Amitriptyline for pain?

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What I was speculating on is the fact that amitriptyline can lower the seizure threshold and induce seizures. You have to be careful in patients with a history of seizures. Could it lower your threshold and cause seizures with elevated PO2 from normal profile dives? Just another thing to think about.
Lloyd
 
Lloyd,

Do you have any data to share regarding your wondering? Doc V.'s article looks like it's August 2003 vintage - you have some newer news? Can you please post the data or a link to it regarding this?

Would patients with a history of seizures above water be appropriate for a physician to OK for diving anyway? This is the one thing in your post I see different from the info on DAN's site - perhaps a physiological predisposition to seizures to begin with is the root cause of sensitivity to agents, and that whatever is then physiologically different, may not cause the same effect in persons who do not share whatever is physiologically different to make a person have a history of seizures above water to start with?

Here's a hit that comes up by doing a search using 'seizure' on DAN's site - and it mentions increased N2 partial pressure, but not increased O2 partial pressure.

http://www.diversalertnetwork.org/medical/faq/faq.asp?faqid=80

Have you read the Doc V. article the link in post #5 takes one to, as well as the info on DAN's site? I saw nothing in any of this documentation showing such an increased risk for those qualified to scuba dive.

I wonder if it would have the opposite effect as postulated, like Doc V.'s reference on rat studies with caffiene? Two wonders don't make a conclusion.

I'm open to reviewing data.

Please show the data - I'm open to being educated. If there's new knowledge, I'd like to be made aware of it. Then I could review it with my physician, to see how it applies to me as an individual.

My favorite theme from both Doc V.'s article and DAN's stuff, in DAN's print is,
"Each situation requires individual evaluation, and no general rule applies to all."

This is what my physician and I have gone by all the time I've been diving.

Thanks!
 
I remembered from my old pharm class days that it lowers the seizure threshold, so I looked up the side effects in my drug program to make sure. Here is an online source where it says to use caution in patients with a history of seizures. Here is a quote from medline plus
"Some side effects can be serious. The following symptoms are uncommon, but if you experience any of them or those listed in the IMPORTANT WARNING section, call your doctor immediately:

slow or difficult speech
dizziness or faintness
weakness or numbness of an arm or a leg
crushing chest pain
rapid, pounding, or irregular heartbeat
severe skin rash or hives
swelling of the face and tongue
yellowing of the skin or eyes
jaw, neck, and back muscle spasms
shaking hands that you cannot control
difficulty sitting still
fainting
unusual bleeding or bruising
seizures
seeing things or hearing voices that do not exist (hallucinating) "

Notice seizures on next to last line. Here is the link

http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682388.html

Since the drug can induce seizures, could it lower your threshold and cause you to seize at a normally save PO2 level? I don't know and probably no one does for sure. I was just letting you know what I know in order to help you make an informed decision. I would hate to hear about you getting an O2 hit and I had not said anything.

I agree totally with individual evaluations. That is what I do with my patients. I also am glad you want to learn. That makes your Drs job alot easier when it comes time to make a decision together. That is why I try to throw out what I know in order to help you make an informed decision.

Good Luck,
Lloyd
 
WarmWaterDiver:
I certainly wouldn't want to be on a public road in my vehicle with someone else in their vehicle behind the wheel while they're hallucinating racing emus and chipmunks

Just imagine that the person is at the wheel of a full size school bus at the time. She did give up driving (and thereby lost her job) once we realized what was going on. However, the onset was gradual (over a month or so) and she didn't realize it was happening. She had been on the stuff through the summer with no apparent side effects. She was not taking any of the drugs it was known to interact with. In retrospect, it probably started with a loss of focus -- "Oh $#!+, I forgot to pick up that kid back there!" A week or two later she's on auto-pilot again and reminisces about our old home, a mile or so from an Emu farm. Then it proceeded to seeing things that we now know probably were not there: "Oh look, an Emu. I havn't seen one of those in years". It wasn't until sometime later, when the Emu starts following her down the road, that she clued in to the absurdities. I won't delve further into the hell our lives became after that.

Halucinations are a rarely reported side effect of amitriptyline, especially at low doses. I suggest that Buddyfan should be especially vigilant for symptoms of distraction and inattentiveness prior to his trip because I suspect there is a possibility nitrogen narcosis would amplify the effect.

Again, I am not a doctor or other qualified professional. I have seen no study or reports suggesting a problem with diving while on amitriptyline. I am only relating my own experience.
 
So . . . any numerical data on occurance of seizures, and /or hallucinations, above and/or below water? All of life is risk management. Numerical data would be very, very helpful for informed decisions. For me, it's so far, so good, and so far, my physician agrees. But, I'd hate to some day be a victim of the tyranny of the few, or the one - like the McDonald's coffee in the lap case. Happens all too often in a litiginous society.

Sorry to hear of the bus driving case - I'm sure it was not pleasant.
 
WarmWaterDiver:
So . . . any numerical data on occurance of seizures, and /or hallucinations, above and/or below water? All of life is risk management. Numerical data would be very, very helpful for informed decisions. For me, it's so far, so good, and so far, my physician agrees. But, I'd hate to some day be a victim of the tyranny of the few, or the one - like the McDonald's coffee in the lap case. Happens all too often in a litiginous society.

No data I know of for underwater here is some above data.

Antidepressants and seizure incidence
Support information on page: Psychotropic Drugs & Developmental Disabilities > Comorbid epilepsy approach > Antidepressants

Antidepressants Seizure Incidence (%)
TCAs and tetracyclic antidepressants
Amitriptyline <0.1-0.3
Amoxapine 24.5-36.4
Clomipramine 0.7-3.0
Desipramine <0.1
Doxepin <0.1
Imipramine <0.1-0.9
Maprotiline 0.4-15.6
Nortriptyline <0.1
Protriptyline <0.1
SSRI and SNRI
Citalopram <0.1
Fluoxetine <0.1-0.2
Fluvoxamine <0.2
Paroxetine <0.1
Sertraline <0.1
Venlafaxine <0.26
Other antidepressants
Bupropion 0.6-1.0
>450 mg/day 0.6-2.19
SR 400 mg/day 0.4
SR 300 mg/day 0.1
Mirtazapine <0.1
Nefazodone NA
Trazodone <0.1


TCAs = tricyclic antidepressants
SNRI = serotonin-norepinephrine reuptake inhibitor
SSRI = selective serotonin reuptake inhibitor
SR = sustained-release formula
NA = limited information



Source
http://professionals.epilepsy.com/page/thera_antidepress.html

Also
Effects of psychotropic drugs on seizure threshold.
Drug Saf 2002;25(2):91-110 (ISSN: 0114-5916)
Pisani F; Oteri G; Costa C; Di Raimondo G; Di Perri R
Department of Neurosciences and of Psychiatric and Anaesthesiological Sciences, First Neurological Clinic, The University of Messina, Messina, Italy. pisanif@www.unime.it.
Psychotropic drugs, especially antidepressants and antipsychotics, may give rise to some concern in clinical practice because of their known ability to reduce seizure threshold and to provoke epileptic seizures. Although the phenomenon has been described with almost all the available compounds, neither its real magnitude nor the seizurogenic potential of individual drugs have been clearly established so far. In large investigations, seizure incidence rates have been reported to range from approximately 0.1 to approximately 1.5% in patients treated with therapeutic doses of most commonly used antidepressants and antipsychotics (incidence of the first unprovoked seizure in the general population is 0.07 to 0.09%). In patients who have taken an overdose, the seizure risk rises markedly, achieving values of approximately 4 to approximately 30%. This large variability, probably due to methodological differences among studies, makes data confusing and difficult to interpret. Agreement, however, converges on the following: seizures triggered by psychotropic drugs are a dose-dependent adverse effect; maprotiline and clomipramine among antidepressants and chlorpromazine and clozapine among antipsychotics that have a relatively high seizurogenic potential; phenelzine, tranylcypromine, fluoxetine, paroxetine, sertraline, venlafaxine and trazodone among antidepressants and fluphenazine, haloperidol, pimozide and risperidone among antipsychotics that exhibit a relatively low risk. Apart from drug-related factors, seizure precipitation during psychotropic drug medication is greatly influenced by the individual's inherited seizure threshold and, particularly, by the presence of seizurogenic conditions (such as history of epilepsy, brain damage, etc.). Pending identification of compounds with less or no effect on seizure threshold and formulation of definite therapeutic guidelines especially for patients at risk for seizures, the problem may be minimised through careful evaluation of the possible presence of seizurogenic conditions and simplification of the therapeutic scheme (low starting doses/slow dose escalation, maintenance of the minimal effective dose, avoidance of complex drug combinations, etc.). Although there is sufficient evidence that psychotropic drugs may lower seizure threshold, published literature data have also suggested that an appropriate psychotropic therapy may not only improve the mental state in patients with epilepsy, but also exert antiepileptic effects through a specific action. Further scientific research is warranted to clarify all aspects characterising the complex link between seizure threshold and psychotropic drugs.

I think for the risks of diving, we are making guesses since I know of no studies. To bad you could not make a few deep chamber dives to see what happens in a controlled environment.

Lloyd
 
Data - thanks - always more useful than just qualitative statements (especially in litiginous society).

Maybe if the pay was right - is that an offer? Do you have the equipment and funding and want to do a SERIOUS study? If it was to assist in making a case against advocating approach #2 in Doc V.'s article (similar to UK and Zyban reference - also not written as linked to ppO2), I'd seriously consider it.

If one has to make guesses, my approach is to make the best educated guess one can, but filter input appropriately. The IMPORTANT WARNING info accompanies prescriptions I receive, and also cautions discussing with your physician if one has any such symptoms occur. Doc V.'s article also talks about discussing with the physician, and observing for effects above water, and that's not what I'm questioning at all.

For amitriptyline, from the data you've supplied, looks like the numerical incidence is pretty low above water (<0.1 to 0.3 % in first half of post) and seems to be related to epilepsy and developmental disabilities (if I'm interpreting the header correctly) - would be great to have data on a control group using the same meds that didn't maybe have the same physiological difference thay would be a contraindication to diving already. And no real quantification of 'theraputic doses' in terms of mg/day on the broad spectrum of drugs lumped together in the second half of post. Overdosing appears to have the highest statistical significance in the second post - no real quantification of that vs. 'theraputic dose'. Also seems risk is centered on a population that would maybe otherwise be contraindicated to OK for diving "(such as history of epilepsy, brain damage, etc.)". It's in the potential application / extraploation of this data to diving and increased ppO2's I'm challenging perhaps needing screening / further review / review of other's work (DAN & Doc V. as examples) - the context.

I'll review again with my physician, but perhaps the DAN physicians also had looked over similar quantification, and that's why it's not mentioned in their articles? Just speculating.

Doc V. did mention 'Although the risk is very low . . ' and mentioned 'most particularly SSRI's at high doses' (not tricyclics) but also did not quantify. Nothing on increased ppO2 synergy either. Doc's #3 approach gets my vote for whatever condition the medication is precribed for, and whatever activity, since his article wasn't written in reference to pain or migraine, or other activities like motor vehicle operation. Looking at the last lines of your post, it appears we're in consensus.
 
Sorry, no money or equipment for that area of research. It would be nice to have more done. The header is a little misleading. It is from an article for epilepsie docs, but the incidences are for "normal" subjects. They are still low, but worthwhile to think about. It might be worth seeing how long it takes for Amitriptyline to wash out of your system. If it has a short half life, you could see about skipping some doses before you dive. You are also better off since you take a low dose.
Lloyd
 
The half-life is 17 to 40 hours. I don't know how that would work for you. Maybe your doc would know.
Lloyd
 
Other than all those said above, do be aware that tricyclics do interact with alcohol which is found in diving places most of the time.

Based on the information of a half life of max 40 hours, the time to clear the drug from the system is 200 hours. (5 half-lives)
 

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