Trimipramine – Summary of West Suffolk CCG and PrescQIPP Guidance By Stuart Maddock – Non-medical Prescriber
Overview and History Tricyclic Launched in UK - 1966 Patent Expired c1988 Tricyclics discovered in 1950’s and marketed in the later part of the decade, named after chemical structure with three atoms. Who is on this and why, older people who have been taking it a long time and because it used to be cost effective.
Patients not on trimipramine NICE state that if an antidepressant is indicated then SSRI should be first choice over TCA TCA’s have less favourable risk-benefit ratio compared to SSRIs If SSRI not tolerated or ineffective a cost-effective TCA may be trialled such as imipramine SSRI’s have less side effects, safer in overdose, require less dose titration and once daily administration.
Cost per 28 days
Rationale for the guidance WSCCG is on track to spend an estimated £150k on trimipramine in 2017 Trimipramine is not included in the NSFT formulary Trimipramine is not included in the WSCCG-WSFT Neuropathic Pain Ladder
Antidepressants Should not be used for persistent subthreshold depressive symptoms or mild depression Antidepressants should be used where there is a history of past moderate-severe depression Or where subthreshold depressive symptoms of mild depression that persists after other interventions risk-benefit ratio
Risk of relapse If a person is considered a risk of relapse then antidepressants should be continued for at least two years Two or more episodes in recent past with significant functional impairment Or they have residual symptoms, multiple episodes, or severe or prolonged episodes of inadequate response Or consequences of relapse are likely to be severe. (NICE 2016)
Withdrawal If withdrawal symptoms are mild (which they usually are) persist, if they are severe restart antidepressant from original class and taper off much more gradually.
Take home points Do not initiate trimipramine Consider stopping trimipramine in patients who are not at risk of relapse For patients at risk of relapse switch trimipramine to sertraline (better tolerated, safer, reduced side effects, less risks, less sedating…) Where appropriate trimipramine can be switched to imipramine where another tricyclic is indicated