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Dec 04, 2020
5 min read

Amitriptyline dosage: finding the right dose for you

Dosage for amitriptyline will vary depending on your age, weight, and the condition(s) for which you are taking it. Typically, your healthcare provider will start you at a low dose and move you up gradually to test your tolerance for the drug. When starting treatment for major depressive disorder, 75 mg a day usually achieves the desired result. It may be taken in multiple small doses throughout the day, with a larger one at bedtime due to the potential sedative effects.

mike bohl

Reviewed by Mike Bohl, MD, MPH

Written by Seth Gordon

Disclaimer

If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.

What is amitriptyline?

Amitriptyline, sold as a generic drug or under the brand name Elavil, is a tricyclic antidepressant drug (TCA) that works by increasing the amount of norepinephrine and serotonin available to the brain. These are two important neurotransmitters necessary for brain function. 

While the FDA approves amitriptyline for the treatment of depression, it has many off-label uses as well. These include treating anxiety, chronic pain, and insomnia, among others (Thour, 2020).

Newer drug classes, such as selective serotonin reuptake inhibitors (SSRIs), are more commonly prescribed for depression today. But as of 2018, the last year we have data, amitriptyline remained one of the 100 most common medications in the United States, prescribed to almost two million people in the US (AHRQ, 2020).

Amitriptyline dosage

Dosage for amitriptyline will vary depending on your age, weight, and the condition(s) for which you are taking it. Typically, your healthcare provider will start you at a low dose and move you up gradually to test your tolerance for the drug.

When starting treatment for major depressive disorder, 75 mg a day usually achieves the desired result. It may be taken in multiple small doses throughout the day, with a larger one at bedtime due to the potential sedative effects. If not achieving satisfactory results, your prescriber may increase your dose gradually to a maximum of 150 mg per day. In some cases, they may start you with a single daily dose at bedtime, from 50 mg to 100 mg, and increase to the maximum from there if necessary (DailyMed, 2016).

The therapeutic effects of amitriptyline for depression may take up to a month to become apparent. It is important to be patient and follow your prescriber’s medical advice. Do not alter your dose on your own. Taking a larger dose will not speed up the therapeutic process and carries an increased risk of overdose (DailyMed, 2016).

Once a proper therapeutic dose has been reached, and the symptoms of depression have faded, your healthcare provider may switch you to a maintenance dose. This is the lowest dose you can take without symptoms returning and will usually be one dose per day taken at bedtime. It could be as low as 40 mg for some patients, but typically it ranges from 50 to 100 mg (DailyMed, 2016). Patients should continue maintenance doses for a minimum of three months after remission to lower the possibility of relapse. 

Young adult and elderly patients may not tolerate higher doses. In these cases, a lower overall dose, up to 50 mg per day divided into four doses, is preferable (DailyMed, 2016).

Healthcare providers may also prescribe amitriptyline off-label for other conditions, such as:

  • Fibromyalgia
  • Chronic fatigue syndrome (CFS)
  • Neuropathic pain, such as diabetic neuropathy
  • Irritable bowel syndrome (IBS)
  • Migraine headaches

For treating chronic pain, a much lower dose is necessary than would be used for depression. In trials, doses as low as 25 mg were found useful for treating certain conditions. Relief is also achieved faster, sometimes within one week of beginning therapy (Lynch, 2001).

Amitriptyline is commonly used to treat insomnia. Doses of 10 mg to 20 mg per day have been sufficient for many patients with insomnia, if unrelated to depression or other causes (Everitt, 2014).

Amitriptyline may be prescribed in combined pills with other medications. These include (MedlinePlus, 2017):

  • Perphenazine, an antipsychotic used for treating schizophrenia
  • Chlordiazepoxide, a sedative for treating anxiety and alcohol withdrawal symptoms

Never take more than your prescribed dose of amitriptyline. Overdoses can occur. Severe overdose can result in irregular heartbeat, low blood pressure, hallucinations, seizure, coma, and death (DailyMed, 2016). If you believe you or someone you know has overdosed, call 911 or the poison control helpline at 1-800-222-1222.

Cost and storage

Keep amitriptyline at room temperature. Store it in its original container, out of sight and reach of children. Do not keep amitriptyline in areas that can become hot or moist, such as the bathroom (MedlinePlus, 2017).

Amitriptyline is inexpensive. If not covered by your insurance, prices range from $4 to $25 for a 30-day supply, depending on the dose (GoodRx, n.d.). 

Side effects of amitriptyline

Amitriptyline is generally well tolerated, especially in low doses. The most common side effects of amitriptyline include (MedlinePlus, 2017):

  • Drowsiness/sleepiness
  • Nausea or vomiting
  • Headaches
  • Dry mouth
  • Weight gain/appetite changes
  • Urinary retention, difficulty peeing
  • Constipation
  • Blurred vision
  • Confusion
  • Dizziness
  • Changes in libido
  • Nightmares

Some side effects are temporary and go away after a week or two of adjustment. If you experience problematic side effects, consult with your healthcare provider before stopping the medication. Your prescriber may prefer to lower your dose gradually, as some patients can experience withdrawal symptoms, especially with abrupt discontinuation. Withdrawal symptoms include headaches, nausea, fatigue, agitation, irritability, and insomnia (DailyMed, 2016).

Amitriptyline in rare cases may cause serious side effects, including (MedlinePlus, 2017):

  • Heart attack
  • Stroke
  • Irregular heartbeats
  • Chest pain
  • Numbness in the arms or legs
  • Slurred or difficult speech
  • Skin rash or hives
  • Swelling of the face or tongue
  • Yellowing of the skin or eyes
  • Orthostatic hypotension (sudden drop in blood pressure when you stand up)
  • Spasms in the back, neck, or jaw
  • Fainting
  • Seizures
  • Hallucinations

If you notice any of the above adverse effects, contact your healthcare provider or call 911 immediately. Some could be signs of overdose or an allergic reaction.

Drug interactions

Tell your healthcare provider about any prescription drugs, nonprescription drugs, and supplements, including herbal supplements you are taking or may take. Certain medications, when combined with amitriptyline, can cause dangerous interactions. These include, but are not limited to (MedlinePlus, 2017):

  • Monoamine oxidase inhibitors (MAOIs). You should not take amitriptyline if you are taking or have recently taken MAOIs. At least 14 days should pass between taking MAOIs and amitriptyline.
  • Selective serotonin reuptake inhibitors (SSRIs). These include citalopram (brand name Celexa), escitalopram (brand name Lexapro), fluoxetine (brand name Prozac), fluvoxamine (brand name Luvox), paroxetine (brand name Paxil), and sertraline (brand name Zoloft).
  • Any other antidepressants
  • Sedatives, sleeping pills, or tranquilizers
  • Thyroid medications
  • Cisapride (brand name Propulsid) 
  • Guanethidine (brand name Ismelin) 
  • Quinidine (brand name Quinidex)

Combining multiple medications or supplements that affect serotonin levels can lead to a very serious condition called serotonin syndrome. Serotonin syndrome symptoms can include increased heart rate, shivering, excessive sweating, involuntary muscle spasms, and twitching. Severe cases can result in muscle breakdown, seizures, kidney failure, and death (Boyer, 2005).

Do not consume alcohol while taking amitriptyline. Amitriptyline may increase the effects of alcohol (DailyMed, n.d.).

Precautions

Your healthcare provider will want to know if any of the following conditions apply to you, as you may be at a higher risk for some side effects (MedlinePlus, 2017):

  • If you have a history of heart disease or have suffered a heart attack
  • If you have any liver or kidney disease
  • If you are a heavy drinker of alcohol
  • If you have diabetes
  • If you have had glaucoma
  • If you have ever had a seizure

Amitriptyline should not be used by patients with bipolar disorder. If you are being treated for depression, your healthcare provider may wish to screen you for risk factors. Be sure to tell them if you or anyone in your family has a history of bipolar disorder (DailyMed, 2016).

Tell your provider if you are pregnant, could become pregnant, or are nursing. Studies have shown evidence of amitriptyline in breast milk (LactMed, 2020).

This is not an exhaustive list, and your healthcare provider will have many questions to determine if amitriptyline is the right treatment for you. 

References

  1. Agency for Healthcare Research and Quality (AHRQ) (n.d.). Number of people with purchase in thousands by therapeutic class, United States, 1996-2018. Medical Expenditure Panel Survey. Generated interactively: Retrieved 01 December 2020 from https://meps.ahrq.gov/mepstrends/hc_pmed/
  2. Boyer, E. W., & Shannon, M. (2005). The serotonin syndrome. New England Journal of Medicine, 352(11), 1112–1120. https://doi.org/10.1056/NEJMra041867
  3. DailyMed (2016) ELAVIL 25 MG- amitriptyline hydrochloride tablet Retrieved 01 December 2020 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cb986e14-d618-4021-91d7-599e038d9d39
  4. Drugs and Lactation Database (LactMed) [Internet]. (2020, October 19). Amitriptyline. Retrieved 01 December 2020 from https://www.ncbi.nlm.nih.gov/books/NBK501174/
  5. Everitt, H., McDermott, L., Leydon, G., Yules, H., Baldwin, D., & Little, P. (2014). GPs’ management strategies for patients with insomnia: A survey and qualitative interview study. British Journal of General Practice, 64(619), e112–e119. https://doi.org/10.3399/bjgp14X677176
  6. GoodRX (n.d.) Amitriptyline Generic Amitril, Amitid, Elavil, Endep. Generated interactively: Retrieved 01 December 2020 from https://www.goodrx.com/amitriptyline
  7. Lynch, M. E. (2001). Antidepressants as analgesics: A review of randomized controlled trials. Journal of Psychiatry & Neuroscience, 26(1), 30-36. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1408040/
  8. MedlinePlus (2017). Amitriptyline: MedlinePlus Drug Information. Retrieved 01 December 2020, from https://medlineplus.gov/druginfo/meds/a682388.html
  9. Thour, A., & Marwaha, R. (2020, August 24). Amitriptyline. StatPearls. Retrieved from https://www.statpearls.com/kb/viewarticle/17465/