Protriptyline

Overview

Protriptyline, sold under the brand name Vivactil among others, is a tricyclic antidepressant (TCA), specifically a secondary amine. Uniquely among most of the TCAs, protriptyline tends to be energizing instead of sedating, and is sometimes used for narcolepsy to achieve a wakefulness-promoting effect.[1] WP

TCAs including protriptyline are also used to reduce the incidence of recurring headaches such as migraine, and for other types of chronic pain.[2] WP

Uses, dosage and effects

Medical uses

Protriptyline is used primarily to treat depression and to treat the combination of symptoms of anxiety and depression. Like most antidepressants of this chemical and pharmacological class, protriptyline has also been used in limited numbers of patients to treat panic disorder, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, enuresis, eating disorders such as bulimia nervosa, cocaine dependency, and the depressive phase of bipolar disorder (manic-depressive) disorder. It has also been used to support smoking cessation programs.[3][4] WP

Protriptyline is available as 5 mg and 10 mg tablets. Doses range from 15 to 40 mg per day and can be taken in one daily dose or divided into up to four doses daily. Some people with severe depression may require up to 60 mg per day.[5] WP

In adolescents and people over age 60, therapy should be initiated at a dose of 5 mg three times a day and increased under the supervision of a physician as needed. Patients over age 60 who are taking daily doses of 20 mg or more should be closely monitored for side effects such as rapid heart rate and urinary retention.[5] WP

Like all TCAs, protriptyline should be used cautiously and with close physician supervision. This is especially so for persons with glaucoma, especially angle-closure glaucoma (the most severe form) or urinary retention, for men with benign prostatic hyperplasia (enlarged prostate gland), and for the elderly. Before starting treatment, people should discuss the relative risks and benefits of treatment with their doctors to help determine if protriptyline is the right antidepressant for them.[6] WP

Risks and side effects

Contraindications

Protriptyline may increase heart rate and stress on the heart. It may be dangerous for people with cardiovascular disease, especially those who have recently had a heart attack, to take this drug or other antidepressants in the same pharmacological class. In rare cases in which patients with cardiovascular disease must take protriptyline, they should be monitored closely for cardiac rhythm disturbances and signs of cardiac stress or damage.[7] WP

When protriptyline is used to treat the depressive component of schizophrenia, psychotic symptoms may be aggravated. Likewise, in manic-depressive psychosis, depressed patients may experience a shift toward the manic phase if they are treated with an antidepressant drug. Paranoid delusions, with or without associated hostility, may be exaggerated. In any of these circumstances, it may be advisable to reduce the dose of protriptyline or to use an antipsychotic drug concurrently.[5] WP

Side effects

Protriptyline shares side effects common to all TCAs. The most frequent of these are dry mouth, constipation, urinary retention, increased heart rate, sedation, irritability, decreased coordination, anxiety, blood disorders, confusion, decreased libido, dizziness, flushing, headache, impotence, insomnia, low blood pressure, nightmares, rapid or irregular heartbeat, rash, seizures, sensitivity to sunlight, stomach and intestinal problems. Other more complicated side effects include; chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling; sudden numbness or weakness, especially on one side of the body; sudden headache, confusion, problems with vision, speech, or balance; hallucinations, or seizure (convulsions); easy bruising or bleeding, unusual weakness; restless muscle movements in your eyes, tongue, jaw, or neck; urinating less than usual or not at all; extreme thirst with headache, nausea, vomiting, and weakness; or feeling light-headed or fainting.[3][5] WP

Dry mouth, if severe to the point of causing difficulty speaking or swallowing, may be managed by dosage reduction or temporary discontinuation of the drug. Patients may also chew sugarless gum or suck on sugarless candy in order to increase the flow of saliva. Some artificial saliva products may give temporary relief. Men with prostate enlargement who take protriptyline may be especially likely to have problems with urinary retention. Symptoms include having difficulty starting a urine flow and more difficulty than usual passing urine. In most cases, urinary retention is managed with dose reduction or by switching to another type of antidepressant. In extreme cases, patients may require treatment with bethanechol, a drug that reverses this particular side effect.[3][5] WP

A common problem with TCAs is sedation (drowsiness, lack of physical and mental alertness), but protriptyline is considered the least sedating agent among this class of agents. Its side effects are especially noticeable early in therapy. In most people, early TCA side effects decrease or disappear entirely with time, but, until then, patients taking protriptyline should take care to assess which side effects occur in them and should not perform hazardous activities requiring mental acuity or coordination. Protriptyline may increase the possibility of having seizures.[6][8] WP

Withdrawal

Though not indicative of addiction, abrupt cessation of treatment after prolonged therapy may produce nausea, headache, and malaise.[7] WP

List of side effects

• Cardiovascular: Myocardial infarction; stroke; heart block; arrhythmias; hypotension, particularly orthostatic hypotension; hypertension; tachycardia; palpitation.[9] WP
• Psychiatric: Confusional states (especially in the elderly) with hallucinations, disorientation, delusions, anxiety, restlessness, agitation; hypomania; exacerbation of psychosis; insomnia, panic, and nightmares.[3] WP
• Neurological: Seizures; incoordination; ataxia; tremors; peripheral neuropathy; numbness, tingling, and paresthesias of extremities; extrapyramidal symptoms; drowsiness; dizziness; weakness and fatigue; headache; syndrome of inappropriate ADH (antidiuretic hormone) secretion; tinnitus; alteration in EEG patterns.[3] WP
• Anticholinergic: Paralytic ileus; hyperpyrexia; urinary retention, delayed micturition, dilatation of the urinary tract; constipation; blurred vision, disturbance of accommodation, increased intraocular pressure, mydriasis; dry mouth and rarely associated sublingual adentitis.[3] WP
• Allergic: Drug fever; petechiae, skin rash, urticaria, itching, photosensitization (avoid excessive exposure to sunlight); edema (general, or of face and tongue).[3] WP
• Hematologic: Agranulocytosis; bone marrow depression; leukopenia;thrombocytopenia; purpura; eosinophilia.[3] WP
• Gastrointestinal: Nausea and vomiting; anorexia; epigastric distress; diarrhea; peculiar taste; stomatitis; abdominal cramps; black tongue.[3] WP
• Endocrine: Impotence, increased or decreased libido: gynecomastia in the male; breast enlargement and galactorrhea in the female; testicular swelling; elevation or depression of blood sugar levels.[3] WP
• Other: Jaundice (simulating obstructive); altered liver function; parotid swelling; alopecia; flushing; weight gain or loss; urinary frequency, nocturia; perspiration.[3] WP

Overdose

Deaths may occur from overdose with this class of drugs. Multiple drug ingestion (including alcohol) is common in deliberate TCA overdose. As management of overdose is complex and changing, it is recommended that the physician contact a poison control center for current information on treatment. Signs and symptoms of toxicity develop rapidly after TCA overdose, therefore, hospital monitoring is required as soon as possible.[3][8] WP

Critical manifestations of overdose include: cardiac dysrhythmias, severe hypotension, convulsions, and CNS depression, including coma. Changes in the electrocardiogram, particularly in QRS axis or width, are clinically significant indicators of TCA toxicity. Other signs of overdose may include: confusion, disturbed concentration, transient visual hallucinations, dilated pupils, agitation, hyperactive reflexes, stupor, drowsiness, muscle rigidity, vomiting, hypothermia, hyperpyrexia.[5] WP

Interactions

Interactions

The side effects of protriptyline are increased when it is taken with central nervous system depressants, such as alcoholic beverages, sleeping medications, other sedatives, or antihistamines, as well as with other antidepressants including SSRIs, SNRIs or monoamine oxidase inhibitors. It may be dangerous to take protriptyline in combination with these substances.[8] WP

Pharmacology

Pharmacodynamics

Protriptyline acts by decreasing the reuptake of norepinephrine and to a lesser extent serotonin (5-HT) in the brain. Its affinity for the human norepinephrine transporter (NET) is 1.41 nM, 19.6 nM for the serotonin transporter and 2,100 nM for the dopamine transporter. TCAs act to change the balance of naturally occurring chemicals in the brain that regulate the transmission of nerve impulses between cells. Protriptyline increases the concentration of norepinephrine and serotonin (both chemicals that stimulate nerve cells) and, to a lesser extent, blocks the action of another brain chemical, acetylcholine. The therapeutic effects of protriptyline, like other antidepressants, appear slowly. Maximum benefit is often not evident for at least two weeks after starting the drug.[7][10] WP

Protriptyline is a TCA. It was thought that TCAs work by inhibiting the reuptake of the neurotransmitters norepinephrine and serotonin by neurons. However, this response occurs immediately, yet mood does not lift for around two weeks. It is now thought that changes occur in receptor sensitivity in the cerebral cortex and hippocampus. The hippocampus is part of the limbic system, a part of the brain involved in emotions. TCAs are also known as effective analgesics for different types of pain, especially neuropathic or neuralgic pain. A precise mechanism for their analgesic action is unknown, but it is thought that they modulate anti-pain opioid systems in the central nervous system via an indirect serotonergic route. TCAs are also effective in migraine prophylaxis, but not in abortion of acute migraine attack. The mechanism of their anti-migraine action is also thought to be serotonergic, similar to psilocybin.[5] WP

Pharmacokinetics

Metabolic studies indicate that protriptyline is well absorbed from the gastrointestinal tract and is rapidly sequestered in tissues. Relatively low plasma levels are found after administration, and only a small amount of unchanged drug is excreted in the urine of dogs and rabbits. Preliminary studies indicate that demethylation of the secondary amine moiety occurs to a significant extent, and that metabolic transformation takes place in the liver. It penetrates the brain rapidly in mice and rats, and moreover that which is present in the brain is almost all unchanged drug. Studies on the disposition of radioactive protriptyline in human test subjects showed significant plasma levels within 2 hours, peaking at 8 to 12 hours, then declining gradually.[3] WP

Urinary excretion studies in the same subjects showed significant amounts of radioactivity in 2 hours. The rate of excretion was slow. Cumulative urinary excretion during 16 days accounted for approximately 50% of the drug. The fecal route of excretion did not seem to be important.[3] WP

Protriptyline has uniquely low dosing among TCAs, likely due to its exceptionally long terminal half-life. It is used in dosages of 15 to 40 mg/day, whereas most other TCAs are used at dosages of 75 to 300 mg/day. The maximum dose is 60 mg/day. Therapeutic levels of protriptyline are typically in the range of 70 to 250 ng/mL (266-950 nmol/L), which is similar to that of other TCAs[11–14] WP

History

History

Protriptyline was developed by Merck. It was patented in 1962 and first appeared in the literature in 1964. The drug was first introduced for the treatment of depression in 1966.[15][16] WP

Legal status

Generic names

Protriptyline is the English and French generic name of the drug and its INN (International Nonproprietary Name), BAN (British Approved Name), and DCF (Dénomination Commune Française), while protriptyline hydrochloride is its USAN (United States Adopted Name), USP (United States Pharmacopeia), and BANM (British Approved Name). Its generic name in Spanish and Italian and its DCIT (Denominazione Comune Italiana) are protriptylina, in German is protriptylin, and in Latin is protriptylinum.[17–20] WP

Brand names

Protriptyline is or has been marketed throughout the world under a variety of brand names including Anelun, Concordin, Maximed, Triptil, and Vivactil.[17][18] WP

Availability

The sale of protriptyline was discontinued in the United Kingdom, Australia, and Ireland in 2000. It remains available worldwide only in the United States as of 2024.[21][22][23] WP

Chemistry

Formula

C19H21N PC

CAS number

438-60-8 PC

Molar mass (g/mol)

263.4 PC

IUPAC name (computed by PubChem)

N-methyl-3-(2-tricyclo[9.4.0.03,8]pentadeca-1(15),3,5,7,9,11,13-heptaenyl)propan-1-amine PC

SMILES

CNCCCC1C2=CC=CC=C2C=CC3=CC=CC=C13 PC

InChIKey

BWPIARFWQZKAIA-UHFFFAOYSA-N PC

PubChem CID

4976

Harm reduction information

No harm reduction data is on file for this compound yet. That means no dose, timing or combination data from PsychonautWiki or TripSit. Please don't guess a dose from similar compounds. If you have taken it and feel unwell, contact emergency services or a poison control center.

User reports

Pop culture

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Sources

1. Journal / agency Schmidt, H. S., Clark, R. W., & Hyman, P. R. (1977). Protriptyline: An effective agent in the treatment of the narcolepsy-cataplexy syndrome and hypersomnia. The American Journal of Psychiatry, 134(2), 183–185
2. Journal / agency Cohen, G. L. Protriptyline, chronic tension-type headaches, and weight loss in women. Headache. 1997. doi:10.1046/j.1526-4610.1997.3707433.x · PMID 9277026
3. Other DURAMED PHARMACEUTICALS, INC.,. (Ed.). (2007). Protriptyline drug facts. Pomona, New York: Barr Pharmaceuticals, Inc
4. Other ULTRAM,. (Ed.). (2007). Protriptyline. Ortho-McNeil Pharmaceutical Inc
5. Other American Society of Health-System Pharmacists. AHFS Drug Information 2002. Bethesda: American Society of Health-System Pharmacists, 2002
6. Journal / agency Kirchheiner J, Nickchen K, Bauer M, Wong ML, Licinio J, Roots I, Brockmöller J. Pharmacogenetics of antidepressants and antipsychotics: the contribution of allelic variations to the phenotype of drug response. Molecular Psychiatry. May 2004. doi:10.1038/sj.mp.4001494 · PMID 15037866
7. Other Advameg, Inc. (2010). Protriptyline at MindDisorders.com
8. Other DeVane, C. Lindsay, Pharm.D. "Drug Therapy for Mood Disorders." In Fundamentals of Monitoring Psychoactive Drug Therapy. Baltimore: Williams and Wilkins, 1990
9. Journal / agency Sériès F, Cormier Y. Effects of protriptyline on diurnal and nocturnal oxygenation in patients with chronic obstructive pulmonary disease. Ann. Intern. Med. October 1990. doi:10.7326/0003-4819-113-7-507 · PMID 2393207
10. Other PDSP Database - UNC
11. Other Stahl SM. Prescriber's Guide: Stahl's Essential Psychopharmacology. 31 March 2017
12. Other Van Leeuwen AM, Bladh ML. Textbook of Laboratory and Diagnostic Testing: Practical Application of Nursing Process at the Bedside. 19 February 2016
13. Other Pagliaro LA, Pagliaro AM. Psychologists' Psychotropic Drug Reference. 1999
14. Other Schatzberg AF, Nemeroff CB. The American Psychiatric Publishing Textbook of Psychopharmacology. 2009
15. Journal / agency Andersen J, Kristensen AS, Bang-Andersen B, Strømgaard K. Recent advances in the understanding of the interaction of antidepressant drugs with serotonin and norepinephrine transporters. Chem. Commun. 2009. doi:10.1039/b903035m · PMID 19557250
16. Other Dart RC. Medical Toxicology. 2004
17. Other Elks J. The Dictionary of Drugs: Chemical Data: Chemical Data, Structures and Bibliographies. 14 November 2014
18. Other Index Nominum 2000: International Drug Directory. 2000
19. Other Morton IK, Hall JM. Concise Dictionary of Pharmacological Agents: Properties and Synonyms. 6 December 2012
20. Other Protriptyline Uses, Side Effects & Warnings
21. Other Protriptyline
22. Other Protriptyline. 17 August 2017
23. Journal / agency Drugs@FDA: FDA-Approved Drugs

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