Amitriptyline

Nutrients Depleted: Coenzyme Q10, Vitamin B12

U.S. Brand Names: Elavil®; Enovil®

Use: Treatment of various forms of depression, often in conjunction with psychotherapy; analgesic foe certain chronic and neuropathic pain, prophylaxis against migraine headaches.

Contraindications: Do not use these medicines if you have heart problems, if you drink alcohol, while you are taking other sedatives and tranquilizers, and while you are taking some cold medicines and stomach remedies.

Pregnancy Risk Factor and Implications: D; Enters breast milk/not recommended.

Contraindications: Hypersensitivity to amitriptyline (cross-sensitivity with other tricyclics may occur); patients receiving MAO inhibitors within past 14 days; narrow-angle glaucoma; avoid use during pregnancy and lactation.

Dietary Considerations: Alcohol: Additive CNS effects, avoid use.

Warnings/Precautions: Amitriptyline should not be abruptly discontinued in patients receiving high doses for prolonged periods. Use with caution in patients with cardiac conduction disturbances; an EKG prior to initiation of therapy is advised; use with caution in patients with a history of hypothyroidism, renal or hepatic impairment. The most anticholinergic and sedating of the antidepressants; pronounced effects on the cardiovascular system (hypotension), hence, many psychiatrists agree it is best to avoid in the elderly.

Adverse Reactions: Anticholinergic effects may be pronounced; moderate to marked sedation can occur (tolerance to these effects usually occurs).

Greater than 10% experience:

Central nervous system: Dizziness, drowsiness, headache
Gastrointestinal: Xenostomia, constipation, increased appetite, nausea, unpleasant taste, weight gain
Neuromuscular & skeletal: Weakness

1% to 10% experience:

Cardiovascular: Hypotension, postural hypotension, arrhythmias, tachycardia, sudden death
Central nervous system: Nervousness, restlessness, parkinsonian syndrome, insomnia, sedation, fatigue, anxiety, impaired cognitive function, seizures have occurred occasionally, extrapyramidal symptoms are possible
Gastrointestinal: Diarrhea, heartburn
Genitourinary: Sexual dysfunction, urinary retention
Neuromuscular & skeletal: Tremor
Ocular: Eye pain, blurred vision
Miscellaneous: Diaphoresis (excessive)

Less than 1% experience: Alopecia, photosensitivity, breast enlargement, galactorrhea, rarely SIADH, trouble with gums, decreased lower esophageal sphincter tone may cause GE reflux, testicular edema, leukopenia, eosinophilia, rarely agranulocytosis, cholestatic jaundice, increased liver enzymes, increased intraocular pressure, tinnitus, allergic reactions

Overdose/Toxicology: Symptoms of overdose include agitation, confusion, hallucinations, urinary retention, hypothermia, hypotension, ventricular tachycardia, and seizures. Treatment is symptomatic and supportive. Alkalinization by sodium bicarbonate and/or hyperventilation may limit cardiac toxicity.

Imipramine

Nutrients Depleted: Coenzyme Q10, Vitamin B2

U.S. Brand Names: Trofranil®; Janimine®; Tofranil-PM®

Use: Treatment of various forms of depression, often in conjunction with psychotherapy; enuresis in children; analgesic for certain chronic and neuropathic pain.

Pregnancy Risk Factor and Implications: D; enter breast milk/not recommended.

Contraindications: Hypersensitivity to imipramine (cross-sensitivity with other tricyclics may occur); patients receiving MAO inhibitors or fluxetine within past 14 days; narrow-angle glaucoma.

Dietary Considerations: Alcohol: Additive CNS effect, avoid use.

Warnings/Precautions: Use with caution in patients with cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism or those receiving thyroid replacement; do not discontinue abruptly in patients receiving long-term, high-dose therapy; some oral preparations contain tartrazine and injection contains sulfites, both of which can cause allergic reactions. Orthostatic hypertension is a concern with this agent, especially in patients taking other medications that may affect blood pressure; may precipitate arrhythmias in predisposed patients; may aggravate seizures; a less anticholinergic antidepressant may be a better choice.

Adverse Reactions: Less sedation and anticholinergic effects than amitriptyline

Greater than 10% experience:
Central nervous system: Dizziness, drowsiness, headache
Gastrointestinal: Increased appetite, nausea, unpleasant taste, weight gain, xerostomia, constipation
Genitourinary: Urinary retention
Neuromuscular & skeletal: Weakness

1% to 10% experience:

Cardiovascular: Postural hypotension, aarhythmias, tachycardia, sudden death
Central Nervous System: Confusion, delirium, halluncination, nervousness, restlessness, parkinsonian syndrome, insomnia
Endocrine & metabolic: Sexual dysfunction
Gastrointestinal: Diarrhea, heartburn
Genitourinary: Dysuria
Neuromuscular & skeletal: Fine muscle tremors
Ocular: Blurred vision, eye pain
Miscellaneous: Diaphoresis (excessive)

Less than 1% experience: Anxiety, seizures, alopecia, photosensitivity, breast enlargement, galactorrhea, SIADH, trouble with gums, decreased lower esophageal sphincter tone may cause GE reflux, testicular edema, leukopenia, eosinophilia, rarely agranulocytosis, increased liver enzymes, cholestatic jaundice, increased intraocular pressure, tinnitus, allergic reactions, has been associated with falls

Overdose/Toxicology: Symptoms of overdose include confusion, hallucinations, constipation, cyanosis, tachycardia, urinary retention, ventricular tachycardia, and seizures. Following initiation of essential overdose management, toxic symptoms should be treated. Ventricular arrhythmias often respond to concurrent systemic alkalinization (sodium bicarbonate 0.5-2 mEq/kg I.V.) Physostigmine (1-2 mg I.V. slowly for adults) may be indicated to reverse life-threatening cardiac arrhythmias.

Doxepin

Nutrients Depleted: Coenzyme Q10, Vitamin B2

U.S. Brand Names: Adapin® Oral; Sinequan® Oral; Zonalon® Topical Cream

Use:

Oral: Treatment of various forms of depression, usually in conjunction with psychotherapy; treatment of anxiety disorders.

Unlabeled Use: Analgesic for certain chronic and neuropathic pain

Topical: Short term (less than 8 days) management of moderate pruritus in adults with atopic dermatitis or lichen simplex chronicus.

Pregnancy Risk Factor and Implications: C; Excretion in breast milk unknown/not recommended.

Contraindications: Hypersensitivity to doxepin or any component (cross-sensitivity with other tricyclic antidepressants may occur); narrow-angle glaucoma.

Warnings/Precautions: Use with caution in patients with cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, or those receiving thyroid replacement; avoid use during lactation; use with caution in pregnancy; do not discontinue abruptly in patients receiving chronic high-dose therapy.

Adverse Reactions:

Greater than 10% experience:

Central Nervous System: Sedation, drowsiness, dizziness, headache
Gastrointestinal: Xerostomia, constipation, increased appetite, nausea, unpleasant taste, weight gain
Neuromuscular & skeletal: Weakness

1% to 10% experience:

Central nervous system: Confusion, delirium, hallucinations, nervousness, restlessness, parkinsonian syndrome, insomnia
Gastrointestinal: Diarrhea, heartburn
Genitourinary: Sexual dysfunction, dysuria
Neuromuscular & skeletal: Fine muscle tremors
Ocular: Blurred vision, eye pain
Miscellaneous: Diaphoresis (excessive)

Less than 1% experience: Anxiety, seizures, alopecia, photosensitivity, breast enlargement, galactorrhea, SIADH, trouble with gums, decreased lower esophageal sphincter tone may cause GI reflux, urinary retention, testicular edema, agranulocytosis, leukopenia, eosinophilia, hepatitis, cholestatic jaundice, and increased liver enzymes, increased intraocular pressure, tinnitus, allergic reactions.

Overdose/Toxicology: Symptoms of overdose include confusion, hallucinations, seizures, urinary retention, hypothermia, hypotension, tachycardia, and cyanosis. Following initiation of essential overdose management, toxic symptoms should be treated symptomatically.

Desipramine

Nutrients Depleted: Coenzyme Q10, B2

U.S. Brand Names: Norpramin®

Use: Treatment of various forms of depression, often in conjunction with psychotherapy; analgesic adjunct in chronic pain. Unlabeled Use: Peripheral neuropathies

Pregnancy Risk Factor and Implications: C; enters breast milk/not recommended.

Contraindications: Hypersensitivity to desipramine (cross-sensitivity with other tricyclic antidepressants may occur); patients receiving MAO inhibitors within past 14 days; narrow-angle glaucoma; use immediately postmyocardial infarction.

Dietary Considerations:
Alcohol: Additive CNS effects, avoid use.

Warnings/Precautions: Use with caution in patients with cardiovascular disease, conduction disturbances, urinary retention, seizure disorders, hyperthyroidism or those receiving thyroid replacement; do not discontinue abruptly in patients receiving long-term high-dose therapy.

Adverse Reactions:

Greater than 10% experience:

Central nervous system: Dizziness, drowsiness, headache
Gastrointestinal: Xerostomia, constipation, increased appetite, nausea, unpleasant taste, weight gain
Neuromuscular & skeletal: Weakness

1% to 10% experience:

Cardiovascular: Arrthymias, hypotension
Central nervous system: Confusion, delirium, hallucinations, nervousness, restlessness, parkinsonian syndrome, insomnia
Gastrointestinal: Diarrhea, heartburn
Genitourinary: Dysuria, sexual dysfunction
Neuromuscular & skeletal: Fine muscle tremors
Ocular: Blurred vision, eye pain
Miscellaneous: Diaphoresis (excessive)

Less than 1% experience: Anxiety, seizures, alopecia, photosensitivity, breast enlargement, galactorrhea, SAIDH, trouble with gums, decreased lower esophageal sphincter tone may cause GE reflux, testicular edema, agranulocytosis, leukopenia, eosinophilia, cholestatic jaundice, increased liver enzymes, increased intraocular pressure, tinnitus, allergic reactions.

Overdose/Toxicology: Symptoms of overdose include agitation, confusion, hallucinations, hyperthermia, urinary retention, CNS depression, cyanosis, dry mucous membranes, cardia arrhythmias, and seizures. Treatment is supportive. Ventricular arrhythmias and EKG changes (eg, QRS widening) often respond with concurrent systemic alkalinization (sodium bicarbonate 0.5-2 mEq/kg I.V. or hyperventilation). Arrhythmias unresponsive to phenytoin 15-20 mg/kg (adults) may respond to lidocaine. Physostigmine (1-2 mg I.V. slowly for adults) may be indicated for reversing life-threatening cardiac arrhythmias.

Nortriptyline

Nutrients Depleted: Coenzyme Q10, B2

U.S. Brand Names: Aventyl® Hydrochloride; Pamelor®

Use: Treatment of various forms of depression, often in conjunction with psychotherapy. Maximum antidepressant effect may not be seen for 2 or more weeks after initiation of therapy; has also demonstrated effectiveness for chronic pain.

Pregnancy Risk Factor and Implications: D; enters breast milk/contraindicated.

Contraindications: Narrow-angle glaucoma, avoid use during pregnancy and lactation; hypersensitivity to tricyclic antidepressants.

Dietary Considerations:

Alcohol: Additive CNS effects, avoid use.

Warnings/Precautions: Use with caution in patients with cardiac conduction disturbances, history of hyperthyroid; should not be abruptly discontinued in patients receiving high doses for prolonged periods; use with caution with renal or hepatic impairment.

Adverse Reactions:

Over 10% experience:

Central nervous system: Dizziness, drowsiness, headache
Gastrointestinal: Xerostomia, constipation, increased appetite, nausea, unpleasant taste, weight gain
Neuromuscular & skeletal: Weakness

1% to 10% experience:

Cardiovascular: Postural hypotension, arrhythmias, tachycardia, sudden death
Central nervous system: Confusion, delirium, hallucinations, nervousness, restlessness, parkinsonian syndrome, insomnia
Endocrine & metabolic: Sexual dysfunction
Gastrointestinal: Diarrhea, heartburn, constipation
Genitourinary: Dysuria, urinary retention
Ocular: Blurred vision, eye pain, increased intraocular pressure
Neuromuscular & skeletal: Fine muscle tremors
Miscellaneous: Diaphoresis (excessive)

Less than 1% experience: Anxiety, seizures, alopecia, photosensitivity, breast enlargement, galacxtorrhea, SIADH, trouble with gums, decreased lower esophageal sphincter tone may cause GE reflux, testicular edema, leukopenia, rarely agranulocytosis, eosinophilia, increased liver enzymes, cholestatic jaundice, increased intraocular pressure, tinnitus, allergic reactions.

Overdose/Toxicology: Symptoms of overdose include agitation, confusion, hallucinations, urinary retention, hypothermia, hypotension, seizures, and ventricular tachycardia. Treatment is symptomatic and supportive. Alkalinization by sodium bicarbonate and/or hyperventilation may limit cardic toxicity.

Clomipramine

Nutrients Depleted: Coenzyme Q10, Vitamin B2

U.S. Brand Names: Anafranil®

Use: Treatment of obsessive-complusive disorder (OCD); may also relieve depression, panic attacks, and chronic pain.

Pregnancy Risk Factor and Implications: C; enters breast milk/contraindicated.

Contraindications: Patients in acute recovery stage of recent myocardial infarction; not to be used within 14 days of MAO inhibitors.

Warnings/Precautions: Seizures are likely and are dose-related; can be additive when coadministered with other drugs that can lower the seizure threshold; use with caution in patients with asthma, bladder outlet destruction, narrow-angle glaucoma.

Adverse Reactions:

Over 10% experience:

Central Nervous System: Dizziness, drowsiness, headache
Gastrointestinal: Xerostomia, constipation, increased appetite, nausea, unpleasant taste,

1% to 10% experience:

Dermatologic: Rash, urticaria, photosensitivity
Miscellaneous: Decreased vitamin B12 levels

Less than 1% experience: Blood dyscrasias, aplastic anemia, hemolytic anemia, bone marrow suppression, thrombocytopenia, agranulocytosis.

Overdose/Toxicology: Hypoglycemia has not been observed with ingestion up to 85 g of metformin, although lactic acidosis has occurred in such circumstances. Metformin is dialyzable with a clearance of up to 170 mL/minute. Hemodialysis may be useful for removal of accumulated drug from patients in whom metformin overdose is suspected. Treatment is supportive.

Nonsteroidal Anti-Inflammatory Drugs

Nutrients Depleted: Folic Acid

U.S. Brand Names: Aches-N-Pain® [OTC]; Actron® [OTC]; Acular® Ophthalmic; Advil®[OTC]; Aleve® [OTC]; Anaprox®; Cataflam® Oral; Children's Advil® Suspension [OTC]; Children's Motrin® Oral Suspension [OTC]; Clinoril®; Dolobid® Excedrin® IB [OTC]; Feldene®; Genpril ® [OTC]; Haltran® [OTC]; Ibuprin® [OTC]; Ibuprohm® [OTC]; Ibu-Tab®; Indochron ER®; Indocrin®; Indocrin® SR; Junior Strength Motrin® [OTC]; Lodine®; Lodine® XL; Meclomen®; Medipren® [OTC]; Menadol® [OTC]; Midol® 200 [OTC]; Motrin®; Motrin® IB [OTC]; Nalfon®; Naprelan®; Naprosyn®; Nuprin® [OTC]; Orudia®; Orudis® KT [OTC]; Oruvail®; Pamprin IB® [OTC]; PediaProfen™; Ponstel®; Relafen®; Saleto-200® [OTC]; Saleto-400®; Tolectin®; Tolectin® DS; Toradol® Injection; Toradol® Oral; Trendar® [OTC]; Uni-Pro® [OTC]; Voltaren® Ophthalmic; Voltaren® Oral; Voltaren XR® Oral

Use: Management of inflammatory and rheumatoid disorders; gout, ankylosing spondylitis, mild to moderate pain, fever, dysmenorrhea, and acute migraine headache. Specific agents in this class are used in the management of postoperative pain or for closure of patent ductus arteriosus.

Pregnancy Risk Factor and Implications: B (D in 3rd trimester); Many NSAIDS enter breast milk/use caution. Etodolac: excretion in breast milk unknown/contraindicated.

Contraindications: Hypersensitivity to nonsteroidal anti-inflammatory agents, including aspirin, or any component of formulation.

Dietary Precaution: Should be taken with food or milk to minimize gastrointestinal irritation. Food may decrease the rate but not the extent of absorption.

Warnings/Precautions: Use caution in patients with renal or hepatic insufficiency, congestive heart failure, hypertension, history of GI bleeding or ulcers, and patients receiving anticoagulants. NSAIDS may compromise renal function, particularly when pre-existing renal impairment (CI_CR less than 30 mL/minute) is present. Photosensitivity and severe hepatotoxicity have been reported with some agents. Pain is not a reliable indicator of gastrointestinal damage. Gastrointestinal ulceration and/or hemorrhage may be subtle or even painless in many patients. The elderly are at high risk for adverse reactions. To minimize adverse effects, the lowest effective dose should be used for the shortest possible period of time. Adverse central nervous system effects, including dizziness, hallucinations, agitation, and seizures normally occur only in overdose but may occur with therapeutic dosages, particularly in elderly patients.

Adverse Reactions: Individual NSAIDS may vary in their potential to cause specific adverse effects. The listing below provides a general indication of the spectrum and frequency of adverse reactions to NSAIDS.

1% to 10% experience:

Central Nervous System: Headache, nervousness, dizziness, fatigue
Dermatologic: Rash, urticaria, itching
Endocrine & metabolic: Fluid retention
Gastrointestinal: Heartburn, vomiting, abdominal pain, peptic ulcer, GI bleeding, GI perforation, abdominal cramps, indigestion, nausea
Otic: Tinnitus

Less than 1% experience (Limited to important or life-threatening symptoms): Edema, congestive heart failure, arrhythmias, tachycardia, hypertension, erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson syndrome, lupus erythematosus syndrome, Henoch-Schonlein vasculitis, angioedema, aseptic meningitis with fever and coma, neutropenia, agranulocytosis, aplastic anemia, inhibit platelet aggregation, hemolytic anemia, bone marrow depression, leukopenia, thrombocytopenia, eosinophilia, hepatitis acute renal failure, polyuria, azotemia, hematuria, elevated serum creatinine, dyspnea.

Overdose/Toxicology: Symptoms of overdose include apnea, metabolic acidosis, coma, nystagmus, seizures, leukocytosis, and renal failure. Management of nonsteroidal anti-inflammatory (NSAID) intoxication is supportive and symptomatic. Since many NSAIDS undergo enterohepatic cycling, multiple doses of charcoal may be needed to reduce the potential for delayed toxicities.