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(pro-TRIP-tih-leen HIGH-droe-KLOR-ide)
Vivactil,  Triptil
Class: Tricyclic antidepressant

 Action Inhibits reuptake of norepinephrine and serotonin in CNS.

 Indications Relief of symptoms of mental depression in patients who are under close medical supervision. Unlabeled use(s): Treatment of obstructive sleep apnea and panic disorder.

 Contraindications Hypersensitivity to tricyclic antidepressants. Generally not to be given in combination with or within 14 days of treatment with MAO inhibitors, nor during acute recovery phases of MI.

 Route/Dosage

ADULTS: PO 15 to 60 mg/day in divided doses. Maintenance dose: May be given as a single daily dose. ELDERLY & ADOLESCENTS: PO Initial dose: 5 mg tid. Increase slowly if needed.

 Interactions

Cimetidine, fluoxetine: Increased protriptyline blood levels and effects. CNS depressants: Additive depressant effects. Clonidine: Hypertensive crisis. Dicumarol: Increased anticoagulant actions. Guanethidine: Inhibition of hypotensive action by guanethidine. MAO inhibitors: Hyperexcitability, hyperthermia, convulsions, and death may occur. Sympathomimetics, direct-acting (eg, norepinephrine, phenylephrine): Increased pressor response. Sympathomimetics, indirect-acting (eg, dopamine, ephedrine): Decreased pressor response.

 Lab Test Interferences None well documented.

 Adverse Reactions

CV: Orthostatic hypotension; hypertension; tachycardia; palpitations; arrhythmias; ECG changes; heart block; CHF. CNS: Confusion; hallucinations; disorientation; delusions; nervousness; restlessness; anxiety; agitation; panic; insomnia; nightmares; mania; exacerbation of psychosis; drowsiness; dizziness; weakness; fatigue; emotional lability; seizures; tremors. DERM: Rash; pruritus; photosensitivity reaction; dry skin; acne; itching. EENT: Mydriasis; blurred vision; increased intraocular pressure; tinnitus; peculiar taste. GI: Nausea; vomiting; anorexia; GI distress; diarrhea; flatulence; dry mouth; constipation. GU: Impotence; sexual dysfunction; nocturia; dysmenorrhea; amenorrhea; urinary retention and hesitancy. HEMA: Bone marrow depression, including agranulocytosis; eosinophilia; purpura; thrombocytopenia; leukopenia. META: Elevation or depression of blood glucose. RESP: Pharyngitis, rhinitis; sinusitis; laryngitis; cough. OTHER: Numbness; breast enlargement; extrapyramidal symptoms (eg, pseudoparkinsonism, movement disorders, akathisia).

 Precautions

Pregnancy: Pregnancy category undetermined. Lactation: Excreted in breast milk. Children: Not recommended for use in children. Special-risk patients: Use drug with caution in patients with history of seizures, urinary retention, urethral or ureteral spasm, angle-closure glaucoma or increased intraocular pressure, cardiovascular disorders, hyperthyroid patients or those receiving thyroid medication, hepatic or renal impairment, schizophrenic or paranoid patients. Anticholinergic effects: Additive with other medications with anticholinergic effects. Tachycardia/Postural hypotension: Tachycardia and postural hypotension may occur more frequently with protriptyline.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

  • Give with food or milk to minimize GI irritation.
  • Maintenance doses may be given as a single daily dose, in the morning and not at night, because of the mild stimulant effect of the drug.
  • Store at room temperature in tightly-closed, light-resistant container.

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies. Note recent MI, seizure disorder or prostatic hypertrophy.
  • Ensure that baseline CBC with differential, ECG and hepatic studies have been obtained before beginning therapy and monitor regularly.
  • Obtain baseline weight, BP (standing and lying), and pulse.
  • Supervise patient closely during initiation of therapy. Assess appearance, behavior, speech pattern, level of interest, and mood.
  • Monitor for weight gain (appetite may increase), dysrhythmias, and drop in BP. Withhold drug and notify physician if systolic pressure drops 20 mm Hg.
  • Closely monitor cardiovascular response of elderly patients receiving > 20 mg/day.
  • Assist with ambulation at start of therapy and provide safety measures (eg, side rails up), especially for elderly patients.
  • Monitor for headache, nausea, vertigo, malaise, and nightmares (symptoms of withdrawal when drug is abruptly discontinued or dose reduced).
  • Monitor pattern of daily bowel activity, stool consistency, and urinary output. Modify fluid and bulk in diet to offset constipation.
OVERDOSAGE: SIGNS & SYMPTOMS
  CNS stimulation (agitation, irritability, delirium) followed by depression (drowsiness to coma), hypertension followed by hypotension, hyperpyrexia followed by hypothermia, cardiac arrhythmias, seizures

 Patient/Family Education

  • Explain that therapeutic effect of drug may be seen within 2 to 5 days, but full effectiveness of drug may not occur for 2 to 3 wk.
  • Tell patient that dosage will be tapered slowly before stopping to prevent withdrawal symptoms.
  • Warn patient to monitor food intake; weight gain can occur because of increased appetite.
  • Emphasize importance of follow-up visits to monitor effectiveness of therapy.
  • Instruct patient to report the following symptoms to physician: Visual disturbances, mental status changes (especially increase in depression or panic), urinary retention and extrapyramidal symptoms (frequently noted in elderly) such as rigidity or fine hand tremors.
  • Advise patient to take sips of water frequently or to suck on ice chips, sugarless hard candy or chew sugarless gum to relieve dry mouth.
  • Caution patient to avoid sudden position changes to avoid dizziness.
  • Instruct patient to avoid intake of alcoholic beverages or other CNS depressants.
  • Advise patient that drug may cause drowsiness and to use caution while driving or performing other activities requiring mental alertness while dose is being stabilized.
  • Caution patient to avoid exposure to sunlight and use sunscreen or wear protective clothing to avoid photosensitivity reaction.
  • Instruct patient to avoid taking otc medications without consulting physician.

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