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Your doctor may gradually increase this dose to 150 milligrams per day. The total daily dose is generally never higher than 200 milligrams. Alternatively, your doctor may want you to start with 50 milligrams to 100 milligrams at bedtime. He or she may increase this bedtime dose by 25 or 50 milligrams up to a total of 150 milligrams a day. For long-term use, the usual dose ranges from 40 to 100 milligrams taken once daily, usually at bedtime.

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Precautions

Included in the listing are a few adverse reactions which have not been reported with this specific drug. After prolonged administration, abrupt cessation of treatment may produce nausea, headache, and malaise. Gradual dosage reduction has been reported to produce, within two weeks, transient symptoms including irritability, restlessness, and dream and sleep disturbance. These symptoms are not indicative of addiction. Critical manifestations of overdose include: cardiac dysrhythmias, severe hypotension, convulsions, and CNS depression, including coma. A minimum of 6 hours of observation with cardiac monitoring and observation for signs of CNS or respiratory depression, hypotension, cardiac dysrhythmias and/or conduction blocks, and seizures is necessary.

Side Effects

Drugs Metabolized by P450 2D6 ? The biochemical activity of the drug metabolizing isozyme cytochrome P450 2D6 (debrisoquin hydroxylase) is reduced in a subset of the caucasian population (about 7-10% of caucasians are so called "poor metabolizers"); reliable estimates of the prevalence of reduced P450 2D6 isozyme activity among Asian, African and other populations are not yet available. Poor metabolizers have higher than expected plasma concentrations of tricyclic antidepressants (TCAs) when given usual doses.

Overdose

Changes in the electrocardiogram, particularly in QRS axis or width, are clinically significant indictors of tricyclic antidepressant toxicity. Obtain an ECG and immediately initiate cardiac monitoring. Protect the patient's airway, establish and intravenous line, and initiate gastric decontamination. If signs of toxicity occur at any time during this period, extended monitoring is required. There are case reports of patients succumbing to fatal dysrhythmias late after overdose; these patients had clinical evidence of significant poisoning prior to death, and most received inadequate gastrointestinal decontamination.