1. Trimipramine – Summary of West Suffolk CCG and PrescQIPP Guidance
By Stuart Maddock – Non-medical Prescriber

2. 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.

3. 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.

4. Cost per 28 days

5. 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

6. 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

7. 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)

8. 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.

9. 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