Dosing and uses of Surmontil, Trimip (trimipramine)
Adult dosage forms and strengths
capsule
- 25mg
- 50mg
- 100mg
Depresssion
Outpatient
- Initial: 50-75 mg PO qDay in divided doses; gradually titrate upward q2-3Weeks
- Maintentance: 50-150 mg PO qDay; may increase up to 200 mg/day if needed
- Adolscents: Not to exceed 100 mg/day
Inpatient
- 100 mg PO qDay; initially, may increase over a few days up to 200 mg/day
- May increase up to 250-300 mg/day if no improvement in 2-3 weeks
Pediatric dosage forms and strengths
capsule
- 25mg
- 50mg
- 100mg
Depression
<12 years: Safety and efficacy not established
≥12 years: 50 mg/day initially; titrate to 100 mg/day
Administer lowest effective dose for maintenance
Geriatric dosage forms and strengths
Avoid; strong anticholinergic and sedative effects; may cause orthostatic hypotension (Beers criteria)
Consider alternatives; if must use, initiate with lower initial dose
50 mg/day PO initially; may increase up to 100 mg/day
Surmontil, Trimip (trimipramine) adverse (side) effects
Frequency not defined
Sedation (less than amitriptyline, but greater than imipramine)
Fatigue
Dry mouth
Constipation
Blurred vision
Weakness
Lethargy
Headache
Agitation
Insomnia
Nausea/vomiting
Anxiety
Sweating
Confusion
EPs
Dizziness
Tinnitus
Paresthesia
Orthostatic hypotension
ECG changes
Tachycardia
Incr LFTs
Sexual dysfunction
Rash
Seizure (rare)
Agranulocytosis, thrombocytopenia, eosinophilia, leukopenia (rare)
SIADH (rare)
Warnings
Black box warnings
In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (<24 yr of age) taking antidepressants for major depressive disorders and other psychiatric illnesses
This increase was not seen in patients aged >24 years; a slight decrease in suicidal thinking was seen in adults >65 years
In children and young adults, risks must be weighed against the benefits of taking antidepressants
Patients should be monitored closely for changes in behavior, clinical worsening, and suicidal tendencies; this should be done during initial 1-2 months of therapy and dosage adjustments
The patient’s family should communicate any abrupt changes in behavior to the healthcare provider
Worsening behavior and suicidal tendencies that are not part of the presenting symptoms may require discontinuation of therapy
This drug is not approved for use in pediatric patients
Contraindications
Hypersensitivity
Severe cardiovascular disorder
Narrow angle glaucoma
Any drugs or conditions that prolong QT intervaL
Acute recovery post-MI
Coadministration with serotonergic drugs
- Do not use MAOIs concomitantly or within 14 days before initiating trimipraminw or within 14 days after discontinuing trimipramine
- Symptoms include tremor, myoclonus, diaphoresis, nausea, vomiting, flushing, dizziness, hyperthermia with features resembling neuroleptic malignant syndrome, seizures, rigidity, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes that include extreme agitation progressing to delirium and coma
- Starting trimipramine in a patient who is being treated with linezolid or IV methylene blue is contraindicated because of an increased risk of serotonin syndrome
- If linezolid or IV methylene blue must be administered, discontinue trimipramine immediately and monitor for CNS toxicity; may resume imipramine 24 hr after last linezolid or methylene blue dose or after 2 weeks of monitoring, whichever comes first
Cautions
BPH, urinary/GI retention, increases IOP, hyperthyroidism, open-angle glaucoma, seizure disorder, brain tumor, respiratory impairment
Clinical worsening and suicide ideation may occur despite medication
Risk of anticholinergic side-effects
Risk of mydriasis; may trigger angle closure attack in patients with angle closure glaucoma with anatomically narrow angles without a patent iridectomy
Pregnancy and lactation
Pregnancy category: C
Lactation: avoid
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of Surmontil, Trimip (trimipramine)
Mechanism of action
Neurotransmitter (esp NE & serotonin) reuptake inhibitor; inhibits reuptake by neuronal membrane; may also downregulate beta-adrenergic receptors and serotonin receptors
Pharmacokinetics
Half-Life elimination: 16-40 hr
Peak Plasma Time: 2 hr
Metabolism: Hepatic
Bioavailability: 18-63%
Excretion: Urine
Vd: 17-48 L/kg
Protein binding: 95%
