B204. Trimipramine 2.0 children andadolescents (aged under 18 years). by NICEandthey are not recommended at allfor line treatment option inadults withdepression However, TCAs are not recommended asafirst illness, particularly where sedation is required. indicated for thetreatment of depressive Trimipramine isatricyclic antidepressant (TCA) Trimipramine Recommendations • • • • • If trimipramine isbeingprescribed for depending ontheperson’s riskof relapse. be reviewed after sixmonths or two years ongoing prescribing of antidepressants should After remission of an eposode of depression, bulletin. supporting resources accompanying this with thecurrent NICEclinicalguidance and trimipramine shouldbereviewed inline Patients already beingprescribed prescribing ontheNHS. as itisnot considered to becost effective for NICE, trimipramine shouldnot beprescribed Where a TCA isindicated inaccordance with benefit ratio. effective and have amore favourable risk- are recommended by NICEasthey are equally Selective serotonin reuptake inhibitors (SSRIs) used first line for thetreatment of depression. Tricyclic antidepressants (TCAs) shouldnot be collaboration withanappropriate specialist. treatment to amore appropriate alternative in consider discontinuation or switching neuropathic pain,fibromyalgia or insomnia) an unlicenced indication (e.g. anxiety, This document isfor use inthe NHS 1,2 trimipramine and how to slowly cross-taper when switching to analternative antidepressant –SSRI or TCA. The trimipramine bulletin provides additional guidance on how tomanage gradual discontinuation of tolerability. If patients are not tolerating thechange, cross-taper more slowly. appropriate cross taperingregimen. to another, abrupt withdrawal shouldusually beavoided. Any switching shouldbecarriedout with the been takinganantidepressant regularly for eight weeks or more. Any discontinuation of therapy shouldbedoneslowly, with gradual dose reductions, for patients who have response. therapy shouldbekept at thelowest effective level, subsequent with adjustment dependingontherapeutic on anindividualpatient basis, to maintain the patient atthe lowest effective dose. Dosage during long term discontinuation andswitching mustbemanaged carefully. Dosage adjustments shouldbemadecarefully Due to therisk of discontinuation syndrome withsudden cessation oftherapy with antidepressants, increased likelihood of theperson stopping treatment becauseof sideeffects. in mindthat TCAs are associated with thegreatest riskinoverdose of allantidepressant classesandan to imipramine isrecommended asitislesssedative, cost effective andless cardiotoxic in overdose. Bear If anSSRIisn’t appropriate andanalternative TCA would beamore alternative, suitable amanaged switch anti-inflammatory drugs(NSAIDs) or aspirin. particular, consider prescribing agastroprotective druginolder people who are alsotakingnon-steroidal other drugsthat have thepotential to damage thegastrointestinal mucosa or interfere withclotting. SSRIs are associated with anincreased riskof bleeding,especially inolder peopleor inpeopletaking from trimipramine to sertraline shouldbetried. If anSSRIrepresents aclinically appropriate alternative for theindividualpatient, thenamanaged switch Stopping or switching trimipramine 100,000 patients. has thepotential to release savings of £17.9million equateswhich to £30,711per Reducing theuseof trimipramine infavour of amore cost-effective alternative, the course of a year (ePACT July 2017to September 2017). In England and Wales, over £17.9millioniscurrently beingspent ontrimipramine preparations in day supply (basedonamaintenance doseof 100mgdaily). dose of 75mgdaily). daily). The cost per 28days for trimipramine iscurrently £380(basedonamaintenance doseof 100mg been subjected to excessive price inflation. More cost effective products are available. Where a TCA isindicated, trimipramine doesnot represent acost effective choice of TCA asithas Costs andsavings 4 3,4 The comparative cost of analternative TCA imipramine is£2.91(basedonamaintenance and isnot to be used for commercial or marketing purposes 5 Where anSSRI would bemore appropriate, sertraline costs is£1.21for a28 4 The speedof cross-tapering isbestjudged by individualpatient 1 5

4 When changingfrom oneantidepressant 1 1 In In B204. Trimipramine 2.0 appropriate to localneedandthecircumstances of individualpatients (inconsultation with thepatient and/or guardian or carer). The useandapplication of thisguidance doesnot override theindividualresponsibility of healthandsocialcare professionals to make decisions evidence, andinaccordance with PrescQIPP’s quality assurance framework. This document represents the view of PrescQIPP CICat thetimeof publication, which was arrived at after careful consideration of thereferenced Contact wish to access theimplementation resources shouldcontact writer for PrescQIPP CIC,November 2017andreviewed by Sue Smith, Senior Medicines Evidence Reviewer, December 2017.Non-subscribers who This resource hasbeencommissioned by NHSClinicalCommissioners onbehalf of CCGs inEngland. Information prepared by Gemma Dowell, Clinical 5. 4. 3. 2. 1. References Bulletindata?%3Aiid=2&%3AisGuestRedirectFromVizportal=y&%3Aembed=y Data packavailable here: Additional resources available: Department of Health. Drug Tariff. September 2017. Available via Guidelines. 12thEdition. June 2015. Taylor D, Paton, C,Kapur Shitij, The South London and Maudsley NHS Foundation Trust. OxleasNHS Foundation Trust. The Maudsley Prescribing www.medicinescomplete.com Joint Formulary Committee. British National Formulary (online) London:BMJ Groupand Pharmaceutical Press; September 2017. Available at management. September 2005,updated March 2015. Available via National Institute for Health andCare Excellence (NICE). ClinicalGuideline 28.Depression inchildren and young people:identification and updated April 2016. Available via National Institute for Health andCare Excellence (NICE).ClinicalGuideline 90.Depression inadults:recognition andmanagement. October 2009, [email protected] https://pdata.uk/views/B204_Trimipramine/ This document isfor use inthe NHS with any queriesor comments related to thecontent of thisdocument. https://www.prescqipp.info/b204-trimipramine/category/416-trimipramine / Lastaccessed 22/09/2017. https://www.nice.org.uk/guidance/cg90 [email protected] and isnot to be used for commercial or marketing purposes www.nhsbsa.nhs.uk https://www.nice.org.uk/guidance/cg28 Lastaccessed 24/07/17. Lastaccessed 22/09/2017. Lastaccessed 24/07/17. Community Interest Company Bulletin Data pack Terms andconditions Audit, patient letter https://