Dr. Bob's Psychopharmacology Tips

Tricyclics in children

From: CharanL@aol.com (Michael Levin, MD)
Date: Fri, 1 Sep 1995 01:01:30 -0400
Subject: Tricyclics in children

At 9:17 PM 8/28/95, Troy Caldwell wrote:

I treat a girl who suffers a mood disorder (MDD) and ADHD.

I thought of desipramine, however, the concerns about its associations to pediatric sudden death inhibit me.

• ECGs at baseline
• initial dose 3 mg/kg/day, final dose no greater than 5 mg/kg/day
• PR interval less than or equal to 210 ms
• QRS interval no more that 30% over baseline
• QTc interval less than 450 ms
• blood levels after every increase above 3 mg/kg/day
• heart rate and blood pressure monitoring.

Date: Fri, 12 Jan 1996 21:18:12 EST
From: HRudMD@aol.com (Howard Rudominer, M.D.)
Subject: Tricyclics in children

Desipramine makes me and a lot of psychiatrists nervous because of its possible cardiotoxic effects. I think the sudden death toll in children is now up to around 10. I guess if I were in a facility where I could keep very close watch on the PR interval, then I would feel a little more comfortable. However, my general feeling is to avoid desipramine unless all else fails.

Date: Tue, 17 Dec 1996 18:14:00 -0800
From: "Kenneth W. Steinhoff" <ksteinho@uci.edu>
Subject: Tricyclics in children

It was my understanding from Thomas Spencer's presentation at AACAP that subsequent investigation and cardiologic review of the cases reported did not find evidence that there was any higher risk of sudden death in patients on desipramine than you would find in an untreated population.

I got the impression that MDs should be monitoring the EKG when prescribing this medication (desipramine), but that there was no cause for additional concern.

--Leslie E. Packer, PhD

In my experience prescribing practices have changed dramatically. Only the boldest M.D.s are able to, or wish to, sell parents that the risk of sudden death is minimal. If in fact someone prescribed desipramine and a child died they and the parents would be left with a lot of rationalizing to do.

Science-wise desipramine does lengthen the QTc interval. How much is a safe lengthening I myself do not care to judge, so if I am pushed into needing desipramine I consult with a pediatric cardiologist.

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