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Due to the risk of toxicity in overdose and the potential for suicide attempts or self-harm, consider limiting the quantity prescribed on each prescription (see Suicide risk, here).
Tricyclic antidepressants (TCAs) are associated with the greatest risk in overdose; lofepramine is associated with fewer anticholinergic side effects, is less sedating and is considered to be safer in overdose. Amitriptyline, imipramine and clomipramine should be avoided where there is a suicide risk. It is accepted that Selective Serotonin Re-uptake Inhibitors (SSRIs) are better tolerated and are safer in overdose than other classes of antidepressants and should be considered first-line for treating depression. Refer to formulary guidance on the management of unipolar depression here.
Elderly patients are particularly susceptible to many of the side-effects of tricyclic antidepressants; low initial doses should be used, with close monitoring, particularly for psychiatric and cardiac side-effects.
Healthcare professionals should be aware of the small increased risk of fractures in patients taking, or starting to take TCAs (MHRA, 2014).
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Following national guidance from NHS England, dosulepin is not recommended for use due to significant safety concerns. It is more toxic than other tricyclic antidepressants due to its pro-convulsive and cardiac arrhythmic effects and it is very dangerous in overdose. Click here for more information. Prescribers should not initiate dosulepin for any new patient. If, in exceptional circumstances, there is a clinical need for dosulepin to be initiated, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional. Patients currently prescribed dosulepin should be regularly reviewed, and alternative treatments considered. Click the following link for a patient information leaflet to support deprescribing.
Following national guidance from NHS England, trimipramine is not recommended for use due to significantly higher costs; more cost-effective tricyclic antidepressants are available. Click here for more information. Prescribers should not initiate trimipramine for any new patient. Click the following link for a patient information leaflet to support deprescribing.
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