Imipramine

Contents

What is imipramine

What is imipramine

Imipramine is a tricyclic antidepressant that continues to be widely used in the therapy of depression. Imipramine is also used for childhood bedwetting (enuresis) in children ages 6 and older. Imipramine is available in generic forms and under the brand names of Tofranil in 10, 25, and 50 mg tablets and as capsules of 75, 100, 125 and 150 mg for nighttime dosing. The typical recommended dose for depression in adults is 75 to 100 mg daily in divided doses, increasing gradually to a maximum of 200 mg daily. Imipramine can also be given as a single nighttime dose. The recommended dose in children (ages 6 years or above) is 25 to 75 mg daily 1 hour before bedtime. Common side effects include dizziness, headache, drowsiness, restlessness, confusion, gastrointestinal upset, increased appetite, weight gain, blurred vision, dry mouth and urinary retention. Imipramine can cause mild and transient serum enzyme elevations and is rare cause of clinically apparent acute cholestatic liver injury.

Imipramine is a dibenzazepine derived tricyclic antidepressant that acts by inhibition of serotonin and norepinephrine reuptake within synaptic clefts in the central nervous system, thus increasing brain levels of these neurotransmitters. Imipramine is indicated for therapy of depression and was approved for this indication in the United States in 1959; it is still widely used, with more than 1 million prescriptions being filled yearly.

Imipramine comes as a tablet and a capsule to take by mouth. When imipramine tablets or capsules are used to treat depression, they are usually taken one or more times a day and may be taken with or without food. When imipramine tablets are used to prevent bedwetting in children, they are usually taken one hour before bedtime. Children who wet the bed early in the evening may be given one dose in the mid-afternoon and another dose at bedtime. Try to take imipramine at around the same time(s) every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take imipramine exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Your doctor may start you on a low dose of imipramine and gradually increase your dose.

It may take 1-3 weeks or longer for you to feel the full benefit of imipramine. Continue to take imipramine even if you feel well. Do not stop taking imipramine without talking to your doctor. Your doctor will probably want to decrease your dose gradually.

IMPORTANT WARNING

A small number of children, teenagers, and young adults (up to 24 years of age) who took antidepressants (‘mood elevators’) such as imipramine during clinical studies became suicidal (thinking about harming or killing oneself or planning or trying to do so). Children, teenagers, and young adults who take antidepressants to treat depression or other mental illnesses may be more likely to become suicidal than children, teenagers, and young adults who do not take antidepressants to treat these conditions. However, experts are not sure about how great this risk is and how much it should be considered in deciding whether a child or teenager should take an antidepressant. Children younger than 18 years of age should not normally take imipramine except to prevent bedwetting, but in some cases, a doctor may decide that imipramine is the best medication to treat a child’s condition.

You should know that your mental health may change in unexpected ways when you take imipramine or other antidepressants even if you are an adult over 24 years of age. You may become suicidal, especially at the beginning of your treatment and any time that your dose is increased or decreased. You, your family, or your caregiver should call your doctor right away if you experience any of the following symptoms: new or worsening depression; thinking about harming or killing yourself, or planning or trying to do so; extreme worry; agitation; panic attacks; difficulty falling asleep or staying asleep; aggressive behavior; irritability; acting without thinking; severe restlessness; and frenzied abnormal excitement. Be sure that your family or caregiver knows which symptoms may be serious so they can call the doctor if you are unable to seek treatment on your own.

Your healthcare provider will want to see you often while you are taking imipramine, especially at the beginning of your treatment. Be sure to keep all appointments for office visits with your doctor.

The doctor or pharmacist will give you the manufacturer’s patient information sheet (Medication Guide) when you begin treatment with imipramine. Read the information carefully and ask your doctor or pharmacist if you have any questions. You also can obtain the Medication Guide from the FDA website: https://www.fda.gov/Drugs/default.htm

No matter your age, before you take an antidepressant, you, your parent, or your caregiver should talk to your doctor about the risks and benefits of treating your condition with an antidepressant or with other treatments. You should also talk about the risks and benefits of not treating your condition. You should know that having depression or another mental illness greatly increases the risk that you will become suicidal. This risk is higher if you or anyone in your family has or has ever had bipolar disorder (mood that changes from depressed to abnormally excited) or mania (frenzied, abnormally excited mood) or has thought about or attempted suicide. Talk to your doctor about your condition, symptoms, and personal and family medical history. You and your doctor will decide what type of treatment is right for you.

Imipramine special precautions

Before taking imipramine,

tell your doctor and pharmacist if you are allergic to imipramine, any other medications, or any of the ingredients in imipramine tablets or capsules. Ask your doctor or pharmacist for a list of the ingredients.
tell your doctor if you are taking a monoamine oxidase (MAO) inhibitor such as isocarboxazid (Marplan), linezolid (Zyvox), methylene blue, phenelzine (Nardil), selegiline (Eldepryl, Emsam, Zelapar), and tranylcypromine (Parnate), or if you have stopped taking an MAO inhibitor within the past 14 days. Your doctor will probably tell you not to take imipramine. If you stop taking imipramine, you should wait at least 14 days before you start to take an MAO inhibitor.
tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention any of the following: anticoagulants (blood thinners) such as warfarin (Coumadin, Jantoven); antihistamines; cimetidine (Tagamet); flecainide (Tambocor); levodopa (Sinemet, Larodopa); lithium (Eskalith, Lithobid); medication for high blood pressure, mental illness, nausea, seizures, Parkinson’s disease, asthma, colds, or allergies; methylphenidate (Ritalin); muscle relaxants; propafenone (Rhythmol); quinidine; sedatives; selective serotonin reuptake inhibitors (SSRIs) such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft); sleeping pills; thyroid medications; and tranquilizers. Your doctor may need to change the doses of your medications or monitor you carefully for side effects. Your doctor may tell you not to take imipramine if you have taken fluoxetine in the past 5 weeks.
tell your doctor if you have recently had a heart attack. Your doctor may tell you not to take imipramine.
tell your doctor if you are being treated with electroshock therapy (procedure in which small electric shocks are administered to the brain to treat certain mental illnesses), and if you have or have ever had an enlarged prostate (a male reproductive gland), difficulty urinating, seizures, an overactive thyroid gland, or liver, kidney, or heart disease.
tell your doctor if you are pregnant, plan to become pregnant, or are breastfeeding. If you become pregnant while taking imipramine, call your doctor.
if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking imipramine.
you should know that this medication may make you drowsy. Do not drive a car or operate machinery until you know how this medication affects you.
remember that alcohol can add to the drowsiness caused by this medication.
tell your doctor if you use tobacco products. Cigarette smoking may decrease the effectiveness of this medication.
plan to avoid unnecessary or prolonged exposure to sunlight and to wear protective clothing, sunglasses, and sunscreen. Imipramine may make your skin sensitive to sunlight.
talk to your doctor about the risks and benefits of taking imipramine if you are 65 years of age or older. Older adults should not usually take imipramine because it is not as safe and effective as other medications that can be used to treat the same condition.
you should know that imipramine may cause angle-closure glaucoma (a condition where the fluid is suddenly blocked and unable to flow out of the eye causing a quick, severe increase in eye pressure which may lead to a loss of vision). Talk to your doctor about having an eye examination before you start taking this medication. If you have nausea, eye pain, changes in vision, such as seeing colored rings around lights, and swelling or redness in or around the eye, call your doctor or get emergency medical treatment right away.

Breastfeeding

There are no adequate studies in women for determining infant risk when using imipramine during breastfeeding. Weigh the potential benefits against the potential risks before taking imipramine while breastfeeding.

Drug Interactions

Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking imipramine, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Using imipramine with any of the following medicines is not recommended. Your doctor may decide not to treat you with imipramine or change some of the other medicines you take.

Amifampridine
Bepridil
Bromopride
Cisapride
Dronedarone
Furazolidone
Grepafloxacin
Iproniazid
Isocarboxazid
Levomethadyl
Linezolid
Mesoridazine
Methylene Blue
Metoclopramide
Moclobemide
Pargyline
Phenelzine
Pimozide
Piperaquine
Procarbazine
Ranolazine
Rasagiline
Safinamide
Saquinavir
Selegiline
Sparfloxacin
Terfenadine
Thioridazine
Tranylcypromine
Ziprasidone

Using imipramine with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

Acecainide
Aceclofenac
Acemetacin
Albuterol
Alfentanil
Alfuzosin
Almotriptan
Amiodarone
Amisulpride
Amitriptyline
Amoxapine
Amphetamine
Amtolmetin Guacil
Anagrelide
Apomorphine
Aprindine
Aripiprazole
Aripiprazole Lauroxil
Arsenic Trioxide
Artemether
Asenapine
Aspirin
Astemizole
Atazanavir
Azimilide
Azithromycin
Benzhydrocodone
Benzphetamine
Bretylium
Bromfenac
Bufexamac
Buprenorphine
Bupropion
Buserelin
Celecoxib
Chloral Hydrate
Chloroquine
Chlorpromazine
Choline Salicylate
Ciprofloxacin
Clarithromycin
Clomipramine
Clonidine
Clonixin
Clozapine
Codeine
Crizotinib
Cyclobenzaprine
Dabrafenib
Darifenacin
Darunavir
Dasatinib
Degarelix
Delamanid
Desipramine
Deslorelin
Desmopressin
Desvenlafaxine
Deutetrabenazine
Dexibuprofen
Dexketoprofen
Dextroamphetamine
Dextromethorphan
Diclofenac
Diflunisal
Dihydrocodeine
Dipyrone
Disopyramide
Dofetilide
Dolasetron
Domperidone
Donepezil
Droperidol
Droxicam
Efavirenz
Encorafenib
Enflurane
Epinephrine
Erythromycin
Escitalopram
Etilefrine
Etodolac
Etofenamate
Etoricoxib
Felbinac
Fenoprofen
Fentanyl
Fepradinol
Feprazone
Fingolimod
Flecainide
Floctafenine
Fluconazole
Flufenamic Acid
Fluoxetine
Flurbiprofen
Foscarnet
Frovatriptan
Gatifloxacin
Gemifloxacin
Glycopyrrolate
Glycopyrronium Tosylate
Gonadorelin
Goserelin
Granisetron
Halofantrine
Haloperidol
Halothane
Histrelin
Hydrocodone
Hydromorphone
Hydroxychloroquine
Hydroxyzine
Ibuprofen
Ibutilide
Iloperidone
Indomethacin
Inotuzumab Ozogamicin
Iobenguane I 123
Iobenguane I 131
Isoflurane
Isradipine
Ivabradine
Ivosidenib
Ketoprofen
Ketorolac
Lapatinib
Leuprolide
Levalbuterol
Levofloxacin
Levomilnacipran
Levorphanol
Levothyroxine
Lidoflazine
Lisdexamfetamine
Lithium
Lofexidine
Lorcainide
Lorcaserin
Lornoxicam
Loxapine
Loxoprofen
Lumefantrine
Lumiracoxib
Macimorelin
Meclofenamate
Mefenamic Acid
Mefloquine
Meloxicam
Meperidine
Metaxalone
Methadone
Methamphetamine
Methoxamine
Metronidazole
Midodrine
Mifepristone
Mirtazapine
Moricizine
Morniflumate
Morphine
Morphine Sulfate Liposome
Moxifloxacin
Nabumetone
Nafarelin
Nalbuphine
Naproxen
Naratriptan
Nefopam
Nepafenac
Niflumic Acid
Nilotinib
Nimesulide
Nimesulide Beta Cyclodextrin
Norepinephrine
Norfloxacin
Nortriptyline
Octreotide
Ofloxacin
Ondansetron
Osimertinib
Oxaprozin
Oxilofrine
Oxycodone
Oxymetazoline
Oxymorphone
Oxyphenbutazone
Paliperidone
Palonosetron
Panobinostat
Parecoxib
Paroxetine
Pasireotide
Pazopanib
Peginterferon Alfa-2b
Pentamidine
Pentazocine
Phenylbutazone
Phenylephrine
Piketoprofen
Pimavanserin
Piroxicam
Pitolisant
Pixantrone
Posaconazole
Pranoprofen
Procainamide
Prochlorperazine
Proglumetacin
Promethazine
Propafenone
Propyphenazone
Proquazone
Protriptyline
Quetiapine
Quinidine
Quinine
Remifentanil
Ribociclib
Risperidone
Rofecoxib
Salicylic Acid
Salsalate
Secretin Human
Sematilide
Sertindole
Sertraline
Sevoflurane
Sodium Phosphate
Sodium Phosphate, Dibasic
Sodium Phosphate, Monobasic
Sodium Salicylate
Solifenacin
Sorafenib
Sotalol
Spiramycin
Sufentanil
Sulfamethoxazole
Sulindac
Sulpiride
Sultopride
Sumatriptan
Sunitinib
Tacrolimus
Tapentadol
Tedisamil
Telavancin
Telithromycin
Tenoxicam
Tetrabenazine
Tiaprofenic Acid
Tiotropium
Tolfenamic Acid
Tolmetin
Toremifene
Tramadol
Trazodone
Trifluoperazine
Trimethoprim
Triptorelin
Tryptophan
Valdecoxib
Vandetanib
Vardenafil
Vasopressin
Vemurafenib
Venlafaxine
Vilanterol
Vilazodone
Vinflunine
Voriconazole
Vortioxetine
Zolmitriptan
Zotepine
Zuclopenthixol

Using imipramine with any of the following medicines may cause an increased risk of certain side effects, but using both drugs may be the best treatment for you. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

Acenocoumarol
Alprazolam
Arbutamine
Atomoxetine
Cannabis
Carbamazepine
Cimetidine
Citalopram
Dicumarol
Fluvoxamine
Fosphenytoin
Mibefradil
Phenindione
Phenprocoumon
Phenytoin
Ritonavir
S-Adenosylmethionine

Other Interactions

Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Using imipramine with any of the following is usually not recommended, but may be unavoidable in some cases. If used together, your doctor may change the dose or how often you use this medicine, or give you special instructions about the use of food, alcohol, or tobacco.

Tobacco

Using imipramine with any of the following may cause an increased risk of certain side effects but may be unavoidable in some cases. If used together, your doctor may change the dose or how often you use this medicine, or give you special instructions about the use of food, alcohol, or tobacco.

Ethanol

What should I avoid while taking imipramine?

Do not drink alcohol. Dangerous side effects or death can occur when alcohol is combined with imipramine. Check your food and medicine labels to be sure these products do not contain alcohol.

Imipramine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

Avoid exposure to sunlight or tanning beds. Imipramine can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when you are outdoors.

Imipramine mechanism of action

Imipramine hydrochloride is a synthetic tricyclic antidepressant. Imipramine treats depression by increasing the amounts or activity of a chemical called serotonin and norepinephrine in certain areas of the brain that are needed to maintain mental balance. There is not enough information to explain how imipramine prevents bedwetting.

In childhood bedwetting, imipramine is thought to work one of several ways:

by changing the child’s sleep and wakening pattern
by affecting the time a child can hold urine in the bladder or
by reducing the amount of urine produced.

Imipramine also induces sedation through histamine-1 receptor blockage; hypotension through beta-adrenergic blockage; and diverse parasympatholytic effects. Imipramine has less sedative effect than other members of its therapeutic family. Imipramine is used in major depression, dysthymia, bipolar depression, attention-deficit disorders, agoraphobia, and panic disorders.

Imipramine uses

Imipramine tablets and capsules are used to treat depression. Imipramine tablets are also used to prevent bedwetting (enuresis) in children ages 6 and older. Imipramine generally is not used to treat bed-wetting in children younger than 6 to 7 years of age. Success rates have been found to be higher in older children. As with all drugs used to treat bed-wetting if imipramine is stopped, bed-wetting is likely to reoccur. The usual dose of imipramine is taken 1 to 2 hours before bedtime for children 6 to 8 years old. A higher dose is needed for older children and adolescents. A child should be seen by a doctor after three to six months on the drug. If the child starts wetting again, then a repeat course of treatment may be restarted.

Imipramine is also used occasionally to treat eating disorders and panic disorders. Talk to your doctor about the possible risks of using this medication for your condition.

Imipramine may be prescribed for other uses. Ask your doctor or pharmacist for more information.

Imipramine dosage

Follow all directions on your prescription label. Your doctor may occasionally change your dose to make sure you get the best results. Do not use imipramine in larger or smaller amounts or for longer than recommended.

If you need surgery, tell the surgeon ahead of time that you are using imipramine. You may need to stop using the medicine for a short time.

It may take up to 3 weeks before your symptoms improve. Keep using the medication as directed and tell your doctor if your symptoms do not improve.

Call your doctor if your symptoms do not improve, or if they get worse.

You should not stop using imipramine suddenly. Follow your doctor’s instructions about tapering your dose.

The following information includes only the average doses of imipramine. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of imipramine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take imipramine depend on the medical problem for which you are using imipramine.

Adult Dose for Depression

Use: Relief of symptoms of depression

TABLETS:

Hospitalized Patients:

Initial dose: 100 mg orally once a day, increasing to 200 mg/day if necessary
Titration dose: After increasing the dose to 200 mg/day, if there is no response after 2 weeks, increase the dose to 250 to 300 mg/day.
Maintenance dose: 100 to 200 mg orally once a day
Maximum dose: 300 mg/day

Outpatients:

Initial dose: 75 mg orally once a day
Maintenance dose: 50 to 150 mg orally once a day
Maximum dose: 200 mg/day

CAPSULES:

Hospitalized Patients:

Initial dose: 100 to 150 mg orally once a day, increasing to 200 mg/day if necessary
Titration dose: After increasing the dose to 200 mg/day, if there is no response after 2 weeks, increase the dose to 250 to 300 mg/day.
Maintenance dose: 75 to 150 mg orally once a day
Maximum dose: 300 mg/day

Outpatients:

Initial dose: 75 mg orally once a day
Maintenance dose: 75 to 150 mg orally once a day
Maximum dose: 200 mg/day

Comments:

Approximately 1 to 3 weeks of treatment may be needed before effects are observed.
Treatment may be more effective in patients with endogenous depression compared to patients with other depressive states.
The daily dosage may be given at bedtime or in divided doses.
In cases of relapse due to premature withdrawal of the drug, the effective dosage should be reinstituted.

Geriatric Dose for Depression

Use: Relief of symptoms of depression

TABLETS:

Initial dose: 30 to 40 mg orally once a day
Maximum dose: 100 mg/day

CAPSULES:

Initial dose: 25 to 50 mg orally once a day
Maximum dose: 100 mg/day

Comments:

Approximately 1 to 3 weeks of treatment may be needed before effects are observed.
Treatment may be more effective in patients with endogenous depression compared to patients with other depressive states.
Capsules may be used when total daily dosage is established at 75 mg or higher.
The daily dosage may be given at bedtime or in divided doses.
In cases of relapse due to premature withdrawal of the drug, the effective dosage should be reinstituted.

Pediatric Dose for Bedwetting

Use: Temporary adjunctive therapy in reducing bedwetting (enuresis) in children after possible organic causes have been excluded by appropriate tests

TABLETS:

6 years to 12 years:

Initial dose: 25 mg orally once a day
Maintenance dose: 50 mg orally once a day
Maximum dose: 2.5 mg/kg/day

12 years to 18 years:

Initial dose: 25 mg orally once a day
Maintenance dose: 75 mg orally once a day
Maximum dose: 2.5 mg/kg/day

Comments:

Examination may include voiding cystourethrography and cystoscopy in patients with daytime symptoms of frequency and urgency.
Effectiveness may decrease with continued treatment.
This dose should be given one hour before bedtime.
In early night bedwetters, the drug is more effective when given earlier and in divided amounts, i.e., 25 mg in midafternoon, repeated at bedtime.
Dosage should be tapered off gradually.

Renal Dose Adjustments

Mild to moderate renal dysfunction: Data not available
Severe renal dysfunction: Use with caution

Liver Dose Adjustments

Mild to moderate liver dysfunction: Data not available
Severe liver dysfunction: Use with caution

What should I do if I forget a dose?

Take the missed dose as soon as you remember it. However, if it is almost time for your next dose, skip the missed dose and continue your regular dosing schedule.

Imipramine side effects

Imipramine may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

nausea
drowsiness
weakness or tiredness
excitement or anxiety
nightmares
dry mouth
skin more sensitive to sunlight than usual
changes in appetite or weight
constipation
difficulty urinating
frequent urination
changes in sex drive or ability
excessive sweating

Some side effects can be serious. If you experience any of the following symptoms or those listed in the IMPORTANT WARNING or SPECIAL PRECAUTIONS sections, call your doctor immediately or get emergency medical treatment:

jaw, neck, and back muscle spasms
slow or difficult speech
shuffling walk
uncontrollable shaking of a part of the body
fever, sore throat, or other signs of infection
difficulty breathing or swallowing
severe rash
yellowing of the skin or eyes
irregular heartbeat

Imipramine may cause other side effects. Tell your doctor if you have any unusual problems while you are taking this medication.

Imipramine overdose

In case of overdose, call the poison control helpline at 1-800-222-1222. Information is also available online at https://www.poisonhelp.org/help. If the victim has collapsed, had a seizure, has trouble breathing, or can’t be awakened, immediately call your local emergency services number.

Imipramine overdose symptoms

Below are symptoms of an imipramine overdose in different parts of the body.

AIRWAYS AND LUNGS

Slow, labored breathing

BLADDER AND KIDNEYS

Cannot urinate
Hard to start urinating, or weak urine stream

EYES, EARS, MOUTH, NOSE, AND THROAT

Blurred vision
Dry mouth
Enlarged pupils
Very dry eyes
Ringing in the ears

HEART AND BLOOD VESSELS

Low blood pressure
Irregular heartbeat
Pounding heartbeat (palpitations)
Rapid heartbeat

NERVOUS SYSTEM

Agitation
Coma (lack of responsiveness)
Confusion
Seizures
Delirium (confusion and agitation)
Depression
Drowsiness
Hallucinations
Inability to concentrate
Nervousness
Tremor
Unsteadiness

SKIN

Dry, red skin

STOMACH AND INTESTINES

Constipation
Increased appetite
Weight gain
Vomiting

What to expect at the emergency room

Take the container to the hospital with you, if possible.

The health care provider will measure and monitor the person’s vital signs, including temperature, pulse, breathing rate, and blood pressure.

Tests that may done include:

Blood and urine tests
Chest x-ray
CT scan (computerized tomography or advanced imaging)
ECG (electrocardiogram, or heart tracing)

Treatment may include:

Fluids through a vein (by IV)
Medicines to treat symptoms
Activated charcoal
Laxative
Breathing support, including a tube through the mouth into the lungs and connected to a breathing machine (ventilator)

Imipramine overdose prognosis

An imipramine overdose can be very serious. Heart rhythm disturbances can be fatal.

People who overdose on this drug are almost always admitted to the hospital. The faster they get medical help, the better the chance of recovery. Complications such as pneumonia, muscle damage from lying on a hard surface for a prolonged period of time, or brain damage from lack of oxygen may result in permanent disability. Death can occur.