|Adapin® Oral; Sinequan® Oral;
Antidepressant, Tricyclic (Tertiary Amine); Topical Skin
Psychoneurotic patients with depression and/or anxiety; depression and/or
anxiety associated with alcoholism; depression and/or anxiety associated with
organic disease; psychotic depressive disorders with associated anxiety,
including involutional depression and manic-depressive disorder
Topical: Short-term (<8 days) management of moderate pruritus in adults
with atopic dermatitis or lichen simplex chronicus
Hypersensitivity to this drug and similar chemical class; narrow angle
glaucoma; urinary retention; use of monoamine oxidase inhibitors within 14 days;
use in a patient during the acute recovery phase of MI
Often causes sedation, which may result in impaired performance of tasks
requiring alertness (ie, operating machinery or driving). Sedative effects may
be additive with other CNS depressants and/or ethanol. The degree of sedation is
very high relative to other antidepressants. May worsen psychosis in some
patients or precipitate a shift to mania or hypomania in patients with bipolar
disease. May increase the risks associated with electroconvulsive therapy. This
agent should be discontinued, when possible, prior to elective surgery. Therapy
should not be abruptly discontinued in patients receiving high doses for
Use caution in patients with depression, particularly if suicidal risk may be
present. Use with caution in patients with a history of cardiovascular disease
(including previous MI, stroke, tachycardia, or conduction abnormalities). The
risk of conduction abnormalities with this agent is moderate relative to other
antidepressants. Use caution in patients with a previous seizure disorder or
condition predisposing to seizures such as brain damage, alcoholism, or
concurrent therapy with other drugs which lower the seizure threshold. Use with
caution in hyperthyroid patients or those receiving thyroid supplementation. Use
with caution in patients with hepatic or renal dysfunction and in elderly
patients. Use in children <12 years of age has not been established.
Cardiovascular: Hypotension, hypertension, tachycardia
Central nervous system: Drowsiness, dizziness, headache, disorientation,
ataxia, confusion, seizure
Dermatologic: Alopecia, photosensitivity, rash, pruritus
Endocrine & metabolic: Breast enlargement, galactorrhea, SIADH, increase
or decrease in blood sugar, increased or decreased libido
Gastrointestinal: Xerostomia, constipation, vomiting, indigestion, anorexia,
aphthous stomatitis, nausea, unpleasant taste, weight gain, diarrhea, trouble
with gums, decreased lower esophageal sphincter tone may cause GE reflux
Genitourinary: Urinary retention, testicular edema
Hematologic: Agranulocytosis, leukopenia, eosinophilia, thrombocytopenia,
Neuromuscular & skeletal: Weakness, tremors, numbness, paresthesia,
extrapyramidal symptoms, tardive dyskinesia
Ocular: Blurred vision
Miscellaneous: Diaphoresis (excessive), allergic reactions
Symptoms of overdose include confusion, hallucinations, seizures, urinary
retention, hypothermia, hypotension, tachycardia, cyanosis
Following initiation of essential overdose management, toxic symptoms should
be treated. Sodium bicarbonate is indicated when QRS interval is >0.10
seconds or QTc >0.42 seconds. Ventricular arrhythmias often
respond to systemic alkalinization with or without phenytoin 15-20 mg/kg
(adults) (sodium bicarbonate 0.5-2 mEq/kg I.V.). Arrhythmias unresponsive to
this therapy may respond to lidocaine 1 mg/kg I.V. followed by a titrated
infusion. Physostigmine (1-2 mg I.V. slowly for adults or 0.5 mg I.V. slowly for
children) may be indicated in reversing cardiac arrhythmias that are
life-threatening. Seizures usually respond to diazepam I.V. boluses (5-10 mg for
adults up to 30 mg or 0.25-0.4 mg/kg/dose for children up to 10 mg/dose). If
seizures are unresponsive or recur, phenytoin or phenobarbital may be required.
CYP2D6 enzyme substrate CYP1A2, 2C9, 2C19, 2D6, and 3A3/4 enzyme substrate
Doxepin inhibits the antihypertensive response to bethanidine, clonidine,
debrisoquin, guanadrel, guanethidine, guanabenz, guanfacine; monitor BP;
consider alternate antihypertensive agent
Abrupt discontinuation of clonidine may cause hypertensive crisis, doxepin
may enhance the response
Use with altretamine may cause orthostatic hypertension
Doxepin may be additive with or may potentiate the action of other CNS
depressants (sedatives, hypnotics, or ethanol); with MAO inhibitors,
hyperpyrexia, hypertension, tachycardia, confusion, seizures, and deaths
have been reported (serotonin syndrome), this combination should be avoided
Doxepin may increase the prothrombin time in patients stabilized on warfarin
Cimetidine and methylphenidate may decrease the metabolism of doxepin
Additive anticholinergic effects seen with other anticholinergic agents
The SSRIs, to varying degrees, inhibit the metabolism of TCAs and clinical
toxicity may result
Use of lithium with a TCA may increase the risk for neurotoxicity
Phenothiazines may increase concentration of some TCAs and TCAs may increase
concentration of phenothiazines; monitor for altered clinical response
TCAs may enhance the hypoglycemic effects of tolazamide, chlorpropamide, or
insulin; monitor for changes in blood glucose levels
Cholestyramine and colestipol may bind TCAs and reduce their absorption;
monitor for altered response
TCAs may enhance the effect of amphetamines; monitor for adverse CV effects
Verapamil and diltiazem appear to decrease the metabolism of imipramine and
potentially other TCAs; monitor for increased TCA concentrations. The pressor
response to I.V. epinephrine, norepinephrine, and phenylephrine may be enhanced
in patients receiving TCAs, this combination is best avoided.
Grapefruit juice,amprenavir, indinavir, ritonavir may inhibit the metabolism
of clomipramine and potentially other TCAs; monitor for altered effects; a
decrease in TCA dosage may be required
Quinidine may inhibit the metabolism of TCAs; monitor for altered effect
Combined use of anticholinergics with TCAs may produce additive
anticholinergic effects; combined use of beta-agonists with TCAs may predispose
patients to cardiac arrhythmias
Protect from light
Increases the synaptic concentration of serotonin and norepinephrine in the
central nervous system by inhibition of their reuptake by the presynaptic
Peak effect (antidepressant): Usually more than 2 weeks; anxiolytic effects
may occur sooner
Distribution: Crosses the placenta; appears in breast milk
Protein binding: 80% to 85%
Metabolism: Hepatic; metabolites include desmethyldoxepin (active)
Half-life: Adults: 6-8 hours
Oral (entire daily dose may be given at bedtime):
Adolescents: Initial: 25-50 mg/day in single or divided doses; gradually
increase to 100 mg/day
Adults: Initial: 30-150 mg/day at bedtime or in 2-3 divided doses; may
gradually increase up to 300 mg/day; single dose should not exceed 150 mg;
select patients may respond to 25-50 mg/day
Dosing adjustment in hepatic impairment: Use a lower dose and adjust
Topical: Adults: Apply a thin film 4 times/day with at least 3- to 4-hour
interval between applications
Alcohol: Additive CNS effect, avoid use
Monitor blood pressure and pulse rate prior to and during initial therapy;
monitor mental status, weight
Therapeutic: 30-150 ng/mL; Toxic: >500 ng/mL; utility of serum level
monitoring is controversial
|Dental Health: Local
Use with caution; epinephrine, norepinephrine and levonordefrin have been
shown to have an increased pressor response in combination with
Effects on Dental Treatment|
>10% of patients experience dry mouth; long-term treatment with TCAs
increases the risk of caries by reducing salivation and salivary buffer
Oral: Take exactly as directed (do not increase dose or frequency); may take
several weeks to achieve desired results; may cause physical and/or
psychological dependence. Avoid excessive alcohol, caffeine, and other
prescription or OTC medications not approved by prescriber. Maintain adequate
hydration (2-3 L/day of fluids unless instructed to restrict fluid intake). You
may experience drowsiness, lightheadedness, impaired coordination, dizziness, or
blurred vision (use caution when driving or engaging in tasks requiring
alertness until response to drug is known); constipation (increased exercise,
fluids, or dietary fruit and fiber may help); urinary retention (void before
taking medication); postural hypotension (use caution climbing stairs or when
changing position from lying or sitting to standing); altered sexual drive or
ability (reversible); or photosensitivity (use sunscreen, wear protective
clothing and eyewear, and avoid direct sunlight). Report persistent CNS effects
(eg, nervousness, restlessness, insomnia, anxiety, excitation, headache,
agitation, impaired coordination, changes in cognition); muscle cramping,
weakness, tremors, or rigidity; chest pain, palpitations, or irregular
heartbeat; blurred vision or eye pain; yellowing of skin or eyes; or worsening
of condition. Pregnancy/breast-feeding precautions: Inform prescriber if
you are or intend to be pregnant. Breast-feeding is not recommended.
Topical: Use as directed. Apply in thin layer; do not overuse. Report
increased skin irritation, worsening of condition or lack of improvement.
May increase appetite; may cause drowsiness, raise bed rails, institute
Capsule, as hydrochloride: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
Concentrate, oral, as hydrochloride: 10 mg/mL (120 mL)
Cream: 5% (30 g)
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