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imipramine

imipramine
Brand names: Tofranil
Form Strength
TABLET, ORAL 25 mg
Display Tricyclics and Other Norepinephrine-reuptake Inhibitors Class: 28160428
Medication comments:
2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medication use in older adults.
Medication: imipramine (Tofranil)
Criteria 1: Potentially inappropriate medication use in older adults. (Table 2)
Drug(s) antidepressants with strong anticholinergic activity, alone or in combination
Rationale Highly anticholinergic, sedating, and cause orthostatic hypotension.
Recommendation Avoid
 Quality of evidence: High, Strength of Recommendation: Strong
 
Criteria 2: Potentially inappropriate medication use in older adults due to drug–disease or drug–syndrome interactions that may exacerbate the disease or syndrome. (Table 3)
Drug(s) ⇆ disease or syndrome anticholinergics ⇄ Delirium
Rationale Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 
Drug(s) ⇆ disease or syndrome anticholinergics ⇄ Dementia or cognitive impairment
Rationale Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 
Drug(s) ⇆ disease or syndrome anticholinergics ⇄ History of falls or fractures
Rationale May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation Avoid unless safer alternatives are not available.
 Quality of evidence: High, Strength of Recommendation: Strong
 
Drug(s) ⇆ disease or syndrome tricyclic antidepressants (TCAs) ⇄ History of falls or fractures
Rationale May cause ataxia, impaired psychomotor function, syncope, or additional falls.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation Avoid unless safer alternatives are not available.
 Quality of evidence: High, Strength of Recommendation: Strong
 
Drug(s) ⇆ disease or syndrome strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale May decrease urinary flow and cause urinary retention
Recommendation Avoid in men
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 
Drug(s) ⇆ disease or syndrome tertiary tricyclic antidepressants (TCAs) ⇄ Syncope
Rationale Tertiary TCAs increase the risk of orthostatic hypotension.
Recommendation Avoid
 Quality of evidence: High, Strength of Recommendation: Strong
 
Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4)
Drug(s) antidepressants (selected: TCAs)
Rationale May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults.
Recommendation Use with caution
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 
Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5)
Interacting drug(s) or class(es) anticholinergics ⇄ anticholinergics
Risk Rationale Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures.
Recommendation Avoid; minimize the number of anticholinergic drugs Click for list.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 
Interacting drug(s) or class(es) antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents
Risk Rationale Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants).
Recommendation Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs.
 Quality of evidence: High, Strength of Recommendation: Strong
Pediatric Pharmacy Association 2025 KIDs List of Key Potentially Inappropriate Drugs in Pediatrics 
Medication: imipramine (Tofranil)
Key Potentially Inappropriate Drugs in Pediatrics (KIDs) List: Second Edition (Table 1)
Drug tricyclic antidepressants
Risk/Rationale Sudden cardiac death
Recommendation Avoid in 18 yr of age and younger
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Last updated: Sep. 25, 2025
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