TCA, Drug interactions, Interaction between tricyclic antidepressants and other drugs, Depression, Alternative therapies, mind-body medicine, integrative therapies

Serotonin syndrome is a dangerous and potentially fatal syndrome which includes rapid changes in vital signs (fever, oscillations in blood pressure), sweating, nausea, vomiting, rigid muscles, myoclonus, agitation, delirium, seizures, and coma.

Serotonin antagonists, including trazodone (Desyrel) and nefazodone (Serzone)

Low blood pressure.

Bupropion (Wellbutrin)

Increased risk of seizures.

Extreme caution recommended.

Interaction of Tricyclic and tetracyclic antidepressants with Antibiotics

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Chloramphenicol (Chloromycetin)	TCA levels and toxicity may increase
Doxycyline (Vibramycin)	TCA levels and effectiveness may decrease
Isoniazid (INH, Nydrazid)	TCA levels and toxicity may increase

Interaction of Tricyclic and tetracyclic antidepressants with Antifungal Agents

Interaction of Tricyclic and tetracyclic antidepressants with

Results in

Imidazoles such as

	Fluconazole (Diflucan)
	Itraconazole (Sporanox)
	Ketoconazole (Nizoral)
	Miconazole (Monistat Vaginal Suppositories or Cream)

TCA levels may increase. (especially nortriptyline)

Griseofulvin (Fulvicin)

TCA levels may decrease

Interaction of Tricyclic and tetracyclic antidepressants with Diabetes Medications

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Insulin	Greater than expected drop in blood sugar
Oral hypoglycemic drugs	Greater than expected drop in blood sugar

Interaction of Tricyclic and tetracyclic antidepressants with Medical Conditions

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Glaucoma	TCA can trigger attacks of narrow-angle glaucoma. Symptoms include eye pain, blurred vision, and halos around lights.
Heart disease	Use TCA with extreme caution May trigger abnormal heart rhythms
Liver disease	Use TCA with caution. The metabolism by the liver may be impaired, with excessively high blood levels and increased side effects and toxic effects.
Seizure disorder	Use TCA with caution. TCA may cause increase in seizures (TCA lowers the seizure threshold.)
Thyroid disease	Use TCA with caution in patients with thyroid disease, or those taking thyroid medication. May trigger abnormal heart rhythms

Interaction of Tricyclic and tetracyclic antidepressants with Medications for Abnormal Heart Rhythms

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Disopyramide (Norpace)	Abnormal heart rhythms
Epinephrine	TCA may enhance the effects, leading to rapid heart, abnormal heart rhythms, and increase in blood pressure
Quinidine	Blood levels of quinidine and TCA may increase. Abnormal heart rhythms and weakened heart muscle. Can lead to *congestive heart failure*.

Interaction of Tricyclic and tetracyclic antidepressants with Medications for High Blood Pressure

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Beta-blockers such as propranolol (Inderal)	Beta-blockers may cause increased depression. TCA may cause greater than expected drop in blood pressure.
Clonidine (Catapres)	TCA [e.g., desipramine (Norpramin)] may reduce effectiveness of clonidine because blood levels of clonidine decreases when used with TCAs.
Calcium channel blockers	Blood-pressure drop may be greater than expected
Guanethidine (Ismelin)	May lose antihypertensive effect when combined with TCA [e.g., desipramine (Norpramin)]
Methyldopa (Aldomet)	Blood-pressure drop may be greater than expected, especially with amitriptyline (Elavil). Some TCAs [e.g., desipramine (Norpramin)] may reduce the antihypertensive effect.
Prazosin (Minipress)	Blood pressure may increase because levels of prazosin may be suppressed by TCAs.
Reserpine (Serpasil)	May cause greater than expected drop in blood pressure. May also cause excessive stimulation.
Thiazide diuretics such as hydrochlorothiazide (Dyazide)	Blood-pressure drop may be greater than expected. Effects of TCA may increase.

Interaction of Tricyclic and tetracyclic antidepressants with Medications for Low Blood Pressure

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Epinephrine	TCA may enhance the effects, leading to: Rapid heart Abnormal heart rhythms, and Increase in blood pressure

Interaction of Tricyclic and tetracyclic antidepressants with Mood Stabilizers and Anticonvulsants

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Carbamazepine (Tegretol)	Blood levels of TCA and carbamazepine may decrease. TCA can make seizures more likely.
Lithium (Eskalith)	May enhance antidepressant effects.
Phenytoin (Dilantin)	Blood levels of TCA may decrease or increase. TCA can make seizures more likely.
Valproic acid (Depakene)	Increase in blood levels of amitriptyline (Elavil) and valproic acid

Interaction of Tricyclic and tetracyclic antidepressants with Pain Medications and Anesthetics

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Acetaminophen (Tylenol)	TCA levels may increase. Acetaminophen levels may decrease.
Aspirin	TCA levels may increase.
Halothane (Fluothane)	TCA levels may increase. TCA with strong anticholinergic effects may cause abnormal heart rhythms.
Cyclobenzaprine (Flexeril)	May cause abnormal heart rhythms.
Methadone (Dolophine)	May have greater than expected narcotic effect. For example, desipramine (Norpramin) may double the blood level of methadone.
Meperidine (Demerol)	Greater than expected narcotic effect. Lower doses of meperidine or another painkiller may be needed.
Morphine (MS Contin)	Greater than expected narcotic effect and sedation. TCA levels may decrease.
Pancuronium (Pavulon)	Abnormal heart rhythms, especially TCA with strong anticholinergic effects.

Interaction of Tricyclic and tetracyclic antidepressants with Sedatives and Tranquilizers

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Alcohol	May have enhanced sedative effects. This could be hazardous when driving or operating dangerous machinery. May cause TCA levels to drop.
Barbiturates (such as phenobarbital)	Enhanced sedative effects. May cause TCA levels to drop.
Buspirone (BuSpar)	Enhanced sedative effects as described above
Chloral hydrate (Noctec)	TCA levels may decrease
ethchlorvynol (Placidyl)	Temporary mental confusion has been reported when combined with amitriptyline (Elavil). This is possible with other TCAs as well.
Major tranquilizers (neuroleptics)	Levels of TCA and phenothiazine neuroleptics [such as chlorpromazine (Thorazine)] may increase, leading to more side effects and greater potency. Abnormal heart rhythms have been observed with thioridazine (Mellaril), clozapine (Clozaril), and pimozide (Orap).
Minor tranquilizers (neuroleptics)	Enhanced sedative effects

Interaction of Tricyclic and tetracyclic antidepressants with Stimulants and Street Drugs

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Amphetamines ("speed" or "crank") Cocaine Benzedrine Benzphetamine (Didrex) Dextroamphetamine (Dexedrine) Methamphetamine (Desoxyn) Methylphenidate (Ritalin)	These drugs may boost the blood levels and effects of some TCA [(e.g., imipramine (Tofranil), clomipramine (Anafranil), desipramine (Norpramin)] and vice versa. Abnormal heart rhythms and increased blood pressure have been observed with cocaine. This effect seems possible when any stimulants are combined with TCA.

Interaction of Tricyclic and tetracyclic antidepressants with Weight Loss and Appetite-Suppression Medications

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Fenfluramine (Pondimin)	Possible serotonin syndrome when combined with clomipramine. Increased TCA levels.

Interaction of Tricyclic and tetracyclic antidepressants with Other Medications

Interaction of Tricyclic and tetracyclic antidepressants with	Results in
Antihistamines	Increased drowsiness. It is safer to use antihistamines that are not sedative.
Acetazolamide (Diamox)	TCA blood levels may increase. Blood pressure may drop.
Birth-control pills and other medications containing estrogen	TCA blood levels may increase, with greater side effects. Higher doses of estrogen may reduce the effects of TCA.
Caffeine	TCA blood levels may increase
Charcoal tablets	TCA blood levels may drop due to poor absorption from the stomach and intestinal tract.
Cholestyramine (Questran)	TCA blood levels may decrease.
Cimetidine (Tagamet)	TCA blood levels may increase (greater side effects)
Disulfiram (Antabuse)	TCA blood levels may increase (greater side effects). Disulfiram plus amitriptyline (Elavil) caused a severe brain reaction (organic brain syndrome) with mental confusion and disorientation in clinical studies.
Ephedrine (found in Bronkaid, Marax, Primatene, Quadrinal, Vicks Vatronol nose drops, and several other asthma and cold medications)	TCA may block the increase in blood pressure ordinarily caused by ephedrine. Ephedrine levels and effects may decrease.
High fiber diet	TCA blood levels may drop due to poor absorption from the stomach and intestinal tract.
Liothyronine (T3, Cytomel)	Can enhance the effects of TCA. Abnormal heart rhythms can result. TCA blood levels may increase.
Prochlorperazine (Compazine)	TCA blood levels may increase with increased side effects and toxic effects.
Psyllium (Metamucil)	TCA blood levels may drop due to poor absorption from the stomach and intestinal tract.
Scopolamine (Transderm)	May cause increase in TCA blood levels
L-dopa (Sinemet)	absorption of TCA from the stomach and intestinal tract into the blood may drop. Effects of both TCA and L-dopa may decrease.
Theophylline (Bronkaid)	TCA blood levels may increase
Tobacco (smoking)	TCA blood levels may decrease

Source: David D. Burns, M.D.: The Feeling Good Handbook ( Plume)

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