Amitriptyline Indications and Dosage
- attention-deficit hyperactivity disorder (ADHD) †
- bulimia nervosa †
- depression
- diabetic neuropathy †
- enuresis †
- fibromyalgia †
- insomnia †
- migraine prophylaxis †
- neuropathic pain †
- panic disorder †
- postherpetic neuralgia †
- singultus (hiccups) †
- social phobia (social anxiety disorder) †
† non-FDA-approved indication
Amitriptyline Indications and Dosage
For the treatment of major depression (including patients with schizophrenia or psychosis with depressive symptoms):
Oral dosage:
Adults and adolescents: Initially, 25 - 75 mg/day PO, given as a single dose at bedtime or in divided doses. Titrate if needed, up to 200 mg/day PO, by increasing the daily dose 25 - 50 mg at weekly intervals, depending on response and adverse effects. Adolescents may use lower doses, such as 10 mg PO three times a day, plus 20 mg PO at bedtime. Maximum dosage in hospitalized patients is 300 mg/day PO.
Elderly: Initially, 10 - 25 mg PO at bedtime. Titrate, as needed, up to 150 mg/day PO given as a single dose at bedtime or in divided doses. Maximum dose is 150 mg/day PO.
Children >= 6 years † : Initially, 1 mg/kg/day PO in 3 divided doses has been used, with further increases up to 1.5 mg/kg/day. Some clinicians suggest doses up to 3 mg/kg/day. The manufacturer does not recommend the use of amitriptyline in children; safety and efficacy in children < 12 years has not been established.
Intramuscular dosage (for patients unable to take oral medication; NOTE: Elavil® injection is no longer available in the US):
Adults: 20 - 30 mg IM three times per day as an initial dose. Use of IM amitriptyline is rarely needed, with the possible exception of persons that are unable to take the medication orally. Oral therapy should replace IM therapy as soon as possible.
Children: Dosage not established.
For neuropathic pain † syndromes:
- for the general treatment of neuropathic pain † :
Oral dosage:
Adults: Doses of 10 - 150 mg/day PO can be used. Start at low doses and gradually increase as needed.
Children >= 6 years: Initially, 0.1 mg/kg PO at bedtime. This dose may be titrated, as tolerated or needed, over 2 - 3 weeks to 0.5 - 2 mg/kg PO at bedtime.
- for the treatment of diabetic neuropathy † :
Oral dosage:
Adults: Initially, 25 mg PO 1 - 2 hours before bedtime has been recommended. Titrate in 10 - 25 mg increments once or twice a week, if needed, until 150 mg PO at bedtime is reached or side effects are limiting.
- for the treatment of postherpetic neuralgia † :
Oral dosage:
Adults: A median dose of 75 mg/day PO at bedtime (range 25 - 137.5 mg/day) after titration has provided good to excellent responses; patients rated as having a poor response took a median dose of 50 mg/day PO at bedtime (range 25 - 125 mg/day).
For the treatment of social phobia (social anxiety disorder) † or panic disorder † :
Oral dosage:
Adults: 25 mg PO three times per day initially. Titrate the dose up to 200 mg/day PO, as tolerated or needed, by increasing the daily dose 25 - 50 mg at weekly intervals, depending on response and adverse effects. Maximum dosage in hospitalized patients is 300 mg/day PO.
For the treatment of attention-deficit hyperactivity disorder (ADHD) † or bulimia nervosa † :
Oral dosage:
Adults: 25 mg PO three times per day initially. Titrate the dose to 200 mg/day PO by increasing the daily dose 25 - 50 mg at weekly intervals, as tolerated or needed. Maximum dosage in hospitalized patients is 300 mg PO per day.
Children 6 - 12 years: 10 - 30 mg/day PO, or 1 - 5 mg/kg/day PO, given in divided doses.
For the treatment of insomnia † :
Oral dosage:
Adults: 10 - 50 mg PO at bedtime.
For migraine prophylaxis † :
Oral dosage:
Adults: Titrate to response. 10 - 300 mg PO per day has been used.
For the treatment of fibromyalgia † :
Oral dosage:
Adults: In one trial, amitriptyline 10 mg PO once daily at bedtime and titrated up to 50 mg PO at bedtime was superior to placebo at 1 month but not significantly better at 3 or 6 months. In another small study comparing amitriptyline to fluoxetine, placebo, or the combination of amitriptyline with fluoxetine, amitriptyline 25 mg PO once daily alone was superior to placebo.
For the treatment of persistent singultus (hiccups) † :
Oral dosage:
Adults: 10 mg PO three times per day was effective for relieving idiopathic intractable hiccups resistant to both chlorpromazine and metoclopramide.
For the treatment of primary nocturnal enuresis † :
Oral dosage:
Children 11 - 14 years: 50 mg PO at bedtime has been successful either alone or in combination with desmopressin.
Children 6 - 10 years: 25 mg PO at bedtime has been successful either alone or in combination with desmopressin.
Maximum Dosage Limits:
- Adults: 200 mg/day PO in outpatients; 300 mg/day PO for hospitalized patients.
- Elderly: 150 mg/day PO.
- Adolescents: 200 mg/day PO in outpatients; 300 mg/day PO for hospitalized patients.
- Children >= 6 years: 1.5 mg/kg/day PO for outpatients; 3 - 5 mg/kg/day PO for hospitalized patients under close monitoring, have been suggested.
- Children < 6 years: Safe and effective use not established.
Patients with hepatic impairment:
Amitriptyline should be used with caution in those with hepatic impairment; if the drug must be used, a lower initial dosage and caution in dose titration is recommended.
Patients with renal impairment:
Specific guidelines for dosage adjustments in renal impairment are not available; it appears no dose adjustment is needed. Little unchanged drug appears in the urine. Hemodialysis is reported as ineffective in removing amitriptyline from the body.
† non-FDA-approved indication
[ Last revised: 5/23/2005 11:21:00 AM ]
References
. Schulman EA, Silberstein SD. Symptomatic and prophylactic treatment of migraine and tension-type headache. Neurology 1992;42(suppl 2):16 - 21.
. Belgrade MJ, Lev BI. Diabetic neuropathy. Postgrad Med 1991;90:263 - 70.
. Carette S, Bell MJ, Reynolds WJ et al. Comparison of amitriptyline, cyclobenzaprine, and placebo in the treatment of fibromyalgia. A randomized, double-blind clinical trial. Arthritis Rheum 1994;37:32 - 40.
. Lewis JH. Hiccups: causes and cures. J Clin Gastroenterol 1985;7:539 - 52.
. Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emer Med 1992;20:565 - 72.
. Watson CP, Evan RJ, Reed K et al. Amitriptyline versus placebo in postherpetic neuralgia. Neurology 1982;32:671 - 3.
. Goldenberg D et al. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum 1996;39:1852 - 9.
. Burke JR, Mizusawa Y, Chan A, et al. A comparison of amitriptyline, vasopressin and amitriptyline with vasopressin in nocturnal enuresis. Pediatr Nephrol 1995;9:438 - 40.
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