Other antidepressant drugs

4.3.4 Other antidepressant drugs

Antidepressant drugs are effective for treating moderate to severe depression associated with psychomotor and physiological changes such as loss of appetite and sleep disturbance; improvement in sleep is usually the first benefit of therapy. They are also effective for dysthymia (lower grade chronic depression). Antidepressant drugs are not generally effective in mild depression, and cognitive behavioural therapy should be considered initially; however, a trial of antidepressant therapy may be considered in cases refractory to psychological treatments or those associated with psychosocial or medical problems. Drug treatment of mild depression may also be considered in patients with a history of moderate or severe depression.

Choice The major classes of antidepressants include the tricyclics and related antidepressants, the selective serotonin re-uptake inhibitors (SSRIs), and the monoa- mine oxidase inhibitors (MAOIs). A number of anti- depressants cannot be accommodated easily into this classification; these are included in section 4.3.4.

There is little to choose between the different classes of antidepressants in terms of efficacy, so choice should be based on the individual patient’s requirements, including the presence of concomitant disease, existing therapy, suicide risk, and previous response to antidepressant therapy. Since there may be an interval of 2 weeks before the antidepressant action takes place, electro- convulsive treatment may be required in severe depres- sion when delay is hazardous or intolerable.

SSRIs are better tolerated and are safer in overdose than other classes of antidepressants and should be consid- ered first-line for treating depression. In patients with

unstable angina or who have had a recent myocardial infarction, sertraline has been shown to be safe.

Tricyclic antidepressants have similar efficacy to SSRIs but are more likely to be discontinued because of side- effects; toxicity in overdosage is also a problem. See section 4.3.1 for more details.

MAOIs have dangerous interactions with some foods and drugs, and should be reserved for use by specialists.

Although anxiety is often present in depressive illness (and may be the presenting symptom), the use of an antipsychotic or an anxiolytic may mask the true diag- nosis. Anxiolytics (section 4.1.2) or antipsychotics (sec- tion 4.2.1) should therefore be used with caution in depression but they are useful adjuncts in agitated patients.

See also section 4.2.3 for references to the management of bipolar disorders.

St John’s wort (Hypericum perforatum) is a popular unlicensed herbal remedy for treating mild depression. However, preparations of St John’s wort can induce drug metabolising enzymes and a number of important interactions with conventional drugs have been identi- fied, see Appendix 1 (St John’s wort). The amount of active ingredient can vary between different prepara- tions of St John’s wort and switching from one to another can change the degree of enzyme induction. Furthermore, when a patient stops taking St John’s wort, concentrations of interacting drugs may increase, lead- ing to toxicity. Antidepressants should not be used with St John’s wort because of the potential for interaction.

Hyponatraemia and antidepressant therapy Hyponatraemia (usually in the elderly and possibly due to inappropriate secretion of antidiuretic horm- one) has been associated with all types of anti- depressants; however, it has been reported more frequently with SSRIs than with other antidepres- sants. The CSM has advised that hyponatraemia should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.

Suicidal behaviour and antidepressant ther- apy The use of antidepressants has been linked with suicidal thoughts and behaviour; children, young adults, and patients with a history of suicidal beha- viour are particularly at risk. Where necessary patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed.

Management Patients should be reviewed every 1–2 weeks at the start of antidepressant treatment. Treat- ment should be continued for at least 4 weeks (6 weeks in the elderly) before considering whether to switch antidepressant due to lack of efficacy. In cases of partial response, continue for a further 2 weeks (elderly patients may take longer to respond).

Following remission, antidepressant treatment should

be continued at the same dose for at least 6 months (about 12 months in the elderly). Patients with a history of recurrent depression should continue to receive maintenance treatment for at least 2 years.

206

4.3 Antidepressant drugs BNF 57

C entra

l nervous

sys

tem

BNF 57

4.3.1 Tricyclic and related antidepressant drugs 207

Failure to respond Failure to respond to initial treat- quate dosage may account for some of these failures. It ment with an SSRI may require an increase in the dose,

is important to use doses that are sufficiently high for or switching to a different SSRI or mirtazapine; in

effective treatment but not so high as to cause toxic patients with atypical depression, an MAOI such as

effects. Low doses should be used for initial treatment in phenelzine may be effective. Other second-line choices

the elderly (see under Side-effects, below). include lofepramine, moclobemide, and reboxetine. Other tricyclic antidepressants and venlafaxine should

In most patients the long half-life of tricyclic antidepres-

be considered for more severe forms of depression; sant drugs allows once-daily administration, usually at dosulepin (dothiepin) and irreversible MAOIs should

night; the use of modified-release preparations is there- only be prescribed by specialists. Failure to respond to

fore unnecessary.

a second antidepressant may require the addition of another antidepressant of a different class, or an aug-

Choice Tricyclic and related antidepressants block the menting agent such as lithium, but such adjunctive

re-uptake of both serotonin and noradrenaline, although treatment should be initiated only by doctors with

to different extents. For example, clomipramine is more special experience of these combinations. Electro-

selective for serotonergic transmission, and imipramine convulsive therapy may be initiated in severe refractory

is more selective for noradrenergic transmission. Tri- depression.

cyclic and related antidepressant drugs can be roughly divided into those with additional sedative properties

Withdrawal Gastro-intestinal symptoms of nausea, and those that are less sedating. Agitated and anxious vomiting, and anorexia, accompanied by headache,

patients tend to respond best to the sedative com- giddiness, ‘chills’, and insomnia, and sometimes by

pounds, whereas withdrawn and apathetic patients will hypomania, panic-anxiety, and extreme motor restless-

often obtain most benefit from the less sedating ones. ness may occur if an antidepressant (particularly an

Those with sedative properties include amitriptyline, MAOI) is stopped suddenly after regular administration

clomipramine, dosulepin (dothiepin), doxepin, mian- for 8 weeks or more. The dose should preferably be

serin, trazodone, and trimipramine. Those with less reduced gradually over about 4 weeks, or longer if

sedative properties include imipramine, lofepramine, withdrawal symptoms emerge (6 months in patients

and nortriptyline.

who have been on long-term maintenance treatment). Tricyclic and related antidepressants also have varying SSRIs have been associated with a specific withdrawal

degrees of antimuscarinic side-effects and cardiotoxi- syndrome (section 4.3.3).

city in overdosage, which may be important in indivi- dual patients. Lofepramine has a lower incidence of

Anxiety disorders and obsessive-compulsive side-effects and is less dangerous in overdosage but is

disorder Management of acute anxiety generally infrequently associated with hepatic toxicity. Imipra- C entral

involves the use of a benzodiazepine or buspirone (sec- mine is also well established, but has more marked tion 4.1.2). For chronic anxiety (of longer than 4 weeks’

antimuscarinic side-effects than other tricyclic and duration) it may be appropriate to use an antidepres-

related antidepressants. Amitriptyline and dosulepin

nervous

sant. Combined therapy with a benzodiazepine may be (dothiepin) are effective but they are particularly dan- required until the antidepressant takes effect. General-

gerous in overdosage (see Overdosage, below) and are ised anxiety disorder , a form of chronic anxiety, is treated

not recommended for the treatment of depression; with an SSRI such as escitalopram or paroxetine; preg-

dosulepin (dothiepin) should only be prescribed by

syst

abalin and venlafaxine are also licensed for the treat-

specialists.

em

ment of generalised anxiety disorder.

Panic disorder , obsessive-compulsive disorder, post-trau- Children and adolescents Evidence of the efficacy matic stress disorder , and phobic states such as social

of tricyclic antidepressants for depression in children anxiety disorder are treated with SSRIs. Clomipramine or

has not been established; see also CSM advice, p. 212. imipramine can be used second-line in panic disorder

[unlicensed]; clomipramine can also be used second-line Side-effects Arrhythmias and heart block occasionally for obsessive-compulsive disorder. Moclobemide is

follow the use of tricyclic antidepressants, particularly licensed for the treatment of social anxiety disorder.

amitriptyline, and may be a factor in the sudden death of patients with cardiac disease. They are also sometimes associated with convulsions (and should be prescribed with special caution in epilepsy as they lower the con- vulsive threshold). Hepatic and haematological reactions

4.3.1 may occur and have been particularly associated with Tricyclic and related

mianserin.

antidepressant drugs

Other side-effects of tricyclic and related antidepres- sants include drowsiness, dry mouth, blurred vision (very

This section covers tricyclic antidepressants and also 1-, rarely precipitation of angle-closure glaucoma), constipa- 2-, and 4-ring structured drugs with broadly similar

tion , and urinary retention (all attributed to anti- properties.

muscarinic activity), and sweating. The patient should

be encouraged to persist with treatment as some toler- Some tricyclic antidepressants are used in the manage-

ance to these side-effects seems to develop. They are ment of panic disorder (section 4.3). For reference to the

reduced if low doses are given initially and then gradu- role of some tricyclic antidepressants in some forms of

ally increased, but this must be balanced against the neuralgia , see section 4.7.3, and in nocturnal enuresis in

need to obtain a full therapeutic effect as soon as children, see section 7.4.2.

possible. Gradual introduction of treatment is particu- larly important in the elderly, who, because of the

Dosage About 10 to 20% of patients fail to respond to hypotensive effects of these drugs, are prone to attacks tricyclic and related antidepressant drugs and inade-

of dizziness or even syncope. Another side-effect to which

4.3.1 Tricyclic and related antidepressant drugs BNF 57 the elderly are particularly susceptible is hyponatraemia

turition; cardiovascular side-effects (such as ECG (see Hyponatraemia and Antidepressant Therapy on

changes, arrhythmias, postural hypotension, tachy- p. 206).

cardia, syncope, particularly with high doses); sweat- Neuroleptic malignant syndrome (section 4.2.1) may, very

ing, tremor, rashes and hypersensitivity reactions rarely, arise in the course of antidepressant treatment.

(including urticaria, photosensitivity), behavioural disturbances (particularly children), hypomania or

Suicidal behaviour has been linked with antidepressants mania, confusion or delirium (particularly elderly), (see p. 206).

headache, interference with sexual function, blood sugar changes; increased appetite and weight gain

Overdosage Limited quantities of tricyclic antidepres- (occasionally weight loss); endocrine side-effects such sants should be prescribed at any one time because their

as testicular enlargement, gynaecomastia, galacto- cardiovascular effects are dangerous in overdosage. In

rrhoea; also convulsions (see also Cautions), move- particular, overdosage with dosulepin (dothiepin) and

ment disorders and dyskinesias, dysarthria, paraes- amitriptyline is associated with a relatively high rate of

thesia, taste disturbances, tinnitus, fever, fatality. For advice on overdosage see Emergency

agranulocytosis, leucopenia, eosinophilia, purpura, Treatment of Poisoning, p. 31.

thrombocytopenia, hyponatraemia (see Hyponatr- aemia and Antidepressant Therapy, p. 206), abnormal

Withdrawal If possible tricyclic and related anti- liver function tests (jaundice); for a general outline of depressants should be withdrawn slowly (see also sec-

side-effects see also notes above; overdosage: see tem tion 4.3).

Emergency Treatment of Poisoning, p. 31 (high rate of fatality—see notes above)

sys Interactions

A tricyclic or related antidepressant (or

Dose

an SSRI or related antidepressant) should not be started . Depression (but not recommended, see notes above), until 2 weeks after stopping an MAOI (3 weeks if starting

initially 75 mg (elderly and adolescents 30–75 mg) nervous clomipramine or imipramine). Conversely, an MAOI

daily in divided doses or as a single dose at bedtime l should not be started until at least 7–14 days after a

increased gradually as necessary to 150–200 mg; tricyclic or related antidepressant (3 weeks in the case of

CHILD under 16 years not recommended for depres- entra clomipramine or imipramine) has been stopped. For

sion

C guidance relating to the reversible monoamine oxidase . Nocturnal enuresis, CHILD 7–10 years 10–20 mg, 11–

4 inhibitor, moclobemide, see p. 212. For other tricyclic

16 years 25–50 mg at night; max. period of treatment antidepressant interactions, see Appendix 1 (anti-

(including gradual withdrawal) 3 months—full physi- depressants, tricyclic and antidepressants, tricyclic

cal examination before further course (related)).

. Neuropathic pain [unlicensed indication], initially 10–

25 mg daily at night, increased if necessary to 75 mg daily; higher doses under specialist supervision . Migraine prophylaxis [unlicensed indication], initially

10 mg at night, increased if necessary to maintenance

Tricyclic antidepressants

of 50–75 mg at night Amitriptyline (Non-proprietary) A

AMITRIPTYLINE HYDROCHLORIDE

Tablets , coated, amitriptyline hydrochloride 10 mg, net price 28 = 97p; 25 mg, 28 = 97p; 50 mg, 28 =

Indications depressive illness (but not recommended,

£1.12. Label: 2

see notes above); nocturnal enuresis in children Oral solution , amitriptyline hydrochloride 25 mg/ (section 7.4.2); neuropathic pain [unlicensed] (section

5 mL, net price 150 mL = £13.30; 50 mg/5 mL, 4.7.3); migraine prophylaxis [unlicensed] (section

150 mL = £14.48. Label: 2 4.7.4.2) Cautions cardiac disease (particularly with arrhyth-

Compound preparations mias, see Contra-indications below), history of epi-

Triptafen lepsy, pregnancy (Appendix 4), breast-feeding c (Goldshield) AU , pink, s/c, amitriptyline hydrochloride 25 mg, (Appendix 5), elderly, hepatic impairment (avoid if

Tablets perphenazine 2 mg. Net price 20 = £5.10. Label: 2

severe; Appendix 2), thyroid disease, phaeochromo- Dose depression with anxiety, ADULT and CHILD over 14 years, 1 cytoma, history of mania, psychoses (may aggravate

tablet 3 times daily, increased if necessary to 4 tablets daily (with psychotic symptoms), susceptibility to angle-closure

last dose at bedtime); review treatment if no response within 4 glaucoma, history of urinary retention, concurrent

weeks; discontinue after 3 months electroconvulsive therapy; if possible avoid abrupt

Triptafen-M c (Goldshield) withdrawal; anaesthesia (increased risk of arrhythmias

AU Tablets , pink, s/c, amitriptyline hydrochloride 10 mg, and hypotension, see surgery section 15.1); acute

perphenazine 2 mg. Net price 20 = £4.56. Label: 2 porphyria (section 9.8.2); see section 7.4.2 for addi-

Dose mild to moderate depression with anxiety, ADULT and tional nocturnal enuresis warnings; interactions:

CHILD over 14 years, 1 tablet 3 times daily, increased if necessary Appendix 1 (antidepressants, tricyclic)

to 4 tablets daily (with last dose at bedtime); review treatment if Driving Drowsiness may affect performance of skilled tasks

no response within 4 weeks; discontinue after 3 months (e.g. driving); effects of alcohol enhanced

Contra-indications recent myocardial infarction, arrhythmias (particularly heart block), not indicated in

CLOMIPRAMINE HYDROCHLORIDE

manic phase, severe liver disease Indications depressive illness, phobic and obsessional Side-effects dry mouth, sedation, blurred vision (dis-

states; adjunctive treatment of cataplexy associated turbance of accommodation, increased intra-ocular

with narcolepsy

pressure), constipation, nausea, difficulty with mic- Cautions see under Amitriptyline Hydrochloride

BNF 57

4.3.1 Tricyclic and related antidepressant drugs 209

Contra-indications see under Amitriptyline Hydro- chloride

DOXEPIN

Side-effects see under Amitriptyline Hydrochloride; Indications depressive illness, particularly where also diarrhoea; hair loss reported

sedation is required; pruritus in eczema (section 13.3) . Depressive illness, initially 10 mg daily, increased

Cautions see under Amitriptyline Hydrochloride gradually as necessary to 30–150 mg daily in divided

Contra-indications see under Amitriptyline Hydro- doses or as a single dose at bedtime; max. 250 mg

chloride; breast-feeding (Appendix 5) daily; ELDERLY initially 10 mg daily increased carefully

Side-effects see under Amitriptyline Hydrochloride over approx. 10 days to 30–75 mg daily; CHILD and

Dose

ADOLESCENT under 18 years not recommended . ADULT and CHILD over 12 years, initially 75 mg daily in . Phobic and obsessional states, initially 25 mg daily

divided doses or as a single dose at bedtime, adjusted ( ELDERLY

10 mg daily) increased over 2 weeks to 100– according to response; usual maintenance 30–300 mg 150 mg daily; max. 250 mg daily; CHILD and ADOLES-

daily (doses above 100 mg given in 3 divided doses); CENT under 18 years not recommended

ELDERLY initially 10–50 mg daily adjusted according to . Adjunctive treatment of cataplexy associated with

response (usual maintenance 30–50 mg daily) narcolepsy, initially 10 mg daily, gradually increased

Sinepin until satisfactory response (range 10–75 mg daily); c (Marlborough) A CHILD and ADOLESCENT under 18 years not recom-

Capsules , doxepin (as hydrochloride) 25 mg, net price mended

28-cap pack = £3.77; 50 mg, 28-cap pack = £5.71. Label: 2

Clomipramine (Non-proprietary) A Capsules , clomipramine hydrochloride 10 mg, net price 28-cap pack = £2.27; 25 mg, 28-cap pack =

IMIPRAMINE HYDROCHLORIDE

£2.65; 50 mg, 28-cap pack = £3.38. Label: 2 Indications depressive illness; nocturnal enuresis in Anafranil c

children (section 7.4.2) (Novartis) A Cautions see under Amitriptyline Hydrochloride Capsules , clomipramine hydrochloride 10 mg (yel-

Contra-indications see under Amitriptyline Hydro- low/caramel), net price 84-cap pack = £3.23; 25 mg

chloride

(orange/caramel), 84-cap pack = £6.35; 50 mg (grey/

caramel), 56-cap pack = £8.06. Label: 2 see under Amitriptyline Hydrochloride, but less sedating Dose

Side-effects

Modified release c . Depression, initially up to 75 mg daily in divided doses Anafranil SR (Novartis) AU

entral C

increased gradually to 150–200 mg (up to 300 mg in

Tablets , m/r, grey-red, f/c, clomipramine hydro- hospital patients); up to 150 mg may be given as a chloride 75 mg. Net price 28-tab pack = £8.83.

single dose at bedtime; ELDERLY initially 10 mg daily, Label: 2, 25

nervous

Dose see above; to be taken once daily CHILD

increased gradually to 30–50 mg daily; not

recommended for depression . Nocturnal enuresis, CHILD 7–8 years 25 mg, 8–11 years 25–50 mg, over 11 years 50–75 mg at bedtime; max.

syst

DOSULEPIN HYDROCHLORIDE U

period of treatment (including gradual withdrawal) 3 (Dothiepin hydrochloride)

months—full physical examination before further

em

course

Indications

Imipramine (Non-proprietary) A Cautions see under Amitriptyline Hydrochloride

depressive illness, particularly where sedation is required

Tablets , coated, imipramine hydrochloride 10 mg, net Contra-indications see under Amitriptyline Hydro-

price 28-tab pack = £1.20; 25 mg, 28-tab pack = £1.17. chloride

Label: 2

Side-effects see under Amitriptyline Hydrochloride (high rate of fatality—see notes above)

LOFEPRAMINE

Dose Indications depressive illness . Initially 75 mg ( ELDERLY 50–75 mg) daily in divided

Cautions see under Amitriptyline Hydrochloride doses or as a single dose at bedtime, increased gra-

Contra-indications see under Amitriptyline Hydro- dually as necessary to 150 mg daily ( ELDERLY

chloride; hepatic and severe renal impairment may be sufficient); up to 225 mg daily in some cir-

75 mg

cumstances (e.g. hospital use); Side-effects CHILD not recom-

see under Amitriptyline Hydrochloride, mended

but less sedating, lower incidence of antimuscarinic effects and less dangerous in overdosage; hepatic

Dosulepin (Non-proprietary) AU

disorders reported

Capsules , dosulepin hydrochloride 25 mg, net price

Dose

28-cap pack = £1.25. Label: 2 . 140–210 mg daily in divided doses; ELDERLY may Tablets , dosulepin hydrochloride 75 mg, net price 28-

respond to lower doses; CHILD not recommended tab pack = £1.97. Label: 2

Lofepramine (Non-proprietary) A

c Tablets Prothiaden , lofepramine 70 mg (as hydrochloride). Net (Teofarma) AU Capsules price 56-tab pack = £20.35. Label: 2 , red/red-brown, dosulepin hydrochloride Brands include 25 mg. Net price 28-cap pack = £1.70. Label: 2 Feprapax

Oral suspension , lofepramine 70 mg/5 mL (as Tablets , red, s/c, dosulepin hydrochloride 75 mg. Net

hydrochloride). Net price 150 mL = £22.22. Label: 2 price 28-tab pack = £2.97. Label: 2

Brands include Lomont (sugar-free)

4.3.1 Tricyclic and related antidepressant drugs BNF 57

Cautions see under Amitriptyline Hydrochloride; Indications

NORTRIPTYLINE

interactions: Appendix 1 (antidepressants, tricyclic depressive illness; nocturnal enuresis in

(related))

children (section 7.4.2); neuropathic pain (section

A full blood count is recommended every 4 4.7.3)

Blood counts

weeks during the first 3 months of treatment; clinical mon- Cautions see under Amitriptyline Hydrochloride;

itoring should continue subsequently and treatment should manufacturer advises plasma-nortriptyline concen-

be stopped and a full blood count obtained if fever, sore throat, stomatitis , or other signs of infection develop. tration monitoring if dose above 100 mg daily, but

evidence of practical value uncertain Contra-indications see under Amitriptyline Hydro- Contra-indications see under Amitriptyline Hydro-

chloride

chloride Side-effects see under Amitriptyline Hydrochloride, Side-effects see under Amitriptyline Hydrochloride,

fewer and milder antimuscarinic and cardiovascular but less sedating

effects; leucopenia, agranulocytosis and aplastic Dose

anaemia (particularly in the elderly); jaundice; arth- ritis, arthralgia

. Depression, low dose initially increased as necessary to 75–100 mg daily in divided doses or as a single dose

Dose

(max. 150 mg daily); ADOLESCENT and ELDERLY 30– . Initially 30–40 mg (elderly 30 mg) daily in divided

50 mg daily in divided doses; CHILD not recommended doses or as a single dose at bedtime, increased gra- for depression

dually as necessary; usual dose range 30–90 mg; CHILD tem . Nocturnal enuresis, CHILD

7 years 10 mg, 8–11 years not recommended

sys

10–20 mg, over 11 years 25–35 mg, at night; max period of treatment (including gradual withdrawal) 3

Mianserin (Non-proprietary) A months—full physical examination and ECG before

Tablets , mianserin hydrochloride 10 mg, net price 28- further course

tab pack = £7.10; 20 mg, 28-tab pack = £4.12; 30 mg, nervous . Neuropathic pain [unlicensed], initially 10–25 mg

28-tab pack = £11.23. Label: 2, 25

daily at night, increased if necessary to 75 mg daily; higher doses under specialist supervision

entra C Allegron c (King) A

4 Tablets , nortriptyline (as hydrochloride) 10 mg, net price 20 = £2.48; 25 mg (orange, scored), 20 = £4.80. Label: 2

TRAZODONE HYDROCHLORIDE

Indications depressive illness, particularly where

sedation is required; anxiety Cautions see under Amitriptyline Hydrochloride; Indications depressive illness, particularly where

TRIMIPRAMINE

interactions: Appendix 1 (antidepressants, tricyclic sedation required

(related))

Cautions see under Amitriptyline Hydrochloride Contra-indications see under Amitriptyline Hydro- Contra-indications see under Amitriptyline Hydro-

chloride

Side-effects see under Amitriptyline Hydrochloride see under Amitriptyline Hydrochloride Dose

chloride

Side-effects

but fewer antimuscarinic and cardiovascular effects; rarely priapism (discontinue immediately)

. Initially 50–75 mg daily in divided doses or as a single dose at bedtime, increased as necessary to 150– Dose 300 mg daily; ELDERLY initially 10–25 mg 3 times daily,

. Depression, initially 150 mg (elderly 100 mg) daily in maintenance half adult dose may be sufficient; CHILD

divided doses after food or as a single dose at bedtime; not recommended

may be increased to 300 mg daily; hospital patients up to max. 600 mg daily in divided doses; CHILD not Surmontil c (Aventis Pharma) A recommended

Capsules , green/white, trimipramine 50 mg (as mal- . Anxiety, 75 mg daily, increasing if necessary to eate). Net price 28-cap pack = £7.91. Label: 2

300 mg daily; CHILD not recommended Tablets , trimipramine (as maleate) 10 mg, net price 28-tab pack = £3.57, 84-tab pack = £10.69; 25 mg, 28-

Trazodone (Non-proprietary) A tab pack = £4.71, 84-tab pack = £14.10. Label: 2

Capsules , trazodone hydrochloride 50 mg, net price 84-cap pack = £8.07; 100 mg, 56-cap pack = £8.00. Label: 2, 21

Related antidepressants

Tablets , trazodone hydrochloride 150 mg, net price Tricyclic-related antidepressant drugs have a lower

28-tab pack = £7.07. Label: 2, 21 incidence of antimuscarinic side-effects than older tri-

cyclics. The tricyclic-related antidepressant drugs may Molipaxin c (Hoechst Marion Roussel) A also be associated with a lower risk of cardiotoxicity in

Capsules , trazodone hydrochloride 50 mg (violet/ overdosage.

green), net price 84-cap pack = £20.74; 100 mg (vio- let/fawn), 56-cap pack = £24.40. Label: 2, 21