Response takes weeks or months. One quarter to one half of imipramine patients relapse after tapering from the drug. Not recommended while breast-feeding and used only with physician consent while pregnant. See tricyclic antidepressants side effects , above. Initial use of imipramine occasionally causes an increase in anxiety that usually diminishes in several weeks. Anticholinergic effects are stronger than most other antidepressants. If they are bothersome to you, it may be possible to switch to a different TCA with less anticholinergic effects.
Dizziness from a lowering of blood pressure is moderate. If postural hypotension troubles you, nortriptyline may work more effectively. The tendency toward weight gain is moderate. Some patients, especially males, experience reduced sex drive or responsiveness while taking this drug. Other side effects are palpitations changes in heart beat , sweating and drowsiness.
One third of patients are unable to tolerate side-effects and must switch to another medication. The best way to reduce the early anxiety symptoms with the start of imipramine is to begin with a very small dose, typically 10 mg at bed time, and increase the dose 10 mg every day until you reach the dose of 50 mg per day.
It can block panic in some patients with 50 mg per day, so maintaining this dose level for several days is a good strategy. If the dose is not effective, then the physician can increase it 25 mg every third day up to mg. After one week, if panic continues, then the dose can increase by 50 mg every third day. Although some patients require a smaller or larger dosage, the usual maintenance dosage is between mg and mg per day.
Desipramine Norpramin, Pertofrane and others Possible Benefits. Helpful for depression as well as panic, generalized anxiety and PTSD. Causes little or no drowsiness. Not much help for anticipatory anxiety. Response requires weeks or months.
Use in pregnancy or breast-feeding only with physician's approval. Increases sensitivity to sun. Postural hypotension, memory impairment, jitteriness, tremor, insomnia especially on initiation and the anticholinergic effects of dry mouth, blurred vision, constipation, urinary retention. Tricyclic antidepressants , including doxepin, should not be taken with any of the monoamine oxidase inhibitor MAOI class of antidepressants for example, isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate], selegiline [ Eldepryl ], and procarbazine [ Matulane ] or other drugs that inhibit monoamine oxidase such as linezolid [Zyvox] and intravenous methylene blue.
Such combinations may lead to confusion , high blood pressure , tremor, hyperactivity , coma , and death. Doxepin should not be administered for at least 14 days after stopping. Drug that affect heart rhythm such as amiodarone Cordarone , bepridil Vascor , and disopyramide Norpace should not be combined with doxepin since it also affects heart rhythm. Cimetidine Tagamet increases the breakdown of doxepin by the liver and can increase doxepin blood levels, possibly causing side effects from doxepin.
Both current research and clinical experience suggest that certain medications may help reduce symptoms during one or both of these stages for some people.
However, if a medication can specifically block the panic attack itself, many patients no longer anticipate events with such anxiety and can overcome their phobias more quickly. The primary medications used today for panic disorder are several types of antidepressants, including selective serotonin reuptake inhibitors SSRIs , and the benzodiazepines sometimes in combination with these SSRIs.
The selective serotonin reuptake inhibitors SSRIs are the most commonly prescribed drugs for panic today and offer fewer side effects than the tricyclic antidepressants.
These include fluoxetine Prozac , fluvoxamine Luvox , sertraline Zoloft , paroxetine Paxil , citalopram Celexa and escitalopram Lexapro. This rate is equal to the success rate of the tricyclic antidepressants that have proven helpful. The serotonin-norepinephrine reuptake inhibitor SSNR venlafaxine Effexor has also been shown to help control panic attacks, as has the mild tranquilizer buspirone BuSpar.
They block panic attacks quicker than the antidepressants, often in a week or two. They are also used as needed before a panic-provoking situation. They tend to have fewer side effects than the antidepressants. However, they can cause withdrawal symptoms as you taper off them. Because alprazolam is quicker acting than clonazepam, its withdrawal effects can be stronger as well. The quick acting nature of alprazolam makes it an ideal medication to take as needed just before panic-provoking events.
It takes about 15 to 20 minutes to offer you its anxiety-reducing benefits. If you place it under your tongue to dissolve called sublingual , it can offer benefits within 5 to 8 minutes. Be ready for its bitter taste! Clonazepam and is the extended release XR formula of alprazolam last longer in the body than alprazolam. This allows you to dose twice a day for a full hour coverage, while alprazolam requires four or five dosings for the same period.
Some investigators believe they are a better choice than alprazolam during those times because their primary effects are not as strong and also wear off more slowly. When you are practicing the skills of facing your fears, if you notice the effects of a medication, you may tend to attribute your successes more to the medication than to your own efforts.
Medications should serve as helpers to your own courage and skills and not get all the credit for good results. The clinical significance of this interaction with Doxepin has not been systematically evaluated.
Serious side effects and even death have been reported following the concomitant use of certain drugs with MAO inhibitors. Therefore, MAO inhibitors should be discontinued at least two weeks prior to the cautious initiation of therapy with Doxepin. The exact length of time may vary and is dependent upon the particular MAO inhibitor being used, the length of time it has been administered, and the dosage involved.
Cimetidine has been reported to produce clinically significant fluctuations in steady-state serum concentrations of various tricyclic antidepressants. Serious anticholinergic symptoms i. Additionally, higher than expected tricyclic antidepressant levels have been observed when they are begun in patients already taking cimetidine. In patients who have been reported to be well controlled on tricyclic antidepressants receiving concurrent cimetidine therapy, discontinuation of cimetidine has been reported to decrease established steady-state serum tricyclic antidepressant levels and compromise their therapeutic effects.
It should be borne in mind that alcohol ingestion may increase the danger inherent in any intentional or unintentional Doxepin overdosage. This is especially important in patients who may use alcohol excessively. Since drowsiness may occur with the use of this drug, patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug.
Patients should also be cautioned that their response to alcohol may be potentiated. Since suicide is an inherent risk in any depressed patient and may remain so until significant improvement has occurred, patients should be closely supervised during the early course of therapy. Prescriptions should be written for the smallest feasible amount.
Should increased symptoms of psychosis or shift to manic symptomatology occur, it may be necessary to reduce dosage or add a major tranquilizer to the dosage regimen.
A determination has not been made whether controlled clinical studies of Doxepin included sufficient numbers of subjects aged 65 and over to define a difference in response from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.
In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy. The extent of renal excretion of Doxepin has not been determined. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selections. Sedating drugs may cause confusion and over sedation in the elderly; elderly patients generally should be started on low doses of Doxepin and observed closely.
Some of the adverse reactions noted below have not been specifically reported with Doxepin use. However, due to the close pharmacological similarities among the tricyclics, the reactions should be considered when prescribing Doxepin hydrochloride. Dry mouth, blurred vision, constipation, and urinary retention have been reported.
If they do not subside with continued therapy, or become severe, it may be necessary to reduce the dosage. Central Nervous System Effects: Drowsiness is the most commonly noticed side effect. This tends to disappear as therapy is continued.
Other infrequently reported CNS side effects are confusion, disorientation, hallucinations, numbness, paresthesias, ataxia, extrapyramidal symptoms, seizures, tardive dyskinesia, and tremor. Cardiovascular effects including hypotension, hypertension, and tachycardia have been reported occasionally. Skin rash, edema, photosensitization, and pruritus have occasionally occurred.
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