The main take-home message from this presentation is that despite lower overall use of tricyclic antidepressants (TCAs) since the 1980s, TCA-toxicity-associated hospitalizations and fatalities are on the rise.    TCAs have limited FDA indications, including depression, anxiety, insomnia and OCD.  They have a large number of off-label indications, including chronic pain management, neuropathic pain, diabetic neuropathy, myofascial pain, sialorrhea, , bulimia, irritable bowel syndrome, panic disorder, PTSD, urticaria, fibromyalgia, interstitial cystitis, migraine prophylaxis, smoking cessation,  and post-herpetic neuralgia. 

Tricyclic antidepressants are toxic medications with narrow therapeutic indices and low LD50s..  Antidepressants (a large majority TCAs)  are the 3^rd most frequently reported medication class to poison control centers, after analgesics and sedative-hypnotics.  Among all classes of medications TCAs are second only  to lithium in the percentage of intentional or accidental overdoses in causing near-death or permanent injury. Fully half of TCA overdoses are unintentional or iatrogenic.   Even though overall TCA use has decreased over the past 15 years, serious or fatal outcomes have more than doubled during that same period.  Total TCA-related deaths have increased by a third. 

Tricyclic antidepressant use is expected to rise as part of efforts to move patients off opiate analgesics.   Given the rising safety concerns of TCAs, pharmacy and therapeutics committees may consider ways to promote improved patient safety with TCAs (and other high-toxicity medications). Several strategies will be discussed in the presentation, including safer alternatives to TCAs for several of the conditions they are used off-label for.

After this training, participants will be able to:

1. Assess traditional indications for TCAs, and how they have evolved in recent decades

2. Identify FDA indications and off-label indications for TCAs

3. Detail the toxicity of TCAs and how this toxicity compares to other medications used in Psychiatry and General Medicine

4. Explore alternatives to TCAs for off-label indications

5. Develop an example of how a hospital or clinic can improve patient safety among patients receiving TCAs

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TRANSCRIPT
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