Nurse Teaching on Precautions to be Exercised While Taking Trimipramine

Patient/caregiver was educated on precautions to be observed while taking Trimipramine as below:

  1. Follow closely on the expiration date of the medication. If using a pillbox, check the expiration date on the medication container every time you fill the pillbox. If you are taking this medication for longer periods of time, set enough reminders on your phone for medication pick-up. You can have a reminder 10 days ahead, the next a week ahead, and then, every day, before you run out of the medication. This helps with securing the refill in time and making arrangements for pick-up at the pharmacy. Also, you can avoid the unpleasant withdrawal response from sudden discontinuation of medication due to running out on the medication.
  2. Trimipramine use can result in common general constitutional symptoms such as, nausea and vomiting. Taking dose of trimipramine with a glass of water, after having some food or a snack can help avoid having unpleasant gastrointestinal symptoms with the medication.
  3. Trimipramine intake can induce extreme dry mouth and constipation. Sucking on a sugar free hard candy can help with symptomatic relief of dry mouth. Proper hydration measures and compliance with daily fluid intake recommendations can help with relief from constipation. If you experience any further bothersome constipation, report it to your physician for a recommendation on laxative/stool softener use. Observing compliance with fiber intake recommendations in the diet can also help with preventing episodes of constipation with the medication.
  4. Trimipramine intake carries the risk of lowering the blood pressure. Hypotension, secondary to trimipramine intake, can lead to episodes of confusion and dizziness. Avoid sudden changes in position, until you are used to the side-effects of trimipramine intake. Sudden change of positions can make the confusion and dizzy episodes even worse and precipitate accidents and falls. Observing compliance with use of assistive and supportive devices, such as, walker and cane, can help fall prevention. Report any episodes of increased dizziness, syncope, and loss of consciousness while taking trimipramine. Discuss with your physician regarding all your medications and their risk of causing hypotensive episodes.
  5. Trimipramine intake can induce some dizziness and make one drowsy. Starting the medication at a low dose, watching for the response, and gradually changing the dose, to help optimum control of your symptoms, can contribute to controlling/reducing the risk for drowsiness and dizziness due to the medication. If the dizziness becomes bothersome, report it to your physician and other health care personnel, for any change in plan of care to be considered. Stay away from activities, such as, driving and operating heavy machinery, until you are used to the side effects caused by trimipramine intake.
  6. Do not take trimipramine with alcohol or opioid pain medications, such as, hydrocodone and codeine, as these products can add to the dizziness and confusion caused by trimipramine and contribute to falls and accidents. A number of OTC cough medications and antihistamines, muscle relaxant medications, and antianxiety medications, can potentiate the confusion caused by trimipramine and so, must be avoided taking along with trimipramine. Avoid taking any other medications with potential to cause drowsiness along with trimipramine at the same time.
  7. Trimipramine intake can increase the risk for skin rash and photosensitivity, in individuals exposed to sunlight. Individuals can present with rash, itching, redness, or other discoloration, or severe sunburn upon exposure to sunlight. Individuals taking trimipramine, especially those with history of photosensitivity, should avoid natural bright lights and tanning booths. Using sunscreens and protective clothing, when getting out in the sun, can help prevent any photosensitive responses from developing.
  8. Trimipramine use can result in pupillary dilation and obstruction to the drainage of fluid (aqueous humor) inside the eye. This blockage of fluid in the eye can result in increase in the intraocular pressure, leading to glaucoma. Individuals with glaucoma can present with eye pain, headache, and blurred vision with haloes around light. Observe compliance with any periodical vision exams recommended. Report any eye pain and changes with vision, while taking trimipramine, to your physician immediately, so that, an alternative plan of care could be considered.
  9. Trimipramine intake has the potential to increase the likelihood of seizures. Trimipramine must be very cautiously administered in individuals with seizure history, compliance with recommended anti-seizure therapy observed, and response closely monitored. Trimipramine can also induce a life-threatening reaction called neuroleptic malignant syndrome. Individuals taking trimipramine can present with high fever, episodes of confusion, muscle rigidity, elevated blood pressure, and rapid heart rate. Severe cases can present with muscle breakdown, elevated potassium levels in the blood due to muscle destruction, life-threatening cardiac arrhythmias due to the elevated blood potassium, and seizures. Any of these findings, while taking trimipramine, should be immediately reported to the physician, for necessary changes to be considered. Also, discuss with your physician regarding your history of seizures, if any, if you are newly started on trimipramine. If you are newly diagnosed with seizure complaint, discuss with your physician regarding your safety with continuing on trimipramine, if you have been using trimipramine for long.
  10. Trimipramine carries the risk of causing and/or aggravating cardiac arrhythmias. Trimipramine can also interact with many antibacterial and antifungal antibiotics, antiarrhythmic medications, antidepressants, and antipsychotic medications, resulting in development or aggravation of underlying cardiac arrhythmias, leading to debility and sudden cardiac death. Avoid taking trimipramine along with medications belonging to the above-mentioned groups, to prevent any dangerous arrhythmias from developing. Discuss with your physician regarding your history of cardiac arrhythmias, if any, if you are newly started on trimipramine. If you are newly diagnosed with any cardiac arrhythmias or started on any antiarrhythmic medications, discuss with your physician regarding your safety with continuing on trimipramine, if you have been using the medication for long.
  11. Individuals with complaint of dehydration, secondary to history of diarrhea, vomiting, or poor fluid intake, can suffer electrolyte disturbances and be more prone to develop arrhythmias with trimipramine. Electrolyte disturbances, such as, low potassium and magnesium levels, secondary to diuretic pill intake, can also act as a precipitating factor for cardiac arrhythmias with trimipramine. Observing compliance with recommended hydration measures can help prevent development of arrhythmias in these individuals. Also, observe compliance with any periodical lab draws ordered for electrolyte levels and closely follow for development of signs and symptoms of cardiac arrhythmia, such as, episodes of chest pain, rapid heart rate, palpitations, dizziness, and shortness of breath. Report any such findings to your physician immediately, so that, an alternative plan of care could be considered.
  12. Serotonin is one chemical in the brain, which in permissible amounts, is believed to reduce anxiety and promote happiness and well-being. Very excessive concentrations of serotonin in the brain can lead to serotonin syndrome. Individuals with serotonin syndrome can present with mania, excitement, hallucinations, agitation, insomnia, pounding heartbeat, very rapid heart rate, overactive reflexes, and diarrhea. Trimipramine use, especially along with a few other antidepressants, such as, citalopram, fluoxetine, and sertraline, can significantly increase the serotonin levels in the body, lead to development of serotonin syndrome, and so, is contraindicated. Caution must be exercised even when discontinuing on any of the above mentioned antidepressant medications with potential to increase serotonin levels and starting on trimipramine, by observing a window period of at least 2 weeks, before the transition to trimipramine is made. Using trimipramine with these medications closely can result in dangerously elevated serotonin in the blood, leading to development of serotonin syndrome.
  13. Trimipramine use can sometimes increase the risk for deterioration and worsening of clinical symptoms of mood disorders. Continue taking trimipramine, as recommended, even if your mood feels better and discontinuing the medication abruptly, without your physician’s recommendation, can result in disruption of chemical balance in the brain, resulting in worsening of mood disorder and severe withdrawal symptoms.  Individuals can present with complaints such as, feeling low, anxiety, panic attacks, trouble sleeping, gross appetite changes, impulsiveness, agitation, aggression, hallucinations, mania, and suicidal thoughts. Report any continuing/deteriorating symptoms of mood disorder immediately to your physician, so that, a dose change or change in plan of care could be considered.
  14. Trimipramine takes some time to fairly balance the chemicals in the brain, before any improvement in mood and behavior are noted. It could take about 2 – 4 weeks to see this change in mood. So, do not discontinue taking the medication without consulting your physician, as you failed to see the improvement with depression and anxiety symptoms immediately after taking the medication.
  15. Intake of trimipramine induces relaxation of urinary bladder, prevent/reduce episodes of bladder contraction, induce retention of urine in the bladder, and cause difficulty with emptying the bladder. Retention of urine in the bladder is a significant factor contributing to development of UTI. Individuals with history of retention of urine and frequent urinary tract infections must be aware of this side-effect of trimipramine, as the medication can exacerbate this risk significantly. Observing compliance with proper hydration measures, compliance with daily fluid intake recommendations, practicing hygiene & timed voiding with other UTI prevention measures can help reduce the risk of urinary retention and prevent development of any UTIs, secondary to trimipramine intake.
  16. As the balance between the chemicals in the brain has to be finely regulated to help relieve the anxiety and depressive symptoms and experience feelings of well-being, the dose of trimipramine also needs to be finely regulated, in order to accomplish this goal. Your physician could change the dose of trimipramine, based on the response and side-effects developed. Maintain compliance with follow-up physician appointments and be accommodative to the plan of dose changes, until you show an optimum response.
  17. Notify your doctor of any unresolved and worsening anxiety and depressive symptoms or continuing unpleasant side-effects, so that, your dosage on the medication could be revised.
  18. Trimipramine use in expectant mothers could increase risk for complications in newborn. Trimipramine can cross the placenta and enter the baby. Newborns exposed to trimipramine in the uterus can present with harmful side-effects of the medication, such as, respiratory depression, breathing difficulties, developmental delays, and other toxicity with the medication. After birth, newborns could also demonstrate symptoms of sudden withdrawal from the medication and present with listlessness, lack of energy, sleep disturbances, appetite changes, feeding difficulties, and seizures. So, trimipramine is cautiously administered with careful monitoring or avoided for an alternative drug during pregnancy and in women planning for pregnancy. Women in the child-bearing age group taking trimipramine must employ effective contraceptive measures in order to avoid getting pregnant.
  19. Blood work, labs for liver and kidney function could be periodically ordered while taking trimipramine. Observe compliance with all physician visits and periodical lab draws ordered, for an update on improvement/deterioration with symptoms of mood disorder and side-effects developed. This will also allow your physician to make appropriate changes in your plan of care, as needed.
  20. If you miss a dose, try taking it at the earliest notice of noncompliance. If it is time for the next dose, skip the missed dose and take the dose scheduled. Do not take an extra dose to try making up for the missed dose, as it can lead to toxicity. Notify your doctor and other health care personnel regarding your dose noncompliance.

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