Tricyclic antidepressants (TCAs, e.g. amitriptyline, desi-pramine, nortriptyline) are effective in the treatment of PHN.49[I] These compounds inhibit reuptake of mono-aminergic transmitters and are believed to potentiate the effects of biogenic amines in descending central nervous system pain modulating pathways. In addition, they block voltage-dependent sodium channels and alpha adrenergic receptors. TCAs, of which amitriptyline is the most widely prescribed, have significant side effects limiting their use, especially in the elderly and those with comorbidities. They can produce orthostatic hypotension, sedation, urinary retention, memory loss, dry mouth, constipation, and cardiac conduction abnormalities. Higher doses of tricyclic antidepressants may even be associated with the risk of sudden cardiac death.54 It is considered that the relatively selective noradrenaline reuptake inhibitors, such as desipramine and nortriptyline, cause less anticholinergic side effects as compared to the unse-lective serotonin and noradrenaline reuptake inhibitor, amitriptyline.55
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