Protriptyline
VIVACTIL
What it isActivating tricyclic inhibiting norepinephrine and serotonin reuptake; depression.
Why this oneIt is among the most activating and least sedating tricyclics, suiting anergic depression better than bedtime use.
What limits itInsomnia and anticholinergic effects limit use; overdose can be fatal, and long persistence makes titration slow.
FDA-approved for
- depression (~1967)
FDA label
Read the full label on DailyMed ↗
BOXED WARNING Increased risk of suicidal thinking and behavior in children, adolescents, and young adults; not approved for pediatric use — monitor for clinical worsening and suicidality.
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Depression | Adults | 15–40 mg/day divided TID–QID | 60 mg/day | |
| Depression | Adolescent / elderly | 5 mg TID, titrate gradually |
Renal Undefined
Hepatic Undefined
Instructions
- Initiate at a low dose and increase gradually; make increases in the morning dose
- In elderly, monitor cardiovascular system closely if daily dose exceeds 20 mg
- Allow a minimum of 14 days after discontinuing an MAOI before starting protriptyline
Contraindications
- MAOIs (concurrently or within 14 days) due to risk of hyperpyretic crises, severe convulsions, and death
- Concomitant cisapride (QT prolongation, cardiac arrhythmias, conduction disturbances)
- Acute recovery phase following myocardial infarction
Cautions
- Suicidality — monitor for clinical worsening (boxed)
- More likely than other TCAs to aggravate agitation and anxiety
- Cardiovascular reactions — tachycardia, orthostatic hypotension, arrhythmias
- Anticholinergic effects (urinary retention, blurred vision, constipation, paralytic ileus)
- Lowers seizure threshold
- Confusional states/hallucinations, esp. in the elderly
Adverse reactions
- Orthostatic hypotension
- Tachycardia/palpitations
- Arrhythmias/heart block
- Confusional states with hallucinations (elderly)
- Agitation/anxiety/insomnia
- Anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation)
- Tremor
- Drowsiness/dizziness
- Weight change
- Sexual dysfunction/gynecomastia
Pregnancy Undefined
Lactation Undefined
⚠ BOXED WARNING
- Suicidal thoughts and behaviors in patients under 25
Cost, est. cash$10–$300/month
Generic entry1995
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilityTricyclic anticholinergic and cardiac toxicity become life-threatening in overdose.
Mechanism of action: Protriptyline ballicule
Open Protriptyline in the interactive console ↗
Memory aids: mascots and interaction avatars
tricycle → tricyclic antidepressant
