Nortriptyline (Pamalor), Desipramine (Norpramin), Amitriptyline (Elavil), Doxepin (Sinequan)
On Label Use:
Depression (usually at higher doses)
Neuropathic pain, CRPS 1, CRPS 2, sleep disturbance, fibromyalgia
Decreased burning pain, electrical pain, stabbing pain caused by nerve injury. Improved sleep. Decreased tender point tenderness
Dose Range and Titration:
Nortriptyline 10 mg to 75 mg at bedtime
Desipramine 10 mg to 75 mg at bedtime
Amitriptyline 10 mg to 150 mg at bedtime
Doxepin 10 mg to 150 mg at bedtime
Titrate up q week by one dose increment to maximum dose, good pain relief, or intolerable side effects.
Dry mouth, blurred vision, drowsiness, constipation, urinary retention, hangover effects, sleeplessness, cardiac arrythmias
Levels may be increased precipitously by SSRI's with high protein binding or Cytochrome P450 2D6 metabolizing pathways.
Dependency or Abstinence Syndrome:
None- there may be rebound insomnia or tachycardia with abrupt cessation. Titrate downward over a few days to a few weeks for daily doses above 30-50 mg daily.