Amitriptyline (Elavil) is a very old antidepressant. It was first marketed in the U.S. in 1961. Amitriptyline has one FDA-approved indication: “For the relief of symptoms of depression.” For reasons that mystify us, many health professionals prescribe amitriptyline for sleep problems. This is what is referred to as “off-label” prescribing. Doctors can, of course, prescribe any drug for any purpose they choose, even if the FDA has not given the use its blessing In the case of amitriptyline, though, we think this is not a good idea.
Reader Wants an Alternative to Amitriptyline for Sleep Problems:
Q. Is there an alternative to amitriptyline as a sleeping pill? I worry about it because I have read on your website that it is an anticholinergic drug that could affect memory.
I can’t get to sleep. When I do, I keep waking up. Some nights I only get two to three hours of sleep.
A. Amitriptyline is a sedating antidepressant. That means your doctor is employing a side effect of this medication to treat a different problem. Amitriptyline does have powerful anticholinergic activity and could affect cognitive function. Here is why we think doctors should be very cautious about prescribing amitriptyline for sleep problems:
Anticholinergic “Burden” and Brain Function:
A brand new study published in JAMA Internal Medicine (June 24, 2019) is titled:
The authors describe the importance of their study:
“Anticholinergic medicines have short-term cognitive adverse effects, but it is uncertain whether long-term use of these drugs is associated with an increased risk of dementia.”
In this study they compared over 55,000 people with dementia to more than 225,000 controls. Here is what they found:
“Among specific types of anticholinergic drugs there were significant increases in risk associated with use of antidepressants, antiparkinson drugs, antipsychotics, bladder antimuscarinics [for overactive bladder and incontinence], and antiepileptic drugs.”
Conclusions and Relevance:
“Exposure to several types of strong anticholinergic drugs is associated with an increased risk of dementia. These findings highlight the importance of reducing exposure to anticholinergic drugs in middle-aged and older people.”
This Is Not the First Time Such a Conclusion Was Reached:
A German study tracked nearly 800,000 prescriptions given to about 90,000 older patients in geriatric units (PLOS One, Feb. 10, 2017). The investigators noted that:
“Anticholinergic drugs are commonly used for the treatment of various diseases. Drugs with therapeutic anticholinergic effects comprise e.g. antiemetics (nausea drugs), anti-vertigo drugs, drugs for Parkinson’s disease and antispasmodics. In addition, many commonly used drugs have anticholinergic side effects, e.g. antiarrhythmics, antihistamines, antidepressants and antipsychotics. Known anticholinergic adverse effects last from dry mouth, constipation and visual impairment to confusion, delirium and cognitive decline.”
The authors concluded:
“Using a cross-sectional study design, a significant positive association between anticholinergic drug load and cognitive impairment in European patients treated in specialised geriatric units was found. The most frequently used definitve anticholinergic drugs were quetiapine, amitriptyline and carbamazepine.”
To find out more about anticholinergic drugs, here is a list we have compiled:
Seeking Other Approaches to Insomnia:
A nondrug option is cognitive behavioral therapy (CBT). It is considered an effective approach for chronic insomnia (Annals of Internal Medicine, Aug. 4, 2015).
Other ways to get to sleep include acupressure, melatonin and herbs such as chamomile, valerian, ashwagandha and passionflower. To learn more about these and other strategies, you may wish to consult our online eGuide to Getting a Good Night’s Sleep. It is available in our health guide section at www.PeoplesPharmacy.com.
Share your own experience with anticholinergic drugs like amitriptyline or diphenhydramine in the comment section.