Indications: Depression (not first line), anxiety (not first line), nerve pain, migraine prophylaxis
Examples: Amitriptyline, clomipramine, doxepin, imipramine, desimpraine, nortriptyline
Dosing: most agents can be dosed once daily at bedtime due to drowsiness (may also help with sleep)
Adverse Effects: (Many! Mostly anticholinergeic, hence, not first line)
-drowsiness
-increased heart rate (toxic in overdose due to arrhythmias)
-dizziness (orthostatic hypotension)
-weight gain
-dry mouth
-constipation
-sexual dysfunction
Drug Interactions:
-serotonin syndrome with other serotonin agents such as SSRIs, SNRIs, triptans, MAO inhibitors etc.
-anticholinergic toxicity with other agents such as opioids
-many are metabolized through CYP2D6, so caution with inhibitors such as paroxetine, terbinafine, fluoxetine