Trimipramine

SURMONTIL

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Pronunciation: trye-MI-pra-meen

Trimipramine ballicule: receptor binding, kinetics and half-life diagram — Mechanism of action: Trimipramine ballicule

Trimipramine SURMONTIL mascot mnemonic cartoon — Visual mnemonic: Trimipramine mascot
**“Sermon ‘til trimming”**

What it isTertiary amine tricyclic; depression with prominent insomnia.

Why this oneIt preserves sleep architecture more than other tricyclics, which suits depression with severe insomnia.

What limits itHeavily sedating and anticholinergic; lethal in overdose. Weight gain.

Trimipramine molecular structure (skeletal formula) — Molecular structure: Trimipramine

FDA-approved for

depression (~1979)

FDA label

Read the full label on DailyMed ↗

BOXED WARNING Increased risk of suicidal thinking and behavior in children, adolescents, and young adults; not approved for pediatric use.

FDA dosing	Population	Start	Target	Max
Depression	Outpatient adults	75 mg/day (divided)	150 mg/day	200 mg/day
Depression	Hospitalized adults	100 mg/day (divided)	200 mg/day	250–300 mg/day
Depression	Adolescent/geriatric	50 mg/day	100 mg/day	100 mg/day

Renal Undefined

Hepatic Undefined

Instructions

Total daily dose may be given at bedtime (QHS) to aid compliance
Lower doses for elderly, adolescents, and outpatients
Continue maintenance ~3 months at lowest effective dose
Allow ≥14 days between an MAOI and trimipramine in either direction

Available strengths

cap 25, 50, 100 mg

Contraindications

MAOIs (concurrently or within 14 days) due to risk of serotonin syndrome
Acute recovery period after a myocardial infarction
Cross-sensitivity with other tricyclic antidepressants/dibenzazepines

Cautions

Clinical worsening and suicide risk — monitor closely
Serotonin syndrome risk with MAOIs/linezolid/IV methylene blue
Anticholinergic effects (urinary retention, ileus, blurred vision)
Cardiovascular: arrhythmias, conduction changes, orthostatic hypotension
Lowers seizure threshold
May impair alertness/driving

Adverse reactions

Anticholinergic: dry mouth, blurred vision, constipation, urinary retention
Drowsiness, dizziness, fatigue
Orthostatic hypotension, tachycardia, arrhythmia
Confusion (especially elderly)
Weight change
Sexual dysfunction, endocrine effects

Pregnancy Category C; animal embryotoxicity/anomalies at ~20× human dose; use only if benefit justifies risk

Lactation Undefined

Cost

Trimipramine (SURMONTIL)

Strength		#/mo	CostPlus
25 mg	cap	per unit	offered
50 mg	cap	per unit	offered
100 mg	cap	per unit	offered

NADAC is a voluntary CMS survey of what retail community pharmacies pay for the drugs they stock. Trimipramine is dispensed outside retail pharmacies, so it rarely appears on surveyed invoices.

Generic entry1987

⚠ BOXED WARNING

Suicidal thoughts and behaviors in patients under 25

Classes and tags

Clinical profile

Therapeutic safety burden3 / 4

Overdose danger4 / 4

Weight-gain liability2 / 4

Sedation liability3 / 4

QT / Torsades2 / 4

Direct muscarinic antagonism3 / 4

Embryofetal risk2 / 4

Legacy pregnancy categoryC

Defining liabilityTricyclic anticholinergic and cardiac toxicity become life-threatening in overdose.

Serotonicity

This drug is routinely called serotonergic. By Gillman’s human-effect criteria it does not raise serotonin in the synapse.

Essentially antihistaminic with negligible clinically meaningful SRI activity.

Label contraindicationMAOIs (concurrently or within 14 days) due to risk of serotonin syndrome. The label governs prescribing; Gillman’s point concerns serotonin toxicity only.

It binds the serotonin transporter, and its SERT peg is drawn to that textbook affinity. The pale halo around the peg marks binding that, by Gillman’s human-effect criteria, does not produce clinical serotonin reuptake inhibition.

Gillman’s four human testsA measurable SERT affinity that fails all four is not clinical serotonicity.