reach it, and where other people cannot get to it. A locked box or area may help keep this drug safe. Keep all drugs away from pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.

General drug facts

  • If your symptoms or health problems do not get better or if they become worse, call your doctor.
  • Do not share your drugs with others and do not take anyone else’s drugs.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.
  • This drug comes with an extra patient fact sheet called a Medication Guide. Read it with care. Read it again each time this drug is refilled. If you have any questions about this drug, please talk with the doctor, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.

Consumer Information Use and Disclaimer

This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine. The use of this information is governed by the Lexicomp End User License Agreement, available at https://www.wolterskluwer.com/en/solutions/lexicomp/about/eula.

Last Reviewed Date

2020-10-23

Copyright

© 2021 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.

Tricyclic Antidepressants, Benzodiazepines, Antidepressants, selective serotonin reuptake inhibitors (SSRIs)

Author

Eve G Spratt, MD, MSc Professor of Pediatrics and Psychiatry, Division of Developmental Pediatrics, Medical University of South Carolina; Director, Pediatric Consultation Liaison Psychiatry, Medical University of South Carolina Children’s Hospital at Charleston

Eve G Spratt, MD, MSc is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Coauthor(s)

Rishi Malla, MD, MSc Pediatric Neurologist, Pediatric Epileptologist, Cortica

Rishi Malla, MD, MSc is a member of the following medical societies: American Academy of Neurology, Child Neurology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Martha Karlstad, MD Chief Resident, Child and Adolescent Psychiatry, Medical University of South Carolina College of Medicine

Disclosure: Nothing to disclose.

Katherine Harris, MD Medical University of South Carolina College of Medicine

Katherine Harris, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Mark Anderson, MD Lt Col, United States Air Force, 75th Medical Squadron

Disclosure: Nothing to disclose.

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Disclosure: Nothing to disclose.

Chet Johnson, MD Professor and Chair of Pediatrics, Associate Director, Developmental Pediatrician, Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies, University of Kansas School of Medicine; LEND Director, University of Kansas Medical Center

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose

Amitriptyline (Elavil) Uses + Side Effects & Dosage

Amitriptyline is approved for the treatment of depression but is used off-label for a number of conditions, including insomnia, pain, and irritable bowel syndrome (IBS). However, it also causes many side effects that turn people away, such as sleepiness, weight gain, and impaired immune and sexual function. Learn about the potential uses of this drug and the side effects.

What Is Amitriptyline?

Amitriptyline is a tricyclic antidepressant. It is otherwise known as Elavil or Endep [1, 2].

The tricyclic simply means that it contains three rings in its chemical structure [1].

This drug was at one point the most widely used antidepressant. In England, it was prescribed over 11 million times in 2013 [3, 1].

While amitriptyline is only FDA-approved for the treatment of depression, it is sometimes used off-label for several other conditions, such as migraines, fibromyalgia, and irritable bowel syndrome [4].

Amitriptyline is converted to nortriptyline in the body, which is its active form. This drug works via many mechanisms hence the many benefits and side effects [5, 6].

Mechanism of Action

  • It blocks the reuptake of both serotonin and noradrenaline. Therefore, both serotonin and noradrenaline stay in your system longer, which prolongs their effects [1].
  • It blocks the action of histamine in the brain, which results in drowsiness [7].
  • It blocks NMDA receptors and activates adenosine A1 and opioid receptors. All of these may lead to pain relief [8, 9].

Uses of Amitriptyline

FDA-Approved Uses

1) Depression

Amitriptyline is only FDA-approved for the treatment of depression.

According to a number of clinical trials, amitriptyline may be more effective at improving depression symptoms compared to many other antidepressants. However, the frequency of side effects often limits its use [10].

Two large meta-analyses of 186 and 194 studies compared amitriptyline against other tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). Both found that amitriptyline helped more people. However, it also produced more side effects than the other drugs [11, 12].

More people who were taking amitriptyline dropped out of the studies due to side effects compared to people taking other drugs [12].

With this drug, the antidepressant effects take a long time to take effect. Often, patients see improvements in other areas such as in insomnia or pain before noticing any antidepressant effects [13].

Off-Label Uses

Amitriptyline is used for several off-label conditions, which we’ll discuss in the following sections. If you are prescribed amitriptyline, always take the medication as directed by your doctor.

2) Migraines

A meta-analysis (12 studies, 1,006 participants) found that amitriptyline helped with migraines much better than placebo. The effects were better for those that took the drug for longer periods of time [4].

However, it causes more side effects than other drugs used to treat migraines, such as selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), or nortriptyline [4, 14].

Also, research suggests that amitriptyline may not help children with migraines [15, 16].

3) Neuropathic Pain

Amitriptyline is sometimes used for neuropathic pain, which is caused by damage to nerve tissue.

According to a meta-analysis (17 studies, 1,342 participants), amitriptyline may improve chronic neuropathic pain, but it was only effective in about 25% of people. It may help people with pain due to diabetes, shingles, spinal cord injury, or stroke [1].

However, many studies concluded that this drug was not any better for pain than other pain relievers/antidepressants such as nortriptyline, maprotiline, desipramine, pregabalin, or fluoxetine [17, 18, 19, 20].

4) Irritable Bowel Syndrome (IBS)

There are three types of IBS: IBS with diarrhea (IBS-D), IBS with constipation, and mixed-stool pattern IBS. Tricyclic antidepressants work best against IBS-D [21].

Tricyclic antidepressants like amitriptyline increase the time that food stays in the gut, which allows for more solid defecations [21].

In 101 IBS patients given this drug, IBS improved in 66% of cases. The treatment decreased stomach pain, stomach discomfort, and stool frequency and improved the quality of life. However, side effects were frequent [21].

In a study (double-blind randomized controlled trial) of 54 patients, amitriptyline increased rates of full recovery (no more symptoms) [22].

A different study (double-blind randomized controlled trial) of 32 adolescents (12-18 years) showed similar results [23].

A meta-analysis and other studies all showed that this drug improved IBS [22, 24, 25].

5) Fibromyalgia

Fibromyalgia is a continuous pain in “tender points” lasting over three months. It can lead to sleep loss, fatigue, and depression [26].

A meta-analysis (9 studies, 649 patients) showed that amitriptyline was effective for fibromyalgia in 36% of patients [26].

In two studies (double-blind randomized controlled trial) with 22 and 62 fibromyalgia patients, this drug improved sleep and decreased fatigue [27, 28].

However, one study (double-blind randomized controlled trial) found that it actually worsened fibromyalgia in 4 of the 19 patients [29].

5) Sleep Issues and Insomnia

In a study (double-blind randomized controlled trial) of 27 opiate withdrawal patients suffering from insomnia, amitriptyline induced sleep equally well as another hypnotic drug, lorazepam. However, amitriptyline caused less drowsiness after waking. This may allow patients to go about their mornings without feeling sluggish [30].

Amitriptyline increased total sleep by 15 minutes in a study (double-blind randomized controlled trial) of 14 patients. They also fell asleep faster. The study noted increases in slow-wave sleep, or deep sleep, which is when muscles recover and you re-energize. A week after going off of the drug, patients reported it was harder to fall asleep [3].

This drug may also reduce rapid eye movement (REM) sleep, according to a double-blind randomized controlled trial of 30 patients. REM sleep can be abnormally long in patients with depression [31, 32, 33].

6) Anxiety

Amitriptyline decreased anxiety in a study (double-blind randomized controlled trial) of 55 patients awaiting surgery [34].

In a pilot study of 32 patients with anxiety and depression, this drug was effective in reducing anxiety [35].

Similarly, in two other studies, both with 30 patients, it reduced anxiety in insomnia patients [36, 37].

Anxiety is also common in people with migraines. Reducing the frequency of migraines with amitriptyline may help reduce anxiety as well [38, 39].

Although useful for anxiety, it has a high dropout rate (30 to 50%) due to side effects. Patients tend to prefer selective serotonin reuptake inhibitors (SSRIs) and only move to tricyclic antidepressants when SSRIs fail [40].

Research On Amitriptyline

Clinical Research

Clinical research is also exploring the use of amitriptyline for several other conditions, which are described below. However, this research is preliminary and investigational only. The safety and effectiveness of amitriptyline for these conditions is unclear until more studies are performed.

Functional Dyspepsia

Functional dyspepsia, more commonly known as indigestion, is a disorder that causes pain in the upper stomach, discomfort, and fullness after meals. Fifty-one of the 96 patients with functional dyspepsia improved when given amitriptyline in a double-blind randomized controlled trial [41].

In another double-blind randomized controlled trial of 28 volunteers, amitriptyline increased gut transit time, which may be important for gut function and better digestion. Amitriptyline may also make it easier to drink large volumes of water without problems, which may be important for people suffering from diarrhea [42].

Cystic Fibrosis Symptoms

According to a double-blind randomized controlled trial of 19 patients, amitriptyline may improve cystic fibrosis symptoms. It may also decrease levels of ceramides that tend to accumulate in the lungs of cystic fibrosis patients [43].

Another double-blind randomized controlled trial of 19 patients showed similar results [44].

Autism

According to a study of 50 children with autism, amitriptyline may improve symptoms of [45]:

  • Excessive activity
  • Impulsivity
  • Aggression
  • Self-injury
Chronic Cough

A randomized controlled study of 28 people found that amitriptyline may be more effective in suppressing chronic cough than the cough-suppressant drug codeine/guaifenesin. In total, 14 of the 15 patients on amitriptyline saw some improvement. In fact, 11 of the 15 patients improved by 75 to 100% [46].

Vocal Cord Dysfunction

In a study of 62 patients with vocal cord dysfunction, amitriptyline improved symptoms in 90% of cases. People that have had the condition for less than 12 months showed greater and quicker results [47].

Cyclic Vomiting Syndrome

Cyclic vomiting syndrome is a disorder leading to constant nausea and vomiting. In a double-blind randomized controlled trial of 64 children, 66% of patients given amitriptyline saw temporary recovery [48].

Animal And Cell Research

No clinical evidence supports the use of amitriptyline for any of the conditions listed in this section. Below is a summary of the existing animal and cell-based research, which should guide further investigational efforts. However, the studies listed below should not be interpreted as supportive of any health benefit.

Parkinson’s Disease

In rat models of Parkinson’s disease, amitriptyline decreased the loss of dopamine-sensitive neurons. It also protected neurons with tyrosine hydroxylase activity, which are decreased in patients with Parkinson’s disease [49, 50].

The drug also increased dopamine levels and improved movement in rats with Parkinson’s-like disease [51].

Inflammation

In cell studies, amitriptyline decreased the release of inflammatory agents from mast cells by up to 98% [52, 53].

In rats, this drug also decreased levels of nitric oxide, IL1-beta, and TNF-alpha, which all increase inflammation [54, 55].

Amitriptyline decreased gut and kidney inflammation in rats [56, 57].

Brain Health and Repair

In rat studies, amitriptyline increased BDNF in rats with Alzheimer’s disease, which increased both their short and long-term memory [58].

Similarly, amitriptyline increased GDNF levels in brain cells. Increasing GDNF may improve neuron survival and protect neurons against stress [59, 60].

In cell studies, amitriptyline increased the production of brain-derived neurotrophic factor (BDNF) in brain cells (astrocytes and microglia). BDNF protects neurons and stimulates their growth. Increased BDNF is a potential mechanism by which amitriptyline produces antidepressant effects [61].

Cognitive Function

Amitriptyline improved cognitive function and decreased stress (HPA axis activity) in aged rats [62].

It slightly improved cognitive function in depressed rats [63].

The drug also improved cognitive function in rats with Alzheimer’s disease and in stressed baby rats [58, 64].

Stress

In rats, amitriptyline decreased the functioning of the hypothalamic-pituitary-adrenal (HPA) axis, which reacts to stress by releasing adrenocorticotropic (ACTH) hormone. Amitriptyline decreased stress-induced ACTH levels by 38% [65].

The HPA system also increases levels of corticosterone in response to stress. Rats stressed by separating them from their mothers saw no such increase when given amitriptyline [66].

Stomach Ulcers

In rats, amitriptyline reduced stomach ulcers caused by [67]:

  • Alcohol
  • Aspirin
  • Indomethacin (an anti-inflammatory drug)
  • Stress

The drug reduced the acidity of the stomach [67].

Another rat study found that this drug also decreased gut bleeding [68].

Histamine Regulation

Amitriptyline enhanced histamine-N-methyltransferase (HNMT) and diamine oxidase (DAO) activity in guinea pigs. Both of these enzymes degrade histamine [69].

This drug also caused mast cells to release less histamine, a potent allergy-inducing molecule [70].

Polycystic Ovary Syndrome (PCOS)

According to animal studies, amitriptyline improved the function of ovaries, increased the production of sex hormones (estradiol, testosterone, and progesterone), and restored the reproductive cycle of rats with polycystic ovaries [71].

Safety of Amitriptyline

Side Effects

Side effects can be common when taking amitriptyline. If any side effects persist or worsen, let your doctor know. This is also not a complete list of possible side effects. Tell your doctor if you experience any serious side effects or notice any effects not listed here.

Some common side effects are [72]:

  • Dry mouth
  • Drowsiness
  • Weight gain
  • Dizziness
  • Constipation
  • Difficulty urinating
  • Blurred vision

Some rare, but serious side effects include [72]:

  • Increased agitation
  • Severe stomach pain
  • Decreased sexual desire
  • Muscle spasms
  • Rashes
  • Nightmares
  • Confusion
  • Delirium
  • Seizures
  • Irregular heartbeats
  • Bruising and bleeding

Precautions

1) Increased Risk of Suicide

Antidepressants are associated with a higher risk of suicidal thinking and behavior, especially in children and young adults. Those taking amitriptyline should be monitored and any changes in behavior should be reported to a doctor [72].

2) Withdrawal Symptoms

There is a high risk of experiencing adverse events or withdrawal symptoms after abruptly discontinuing amitriptyline therapy, in as little as 12 hours. Consult with your doctor before stopping this medication [72].

Withdrawing from amitriptyline may cause [73]:

  • Gut distress
  • Pain
  • Fatigue
  • Sleep disturbances
  • Mood changes
  • Movement disorders
3) Drowsiness

Taking amitriptyline may cause drowsiness, dizziness, and blurred vision. Do not operate a vehicle or heavy machinery until you know how this medication may affect you [72].

4) Caution in Pregnancy and Breastfeeding

Some research suggests that amitriptyline may be associated with birth defects, although strong clinical evidence is lacking. Amitriptyline should only be used during pregnancy if a doctor determines that the benefits outweigh risks [72].

Small amounts of amitriptyline are excreted in breast milk. Again, a doctor will decide if amitriptyline can be used during breastfeeding [74].

If you are taking amitriptyline and are pregnant or planning to become pregnant, let your doctor know.

5) Risk of Bleeding

Amitriptyline may increase the risk of bleeding. Tell your doctor that you are taking amitriptyline before having any kind of surgery.

Contraindications

Hypersensitivity

People who are sensitive or allergic to amitriptyline or any other excipients (substances that are present in the medication along with the drug) should avoid using amitriptyline.

Concomitant Use with Monoamine Oxidase Inhibitors (MAOIs)

The concomitant use of amitriptyline with monoamine oxidase inhibitors (another type of antidepressant) is contraindicated. The combination of both medications may result in dangerously high blood pressure, convulsions, and even death [72].

MAOI treatment should not be started until after at least 7 days after discontinuing amitriptyline.

Amitriptyline treatment should not be started within 14 days of discontinuing treatment with MAOIs.

Drug Interactions

Amitriptyline inhibits cytochrome P450 enzymes (CYP1A2, CYP2D6, and CYP2C9) at higher rates than other TCAs such as desipramine and nortriptyline. This causes more side effects and worse drug interactions [14].

Below are some reported drug interactions with amitriptyline. This is not a comprehensive list, always let your doctor know about all the medications and supplements you are taking [72].

  • MAO inhibitors, such as isocarboxazid, linezolid, phenelzine, selegiline
  • Antipsychotics, such as quetiapine (Seroquel) and chlorpromazine (Largactil, Thorazine) [75, 76]
  • Antifungals such as terbinafine (Lamisil) and fluconazole (Diflucan) [77, 78, 79]
  • Valproic acid (Depakote) [80]
  • Rifampicin (Rifadin, Rimactane), an antibiotic [81]
  • Phenprocoumon (Marcoumar), a drug that keeps blood from clumping [82]
  • NSAIDs, such as ibuprofen
  • Warfarin
  • Cimetidine
  • Amiodarone
  • Quinidine
  • Sotalol

Amitriptyline Dosing

Patients will respond to antidepressants differently and it may take time to find the right dose for you. Antidepressants like amitriptyline may take time to work and patients may not feel benefits for 1-3 weeks or more. Always take amitriptyline as directed by a doctor and do not discontinue the medication abruptly.

Amitriptyline is available in various forms and dosages. Amitriptyline is most commonly taken as an oral tablet.

When starting this medication, dosages are typically started low and gradually increased.

For depression in adults, the initial dose of amitriptyline is usually 75 mg per day which may be taken in divided doses [72].

The maintenance dose usually ranges from 40 to 100 mg per day. The maximum dose is 150 mg per day.

Amitriptyline is not approved for patients under 12 years old.

Amitriptyline Compared to Other Medications

Nortriptyline

Research suggests that both are equally effective in relieving pain, headaches, and migraines. However, amitriptyline may have more side effects [5, 1, 14].

Benzodiazepines

Studies suggest that amitriptyline may have better antidepressive effects than adinazolam (Deracyn), a benzodiazepine. However, it also caused more side effects [83].

Amitriptyline may also be more effective than diazepam (Valium) [83].

Both amitriptyline and Xanax (alprazolam) drugs were effective against depression in 80 patients in a double-blind randomized controlled trial. Amitriptyline worked faster, but also caused more people to drop out of the study, even though the overall side effects were similar between the two drugs [84].

Another study (double-blind randomized controlled trial) of 130 patients found that Xanax was the quicker of the two and may be better for anxiety [85].

Selective Serotonin Reuptake Inhibitors (SSRIs)

In a study (double-blind randomized controlled trial) with 148 patients, paroxetine (Paxil, Pexeva) was better in relieving pain, improving quality of life, sleep, and emotional well-being [86].

Both drugs were effective in treating depression in a study (double-blind randomized controlled trial) of 40 patients. However, paroxetine produced a quicker response. Side effects were similar [87].

Opioids

A study (double-blind randomized controlled trial) of 45 patients found that tramadol (Ultram) and meperidine (Pethidine), stopped shivering quicker than amitriptyline. The response rate for amitriptyline was only 13% compared to 87% for tramadol and 93% for meperidine [88].

When used as an anesthetic, amitriptyline was more sedative than meperidine and produced fewer side effects [89].

Genetics

CYP2D6

CYP2D6 ultrarapid metabolizers may need to avoid the use of tricyclic antidepressants due to the potential lack of effectiveness (the drug gets degraded too quickly) [90].

For CYP2D6 intermediate metabolizers, a 25% reduction of the starting dose is recommended [90].

CYP2D6 poor metabolizers have higher than expected blood concentrations of tricyclic antidepressants when given usual doses. If the use of amitriptyline is warranted, it is recommended to take 50% of the starting dose to avoid side effects [90].

In a pilot study of 31 patients, patients with normal or ultrarapid metabolism of amitriptyline (CYP2D6) displayed fewer side effects [91].

However, a study of 100 patients with major depressive order found that those with CYP2D6 ultrarapid metabolism were more likely to drop out from the study when drug doses were low. This was most likely due to a lack of effect [92].

CYP2C19

CYP2C19 ultrarapid metabolizers may need to avoid the use of this drug due to reduced effectiveness [90].

CYP2C19 poor metabolizers, should avoid the drug or consider a 50% reduction of the starting dose while monitoring drug blood levels to avoid side effects [90].

Diazepam: medicine to treat anxiety, muscle spasms and fits

Rectal tube

Diazepam rectal tubes (or rectal diazepam) can be used if you or your child is having a fit.

If you have been prescribed rectal tubes, it’s important that a family member, friend or carer knows how to give you this medicine.

If you’re having a fit, they also need to know how long to wait before giving you rectal diazepam.

Your doctor will decide the right dose for you or your child according to your weight, age and general health.

Tablets and liquid

Take diazepam tablets or liquid with a drink of water. You can take them with or without food.

You’ll usually take your medicine 1 to 3 times a day.

Your doctor will decide the right dose for you. It’s important to take diazepam exactly as your doctor tells you to.

The usual dose for:

  • anxiety – is 2mg taken 3 times a day. This can be increased to 5mg to 10mg 3 times a day.
  • sleep problems (related to anxiety) – is 5mg to 15mg taken once a day at bedtime.
  • muscle spasms in adults – is 2mg to 15 mg a day. This can be given as 1mg twice a day and go up to 5mg 3 times a day. The dose can be increased up to 20mg 3 times a day if needed.
  • muscle spasm in children (aged 1 month to 17 years) – varies depending on age. It’s usually given twice a day, with 10 to 12 hours between each dose.

Your dose might be lower if you’re over 65 or have kidney, liver or severe breathing problems.

What if I forget to take it?

If you’re taking diazepam regularly and forget to take a dose, take the missed dose as soon as you remember, unless it’s nearly time for your next dose.

In this case, just leave out the missed dose and take your next dose as normal.

Never take 2 doses at the same time. Never take an extra dose to make up for a forgotten one.

What if I take too much?

The amount of diazepam that can lead to an overdose varies from person to person.

benzo.org.uk : Sussex Health Authority : Benzodiazepine Withdrawal

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Sussex Health Authority

Benzodiazepine Withdrawal


Practical General Practice · 2001


Every practice needs a policy to avoid initiating dependence in patients given benzodiazepines. For example:

  1. Benzodiazepines will only be used for the short-term relief of severe anxiety or insomnia, or for specific medical emergencies such as alcohol detoxification or the management of convulsions.

  2. Short acting compounds (such as lorazepam) will not be used in the daytime.

  3. No repeat prescriptions will be given except to those already established as long-term users.

  4. No patient not already on benzodiazepines will be prescribed a course which lasts more than 4 weeks.

  5. Current benzodiazepine users will be identified and invited to attend to discuss withdrawal. The invitation will be repeated annually until the drug is withdrawn. An exception to this might be the older patient maintained long-term symptom free on the same dose.

  6. An annual audit of the number of benzodiazepine users will be conducted to monitor success and to learn from failures.

Management of withdrawal

  • Withdrawal symptoms can be distinguished from a return of anxiety and include:

    1. disordered perceptions: feelings of unreality, increased sensory perception, or a sensation of movement.

    2. Serious psychiatric and neurological adverse effects: convulsions or acute psychosis.

  • Symptoms typically emerge in the first week after stopping or reducing the dose. Occasionally they occur in patients on a stable dose, and are temporarily abolished by an increase in the dose. They usually last for up to 3 months but may last for over a year.

  • Withdrawal symptoms may be seen in patients who have been on benzodiazepines for as little as 3 weeks and they occur in up to almost half of patients who have taken them for over 3 months (*).

  • Two-thirds will be able to stop with some disturbance of sleep but without the true withdrawal syndrome. They may, however, need help in finding a different solution to the problem for which they were taking the benzodiazepine.

  • Offer withdrawal with explanation to all patients on long-term benzodiazepines who have become dependent inadvertently following therapeutic use. Record the discussion in the notes.

  • Refer patients who are misusing other drugs or alcohol, as well as benzodiazepines to the specialist services. Concurrent withdrawal of more than one drug is not recommended.

  • Refer patients requiring very high doses or who are injecting the drugs.

A number of withdrawal regimens have been used. There is a spectrum of possibilities with the two proposed below at opposite ends of the spectrum. The two principles behind all regimens are to use a long-acting benzodiazepine and to reduce slowly, or very slowly.

Rapid Withdrawal: for patients who give no indication that a withdrawal syndrome is likely.

Slow Withdrawal: for patients in whom a withdrawal syndrome is likely (because of evidence of tolerance or previous symptoms of withdrawal).

  1. Change patients on short-acting to long-acting benzodiazepines, e.g. diazepam. For equivalent doses see BNF (chapter 4.1); e.g. lorazepam 2 mg is equivalent to diazepam 20 mg. If the changeover proves difficult do it in stages, e.g changing 1 mg lorazepam to 10 mg diazepam at a time.

  2. Start with a plan agreed with the patient, e.g. reducing the daily dose by 1/8th per fortnight, with smaller reductions in the final stages. Expect to take several months or even 1 year. If the patient has been obtaining the drug illegally, start with a dose considerably below the amount claimed.

  3. Be prepared to renegotiate the plan if the patient develops severe withdrawal effects. Keep patients on each dose long enough for them to settle before the next reduction.

  4. If the patient requests a slower rate of reduction because of psychological rather than physical dependence, it is better to keep to the agreed plan and intensify support.

  5. Be prepared for the emergence of anxiety, depression or insomnia, and manage accordingly. Patients on long-term benzodiazepines often have inappropriate reactions to difficulties in their lives. Withdrawal of the drug must be accompanied by re-education by the GP or referral, for instance, to a benzodiazepine-withdrawal support group.

  6. Symptom control: For patients not willing to tolerate the symptoms of withdrawal, consider using other drugs temporarily:

    1. promethazine 25mg at night for insomnia;

    2. propranolol 10 to 40mg t.d.s. for somatic symptoms;

    3. tricyclic antidepressants, e.g. amitriptyline 25 to 75mg daily, for depression and anxiety. This should be started 4 weeks before reducing the benzodiazepine in those in whom its need can be predicted.

  7. Avoid using buspirone or major tranquillizers. They may make withdrawal worse. Do not use zopiclone or chlormethiazole; they have cross-dependency with benzodiazepines.

* Kan CC, Breteler MH, Zitman FG. High prevalence of benzodiazepine dedendence in outpatient users, based on the DSM-III-R and ICD-10 criteria. Acta Psychiatrica Scandinavica 1997; 96: 85-93.




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Panic attacks and panic disorder – Diagnosis and treatment

Diagnosis

Your primary care provider will determine if you have panic attacks, panic disorder or another condition, such as heart or thyroid problems, with symptoms that resemble panic attacks.

To help pinpoint a diagnosis, you may have:

  • A complete physical exam
  • Blood tests to check your thyroid and other possible conditions and tests on your heart, such as an electrocardiogram (ECG or EKG)
  • A psychological evaluation to talk about your symptoms, fears or concerns, stressful situations, relationship problems, situations you may be avoiding, and family history

You may fill out a psychological self-assessment or questionnaire. You also may be asked about alcohol or other substance use.

Criteria for diagnosis of panic disorder

Not everyone who has panic attacks has panic disorder. For a diagnosis of panic disorder, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists these points:

  • You have frequent, unexpected panic attacks.
  • At least one of your attacks has been followed by one month or more of ongoing worry about having another attack; continued fear of the consequences of an attack, such as losing control, having a heart attack or “going crazy”; or significant changes in your behavior, such as avoiding situations that you think may trigger a panic attack.
  • Your panic attacks aren’t caused by drugs or other substance use, a medical condition, or another mental health condition, such as social phobia or obsessive-compulsive disorder.

If you have panic attacks but not a diagnosed panic disorder, you can still benefit from treatment. If panic attacks aren’t treated, they can get worse and develop into panic disorder or phobias.

Treatment

Treatment can help reduce the intensity and frequency of your panic attacks and improve your function in daily life. The main treatment options are psychotherapy and medications. One or both types of treatment may be recommended, depending on your preference, your history, the severity of your panic disorder and whether you have access to therapists who have special training in treating panic disorders.

Psychotherapy

Psychotherapy, also called talk therapy, is considered an effective first choice treatment for panic attacks and panic disorder. Psychotherapy can help you understand panic attacks and panic disorder and learn how to cope with them.

A form of psychotherapy called cognitive behavioral therapy can help you learn, through your own experience, that panic symptoms are not dangerous. Your therapist will help you gradually re-create the symptoms of a panic attack in a safe, repetitive manner. Once the physical sensations of panic no longer feel threatening, the attacks begin to resolve. Successful treatment can also help you overcome fears of situations that you’ve avoided because of panic attacks.

Seeing results from treatment can take time and effort. You may start to see panic attack symptoms reduce within several weeks, and often symptoms decrease significantly or go away within several months. You may schedule occasional maintenance visits to help ensure that your panic attacks remain under control or to treat recurrences.

Medications

Medications can help reduce symptoms associated with panic attacks as well as depression if that’s an issue for you. Several types of medication have been shown to be effective in managing symptoms of panic attacks, including:

  • Selective serotonin reuptake inhibitors (SSRIs). Generally safe with a low risk of serious side effects, SSRI antidepressants are typically recommended as the first choice of medications to treat panic attacks. SSRIs approved by the Food and Drug Administration (FDA) for the treatment of panic disorder include fluoxetine (Prozac), paroxetine (Paxil, Pexeva) and sertraline (Zoloft).
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs). These medications are another class of antidepressants. The SNRI venlafaxine (Effexor XR) is FDA approved for the treatment of panic disorder.
  • Benzodiazepines. These sedatives are central nervous system depressants. Benzodiazepines approved by the FDA for the treatment of panic disorder include alprazolam (Xanax) and clonazepam (Klonopin). Benzodiazepines are generally used only on a short-term basis because they can be habit-forming, causing mental or physical dependence. These medications are not a good choice if you’ve had problems with alcohol or drug use. They can also interact with other drugs, causing dangerous side effects.

If one medication doesn’t work well for you, your doctor may recommend switching to another or combining certain medications to boost effectiveness. Keep in mind that it can take several weeks after first starting a medication to notice an improvement in symptoms.

All medications have a risk of side effects, and some may not be recommended in certain situations, such as pregnancy. Talk with your doctor about possible side effects and risks.

Lifestyle and home remedies

While panic attacks and panic disorder benefit from professional treatment, these self-care steps can help you manage symptoms:

  • Stick to your treatment plan. Facing your fears can be difficult, but treatment can help you feel like you’re not a hostage in your own home.
  • Join a support group. Joining a group for people with panic attacks or anxiety disorders can connect you with others facing the same problems.
  • Avoid caffeine, alcohol, smoking and recreational drugs. All of these can trigger or worsen panic attacks.
  • Practice stress management and relaxation techniques. For example, yoga, deep breathing and progressive muscle relaxation — tensing one muscle at a time, and then completely releasing the tension until every muscle in the body is relaxed — also may be helpful.
  • Get physically active. Aerobic activity may have a calming effect on your mood.
  • Get sufficient sleep. Get enough sleep so that you don’t feel drowsy during the day.

Alternative medicine

Some dietary supplements have been studied as a treatment for panic disorder, but more research is needed to understand the risks and benefits. Herbal products and dietary supplements aren’t monitored by the Food and Drug Administration (FDA) the same way medications are. You can’t always be certain of what you’re getting and whether it’s safe.

Before trying herbal remedies or dietary supplements, talk to your doctor. Some of these products can interfere with prescription medications or cause dangerous interactions.

Preparing for your appointment

If you’ve had signs or symptoms of a panic attack, make an appointment with your primary care provider. After an initial evaluation, he or she may refer you to a mental health professional for treatment.

What you can do

Before your appointment, make a list of:

  • Your symptoms, including when they first occurred and how often you’ve had them
  • Key personal information, including traumatic events in your past and any stressful major events that occurred before your first panic attack
  • Medical information, including other physical or mental health conditions that you have
  • Medications, vitamins, herbal products and other supplements, and the dosages
  • Questions to ask your doctor

Ask a trusted family member or friend to go with you to your appointment, if possible, to lend support and help you remember information.

Questions to ask your primary care provider at your first appointment

  • What do you believe is causing my symptoms?
  • Is it possible that an underlying medical problem is causing my symptoms?
  • Do I need any diagnostic tests?
  • Should I see a mental health professional?
  • Is there anything I can do now to help manage my symptoms?

Questions to ask if you’re referred to a mental health professional

  • Do I have panic attacks or panic disorder?
  • What treatment approach do you recommend?
  • If you’re recommending therapy, how often will I need it and for how long?
  • Would group therapy be helpful in my case?
  • If you’re recommending medications, are there any possible side effects?
  • For how long will I need to take medication?
  • How will you monitor whether my treatment is working?
  • What can I do now to reduce the risk of my panic attacks recurring?
  • Are there any self-care steps I can take to help manage my condition?
  • Are there any brochures or other printed material that I can have?
  • What websites do you recommend?

Don’t hesitate to ask any other questions.

What to expect from your doctor

Your primary care provider or mental health professional may ask:

  • What are your symptoms, and when did they first occur?
  • How often do your attacks occur, and how long do they last?
  • Does anything in particular seem to trigger an attack?
  • How often do you experience fear of another attack?
  • Do you avoid locations or experiences that seem to trigger an attack?
  • How do your symptoms affect your life, such as school, work and personal relationships?
  • Did you experience major stress or a traumatic event shortly before your first panic attack?
  • Have you ever experienced major trauma, such as physical or sexual abuse or military battle?
  • How would you describe your childhood, including your relationship with your parents?
  • Have you or any of your close relatives been diagnosed with a mental health problem, including panic attacks or panic disorder?
  • Have you been diagnosed with any medical conditions?
  • Do you use caffeine, alcohol or recreational drugs? How often?
  • Do you exercise or do other types of regular physical activity?

Your primary care provider or mental health professional will ask additional questions based on your responses, symptoms and needs. Preparing and anticipating questions will help you make the most of your appointment time.

FGBNU NTSPZ. ‹› Panic disorder (clinic, diagnostics, therapy) ››

The allocation of PR was significant not only by clinical criteria, but also by the characteristics of the patient’s response to therapy, which include:

  1. High efficiency of antidepressants;

  2. Insufficient effect of the use of traditional benzodiazepine tranquilizers;

  3. Insufficient effectiveness of psychotherapy.

The practice of traditional benzodiazepines (diazepam, chlordiazepoxide, phenazepam), less often small doses of antidepressants (amitriptyline, azafen) and small antipsychotics (teralen, sonapax), or a combination of these groups of drugs often does not lead to to a persistent and pronounced effect.

It has now been established that PD responds well to pharmacotherapy. Treatment for panic disorder can be divided into 3 main steps:

  1. Relief of PN until remission is established (4-6 weeks – 2-3 months)

  2. Stabilizing (aftercare) therapy to consolidate the results, restore the level of social adaptation, overcome agoraphobic manifestations (anxiety of expectation, avoidance behavior) and early relapses (4-6 months).At this stage, it is necessary to conduct adequate psychotherapy.

  3. Prophylactic (long-term) therapy aimed at preventing the development of relapses and maintaining a stable remission (up to 1 year or more)

Currently, the following antipanic (used for blockade of PN) drugs are allocated: tricyclic antidepressants, selective serotoninergic drugs, MAO inhibitors, etc. atypical (or highly potent) benzodiazepines (alprazolam and clonazepam).

A) Tricyclic antidepressants (TAD).

Of the tricyclic antidepressants, the most commonly used are clomipramine (anafranil), imipramine (melipramine), desimipramine (petylil, pertofran), nortriptyline, and amitriptyline. The efficacy of the tetracyclic antidepressant maprotiline (ludiomil) and the atypical TAD tianeptine (coaxil, stablon), which is close in action to TAD, has been described. Clomipramine (anafranil) is the most commonly used and most effective among TADs in the treatment of PR.

Treatment of TAD begins with low doses (12.5-25 mg / day), then the doses are gradually increased to a tolerable level (on average, 12.5-25 mg for 3-5 days). The average effective daily dose is usually 150-200 mg / day, less often it reaches 300 mg. The anti-panic action of TAD is also “delayed” as well as thymoanaleptic, but comes on a little faster – the latency period is usually about two weeks. TAD has an effect in PR mainly due to its effect on the thymic and especially on the phobic component, less influencing the anxiety of expectation and somatovegetative manifestations.In the case of a good reaction, a decrease in the frequency of PR occurs rather quickly, anxiety of expectation and phobias is reduced, and the mood is leveled. However, in half of the patients, from the first days of using TAD, an increase in anxiety and vegetative symptoms occurs, which increases the appearance of PP, therefore, with an inadequate increase in dosages, the patient’s condition either does not improve at all, or the initial improvement will be lost after a few weeks. Before choosing the final dose, the patient’s condition can reach the “plateau of tolerance” twice or three times.To avoid premature discontinuation of the drug, any benzodiazepine drugs (diazepam 5-10 mg / day, phenazepam 0.5-1 mg / day), as well as -adrenergic blockers (anaprilin 20-40 mg / day) can be added to the TAD, which makes it possible to reduce the severity of exacerbation of PR and wait for a somewhat delayed effect of the antidepressant. TAD treatment is continued for 4-6 months, and if the condition is stable, a gradual decrease in the dose level begins, which usually lasts 1-2 months. In the future, they decide on a longer prophylactic therapy.Thus, the main disadvantages of TAD are a delayed effect and pronounced side effects, especially those associated with hyperstimulation of the autonomic nervous system: palpitations, tremors, hyperhidrosis, dizziness, anticholinergic effects, a paradoxical increase in blood pressure, sexual dysfunction, weight gain. These effects are especially pronounced in amitriptyline, which significantly limits its use in this group of patients. Tianeptine (Coaxil) at a dose of 37.5 mg / day has been shown to be effective in some patients with atypical TAD.Decrease or blockade of PN, reduction or decrease in the intensity of agoraphobia are observed by 5-6 weeks of treatment. A good effect is observed in patients with “atypical” PN and signs of “secondary” depression, comorbid PR.

B) selective serotonin reuptake inhibitors (SSRIs).

In addition to TAD, selective serotonin reuptake inhibitors have been shown to be effective in the treatment of PR: fluoxetine (Prozac, Portal, Prodep), Fluvoxamine (Fevarin, Floxifral.Luvox), Sertraline (Zoloft), Paroxetine (Paxil), Citalopram (Cipramil).The main disadvantage of this group is the occurrence during the first 2-3 weeks of treatment of hyperstimulation (irritability, insomnia, nervousness) and increased anxiety and panic symptoms (probably due to excessive stimulation of serotonin autoreceptors). The method of application does not differ from the treatment of depression, but the initial doses are usually minimal (5 mg fluoxetine, 50 mg fluvoxamine, 25 mg sertraline). Within 2 weeks, the dose is brought to an average, and then, if necessary, is increased or remains the same.Subsequently, even with prolonged therapy, the dose does not change. For long-term (maintenance) treatment, drugs are much more convenient than TAD due to the absence of anticholinergic and adrenergic action and a possible single dose during the day.

B) monoamine oxidase inhibitors (MAOIs).

In Russia, in recent years, only the so-called. reversible MAOIs (moclobemide (aurorix) and pyrazidol). They are usually used in case of intolerance to the above listed funds – research on their use is insufficient.In general, they seem to be inferior in effectiveness to the above-described drugs, but they are much better tolerated. Moclobemide is especially effective when PP is combined with social phobia. Treatment begins with 25-50 mg / day with a gradual increase in the dose of 50 mg / day. The effective daily dose is usually 450-600 mg / day.

D) Atypical (highly potent) benzodizepines (ABZD).

Atypical benzodiazepines: alprazolam (Xanax, cassadan) and clonazepam (antelepsin, rivotril) are an important group for the treatment of PR.A feature of ABZDs is their high affinity for benzodiazepine receptors (3 times higher than that of typical BZDs). Unlike antidepressants, which reduce PN and agoraphobia, but have little effect on the anxiety of waiting for an attack, alprozalam not only suppresses the expectation and avoidance component (agoraphobic), but also suppresses the psychopathological and somatovegetative manifestations of the attack itself (the panic component) and prevents the development of PN. In addition, it practically does not cause side effects up to a dose of 4-6 mg / day, i.e.e is very well tolerated. The drug does not cause exacerbation of anxiety as antidepressants, the anti-panic effect develops without a “latency period”. In addition, alprazolam has a distinct antidepressant (thymoanaleptic) effect, which develops 2-3 weeks after the start of therapy. The disadvantage is the possibility of the development of dependence (substance abuse) and “withdrawal syndrome”, as well as the need for 3-4 times a day due to the short half-life (the prolonged form of Xanax-retard is devoid of this drawback).Weakness, lethargy, drowsiness, fatigue, and ataxia are rarely observed in comparison with other BZD. The likelihood of dependence development limits the possibility of long-term (more than 4-6 weeks) administration of the drug, however, in case of intolerance to antidepressants, it is necessary to prescribe alprazolam for a long time, followed by an extremely slow dose reduction. Initial doses of alprazolam 0.25-0.5 mg / day with an increase of 0.25-0.5 mg every 3 days until complete blockade of PP. Preservation of PP, their recurrence indicates an insufficient dose of the drug, and side effects (sedation, lethargy, drowsiness) indicate the need to reduce the dose.Average doses are 4-6 mg / day, treatment is continued for 4-6 months after which, with good adaptation of patients, the dose is reduced at an average rate of 0.5 mg per week in order to avoid withdrawal syndrome.

Clonazepam (antelepsin, rivotril) also has a pronounced antipanic effect at a dose of 2-6 mg / day, however, it has more pronounced side effects (drowsiness, lethargy, ataxia, depression), which limits its use. At the same time, due to a longer half-life, a milder “withdrawal syndrome” is noted, there is no need for a three-fold mandatory appointment, and it is easier to reduce the dose.The initial dose is usually 0.5 mg 2 times a day, with a gradual increase to 2-6 mg / day.

With long-term treatment with BZD, the safety, efficacy and availability of indications for therapy should be periodically evaluated. It is recommended to answer the following questions at regular intervals (2-4 months):

  1. Do existing disorders justify ongoing therapy? Did the patient feel much better from BZD therapy?

  2. The duration of admission remains within the prescribed period, has the patient avoided taking other drugs not prescribed to him?

  3. Does the patient have no signs of intoxication or clouding of consciousness associated with taking BZD or their combination with other drugs?

Any “no” answer is an indication that treatment should be discontinued.Attempts to gradually reduce the dose are recommended every 4 months. In some patients, it is possible to completely cancel the drug, in others, an exacerbation occurs, requiring the resumption of treatment. Periodic breaks in treatment can help identify patients with persistent anxiety, but a good BZD effect: they are especially indicated for long-term therapy. The FDA Commission (USA) in its recommendations indicates that the use of BZD for more than 4 months has not been studied. In addition, patients with personality disorders and substance abuse tendencies (including alcohol abuse) should not be treated for a long time with BZD, even with a history.

Traditional BZD in isolated form are now rarely used in PR, being prescribed only as “correctors” of antidepressants in the initial phase of treatment, or even preceding the appointment of the latter (“premedication”).

E) Criteria for the selection of drugs.

Therapy with TAD and, especially, clomipramine is clearly effective in patients with rapid adherence to PR depression with traits of “endogeneity”, with a high specific weight in the structure of PN of manophobia and depersonalization-derealization disorders.In patients with late addition of depression to PR, its atypical, erased nature, a high proportion of pseudosomatic (somatovegetative) and conversion disorders, a rare agoraphobia, the effectiveness of TAD is usually low. This subtype of PD is more closely related to the diagnosis of hypochondriacal development or “somatoform disorder” according to ICD-10. Thus, the more pronounced the mental component of anxiety and the more phobic experiences are presented, the greater the effect of TAD can be expected and the less exacerbation of PR during treatment.

With a stronger representation of somatovegetative components of PR (in comparison with “mental”), the effectiveness of TAD is less, they are less tolerated and more often cause exacerbation of PR. In these cases, it is necessary to resolve the issue of replacing TAD with ABZD or IMAO.

The ideal targets for ABZD are mainly somatovegetative PPs without clear agoraphobia; with pronounced phobic symptoms, their use does not lead to a distinct effect, stopping only the anxiety of expectation and PP.The predictors of the low effectiveness of ABZD are also a high frequency of PN and alexithymia (i.e., the inability of patients to adequately express their experiences or talk about them).

Thus, if we proceed from the traditional nosological ideas about the place of PR as a syndrome in the structure of a particular disease, then when choosing a therapy, the following should be taken into account:

in case of PR within the framework of MDP (cyclothymia) or low-grade schizophrenia, when the clinical picture is rich in psychopathological phenomena (fear of going crazy, depression, depersonalization, anxiety), “large” TADs (clomipramine, imramine, amitriptyline) are most effective.Their importance will increase even more when the picture of PR approaches the melancholic raptus. Clomipramine, SSRIs, MAOIs are also the drug of choice for severe agoraphobia or other associated phobias or obsessions that may not be topically related to agoraphobia, i.e. with a large proportion of ideational obsessions within the framework of sluggish schizophrenia, cyclothymia. TIR.

In PR within neuroses, the value of clomipramine and SSRIs is great in the case of obsessive-compulsive disorder, but decreases in asthenic neurosis and hysteria, where ABZD or MAOIs are more effective.

It should be noted that in the treatment of patients with PD, it is often necessary to combine basic “anti-panic” drugs with drugs that can act on psychopathic (most often hysterical) and overvalued (hypochondriacal) disorders. In such situations, drugs from the group of antipsychotics are added to the basic drugs: thioridazine (sonapax), alimemazine (teralen), pericyazine (neuleptyl), sulpiride (eglonil), chrolprothixene. In addition, when diagnosing a schizophrenic process, it is necessary to add antipsychotics to the “syndromic” therapy, which have an anti-negative effect and affect the overall progression of the disease (trifluoperazine (triftazine, stelazine), clozapine (azaleptin, leponex), risperidone (rispolept), etc.).

E) psychotherapy PR.

Effective therapy of PR requires (especially in cases complicated by agoraphobia) the use of psychotherapeutic techniques. The latter usually begin to be applied at the stage of stabilizing (after-treatment) psychopharmacotherapy and continue for some time after stopping the drug intake (largely facilitating the latter).

Behavioral and, less often, cognitive psychotherapy are most effective in PR. They reduce the level of anxiety in phobic situations and reduce the fear of anticipating an attack.

Cognitive psychotherapy is aimed at correcting the recorded erroneous ideas of patients, according to which they give hyperbolic reactions to non-life-threatening somatic sensations.

The leading method of behavioral therapy (PT) is systematic desensitization, i.e. immersion in a phobia situation (imaginary or real). The patient and therapist compose a scale of scenes associated with the onset of symptoms, ranking them in ascending order from the least to the most painful.By applying progressive muscle relaxation techniques, the patient learns to relax by imagining increasingly painful scenes. The sessions are then transferred from the office to a real-life setting, to anxiety-provoking situations. In other behavioral techniques, the patient is directly immersed in a situation that provokes anxiety: after several weeks, during which the patient is no longer bothered by the PC, the doctor encourages him to deliberately encounter phobic stimuli. After a little exercise, many sufferers begin to feel at ease in previously avoided situations.A more formal PT may, however, be needed for prolonged and severe phobias. There are many techniques for treating them, all of which are confronted with a phobic stimulus in real life. The most important for therapeutic success is the length of exposure: sessions lasting 2-3 hours are preferred to those lasting less than an hour. Another important condition is the frequent repetition of sessions, the prevention of the usual for the patient reaction of avoidance and, if possible, the reproduction in the sessions of circumstances close to real life.The effect of PT significantly increases when it is carried out in groups, when patients, after training with imaginary situations, first, accompanied by a therapist, make joint trips, finding themselves in real phobogenic situations. An important modification of the method is the involvement of an instructed relative of the patient as a behavioral co-therapist.

Underestimation of the need for PT leads to rapid recurrence of PN after discontinuation of psychopharmacotherapy and persistence of agoraphobic avoidance.On the other hand, there are patients who recover on the background of exclusively pharmacological treatment, and some patients, despite taking medication, remain too “scared” to even start participating in PT.

The effectiveness of other psychotherapeutic methods in PD is small and differs little from placebo (in particular, the use of psychodynamic therapy itself gives a positive effect only in 13% of cases).

18. Therapy of mental disorders – Department of Psychiatry and Narcology 1SPbGMU named afterI.P. Pavlova

during the test you will be asked 4 questions from this topic

11

What
of the listed
drug groups
most effective
during treatment
disguised
depression?


tranquilizers


psychostimulants


β-blockers


antipsychotics

+
antidepressants

12

Classification
antidepressants
includes:

+
tricyclic
antidepressants

+
four-cycle
antidepressants


derivatives
benzodiazepine

+
inhibitors
monoamine oxidase


derivatives
butyrophenone

13

Contraindications
to appointment
tranquilizers
are:


agitated
depression


alcoholic
delirium


epileptic
status

+
myasthenia gravis

+
respiratory
failure

15

Haloperidol
shown for
treatment:


depressive
syndrome


apato-abulic
states

+
paranoid
syndrome


asthenic
syndrome

17

How
complication
urinary retention
may be
caused by
destination:


Lerivona

+
amitriptyline


pyrazidol


Prozac

18

Probability
development
medicinal
anticholinergic
delirium above
in case of overdose:


Prozac

+
melipramine


pyrazidol


diphenhydramine

20

K
collateral
actions related
using
antipsychotics
include:


hyperhidrosis

+
hypersalivation

+
chronic
extrapyramidal
syndrome


none of
listed

22

K
atypical
antipsychotics
include:


haloperidol

+
rispolept
(risperidone)

+
olanzapine
(zyprexa)

+
azaleptin
(clozapine)


chlorpromazine

23

K
advantages
atypical
antipsychotics
include:

+
Greater influence
to negative
symptomatology
schizophrenia


fast reduction
psychotic
symptoms


antidepressant
effect

+
low severity
extrapyramidal
side effects

24

K
extrapyramidal
side effects
when applying
traditional

antipsychotics
include:

+
dystonia

+
akathisia

+
drug
parkinsonism


athetosis

+
tardive dyskinesia

25

Side
effects inherent
chlorpromazine:

+
pronounced
hypotension

+
depression

+
infiltrates
and phlebitis in
places of introduction

+
hepatitis


fever

26

K
advantages
therapy with prolonged
forms of antipsychotics
include:


absence
side effects

+
relief
control over
reception of the appointed
preparation


great antipsychotic
activity

+
liberation
sick from
the need
daily
multiple
taking medications


less likely
emergence
side effects

27

Probability
development
medicinal
anticholinergic
delirium above
at

Overdose:

+
amitriptyline


rispolepta

+
cyclodol


coaxila


diphenhydramine

28

Change
blood paintings
when applying
psychotropic
drugs
often

May
to be called:


cyclodol


haloperidol

+
azaleptin
(clozapine)


amitriptyline


phenazepam

29

For
treatment of patients,
located
in catatonic
stupor at first
queue showing:


antidepressants


psychostimulants

+
antipsychotics


tranquilizers


nootropics

30

For
alcohol treatment
delirium can
use:


haloperidol


carbamazepine

+
phenazepam and
diazepam

+
detoxification
therapy

+
Group vitamins
B

31

Contraindication
for appointment
benzodiazepine
tranquilizers
is:


convulsive
history of syndrome


hypotension


alcoholic
delirium

+
respiratory
failure

32

V
what
symptoms
effective
tranquilizers


reduced
mood

+
alarm

+
sleep disorders


hallucinations
and delirium

33

Selective
inhibitors
acetylcholinesterase
(Exelon, Reminil)
apply

at:


alcoholism


epilepsy


medicinal
parkinsonism

+
Alzheimer’s disease

34

What
of the listed
funds can
be used
for cupping
epileptic
status:

+
lumbar
puncture

+
general anesthesia
with muscle relaxants

+
phenazepam and
diazepam


chlorpromazine

35

K
selective
inhibitors
reverse
seizing serotonin
relate:


amitriptyline

+
fluoxetine
(Prozac)

+
sertraline
(zoloft)


mianserin
(lerivon)

38

K
anticholinergic
side effects
psychotropic
drugs
include:

+
constipation

+
increase
intraocular
pressure

+
urinary retention


drug phenomenon
parkinsonism


acute dyskinesia

40

Which
from preparations
refers to
antipsychotics – “drugs
reserve “at
therapeutic
resistance
in sick
schizophrenia:


haloperidol


olanzapine
(zyprexa)

+
azaleptin
(clozapine)


clopixol
(supentixol)

41

Name
some
differences between atypical
antipsychotics
compared
with typical:

+
Call out less
extrapyramidal
neuroleptic
disorders


Cause
hyperprolactinemia


Cause a decline
body weight


Cause secondary
diabetes mellitus

+
More influence
to negative
symptoms of schizophrenia
compared
with typical

43

What
from drug groups
can cause
medicinal
addiction:


antipsychotics

+
tranquilizers

+
psychostimulants


nootropics


antidepressants

44

K
non-benzodiazepine
tranquilizers
applies:


sibazon


grandaxin

+
atarax


clonazepam

88

What
of the following
drug groups
preferred
for cupping
psychomotor
excitement
in conditions
somatic
hospital?


barbiturates


amitriptyline


antipsychotics

+
tranquilizers

89

V
treatment of endogenous
depression
most effective:


neuroleptic therapy


autogenous
workout

+
antidepressant treatment


hypnosis


psychostimulants

+
electroconvulsive
therapy

90

What
of the above
preferable
use
for cupping
hallucinatory delusional
excitement?


piracetam


carbamazepine


oxybutyrate
sodium


amitriptyline

+
haloperidol

91

What
of the listed
drugs
are used
for treatment
manic
states?

+
clopixol

+
haloperidol

+
lithium carbonate


phenibut


cyclodol

92

What
of the listed
drugs
apply
as
proofreader
with antipsychotic
therapy?


reladorm


caffeine


nootropil

+
cyclodol


fentanyl

93

Which
of the listed
drugs
is an
preferred
when docking
somatogenic
delirious
syndrome?


cyclodol


amitriptyline

+
haloperidol


lithium salts


nootropil


finlepsin

95

For
treatment of agitated
depression
shown:

+
amitriptyline


melipramine


triftazine

97

For
cupping
epileptic
status most
effective:

+
in \ in introduction
seduxena


in \ in introduction
chlorpromazine


in \ in introduction
oxybutyrate
sodium


in \ in introduction
magnesia

98

Melipramine
refers to
antidepressants:

+
tricyclic
series


tetracyclic
series


inhibitors
MAO


reverse
seizure of serotonin

99

Amitriptyline
refers to
antidepressants:

+
tricyclic
series


tetracyclic
series


inhibitors
MAO


reverse
seizing serotonin

00

K
contraindications
to treatment
amitriptyline
include:

+
glaucoma

+
hypertrophy
prostate

+
atrial
arrhythmia


tuberculosis
lungs


nothing of
listed

101

Phenazepam
may be
used
during treatment:

+
phobic
disorder


Korsakovsky
syndrome


agitated
depression

+
sleep disorders


convulsive
syndrome

102

Spectrum
psychotropic
activity
diazepam
includes:

+
anticonvulsant
action

+
light activating
action

+
vegetotropic
action


nothing of
listed

103

Side
actions at
diazepam treatment
include:

+
muscle weakness

+
drowsiness

+
relaxation


convulsive
seizures


all of the above
wrong

106

K
side effects
during treatment
nootropil
(with piracetam)
include:

+
irritability


drowsiness,
lethargy

+
difficulties in
falling asleep


nothing of
listed

107

Duration
salt therapy
lithium with prophylactic
target is:


several days


several
weeks


several
months


several years

+
many years

09

Which
of the listed
antipsychotics
to a greater extent
able to cause
drug
hepatitis:

+
chlorpromazine


haloperidol


zyprexa


triftazine


clopixol

111

For
dysthymia treatment
used:


antipsychotics

+
antidepressants


nootropics


tranquilizers


anticonvulsant

112

What
from drug groups
most effective
during treatment
somatized
depressions:


antipsychotics


tranquilizers

+
antidepressants


psychostimulants


nootropics

13

K
tricyclic
antidepressants
applies:

+
amitriptyline


fluoxetine
(Prozac)


sertraline
(stimuloton)


maprotiline
(ludiomil)

114

At
violations
sleep in the form of late
falling asleep in
framework of neurotic
depression
shown:


chlorpromazine


piracetam

+
mianserin
(lerivon)


azaleptin

115

Which
of the listed
antidepressants
has a great
stimulating
effect on
compared with
others:


amitriptyline


citalopram
(tsipramil)


fluoxetine
(Prozac)

+
imipramine

118

What
drugs
refer to
atypical
antipsychotics:


haloperidol


chlorpromazine


eglonil (sulpiride)

+
olanzapine
(zyprexa)

+
rispolept
(risperidone)

119

C
the purpose of correction
extrapyramidal
neuroleptic
disorders
used:

+
beta blockers

+
cyclodol


amitriptyline

90,000 Medicines and driving a car | Official dealer of Nissan Auto-Impulse on Dneprostalevskaya


It is known that driving after drinking alcohol is prohibited by law.At the same time, many drivers take some medication and then get behind the wheel of a car. Is this calm always justified? Of course, most painkillers (aspirin, acetylsalicylic acid, analgin, etc.) have been used in domestic medicine for a long time and have earned popularity and authority.

However, some newer combination preparations may contain components that are contraindicated in those who are going to drive.We are talking about drugs of the narcotic and psychotropic series: tranquilizers, hypnotics, anticonvulsants, sedatives, some painkillers.

These medications should not be taken before travel, as they may contribute to drowsiness, lethargy, dizziness, decreased alertness and reaction speed.

Each of the listed symptoms dictates the need to stop driving. Both a professional driver and an amateur should remember this. How to find out about the side effects of medications? To do this, you need to read a brief annotation in the medical reference book.

As a rule, when describing such drugs in reference books of medical preparations, they indicate: “… during treatment with the drug, it is not recommended to engage in activities requiring concentration of attention (driving a car, operating complex machines and mechanisms)” or “… drivers should not take the drug while working transport and persons of other professions associated with the need for the manifestation of rapid mental and motor reactions. When prescribing the drug, transport drivers and persons of other professions requiring quick mental and motor reactions are prohibited from engaging in professional activities for 10-12 hours. “

Below is a list of essential medicines and their synonyms that are contraindicated in vehicle drivers. And if you need to take them and still need to go somewhere, then ask someone else to get behind the wheel.

ALPRAZOLAM (Alprazolam) Alprax, Zotran, Kassadan, Xanax, Xanor, Neyrol, Prinax, Restyl, Solanax, Tafil, Trankimazin, Tricka, Frontal Tranquilizer with a pronounced hypnotic effect. Strengthens the effect of narcotic, neuroleptic and analgesic drugs.Prescribed for the short-term relief of feelings of anxiety, anxiety or fear, the treatment of depression.

AMITRIPTILIN (Amitriptylimum) Adepril, Adepress, Amiprin, Atriptal, Damilen, Daprimen, Lantrone, Laroxal, Laroxil, Lentizol, Novotriptin, Proheptadiene, Redomex, Saropolen, Teptizriptyl, Triptizolipolate , Elavil An antidepressant with a sedative effect.

BUPRENORFIN (Buprenorphine) Anfin, Buprenal, Buprenex, Buprex, Lepetan, Nopan, Norfin, Temjezik, Unifin Synthetic narcotic analgesic.It is prescribed for the treatment of pain syndrome.

BUTORPHANOL-TARTRATE (Butorphanol-tartrate) Beforal, Verstadol, Moradol, Stadol, Torat, Torbujezik, Tordzhezik, Torbutrol. The drug also exists in the form of an aerosol for introduction into the body through the nasal mucosa (Stadol NS). Synthetic narcotic analgesic. A drug for the treatment of pain syndrome of moderate and severe intensity of various etiologies.

CARBAMAZEPIN (Karbamazepinum) Karbasan retard, Mazepin, Mazetol, Nurotol, Simonil, Stazepin, Storilat, Tegretal, Tegretol, Temporal, Finlepsin Antidepressant.It is used in the complex treatment of headaches.

LIDOCAINE HYDROCHLORIDE (Lidocaini hydrochloridum) Alocaine, Anestacon, Anestekaine, Dolikaine, Dulcicaine, Xicaine, Xylocaine, Lidestin, Lignocaine, Maricaine, Octocaine, Remicaine, Solcaine, Xyloxylate used for local administration …

MIDAZOLAM (Midazolam hydrochloride) Versed, Dormikum. Dormonide, Flormidal Hypnotic (hypnotic), sedative, benzodiazepine derivative.

NALBUFIN (Nalbuphine hydrochloride) Nubain Synthetic narcotic analgesic for the relief of moderate to severe pain syndrome.

NITRAZEPAM (Nitrazepam) Apodorm, Benzalin, Hypnax, Gipsal, Dumolid, Insomin, Livetan, Magadon, Mogadon, Nelbon, Neozepam, Nitrenpax, Nitrodiazepam, Pacidrim, Epormipranzin, Sopranzin , Eunoktin A hypnotic, sedative, benzodiazepine derivative.

PENTALGIN (Pentalgin) No synonyms An analgesic preparation of a complex composition containing codeine. Prescribed for the treatment of pain syndrome.

SEDALGIN (Sedalgin) No synonyms An analgesic preparation of a complex composition containing codeine. Prescribed for the treatment of pain syndrome.

SIBAZON (Sibazonum) Anziolin, Apaurin, Apozepam, Atilen, Bensedin, Valitran, Valium, Vatran, Vival, Diazepam, Dapam, Quetinil, Lembrol, Pacitrian, Relanium, Saromeren, Sedukonensin, Sedukonesin, Sardin , Eridan Tranquilizer (benzodiazepine derivative), potentiating the effect of hypnotics, narcotic, neuroleptic and analgesic drugs.

TIAPRIDAL (Tiapridal) Delpral, Doparid, Tiapridex, Taprizal, Triadal A neuroleptic agent with anxiolytic and analyzing effects of action.

SPASMOVERALGIN (Spasmoveralgin) No synonyms Combined, complex spasm-analgesic drug containing: propiphenazone, papaverine, atropine, phenobarbital, codeine phosphate and ephedrine. Prescribed for the treatment of pain syndrome of spastic genesis.

SPASMOVERALGIN NEO (Spasmoveralgin neo) No synonyms Combined analgesic, sedative, antispasmodic drug containing: propiphenazone, papaverine, atropine, phenobarbital, codeine phosphate and ephedrine.Prescribed for the treatment of pain syndrome of spastic genesis in the gastrointestinal tract, bladder. Biliary, hepatic, renal colic. Migraine, spastic dysmenorrhea.

TERA FLU (Thera flu) No synonyms A combined preparation of analgesic, antipyretic and desensitizing action. Prescribed for the treatment of headache, sore throat, nasal congestion; treatment of myalgia (lumbago) and febrile conditions.

TRAMALT RETARD (Tramalt retard) No synonyms Analgesic, antitussive agent.

TRAMADOL (Tramadolum) Crispin, Melanat, Protradon, Tramal Synthetic narcotic analgesic. Prescribed for the relief of moderate or severe pain syndrome.

CINNARIZIN (Cinnarizine) Glamil, Dimitronal, Labyrin, Marisan, Midronal, Mitronal, Stugeron, Cinniprin, etc. A drug that improves cerebral circulation. Used for the treatment of cerebral vascular insufficiency, headache with vasomotor disorders, migraines and conditions after traumatic brain injury (concussion)

These drugs in no way exhaust the entire list of drugs that are incompatible with driving a car.We have given only the main ones, which should be paid the closest attention.

90,000 Drugs that reduce memory. Five groups of drugs that negatively affect memory

Memory impairment is most often referred to as one of the signs of aging, a consequence of the use of psychoactive substances or a symptom of diseases such as Alzheimer’s disease. Many people are unaware that episodes of forgetfulness can occur as a side effect of certain medications.

“Scientists now know that memory loss with aging is by no means inevitable,” writes Geriatric Pharmacist Dr. Armon B. Neel. connections between neurons throughout life ”.

In order to educate patients about the unknown side effects of certain drugs, Dr. Neal has compiled a list of drugs that can induce forgetfulness.

Is memory loss interfering with your life? The culprit could be one of these drugs.

Sedatives (benzodiazepines)

Representatives of : alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), diazepam (Valium), flurazepam (Dalmane), lorazepam (A).

These drugs are usually prescribed for increased anxiety, agitation, muscle spasms, delirium. They suppress the activity of certain areas of the brain, due to which they can disrupt the transfer of data from short-term to long-term memory.This is why benzodiazepines are so commonly used by anesthesiologists.

To avoid these side effects, pharmacists recommend short courses of benzodiazepines. If you suffer from complications associated with increased anxiety, such as insomnia, it is best to opt for alternative treatments.

Drugs that lower blood cholesterol (statins)

Representatives of : atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin.

Statins lower blood cholesterol levels, but can also lower cholesterol levels in the brain where it is needed. If this happens, the connections between nerve cells are disrupted.

If you are on statins with a slight increase in blood cholesterol, but you do not have a diagnosis of coronary artery disease, a vitamin cocktail is the preferred choice.

“Talk to your doctor about this. You may be prescribed a combination of sublingual (under the tongue) supplements of vitamin B12 (1000 mcg per day), folate (800 mcg per day) and vitamin B6 (200 mg per day), ”Dr. Neal recommends.

Antidepressants (tricyclic antidepressants)

Representatives of : amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil).

These drugs are prescribed for patients with depression as well as eating disorders, chronic pain, and obsessive-compulsive disorders. More than a third of adults taking these medications complain of memory impairment and about half of problems with concentration.

In order to avoid these side effects, it is worth talking to your doctor about the possibility of using non-drug methods of treatment. Venlafaxine (Effexor) is also a good alternative – it has minimal negative effects on memory.

Medicines to combat arterial hypertension (beta-blockers)

Representatives of : atenolol (Tenormin), carvedilol (Coreg), metoprolol (Lopressor, Toprol), propranolol (anaprilin), sotalol (Betapace), timolol …

Beta blockers are used to slow the heart rate and lower blood pressure. At the same time, they can block the effects of important substances such as adrenaline and norepinephrine, leading to memory problems.

Calcium channel blockers derived from benzothiazepine are safer in this regard. In addition, they are often more effective.

Hypnotics (non-benzodiazepine hypnotics and sedatives)

Representatives of : eszopiclone (Lunesta), zaleplon (Sonata) and zolpidem (Ambien).

These drugs help to sleep. But just like the aforementioned sedatives, they can disrupt the connection between short-term and long-term memory.

“There are alternative drugs and non-drug treatments for insomnia. Talk to your healthcare provider about them. For example, 3 to 10 mg of melatonin at bedtime helps restore healthy sleep. However, remember that abrupt withdrawal of sleeping pills can lead to side effects, so any changes in the course of treatment must be carried out by the attending physician, ”says Dr. Neal.

Always consult your healthcare professional before making any adjustments to drug therapy.

Table 7. Drugs for preventive treatment of HDN / ConsultantPlus

Daily dose, mg

Recommended level

9

9 909

Strength of recommendation – A (level of evidence – 1a)

Comment.The effect of antidepressants is due to their own analgesic effect due to increased activity of antinociceptive (analgesic) systems [4, 7]. The analgesic effect of antidepressants occurs earlier than the actual antidepressant effect and in smaller doses. – Amitriptyline is recommended (as the first choice drug) [2, 3, 8, 10, 12, 20, 23, 27, 28]

The level of persuasiveness of recommendations – A (Level of Evidence: 1a)

Comment. Treatment with amitriptyline begins with small doses (5-10 mg / day), then every week the dose is titrated by 5-10 mg / day until clinical efficacy or adverse events appear; the average effective dose is 30 – 75 mg / day.To facilitate the tolerability of the drug and in patients with concomitant complaints of disturbed night sleep, most of the dose should be taken 1 to 2 hours before bedtime. It is important to explain to the patient that although amitriptyline is an antidepressant, it has a pronounced analgesic effect and high efficiency in the treatment of HDN.

– Recommended mirtazapine and venlafaxine (as second choice drugs), and other tri- and tetracyclic antidepressants: clomipramine, maprotiline and mianserin (as third choice drugs) (tab.7) [2, 6, 7, 12, 15, 20, 22, 24, 25, 26].

Strength of recommendation – B (level of evidence – 2b)

Comment.

1. If there is no effect 4 weeks after the maximum dose of amitriptyline is reached or if it is poorly tolerated, mirtazapine and venlafaxine may be used.

2. Antidepressants of the group of selective serotonin reuptake inhibitors (SSRIs) have less pronounced analgesic properties and do not have a sufficient evidence base in the treatment of CGHD, but they are better tolerated by patients due to less pronounced side effects.If the main agents listed in Table 6 are ineffective or poorly tolerated, attempts can be made to treat these drugs in standard dosages. The most appropriate use of SSRIs in combination with HDN with panic and / or phobic disorders, in which this class of antidepressants has a level of evidence A. [Error: Reference source not found]

3. When choosing an antidepressant, one should take into account the nature of the concomitant comorbid disorder (panic attacks, -phobic disorders, insomnia, asthenia, etc.). Preference should be given to a drug with an appropriate additional therapeutic effect: anxiolytic, sedative, hypnotic, anti-panic, activating. For example, if a patient with HDN has anxiety-phobic disorders, it is advisable to use antidepressants with sedative and anti-anxiety effects (amitriptyline, mirtazapine, mianserin, fluvoxamine), with leading depressive and asthenic manifestations – with an activating effect (fluoxetine), with senesto-hypochondriacal disorders joining antidepressant antipsychotics (chlorprothixene, quetiapine, thioridazine).With a more severe degree of comorbid mental disorders, consultation and further supervision of a psychiatrist is necessary.

– Anticonvulsants are recommended: topiramate 100 mg per day in two doses, gabapentin 1600 – 2400 mg per day (as reserve drugs in case of ineffectiveness or intolerance to antidepressants) [2, 12, 28].

Strength of recommendations – B (level of evidence – 2b)

– Muscle relaxants are recommended: tizanidine (6 – 8 mg / day) and tolperisone (450 mg / day) (as an additional therapy for CGHD in patients with severe tension of the pericranial muscles) [ 2, 5, 8, 12, 14, 15].

Strength of recommendation – C (level of evidence – 3)

Comment. The duration of therapy with muscle relaxants is on average 2 months. Since the clinical effect of muscle relaxants occurs faster than that of antidepressants, the appointment of combination therapy (antidepressant + muscle relaxant) may increase patient adherence to treatment.

– Not recommended for the prevention of HDN vasoactive and nootropic drugs [2, 10, 12, 15, 20, 29].

Strength of recommendation – A (level of evidence – 1a)

Comment.Vasoactive and nootropic drugs have no proven specific effect in the prevention of HDN, however, they can be used in patients with HDN as additional means for the correction of mild cognitive impairments.

– It is recommended to modify the lifestyle, first of all – to exclude potential triggers of HDN episodes and factors of chronicity of the disease (to increase the effectiveness of preventive treatment) [2, 12, 16, 20, 30].

The level of persuasion of the recommendations – A (level of evidence – 1b)

– Treatment of LHB (in combination with CHBN with LHB) is recommended, which includes: behavioral therapy, withdrawal of drugs of abuse, selection of an anesthetic drug of another pharmacological group for the relief of HD during the withdrawal period, detoxification and preventive treatment of HDN [2, 10 – 12, 20, 23].

Strength of recommendation – A (level of evidence – 1a)

– Behavioral therapy recommended (in combination with CHDH with LHHD): clarification of the role of abuse of painkillers in maintaining / increasing hypertension and the need for withdrawal from analgesics [2, 11, 12, 21] …

Strength of recommendation – A (level of evidence – 1a)

Comment. It is necessary to explain to the patient that the abuse of drugs for the relief of episodes of HDN contributes to an increase in pain episodes, and that the only way to alleviate hypertension is to cancel the drug (s) of abuse.In patients at high risk of LHB (pain episodes frequency of about 10 per month and about 10 doses of pain relief per month), prevention of abusus with behavioral therapy is more effective than treatment of already developed LHB.

– Complete or partial withdrawal of the drug (s) of abuse is recommended when combining CGBN with LHB [2, 10, 11, 12, 20].

Strength of recommendation – A (level of evidence – 1a)

Comment. Cancellation of non-opioid analgesics can be carried out on an outpatient basis, withdrawal of opioids, barbiturate- and benzodiazepine-containing analgesics – in a hospital / day hospital.Cancellation of non-opioid simple and combined analgesics can be carried out simultaneously, withdrawal of opioids, barbiturate- and benzodiazepine-containing analgesics is best done gradually.

– It is recommended to select an anesthetic drug of a different pharmacological group for the relief of hypertension during the withdrawal period when CGBN is combined with LHB [2, 11, 12, 20, 23].

Strength of recommendation – C (level of evidence – 3)

Comment. The drug of abuse should be replaced with an anesthetic of a different pharmacological group, and if it is ineffective, with another drug of the same pharmacological group.Long-acting NSAIDs naproxen (500 mg / day) or flupirtine (200-300 mg / day) can be used for 3 to 4 weeks as symptomatic agents to alleviate hypertension withdrawal [2, 12, 23]. To relieve nausea / vomiting – metoclopramide 10 – 20 mg orally, intramuscularly or in suppositories. – Recommended detoxification therapy for severe abusus (more than 15 days with taking painkillers per month) [2, 10 – 12, 20].

Strength of recommendation – B (level of evidence – 2b)

1.A comment. Detoxification includes: 1.corticosteroids: dexamethasone injection solution 4 – 8 mg per 200.0 saline intravenous drip for 7 – 10 days or oral prednisolone (1 g per kg of body weight), on average 60 mg per day with a gradual dose reduction by 5 – 10 mg every 3 days for 1 to 2 weeks until withdrawal – 7 days; 2. amitriptyline 2.0 ml per 100 ml of physiological solution intravenously for 7 days; rehydration: fluid intake of at least 2 liters per day, infusion of saline – 200.0 – 400.0 ml / day

Detoxification allows you to quickly (within 7 – 10 days) reduce the clinical manifestations of LHB, including withdrawal symptoms: nausea, anxiety, anxiety, nervousness, sleep disturbance.

– It is recommended during the period of withdrawal and treatment of LHB, so that the total number of days with taking any painkillers does not exceed 8 per month, and ideally would be minimized (3 – 5 days per month) [2, 10 – 12, 20].

Strength of recommendations – B (level of evidence – 2b)

– Prophylactic drug therapy of HDN is recommended for patients with a combination of HDN and LHB.Amitriptyline (25–75 mg per day for 2–4 months) is recommended in patients with HDN and LHB [2, 10–12, 28].

– Strength of recommendation – B (level of evidence – 2b)

Comment. The choice of preventive treatment for LHB depends on the initial form of cephalalgia (migraine or HDN). After establishing the initial form of HD – “HDN” – simultaneously with the cancellation of the “guilty” drug and detoxification, it is recommended to start preventive therapy.

– Other antidepressants are recommended if amitriptyline is ineffective (tab.7) [2, 7, 20, 23, 25, 27].

– Strength of recommendation – B (level of evidence – 2b)

– Benzodiazepines (clonazepam) and antipsychotics (chlorpromazine) are recommended as other approaches to the treatment of LHB in HDN [2, 7, 23].

Strength of recommendations – C (level of evidence – 3)

What we are treated with: Phenazepam. Why the sedative worries us

The most recent of these (2016) involved 38 workers who tested various drugs.It was found that Phenazepam and Isoprenaline interfered with their concentrated work most of all. The model of the experiment (its description can be read in Russian) was as follows: in the first series of experiments, ten people received a placebo, and five days later one of the drugs (Haloperidol, Phenazepam, Proroxan, Anabazin hydrochloride). In another three series of experiments, groups of ten people received placebo and other drugs in the same way. The subjects who took Phenazepam had more trembling hands, deteriorated fine motor skills and coordination.These study participants scored poorer on a moving object test than they did after taking a placebo. However, the small size of the group of subjects does not allow, without any doubt, to transfer this result to the entire population.

The model of the experiment is not entirely clear, and from the abstract it is not clear how many of the participants received Phenazepam, and how many – the other ten types of medications or placebo, and the article itself, unfortunately, is not available. But the 1997 article presents the opposite result: if you believe its abstract, the calming down of the neurotic-prone operators thanks to Phenazepam only improved their work.Perhaps the fact is that the earlier study could be biased to a greater extent, since we really wanted to bring a new drug to the market as soon as possible, demonstrating that it is better than foreign analogues. One can only guess about this.

A 1979 study compared the effects of Seduxen (Diazepam) and Phenazepam against anxiety in 32 patients a few days before surgery. The abstract states that the sedative effect of Phenazepam lasted longer and was deeper, however, the full text of the article is again unavailable, and we cannot analyze this data in detail.

A search in the Russian-language open library “CyberLeninka” also did not give promising results: among several articles where the name of the drug and the words “double-blind randomized placebo-controlled study” are mentioned, we are not talking about clinical trials of Phenazepam, but about other drugs.

Indicator.Ru recommends: use with caution

Phenazepam is a stumbling block of foreign medicine. He and his “relative” Diazepam switch places when crossing the border.Diazepam in the West is a drug from the list of essential drugs that WHO experts consider necessary in any country. In Russia, it is on the “List of narcotic and psychotropic substances subject to control.” And vice versa: Phenazepam is allowed in our country, but in many foreign countries it is outlawed. However, both drugs act in a similar manner in both mechanisms and effects.

Why do neurologists prescribe antidepressants?

A couple of decades ago, the use of psychotropic drugs was the exclusive prerogative of a psychiatrist.Therefore, it seems to me, there is still fear and distrust in relation to this class of drugs.

However, the trends of modern medicine are such that a neurologist working on the basis of the principles of evidence-based medicine and adhering to international clinical guidelines should understand psychotropic drugs, since they allow the doctor to improve the patient’s quality of life, avoid endless and useless consultations with doctors and additional expensive examinations …

In this article I will talk about the main types of psychotropic drugs that a neurologist can prescribe on an outpatient basis: tranquilizers / anxiolytics, antidepressants, antipsychotics, antiepileptic drugs.


A little bit of basics. How does our brain work?

The brain is a lot of neuron cells. Neurons transmit information to each other using molecules called neurotransmitters.
There are a lot of neurotransmitters: acetylcholine, histamine, serotonin, dopamine, GABA, etc.
The mediator is ejected from the outgrowth of one neuron and “sits” on the receptor, which is located on the outgrowth or body of another neuron.

Some neurotransmitters activate another neuron, some inhibit it.

The mechanism of action of most psychotropic drugs is associated with the effect on receptors for certain mediators – one or several at once.


What is the fundamental difference between the classes of psychotropic drugs?

1. Tranquilizers (anxiolytics, anti-anxiety drugs)

Representatives: benzodiazepines (phenazepam, alprozalam, clonazepam), hydroxyzine (atarax), tofaxin and others)

Acts on the receptors of “inhibitory” mediators. Due to this, they have a calming, sedative effect. The drugs differ in the “strength” of the effect and the severity of the calming effect.

The effect develops quickly, but does not last long.

When prescribed: if you need to quickly relieve anxiety, panic attack, correct insomnia, reduce anxiety before surgery or medical interventions, to reduce the side effects of antidepressants at the beginning of their use.

Duration of the course: short, no more than 4 weeks, especially benzodiazepine drugs, which may develop addiction with longer use.

Tranquilizers are not available without a prescription. Some drugs are only dispensed with a specific prescription number and batch.

2. Antidepressants
These include tricyclic antidepressants (amitriptyline, clomipramine), selective serotonin reuptake inhibitors (escitalopram, sertraline, fluoxetine and others), selective sertraline and venoxetine reuptake inhibitors.

The old groups of antidepressants act on the receptors of several types of mediators at once, this is due to a large number of uncomfortable side effects (weight gain, drowsiness, arrhythmia, increased intraocular pressure, etc.).

The more modern the drug is, the more “point” its effect is. Some drugs act on a specific subtype of the neurotransmitter receptor. Due to this, the likelihood of developing side effects decreases, but their effectiveness remains high.

To minimize the side effects of antidepressants, which can be especially troubling at the beginning of treatment, the doctor will select the optimal dosage increase regimen (with the lowest possible dose and a gradual gradual increase) and drug withdrawal.

The effect of this group of drugs unfolds within 2-3-4 weeks, but after discontinuation of the drug, a “tail” of their positive action remains for some time.

The course of treatment is long, at least 6 months.

When prescribed correctly, taking into account the individual characteristics of the patient and his concomitant pathology, taking antidepressants, even for a long time, is safe.
Antidepressants are not addictive or addictive.

Used for: anxiety, phobias, panic attacks, within the framework of the treatment of post-traumatic disorder and reaction to a stressful event, with insomnia, chronic headaches, chronic back pain, with painful polyneuropathies, with psychogenic dizziness, with irritable bowel syndrome, with somatized disorders.

Antidepressants are prescribed by a doctor and are not available without a prescription.

3. Neuroleptics
Of the most frequently prescribed by a neurologist – quetiapine, olanzapine, risperidone, alimemazine (teraligen). In Russian realities, sulpiride (eglonil) is also often used, although in my opinion its appointment is not entirely justified.

The main target is dopamine receptors. The indications are rather narrow and specific.
Often prescribed in addition to antidepressants.

Each antipsychotic has its own nuances of increasing the dosage and discontinuing the drug.Also not available without a prescription.

4. Antiepileptic drugs (anticonvulsants, normotimics).
They act on receptors for certain neurotransmitters and on ion channels of neurons themselves.
In addition to epilepsy, they are prescribed to treat pain associated with irritation / inflammation / pinching of nerve structures – the root, trigeminal nerve, nerves in the arms, legs, as well as to stabilize mood, in particular in bipolar disorder.

The duration of treatment depends on the disease.


If your neurologist has prescribed a psychotropic drug for you, be sure to discuss the following questions:

• Regimen for increasing dosage and discontinuing the drug
• Most common side effects and the possibility of minimizing them
• Degree of drowsiness and the ability to drive a car
• Approximate duration of therapy
• Interaction of drugs and other drugs that you take on an ongoing basis, as well as interactions with alcohol

Do not hesitate to ask your doctor any questions that concern you in connection with the prescription of this group of drugs.