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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by KaraS on December 2, 2004, at 19:42:19
Could anyone tell me which, if any, of the sedating TCAs are safe to use in elderly patients (76 years old)? Which are the least cardio-toxic?
My mother is currently taking Effexor and Ativan but she needs something else. The only other possibilities I can think of are Seroquel and Remeron. I'm a little afraid of suggesting an AP. She has a terrible time with acid reflux disease so I'm also a bit afraid of telling her to ask her doctor about Remeron.
Posted by linkadge on December 2, 2004, at 20:29:46
In reply to Sedating tricyclic for use in elderly patients?, posted by KaraS on December 2, 2004, at 19:42:19
doxepin (sinequan in canada) is a sedating TCA, that is one of the less cardiotoxic ones.
Linkadge
Posted by KaraS on December 2, 2004, at 21:17:11
In reply to Re: Sedating tricyclic for use in elderly patients?, posted by linkadge on December 2, 2004, at 20:29:46
> doxepin (sinequan in canada) is a sedating TCA, that is one of the less cardiotoxic ones.
>
> LinkadgeThanks. (I've taken doxepin myself and it worked really well for anxiety and insomnia. It totally healed my panic disorder as well.)
What about maprotiline for an elderly person? It's got a slightly higher chance of causing seizures but I'm not really worried about that - particularly at the low dosages that my mother would take it.
Posted by Colleen D. on December 3, 2004, at 5:31:14
In reply to Re: Sedating tricyclic for use in elderly patients? » linkadge, posted by KaraS on December 2, 2004, at 21:17:11
Hi Kara!
I was going to suggest doxepin too, because I take it. 25mg an hour before bed and it works so well. It looks like maprotiline might be a good choice too. Here's a link and there aren't really any contraindications re: the elderly and or cardio-toxicity.
http://www.psyweb.com/Drughtm/maprot.html
Good luck!
Colleen
> > doxepin (sinequan in canada) is a sedating TCA, that is one of the less cardiotoxic ones.
> >
> > Linkadge
>
> Thanks. (I've taken doxepin myself and it worked really well for anxiety and insomnia. It totally healed my panic disorder as well.)
>
> What about maprotiline for an elderly person? It's got a slightly higher chance of causing seizures but I'm not really worried about that - particularly at the low dosages that my mother would take it.
Posted by SLS on December 3, 2004, at 9:58:39
In reply to Re: Sedating tricyclic for use in elderly patients? » KaraS, posted by Colleen D. on December 3, 2004, at 5:31:14
> Hi Kara!
>
> I was going to suggest doxepin too, because I take it. 25mg an hour before bed and it works so well. It looks like maprotiline might be a good choice too. Here's a link and there aren't really any contraindications re: the elderly and or cardio-toxicity.
>
> http://www.psyweb.com/Drughtm/maprot.html
>
> Good luck!
>
> Colleen
>
>
> > > doxepin (sinequan in canada) is a sedating TCA, that is one of the less cardiotoxic ones.
> > >
> > > Linkadge
> >
> > Thanks. (I've taken doxepin myself and it worked really well for anxiety and insomnia. It totally healed my panic disorder as well.)
> >
> > What about maprotiline for an elderly person? It's got a slightly higher chance of causing seizures but I'm not really worried about that - particularly at the low dosages that my mother would take it.
>
>
I believe maprotiline is more cardiotoxic than doxepin. I would recommend doxepin over maprotiline.
- Scott
Posted by ed_uk on December 3, 2004, at 10:32:41
In reply to Re: Sedating tricyclic for use in elderly patients?, posted by SLS on December 3, 2004, at 9:58:39
Hi,
Is doxepin a safer tricyclic for the heart?
Roose SP, Dalack GW, Glassman AH, Woodring S, Walsh BT, Giardina EG.
New York State Psychiatric Institute, N.Y.
BACKGROUND: Many clinicians believe that doxepin is the safest tricyclic with respect to cardiovascular effects. This belief has persisted for two decades despite the absence of rigorous prospective evaluation. METHOD: To address this issue, the authors studied the cardiovascular effects of doxepin in 32 depressed patients with preexisting left ventricular impairment, ventricular arrhythmias, and/or conduction disease. RESULTS: Doxepin (1) did not have a robust effect on heart rate, (2) did not adversely affect left ventricular function, (3) did have a significant antiarrhythmic effect, (4) slowed cardiac conduction, and (5) caused a significant increase in orthostatic hypotension. Five (16%) of the 32 patients dropped out due to cardiovascular side effects. The overall dropout rate was 41%.
CONCLUSIONS: The cardiovascular effects of doxepin in depressed patients with heart disease are comparable to those documented for imipramine and nortriptyline. Doxepin afforded no greater margin of cardiovascular safety; in fact, the drug was poorly tolerated by this patient population.
Ed.
Posted by Ritch on December 3, 2004, at 13:19:47
In reply to Sedating tricyclic for use in elderly patients?, posted by KaraS on December 2, 2004, at 19:42:19
> Could anyone tell me which, if any, of the sedating TCAs are safe to use in elderly patients (76 years old)? Which are the least cardio-toxic?
>
> My mother is currently taking Effexor and Ativan but she needs something else. The only other possibilities I can think of are Seroquel and Remeron. I'm a little afraid of suggesting an AP. She has a terrible time with acid reflux disease so I'm also a bit afraid of telling her to ask her doctor about Remeron.
>
>
>
>Evidently it appears that all TCA's can be cardiotoxic. What about trazodone? I think that's what nursing homes starting using when it came out in the '80's. I never experienced any major hunger probs with trazodone.
Posted by KaraS on December 3, 2004, at 16:05:34
In reply to Sedating tricyclic for use in elderly patients?, posted by KaraS on December 2, 2004, at 19:42:19
I couldn't tolerate trazadone so I didn't think of it for my mother - but she doesn't always react the same way I do to medications. This is probably the best option for her to try at this point.
Also, I wonder how much difference it would make that the TCA dosage would be very low but I'm a little bit afraid to have her try one.
Posted by Colleen D. on December 3, 2004, at 19:56:32
In reply to Re: Thanks everyone for your input, posted by KaraS on December 3, 2004, at 16:05:34
doesn't do well with it, then it's probably not for her either. I can't tolerate it. Makes me feel like I have a hangover the next day, even at that dosage. Then, I'd say go foa low dosage of the doxepin.
Good luck!
Colleen
Posted by zeugma on December 4, 2004, at 8:25:56
In reply to Re: Thanks everyone for your input, posted by KaraS on December 3, 2004, at 16:05:34
TCA's are all basic, so they should be helpful for acid reflux. In fact my gastroenterologist said his favorite medication for IBS is low dose amitriptyline (10 mg/day), and I had serious problems with acid reflux before starting nortriptyline a few years ago.
I didn't know remeron aggravated acid reflux.
Effexor and Ativan are unlikely to cause serious problems with doxepin. Is the doxepin to be only a sleep aid, or are you thinking along the lines of AD combination?
Posted by RetiredYoung on December 4, 2004, at 10:28:15
In reply to Re: Thanks everyone for your input » KaraS, posted by zeugma on December 4, 2004, at 8:25:56
Just wanted to add a contrary opinion on this. I'm taking clomipramine at 300mg/day. One of it's many side effects for me has been heartburn/acid reflux. It was so bad that I had to get a Rx for Prevacid.
My psychiatrist confirmed in his manual that reflux problems can be caused by TCAs..
Jim
Posted by KaraS on December 4, 2004, at 13:39:14
In reply to Re: Thanks everyone for your input » KaraS, posted by zeugma on December 4, 2004, at 8:25:56
> TCA's are all basic, so they should be helpful for acid reflux. In fact my gastroenterologist said his favorite medication for IBS is low dose amitriptyline (10 mg/day), and I had serious problems with acid reflux before starting nortriptyline a few years ago.
>
> I didn't know remeron aggravated acid reflux.
>
> Effexor and Ativan are unlikely to cause serious problems with doxepin. Is the doxepin to be only a sleep aid, or are you thinking along the lines of AD combination?
Hi z,That's true about the TCAs. I had forgotten they were good for that. I used to have a lot of stomach problems until I started taking doxepin years ago.
Remeron doesn't aggrivate acid reflux but it enhances appetite and my mother already has a hard time keeping food down. It might not be a good side effect for her.
I'm just thinking of doxepin or other sedating medication in low dosage for her to help with anxiety. The Ativan is not enough for her.
K
Posted by KaraS on December 4, 2004, at 13:40:44
In reply to TCAs and Acid Reflux, posted by RetiredYoung on December 4, 2004, at 10:28:15
> Just wanted to add a contrary opinion on this. I'm taking clomipramine at 300mg/day. One of it's many side effects for me has been heartburn/acid reflux. It was so bad that I had to get a Rx for Prevacid.
>
> My psychiatrist confirmed in his manual that reflux problems can be caused by TCAs..
>
> Jim
Interesting. Have you ever taken doxepin or amitriptyline?
Posted by RetiredYoung on December 4, 2004, at 14:39:58
In reply to Re: TCAs and Acid Reflux » RetiredYoung, posted by KaraS on December 4, 2004, at 13:40:44
Amitriptyline = yes. Doxepin = no.
Another source on this is:
http://www.ti.ubc.ca/pages/letter3.html
What drugs decrease lower esophageal sphincter pressure and worsen GERD?
Anticholinergic drugs, antispasmodic drugs, many anti-histamine and antiemetic drugs, tricyclic antidepressants, phenothiazine neuroleptics, nitrates and calcium channel blockers. If possible these should be reduced in dose or discontinued.It's kind of like headaches: sometimes anti-depressants help prevent migraines and headaches/sometimes they exacerbate them.
Best regards,
Jim
Posted by KaraS on December 4, 2004, at 23:21:57
In reply to Re: TCAs and Acid Reflux » KaraS, posted by RetiredYoung on December 4, 2004, at 14:39:58
Posted by zeugma on December 5, 2004, at 12:29:52
In reply to TCAs and Acid Reflux, posted by RetiredYoung on December 4, 2004, at 10:28:15
> Just wanted to add a contrary opinion on this. I'm taking clomipramine at 300mg/day. One of it's many side effects for me has been heartburn/acid reflux. It was so bad that I had to get a Rx for Prevacid.
>
> My psychiatrist confirmed in his manual that reflux problems can be caused by TCAs..
>
> JimI suppose I didn't have problems with reflux so much as nausea. The nausea either tended to trigger, or actually was the result of, a panic attack, so it could be nortriptyline's antipanic properties that caused the nausea to lessen.
On the other hand, SSRI's caused violent nausea and panic attacks.
Clomipramine is the TCA that most closely resembles an SSRI. I was wary of trying clomipramine, despite its reputation for efficacy, because I was worried about its effects on my GI system.
Did you experience acid reflux on SSRI's or on amitriptyline?
Posted by RetiredYoung on December 5, 2004, at 12:40:02
In reply to Re: TCAs and Acid Reflux » RetiredYoung, posted by zeugma on December 5, 2004, at 12:29:52
>> Did you experience acid reflux on SSRI's or on amitriptyline?
No = SSRIs. Don't think so = amitriptyline in early 1990s.
I'm on a very high dose of the clomipramine (150mg BID), which may be a factor. I'm only willing to put up with some of the annoying side effects (such as Heart/cardio, constipation, shaky hands, very dry mouth, urinary hesitation, word slurring/finding (cognitive impairment), exercise tolerance, & dizzy when stand up) because the clomipramine is very helpful for my depression. If I finally have enough of the side effects or it starts losing effectiveness, Cymbalta is next for me to try.
Jim
This is the end of the thread.
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