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Web:	MayoMedicalLaboratories.com
Email:	mml@mayo.edu
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Test ID: TRICY
Tricyclic Antidepressant Screen, Serum

NY State Approved Indicates the status of NY State approval and if the test is orderable for NY State clients.

Yes

Useful For Suggests clinical disorders or settings where the test may be helpful

Monitoring serum concentration during therapy

Evaluating potential toxicity

Evaluating patient compliance

Method Name A short description of the method used to perform the test

High-Performance Liquid Chromatography (HPLC)

Reporting Name A shorter/abbreviated version of the Published Name for a test; an abbreviated test name

Tricyclic Antidepressant Scrn, S

Aliases Lists additional common names for a test, as an aid in searching

Tricyclic Antidepressant Screen, Serum
Tricyclic Screen

Specimen Type Describes the specimen type needed for testing

Serum Red

Specimen Required Defines the optimal specimen. This field describes the type of specimen required to perform the test and the preferred volume to complete testing. The volume allows automated processing, fastest throughput and, when indicated, repeat or reflex testing.

Container/Tube: Red top

Specimen Volume: 2 mL

Additional Information: Serum must be separated from cells within 2 hours of draw.

Specimen Minimum Volume Defines the amount of specimen required to perform an assay once, including instrument and container dead space. Submitting the minimum specimen volume makes it impossible to repeat the test or perform confirmatory or perform reflex testing. In some situations, a minimum specimen volume may result in a QNS (quantity not sufficient) result, requiring a second specimen to be collected.

1 mL

Reject Due To Identifies specimen types and conditions that may cause the specimen to be rejected

Hemolysis	Mild OK; Gross reject
Lipemia	Mild OK; Gross reject
Icterus	NA
Other	Serum gel tube

Specimen Stability Information Provides a description of the temperatures required to transport a specimen to the laboratory. Alternate acceptable temperature(s) are also included.

Specimen Type	Temperature	Time
Serum Red	Refrigerated (preferred)	14 days
	Ambient	14 days
	Frozen	14 days

Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test

Amitriptyline

Amitriptyline is a tricyclic antidepressant (TCA) that is metabolized to nortriptyline, which has similar pharmacologic activity. The relative blood levels of amitriptyline and nortriptyline are highly variable among patients. Amitriptyline is the drug of choice in treatment of depression when the side effect of mild sedation is desirable. Nortriptyline is used when its stimulatory side effect is considered to be of clinical advantage.

Amitriptyline displays major cardiac toxicity when the concentration of amitriptyline and nortriptyline is in excess of 300 ng/mL, characterized by QRS widening leading to ventricular tachycardia and asystole. In some patients, toxicity may manifest at lower concentrations.

Nortriptyline

Nortriptyline is unique among the antidepressants in that its blood level exhibits the classical therapeutic window effect; blood concentrations above or below the therapeutic window correlate with poor clinical response. Thus, therapeutic monitoring to ensure that the blood level is within the therapeutic window is critical to accomplish successful treatment with this drug.

Nortriptyline is a TCA used for treatment of endogenous depression. It also is a metabolite of the antidepressant amitriptyline. Nortriptyline is used when its stimulatory side effect is considered to be of clinical advantage; amitriptyline is used when the side effect of mild sedation is desirable.

Like amitriptyline, nortriptyline can cause major cardiac toxicity when the concentration is in excess of 300 ng/mL, characterized by QRS widening leading to ventricular tachycardia and asystole. In some patients, toxicity may manifest at lower concentrations.

Imipramine

Imipramine and its metabolite desipramine are TCAs used to treat endogenous depression requiring 1 to 3 weeks of treatment before therapeutic effectiveness becomes apparent. Desipramine is used for treatment of endogenous depression when the patient needs a drug with significant stimulatory side effects. These drugs have also been employed in the treatment of enuresis (involuntary urination) in childhood and severe obsessive-compulsive neurosis.

The optimal dosage of imipramine yields trough (just before the next dose) blood levels of imipramine and desipramine combined from 175 to 300 ng/mL. If desipramine is given, no imipramine should be detected and the therapeutic concentration for desipramine alone is 100 to 300 ng/mL.

Toxicity associated with imipramine is characterized by QRS widening leading to ventricular tachycardia and asystole. In some patients, toxicity may manifest at lower concentrations, or at therapeutic concentrations in the early state of therapy. Cardiac toxicity (first-degree heart block) is usually associated with blood concentrations in excess of 300 ng/mL.

Desipramine

Desipramine is a TCA; it also is a metabolite of imipramine. These drugs have also been employed in the treatment of enuresis (involuntary urination) in childhood and severe obsessive-compulsive neurosis. Desipramine is the antidepressant of choice in patients where maximal stimulation is indicated.

The therapeutic concentration of desipramine is 100 to 300 ng/mL. About 1 to 3 weeks of treatment are required before therapeutic effectiveness becomes apparent.

The most frequent side effects are those attributable to anticholinergic effects; dry mouth, constipation, dizziness, tachycardia, palpitations, blurred vision, and urinary retention. These occur at blood concentrations in excess of 300 ng/mL, although they may occur at therapeutic concentrations in the early stage of therapy. Cardiac toxicity (first-degree heart block) is usually associated with blood concentrations in excess of 300 ng/mL.

Doxepin

Doxepin is recommended for the treatment of psychoneurotic patients with depression or anxiety, and depression or anxiety associated with alcoholism or organic disease. Nordoxepin (N-desmethyldoxepin) is the major metabolite and is usually present at concentrations equal to doxepin. Optimal efficacy occurs at combined serum concentrations between 50 ng/mL and 150 ng/mL.

Like other TCA, the major toxicity of doxepin is expressed as cardiac dysrhythmias, which occur at concentrations in excess of 300 ng/mL. Other side effects include nausea, hypotension, and dry mouth.