As the trade name suggests, protriptyline (Vivactil) is a stimulating TCA. It is so energizing that it has been used to treat ADHD and to promote daytime wakefulness with narcolepsy. Protriptyline is safe to use with sleep apnea because it is a respiratory stimulant (the same can be said for fluoxetine, a relatively stimulating SSRI). Potential for weight gain is minimal. It appears to be less toxic in overdose than other TCAs, although sample size is small. Of 77 single-drug overdoses, there were no deaths and only 2 major serious outcomes.
Available since 1966, protriptyline is rarely prescribed, ranked #7 of 10 in TCA sales. Since 2000 it has been unavailable in several countries including the UK and Australia. Protriptyline is the only TCA given in TID–QID divided doses, but it could be dosed less frequently given its long half-life of about 80 hours.
Dosing: Protriptyline has uniquely low dosing among TCAs due to its long half-life of about 80 hours. Protriptyline’s dose range is 15 to 40 mg/day (divided TID–QID) compared to the usual TCA range of 25–300 mg/day. Therapeutic serum range for protriptyline is about 70–250 ng/mL is similar to other TCAs.
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