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Defined by their three-ring chemical structure, almost all tricyclic antidepressants (TCAs) work in pretty much the same way: norepinephrine reuptake inhibition, alpha-1, H1, and M1 antagonism, and sodium voltage channel blocking. Most also do enough serotonin reuptake inhibition to make a difference, and some are also 5HT2A and 5HT2C antagonists. TCAs discussed on this site include:
- Anafranil (clomimpramine)
- dosulepin / dothiepin - Not available in the US
- Elavil (amitriptyline)
- imipramine pamoate
- Norpramin (desipramine)
- Pamelor (nortriptyline)
- Surmontil (trimipramine)
- Tofranil (imipramine)
- Tofranil-PM (imipramine pamoate)
- trimipramine maleate
- Vivactil (protriptyline)
Medicine Is The Best Medicine
I <3 Wellbutrin
Tetracyclic - having four rings - antidepressants like Remeron and amoxapine are usually lumped in with TCAs even they don’t really work enough like TCAs to warrant that. Enough places and papers refer to Remeron (mirtazapine), etc. as TCAs anyway, so we may as well put them on the same page.1 However, Asendin (amoxapine) is unofficially classified as an atypical antipsychotic by Stahl and other pharmacologists, based upon its efficacy in treating schizophrenia and mechanism of action, while all the others have a similar mechanism of action that is completely different than amoxapine, and are grouped as noradrenergic and specific serotonergic antidepressants (NaSSAs). All it takes is one more to be approved in the US and they’re getting their own Crazymeds class.
3. TCA Dosage Equivalents
As far as tricylic ADs are concerned you’d think it would be fairly easy to put together, as there are three essential components of a TCA’s mechanism of action that make it an effective antidepressant: norepinephrine and serotonin reuptake inhibition, and alpha-1 norepinephrine antagonism. Some of them do more, but those are the main three for AD action. Turns out only three are roughly equivalent as far as raw potency is concerned - desipramine, my dear friend protriptyline, and nortriptyline. So while 25mg of desipramine = 25mg of nortriptyline, and it’s close enough to 1:1 until you hit 100mg, protriptyline’s pharmacokinetics are so loopy that I wouldn’t put any money on one 20mg dose of protriptyline being equivalent to two 10mg doses of protriptyline. Then we start getting into some meds being the active metabolites of others and a hell of a lot of other complexities.
Take a look for yourself. These are measures of potency, and potency is not the same as how well a drug works. It isn’t even the same as the effect a drug will have in your brain. Why? These are the base substances, and not the various salts (hydrochloride (HCl), mesylate, pamoate, etc.) that are the active ingredients in many meds. That usually makes a difference in how well a substance is absorbed and distributed throughout your system. According to the results shown on the first table, clomipramine is exactly ten times as potent when it comes to making norepinephrine hang around your synapses than loxapine is, but if the formulations of two drugs resulted in five times as much loxapine per milligram getting to your brain and staying there than was the case with clomipramine, then the clomipramine would be only twice as potent2.
The lower the number, the greater the strength.
SERT: Serotonin transport
NET: Norepinephrine transport
DAT: Dopamine transport
“transport” is another way of referring to reuptake.
These tables are sortable. Just click on a column header to sort the table by that column. Clicking on the same header more than once toggles between ascending and descending.
Binding Profiles of Selected Tricyclic and Tetracyclic Antidepressants
From Tricyclic antidepressant pharmacology and therapeutic drug interactions updated Receptor profile, Ki (nmol/l), of TCAs and comparator drugs: uptake inhibition and receptor antagonism (HCR data)
Medicine Is The Best Medicine
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Mixed with the NSRI reboxetine for comparison.
If you like these kind of data, see the page on SSRI dosage equivalents.
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2 I made that up just to have an example using TCAs. A real case is Paxil vs. Prozac. Paroxetine is 14 times as potent as fluoxetine in serotonin reuptake inhibition, but Paxil (paroxetine HCl) is only twice as potent as Prozac (fluoxetine HCl).
|Last modified on Friday, 01 May, 2015 at 12:43:59 by JerodPoore||Page Author: Jerod Poore||Date created: 26 November 2010|
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Almost all of the material on this site is by Jerod Poore and is copyright © 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, and 2015 Jerod Poore. Except, of course, the PI sheets - those are the property of the drug companies who developed the drugs the sheets are about - and any documents that are written by other people which may be posted to this site will remain the property of the original authors. You cannot reproduce this page or any other material on this site outside of the boundaries of fair use copying without the express permission of the copyright holder. That’s usually me, so just ask first. That means if want to print out a few pages to take to your doctor, therapist, counselor, support group, non-understanding family members or something like that - then that’s OK to just do. Go for it! Please. As long as you include this copyright notice and something along the lines of following disclaimer, I’m usually cool with it.
All rights reserved. No warranty is expressed or implied in this information. Consult one or more doctors and/or pharmacists before taking, or changing how you take any neurological and/or psychiatric medication. Your mileage may vary. What happened to us won’t necessarily happen to you. If you still have questions about a medication or condition that were not answered on any of the pages you read, please ask them on Crazy Talk: the Crazymeds Forum.
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Nobody on this site is a doctor, a therapist, or a pharmacist. We don’t portray them either here or on TV. Only doctors can diagnose and treat an illness. While it’s not as bad as it used to be, some doctors still get pissed off by patients who know too much about medications, so tread lightly when and where appropriate. Diagnosing yourself from a website is like defending yourself in court, you suddenly have a fool for a doctor. Don’t be a cyberchondriac, thinking you have every disease you see a website about, or that you’ll get every side effect from every medication1. Self-prescribing is as dangerous as buying meds from fraudulent online pharmacies that promise you medications without prescriptions.
All information on this site has been obtained from the medications’ product information / summary of product characteristic (PI/SPC) sheets and/or medication guides - which is all you get from sites like WebMD, RxList,
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Crazymeds is not responsible for the content of sites we provide links to. We like them, or they’re paid advertisements, or they’re something else we think you should read to help you make an informed decision about a particular med. Sometimes they’re more than one of those things. But what’s on those sites is their business, not ours.
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‘Everything is true, nothing is permitted.’ - Jerod Poore
1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.
2 Remember kids, Microsloth operating systems are like TOS Star Trek movies with in that every other one sucks way, way more. With TOS Star Trek movies you don’t want to bother watching the odd-numbered ones. With Microsloth OS you don’t want to buy and install the even-numbered ones. Anyone who remembers ME and Vista knows what I mean.
3 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?* I don’t even need my big-ass rant any more. Heartbleed has made my case for me. And that’s just the one that got all the media attention. The very nature of an open source operating system makes security as much of an illusion of anonymity. Before you flip out too much: the domain Crazymeds is hosted on uses a version of SSL that is not affected by the Heartbleed bug. That’s one of the many reasons why I pay a lot of money and keep this site on Lunarpages.
* Yes, I know I’m using open source browsers. I also test the site using the now-defunct IE and Safari browsers. Their popularity - and superiority - killed IE and Safari, so that’s why I rely on the open source browsers. It’s like brand vs. generic meds. Sometimes the generic is better than the brand.