Dosing and uses of Vivactil (protriptyline)
Adult dosage forms and strengths
tablet
- 5mg
- 10mg
Depression
Initiate at low dose (10 mg/day) and gradually titrate upward every 5-7 days
15-60 mg/day PO divided q6-8hr; not to exceed 60 mg/day
Pediatric dosage forms and strengths
tablet
- 5mg
- 10mg
Depression
<12 years: Safety and efficacy not established
≥12 years: 15-20 mg PO qDay
See Black Box Warning
Geriatric dosage forms and strengths
5 mg PO q8hr initially; increase by 5-10 mg q3-7days PRN; cardiovascular adverse effects may increase if doses exceed 20 mg/day
Vivactil (protriptyline) adverse (side) effects
1-10%
Sedation
Fatigue
Headache
Agitation
Insomnia
Blurred vision
Weakness
Lethargy
Anxiety
Dry mouth
Constipation
Nausea
Vomiting
Sweating
Weight change
Frequency not defined
Confusion
EPs
Dizziness
Tinnitus
Paresthesia
Seizure (rare)
Worsening depression/suicide (rare)
Orthostatic hypotension
ECG changes
Tachycardia
Paralytic ileus (rare)
Agranulocytosis (rare)
Thrombocytopenia (rare)
Eosinophilia (rare)
Leukopenia (rare)
Increased LFTs
Sexual dysfunction
Rash
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
Within 14 days of MAOIs (risk of serotonin syndrome); if linezolid or IV methylene blue (MAOIs) must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity; may resume 24 hr after last linezolid or methylene blue dose, or after 2 weeks of monitoring, whichever comes first
Any drugs or conditions that prolong QT intervaL
Acute recovery post-MI
Cautions
Caution in BPH, urinary/GI retention, 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 Vivactil (protriptyline)
Mechanism of action
Neurotransmitter (especially NE and serotonin) reuptake inhibitor; increases concentration of neurotransmitte in the central nervous system.
Pharmacokinetics
Half-Life: 54-92 hr
Peak Plasma Time: 24-30 hr
Protein binding: 92%
Bioavailability: Completely absorbed
Metabolism: Hepatic (oxidation, hydroxylation, glucuronidation)
Excretion: Urine
