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You wake up and realize it’s only 3:26 a.m., but you set your alarm clock for 6 a.m. You try to fall back asleep, but you toss and turn to no avail and decide to get up, despite feeling exhausted.
If this sounds familiar and happens regularly, you may want to talk with a healthcare provider about something called sleep-maintenance insomnia (trouble staying asleep). Depending on your situation, they may recommend an older medication called doxepin to help.
Read on to learn about doxepin’s forms, uses, side effects, dosages, and more.
What is doxepin?
Also called doxepin hydrochloride, this prescription drug belongs to an older class of medications called tricyclic antidepressants (TCAs). The Food and Drug Administration (FDA) first approved it in 1969 (Currax, 2020).
It isn’t fully understood how exactly doxepin works, but it’s thought to enhance the availability of norepinephrine, a brain chemical that regulates mood. The drug also acts like an antihistamine, which explains its anti-itch, anti-anxiety, and sedative effects (Currax, 2020; Mylan, 2017; Par, 2017).
What does anxiety feel like?
The FDA approves doxepin to treat the following conditions (Almasi, 2021; Currax, 2020):
- Insomnia – specifically approved for sleep-maintenance insomnia, a sleep disorder in which you have trouble staying asleep through the night
- Depression, also called major depressive disorder (MDD)
Additionally, doxepin cream (brand name: Zonalon) is FDA-approved to relieve short-term skin itching due to conditions like eczema (Mylan, 2017).
The American Academy of Sleep Medicine recommends doxepin as a treatment option for people with sleep-maintenance or “middle-of-the-night” insomnia. In some cases, low-dose doxepin may be a better choice than other sleeping pills like zolpidem (Ambien) because doxepin is not addictive (Sateia, 2017).
While doxepin still has FDA approval for these conditions, it’s currently not a healthcare provider’s first choice for treating depression or anxiety. Newer classes of antidepressants, namely SSRIs and SNRIs, are more popular for depression or anxiety because they have fewer downsides than TCAs.
TCAs, including doxepin, require a higher dosage to exert antidepressant or anti-anxiety effects and therefore tend to cause more side effects and carry more significant risks than newer treatment options. But, healthcare providers can still prescribe doxepin for people with tough-to-treat cases like treatment-resistant depression (Chockalingam, 2019).
Depression: symptoms, causes, diagnosis, and treatment
Healthcare providers can also prescribe doxepin “off-label” to treat other conditions. Off-label use is when you have a prescription for a drug to treat something outside of its FDA-approved purpose. Non-FDA-approved uses for doxepin include (Almasi, 2021):
- Neuropathy (nerve-related pain, numbness, or tingling)
- Migraine prevention
Doxepin side effects
Doxepin has the potential to cause side effects, some of which are more common than others. Doxepin’s most common side effect is drowsiness or prolonged sleepiness, but these effects may go away with continued treatment (Par, 2017).
Other common side effects of doxepin include (Currax, 2020):
- Prolonged sleepiness
- Upper respiratory tract infection
- Dry mouth
- Blurred vision
- Urinary retention (trouble with completely emptying your bladder when you urinate)
- Heart palpitations or irregular heartbeat
- Fast heart rate
- Changes in appetite
- Weight gain
Tricyclic antidepressants (TCAs): lists, uses, and side effects
Other side effects of doxepin are less common but possible, such as:
- Increases or decreases in blood pressure and blood sugar
- Hair loss
- Heart rhythm problems, heart attack, or stroke
- Trouble with balance or coordination
- Slurred speech
- Skin rash
- Changes in sex drive
- Sleep-walking, sleep-talking, or doing other activities while asleep like driving, cooking, or having sex (sexsomnia)
This list doesn’t cover all of the possible side effects of doxepin. If you have questions about doxepin’s side effects, talk to a healthcare professional.
Doxepin comes in several forms and strengths, as follows (Currax, 2020; Mylan, 2017; Par, 2017):
- Tablet: 3 milligrams (mg) and 6 mg
- Capsule: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, and 150 mg
- Oral solution: 10 mg per milliliter (mL)
- Topical cream: 5%
The rest of this section covers the usual directions for doxepin. But since the typical dosage of doxepin depends on the condition it is treating, be sure to follow your healthcare provider’s instructions. Be careful not to take more doxepin than prescribed as taking excessive amounts can be dangerous and lead to life-threatening overdose (Par, 2017).
Doxepin dosage for sleep
For sleep-maintenance insomnia, the usual dose of doxepin is 3 mg or 6 mg, taken 30 minutes before bedtime. Regarding food, the recommendation is to not eat a meal three hours before taking doxepin. Taking your dose too soon after a meal could increase next-day side effects like sleepiness. Keep in mind that it may take seven to ten days before your insomnia symptoms improve (Currax, 2020; Par, 2017).
Insomnia: what is it, symptoms, causes, treatments
Doxepin dosage for depression or anxiety
For depression or anxiety, the usual starting dose of doxepin is 75 mg per day, and you take it at bedtime. Your healthcare provider may adjust your dose over time, depending on how you respond. The medication may help relieve anxiety soon after you start taking it, but its antidepressant effects usually take a bit longer, at least two to three weeks (Par, 2017).
Using doxepin cream
For itching, you’ll typically apply a thin film of doxepin cream to the affected areas of your skin four times per day for up to eight days, as extended use of the cream beyond eight days can increase side effects like drowsiness. It’s best not to cover the area with a bandage or dressing after applying doxepin cream (Mylan, 2017).
Due to possible drowsiness, it’s better to avoid driving until you become familiar with how doxepin makes you feel. Also, it is best to consult your healthcare provider before changing your dose or stopping doxepin. Abruptly stopping this medication can lead to withdrawal symptoms. Your healthcare provider will guide you on how to gradually decrease your dose before stopping it.
Important warning for doxepin
The Food and Drug Administration (FDA) requires antidepressants, like doxepin, to carry a boxed warning for possible worsening of depression and suicidal thoughts or behaviors, a rare but serious risk.
This increased risk mainly occurs in children, teens, and young adults up to age 25, and the chances may be higher soon after treatment starts or after dose increases. If you notice changes in how you think and act since starting doxepin or have thoughts of harming yourself, help is available. Call emergency medical services or your healthcare provider right away (Currax, 2020; Par, 2017).
Before prescribing doxepin, your healthcare provider will discuss your health history and the treatment’s risks with you. They’ll want to know if you have certain conditions or factors, as these can increase your risk of serious side effects. Be sure to tell your healthcare provider if you have or had (Currax, 2020; Mylan, 2017; Par, 2017):
- Recent heart attack or stroke
- Pregnant or breastfeeding
- Problems with alcohol use
- Any medical or mental health conditions like sleep apnea, high blood pressure, heart disease, bipolar disorder, glaucoma, urination problems, liver or kidney disease
- Past allergic reaction to doxepin hydrochloride
Bipolar disorder: types, symptoms, causes, medications
Drug interactions with doxepin
Certain medications can interact negatively with doxepin, including those that have sedative properties or those that increase serotonin levels.
Doxepin commonly causes sleepiness. While taking doxepin, it may not be safe to take other medications that cause sleepiness. Talk to your healthcare provider about the risks before taking the following types of medicines along with doxepin (Currax, 2020; Mylan, 2017; Par, 2017):
- Central nervous system (CNS) depressants: substances that slow down the activity of your brain. Consuming large amounts of CNS depressants can cause severe drowsiness, trouble breathing, and slowed heart rate. Examples of CNS depressants are alcohol, opioid painkillers like tramadol and oxycodone, benzodiazepines like lorazepam, and sleeping pills like zolpidem.
- Certain antihistamines that cause drowsiness, such as diphenhydramine (Benadryl)
Risk of serotonin syndrome
Several medications, including doxepin, can increase levels of serotonin, a brain chemical that affects your mood. Taking certain medicines along with doxepin could cause serotonin levels to rise too much, and in rare cases, cause serotonin syndrome.
Serotonin syndrome can be mild or severe. The following medications can increase the risk of serotonin syndrome if taken with doxepin (Currax, 2020; Mylan, 2017; Par, 2017):
- Monoamine oxidase inhibitor (MAO inhibitor) drugs such as phenelzine, linezolid, rasagiline
- Other tricyclic antidepressants (TCAs) like amitriptyline, clomipramine, nortriptyline, and imipramine
- Selective serotonin reuptake inhibitors (SSRIs) like citalopram, escitalopram (brand name Lexapro; see Important Safety Information), fluoxetine (brand name Prozac; see Important Safety Information), and sertraline (brand name Zoloft; see Important Safety Information)
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (brand name Cymbalta; see Important Safety Information) and venlafaxine (brand name Effexor XR; see Important Safety Information)
- Buspirone (brand name: Buspar; see Important Safety Information), a drug healthcare providers prescribe for anxiety
- St. John’s Wort, an herbal supplement
- Cimetidine, an antacid
- Tramadol, a medication healthcare providers prescribe for pain
- Triptans, a medication people take for migraines
Doxepin can interact with other medications besides these examples. Your healthcare provider or pharmacist can provide more information about interactions that may be a concern for you, so be sure to tell them about everything you currently take, including over-the-counter medicines and supplements.
- Almasi, A., Meza, C. E. (2021). Doxepin. [Updated Jul 19, 2021]. In: StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK542306/
- Chockalingam, R., Gott, B. M., & Conway, C. R. (2019). Tricyclic antidepressants and monoamine oxidase inhibitors: are they too old for a new look? Handbook of experimental pharmacology, 250, 37–48. doi: 10.1007/164_2018_133. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30105472/
- Currax Pharmaceuticals. (2020). Silenor – doxepin hydrochloride tablet. Retrieved October 28, 2021 from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=1bec1223-5239-4eb6-a9e8-62444106d2c0&type=display
- FDA. (n.d.) Drugs@FDA: FDA-Approved Drugs. Retrieved October 27, 2021 from https://www.accessdata.fda.gov/scripts/cder/daf/
- Mylan Pharmaceuticals. (2017). Zonalon – doxepin hydrochloride cream. Retrieved from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=5f302247-525e-4acc-852b-00eb1d79af4b&type=display
- Par Pharmaceutical. (2017). Doxepin hydrochloride capsule. Retrieved from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=71cff7cd-0410-4194-9cdd-af404a869edd&type=display
- Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of clinical sleep medicine, 13(2), 307–349. doi:10.5664/jcsm.6470 Retrieved from: https://jcsm.aasm.org/doi/10.5664/jcsm.6470
Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.