Amitriptyline - instructions for use, dose, side effects, contraindications

Excipients: corn starch 0.078 g, lactose monohydrate 0.185815 g, silicon dioxide colloid 0.001 g, gelatin medical 0.000885 g, magnesium stearate 0.003 g, talc 0.003 g.

Description:Tablets from white to white with a creamy shade of color, round, biconvex.

Pharmacotherapeutic group:Antidepressant

ATX: & nbsp

N.06.A.A.09 Amitriptyline

Pharmacodynamics:

Amitriptyline is a tricyclic antidepressant from a group of indiscriminate inhibitors of neuronal capture of monoamines. It has a pronounced thymoanaleic and sedative effect.Pharmacodynamics

The mechanism of antidepressant action of amitriptyline is associated with inhibition of reverse neuronal seizure of catecholamines (noradrenaline, dopamine) and serotonin in the central nervous system.

Amitriptyline is an antagonist of muscarinic cholinergic receptors in the central nervous system and periphery, and also has peripheral antihistamine (III) and antiadrenergic properties.

Antidepressant effect develops within 2-4 weeks after the beginning of application.

Pharmacokinetics:

Absorption is high. Amitriptyline quickly and well absorbed from the gastrointestinal tract after oral administration.The time to reach the maximum concentration (Tmah) after ingestion 2-7,7 hours. Bioavailability of amitriptyline from 33 to 62%, its active metabolite nortriptyline - 46-70%. The volume of distribution is 5-10 l / kg. Effective therapeutic concentrations in the blood of amitriptyline are 50-250 ng / ml, for nortriptyline (its active metabolite) 50-150 ng / ml. The maximum concentration in the blood plasma (Cmax) 0.04-0.16 μg / ml. Passes through the histohematological barriers, including the blood-brain barrier (including nortriptyline). The concentrations of amitriptyline in tissues are higher than in plasma. Relationship with plasma proteins 92 - 96%.

Metabolism

Metabolised in the liver by demethylation (isozymes CYP2D19, CYP3A) and hydroxylation (isoenzyme CYP2D6) with the formation of active metabolites - nortriptyline, 10-hydroxyamitriptyline, 10-hydroxynortriptyline and inactive metabolites. The main active metabolite is secondary amine-nortriptyline. Metabolites 10-hydroxyammitiptylip, 10-hydroxynortriptyline are also active, but their effect is much weaker.

Amitriptyline and nortriptyline are conjugated to glucuronic acid, but these conjugates are inactive.

Demethylnortriptyline and amitriptyline-N-oxide are present in blood plasma at low concentrations and are practically devoid of pharmacological activity.In comparison with amitriptyline, all metabolites have a much less pronounced m-holinoblokiruyuschim action.

Excretion

The half-life of plasma from 9 to 46 hours for amitriptyline and from 18 to 95 hours for nortriptyline. The average total creatinine clearance is 39.2 ± 10.18 l / h. It is allocated mainly at night - 80%, in part with bile. Complete excretion within 7-14 days. Amitriptyline penetrates the placental barrier, is excreted in breast milk. The ratio of concentrations of breast milk / plasma is 0.4-1.5. When breastfeeding amitriptyline, the child's body gets on average 2% of the dose taken by the mother, in terms of body weight (in mg / kg). Equilibrium plasma concentrations of amitriptyline and nortriptyline in most patients are achieved within a week.

Elderly patients

In elderly patients there is an increase in the half-life and a decrease in the clearance of amitriptyline due to a decrease in metabolic rate.

Patients with hepatic impairment

Dysfunction of the liver can lead to a slowing of the metabolism of amitriptyline and increase its plasma concentrations.

Patients with impaired renal function

Renal failure does not affect the kinetics of the drug.

Indications:

- Endogenous depression and other depressive disorders.

Contraindications:

- Hypersensitivity to amitriptyline or excipients of the drug, lactose intolerance, lactase deficiency, glucose-galactose malabsorption.

- Simultaneous treatment with monoamine oxidase inhibitors (MAO) and two weeks before the start of treatment (see section "Interaction with other drugs"),

- Heart failure in the stage of decompensation.

- Insufficiency of coronary circulation.

- Acute and recovery periods of myocardial infarction.

- Violation of the conduction of the heart muscle.

- Severe liver and kidney disease with severe impairment of function.

- Stomach ulcer and 12 duodenal ulcer in the stage of exacerbation.

- Hyperplasia of the prostate.

- Retention of urine, including with prostatic hyperplasia.

- Atony of the bladder.

- Pylorosthenosis, paralytic obstruction of the intestine.

- Pregnancy, the period of breastfeeding.

- Children under 18 years.

- Acute poisoning with alcohol, barbiturates or opioids.

- Closed-angle glaucoma.

Carefully:

Amitriptyline should be used with caution in people with alcoholism, with bronchial asthma, manic-depressive psychosis (MDP) and epilepsy (see Special instructions), in elderly patients, with oppression of bone marrow hematopoiesis, hyperthyroidism, diseases of the cardiovascular system (angina, arterial hypertension), bipolar affective disorder (after exiting the depressive phase), intraocular hypertension, decreased motor function of the gastrointestinal tract (risk of paralysis ), simultaneous administration with selective serotonin reuptake inhibitors (SSRIs), schizophrenia (activation of psychosis is possible).

Pregnancy and lactation:The use of the drug during pregnancy and breastfeeding is contraindicated. During pregnancy amitriptyline Should be used only if the intended benefit to the mother exceeds the potential risk to the fetus. The drug can not be used in III trimester of pregnancy, if this is not absolutely necessary. If the drug is used during pregnancy, the patient should be warned about the high risk of such a fetus, especially in the third trimester of pregnancy. During the period of breastfeeding, you must either refuse to take the drug, or cancel breastfeeding. If this is not done, you should monitor the condition of the child, especially during the first four weeks after birth. In order to avoid the development of the "cancellation" syndrome in newborns (manifested by shortness of breath, snotty, intestinal colic, increased nervous excitability, increase or decrease in blood pressure, tremors or spasms) amitriptyline should be abolished gradually, starting a dose reduction at least 7 weeks before the expected delivery.

Dosing and Administration:

Assign inside (during or after eating).

The initial daily intake for oral administration is 50-75 mg (25 mg in 2-3 doses), then the dose is gradually increased by 25-50 mg until the desired antidepressant effect is achieved. The optimal daily therapeutic dose is 150-200 mg (the maximum dose is taken per night).In severe depression, resistant to therapy, the dose is increased to 300 mg or more, to the maximum tolerated dose (maximum dose for outpatients is 150 mg / day). In these cases, treatment is advisable to begin with intramuscular or intravenous administration of the drug, while using higher initial doses, accelerating the build-up of dosages under the control of the somatic state.

After obtaining a persistent antidepressant effect, after 2-4 weeks the doses gradually and slowly decrease. In case of signs of depression with decreasing doses, it is necessary to return to the previous dose.

If the patient's condition improves within 3-4 weeks of treatment, then further therapy is impractical.

In elderly patients with mild disorders, in outpatient practice, the doses are 25-50-100 mg maximum, in divided doses or once a day at night.

The withdrawal syndrome

With long-term treatment, especially in high doses, with a sudden discontinuation of the drug may occur such undesirable reactions as headache, nausea, vomiting, diarrhea, irritability, malaise, insomnia, sleep disturbance with bright unusual dreams, increased excitability.

Side effects:

Basically, they are associated with the anticholinergic action of the drug: paresis of accommodation, blurred vision, increased intraocular pressure, dry mouth, constipation, intestinal obstruction, delayed urination, fever. All these phenomena usually pass after adaptation to the drug or reduce doses. Some of the side effects listed below, for example, headache, impaired concentration. sleep disturbance, anxiety, tremor, decreased libido can be symptoms of depression and usually decrease when the depressive state improves.

The incidence of side effects is indicated as: very often (> 1/10): often (> 1/100 to <1/10); infrequently (from> 1/1000 to <1/100); rarely (from> 1/10000 to <1/1000); very rarely (<1/10000); the frequency is unknown (the frequency of occurrence of the side effect can not be estimated from the available data).

From the side of the rehash system: very often headaches, drowsiness, tremors, dizziness; often - a violation of concentration, increased fatigue, weakness, irritability, tinnitus, dysarthria, polyneuropathy, dysgeusia (a violation of taste sensations), paresthesia, ataxia,agitation, extrapyramidal disorders, frequent epileptic seizures, peripheral neuropathy, infrequently insomnia, convulsions, anxiety; rarely akathisia.

From the side of mental activity: very often confusion, disorientation, decreased libido; infrequently - a decrease in cognitive functions, hypomania, mania, anxiety, night "nightmares"; rarely - aggression, delirium (in the elderly), hallucinations, in women - delay of orgasm, loss of ability to achieve orgasm; frequency is unknown suicidal thoughts, suicidal behavior.

From the cardiovascular system: very often - a feeling of palpitations, tachycardia, orthostatic hypotension, disturbance of the heart rhythm, extrasystole; often atrioventricular block, bundle branch blockade, symptoms of heart failure, fainting; infrequently - increased blood pressure, nonspecific changes in the ECG in patients with ns suffering from heart disease; rarely - myocardial infarction; very rarely - atrial fibrillation, ventricular fibrillation, cardiomyopathy.

From the side of the digestive system: very often - dry mouth, constipation, nausea, heartburn, anorexia,darkening of the tongue, a feeling of discomfort in the epigastrium, gastralgia; often - inflammation of the mucous membrane of the mouth, gum disease, irreversible tooth decay, a feeling of "burning in the mouth," intestinal obstruction; infrequently - cholestatic jaundice, diarrhea, vomiting, swelling of the tongue, stomatitis; rarely - an increase in salivary glands, paralytic intestinal obstruction, a violation of liver function, hepatitis.

From the urinary system: often - urinary retention.

From the side of the reproductive system: often - a change in potency.

From the endocrine system: infrequently - galactorrhea; rarely - swelling of the testicles; frequency unknown - gynecomastia.

On the part of the organs of hematopoiesis: rarely - oppression of bone marrow hematopoiesis, purpura.

From the immune system: infrequent skin rash, itching, urticaria; rarely-photosensitization, angioedema; very rarely - allergic inflammation of the alveoli and lung tissue (pneumonia, Leffler's syndrome);

From the skin and subcutaneous tissue: very often hyperhidrosis; infrequently - swelling of the face.

On the part of the body as a whole: very often an increase in appetite; often fatigue,changes in body weight with prolonged use, nasal congestion; rarely - hair loss, enlarged lymph nodes, hyperpyrexia, impaired functional liver tests, increased alkaline phosphatase in the blood, pollakiuria, decreased appetite; very rarely - allergic vasculitis.

On the part of the organs of vision: often - blurred vision, disruption of accommodation, dilated pupils, increased intraocular pressure; rarely - the paresis of accommodation. From the organs of hearing: rarely - noise in the ears, auditory hallucinations.

From the side of laboratory and instrumental data: very often - an increase in intraocular pressure; often changes in the EEG, violation of intraventricular conduction (prolongation of the QT interval, expansion of the QRS complex on the ECG), "jumping" arterial pressure, decreased production of antidiuretic hormone, hyponatremia; rarely - stump or hyperglycemia, glucosuria. violation of glucose tolerance, agranulocytosis, leukopenia, eosinophilia. thrombocytopenia, increased activity of "liver" transaminases.

Overdose:

Symptoms

Reactions to overdose in different patients can vary significantly.

Symptoms can develop slowly and imperceptibly, or abruptly and suddenly. During the first hours there is drowsiness or agitation, disorientation, confusion. dilated pupils, fever, dyspnea, dysarthria, agitation and hallucinations.

Anticholinergic symptoms (mydriasis, tachycardia, urinary retention, dry mucous membranes, intestinal motility slowing), convulsions, convulsive seizures, muscle stiffness, fever, sudden CNS depression, depression of consciousness down to coma, respiratory depression. Symptoms from the cardiovascular system: arrhythmias (ventricular tachyarrhythmia, cardiac arrhythmias such as torsade des pointes, ventricular fibrillation). The ECG is characterized by prolongation of the PR interval, expansion of the QRS complex, prolongation of the QT interval, flattening or inversion of the T wave, depression of the ST segment and blockade of intracardiac conduction of various degrees, which can progress up to cardiac arrest. The expansion of the QRS complex usually correlates with the severity of toxic effects due to acute overdose. Heart failure, lowering blood pressure, cardiogenic shock. Metabolic disorders: metabolic acidosis, hypokalemia.After awakening, confusion, excitement, hallucinations, and ataxia are again possible.

Treatment

Termination of amitriptyline therapy, hospitalization (in the intensive care unit).

Treatment is symptomatic and supportive. Probing and gastric lavage, even if after taking the drug inside a long time, with the prescription of activated charcoal. Careful observation, even if the case seems uncomplicated. Observation of the level of consciousness, pulse, arterial pressure and respiration. Frequent control of electrolytes in blood serum and blood gases. The control of airway passages, if necessary, should be performed using intubation. To prevent possible stopping of breathing, it is recommended to use an artificial respiration apparatus. Continuous ECG monitoring and monitoring of heart function are shown for 3-5 days. since relapse can occur after 48 hours and later. With the widening of QRS, heart failure and ventricular rhythm disturbances, a positive effect can be achieved by shifting the pH to the alkaline side (by introducing bicarbonate or mild hyperventilation) and by rapid infusion of hypertonic sodium chloride solution (100 200 mmol Na +).It is possible to use appropriate antiarrhythmics, for example, lidocaine in ventricular arrhythmias at a dose of 50-100 mg IV (1-1.5 mg / kg), then 1-3 mg / min by IV infusion. If necessary, cardioversion is performed, defibrillation. For the treatment of circulatory failure should use plasma substitutes, and in severe cases - infusion of dobutamine with an initial rate of 2-3 mcg / ct per minute with an increase in dose, depending on the response. With excitation and convulsions, diazepam can be used. Hemodialysis and forced diuresis are of little effect.

Interaction:

Amitriptyline intensifies the depressing effect on the CPC of the following drugs: neuroleptics, sedatives and hypnotics, anticonvulsant drugs, analgesics, funds for anesthesia, alcohol; shows synergism when interacting with other antidepressants. Tricyclic antidepressants, including amitriptyline, are metabolized by the isoenzyme CYP2D6 of hepatic cytochrome P450. The human CYP2D6 isozyme has several isoforms. CYP2D6 isozymes can inhibit a variety of psychotropic drugs, for example, neuroleptics, selective serotonin reuptake inhibitors (SSRIs) except for citalopram (a very weak inhibitor of the isoenzyme CYP2D6),[3-adrenoblockers and antiarrhythmics of the last generation. These drugs can inhibit the metabolism of tricyclic antidepressants and significantly increase their concentration in blood plasma. In addition, the isoenzymes CYP2C19 and CYP3A are involved in the metabolism of amitriptyline.

MAO inhibitors

Simultaneous reception of amitriptyline with MAO inhibitors can cause the development of serotonin syndrome (agitation, confusion, anxiety, tremor, myoclonus, hyperthermia, coma are possible) and lead to death.

A break in treatment between taking MAO inhibitors and tricyclic antidepressants should be at least 14 days!

Amitriptyline can be prescribed 14 days after cessation of treatment by irreversible non-selective MAO inhibitors and at least 1 day after the abolition of reversible MAO inhibitor therapy with moclobemide. The use of MAO inhibitors can begin 2 weeks after the withdrawal of amitriptyline. In any case, and the MAO inhibitor, and amitriptyline should be started with small doses, gradually increasing them depending on the effect.

Sympathomimetics

Amitriptyline can potentiate the effects of epinephrine, ephedrine, isoprenaline, norepinephrine, phenylephrine and phenylpropanolamine on the cardiovascular system.

Anticholinergic drugs

Tricyclic antidepressants can enhance the effects of anticholinergic drugs on the organs of vision, the central nervous system, the intestines and the bladder; simultaneous use of these drugs should be avoided due to an increased risk of developing paralytic intestinal obstruction.

Drugs that reduce sympathetic activity

Tricyclic antidepressants can reduce the antihypertensive effects of guanethidine, betanidine, reserpine, clonidine and methyldopa. Against the background of therapy with tricyclic antidepressants, it is recommended to correct antihypertensive therapy.

Indirect anticoagulants

With the simultaneous use of amitriptyline and indirect anticoagulants (coumarin derivatives or indadion), an increase in anticoagulant activity of the latter is possible.

Inhibitors of acetaldehyde dehydrogenase

Co-administration with disulfiram and other acetaldehyde dehydrogenase inhibitors may increase the risk of developing psychotic conditions and confusion.

Glucocorticoid means

Amitriptyline may increase depression caused by glucocorticoid agents.

Antithyroid drugs

Simultaneous reception with drugs for the treatment of thyrotoxicosis increases the risk of agranulocytosis.

Drugs that extend the interval QT

Drugs that extend the QT interval, including antiarrhythmics such as quinidine, H1-histamine receptor blockers, such as astsmizol and terfsiadin, some neuroleptics (in particular, pimozide and sertindole), cisapride, halofantrine and sotalol can increase the likelihood of developing ventricular rhythm disturbances with concomitant administration with tricyclic antidepressants.

Drugs that depress the central nervous system

When used simultaneously with blockers III -gistaminovyh receptors, clopidin, alcohol and Barbiturates may increase the inhibitory effect on the central nervous system. Amitriptyline can enhance the effects of other drugs that depress the central nervous system.

St. John's wort perforated

Simultaneous use of amitriptyline and preparations containing St. John's wort can lead to an increase in the metabolism of amitriptyline and a decrease in the maximum serum concentration of amitriptyline by 20%, due to the induction of its metabolism with the isoenzyme CYP3A4 of the liver.Theoretically, an increased risk of developing a serotonin syndrome is possible.

Lithium

With simultaneous use of lithium and tricyclic antidepressants, the risk of psychotic symptoms and toxic complications on the part of CNS may increase, even against the background of therapeutic concentrations of lithium in blood plasma. Described cases of mania, myoclonus, tremor, tonic-clonic seizures, memory disorders, confusion, disorganized thinking, hallucinations, serotonin syndrome and neuroleptic malignant syndrome, begins a few days after the start of the combination therapy; in most cases, treatment was required either with tricyclic antidepressants or with lithium. Elderly patients are particularly prone to the occurrence of such reactions. Tricyclic antidepressants and neuroleptics mutually inhibit each other's metabolism, which can lead to a reduction in the threshold of convulsive readiness and the development of seizures. You may need to adjust the dosage of these drugs.

Fluoxetine and fluvoxamine increase the concentration of tricyclic antidepressants in blood plasma.

Cimetidia and methylphenidate, as well as blockers of "slow" calcium channels, can slow the metabolism of amitriptyline, increase its plasma concentrations and, consequently, increase toxic effects.

Barbiturates and other inducers of microsomal liver enzymes, for example, rifampicin and carbamazepine, can enhance the metabolism of tricyclic antidepressants, reduce their plasma concentrations and reduce the anti-depressant effect.

Amitriptyline increases the effect of antiparkinsonian drugs and other drugs that cause extrapyramidal reactions.

Quinine slows the metabolism of amitriptyline.

Antifungal drugs, such as fluconazole and terbinafine, increase the plasma concentrations of tricyclic antidepressants and enhance the associated toxic effects.

Estrogens and their oral contraceptives can increase the bioavailability of amitriptyline. You may need to adjust the dosage of drugs or cancel one of them. Alcohol increases plasma concentrations of free amitriptyline and nortriptyline.

Pimozide and probucol may increase cardiac arrhythmias.

Phenytoin

Tricyclic antidepressants can increase the serum concentration of phenytoin and. accordingly, increase the risk of its toxic effects (ataxia, hyperreflexia, nystagmus, tremor).

Sibutramine

Destination with sibutramine (inhibits the reuptake of norepinephrine and serotonin) should be avoided, this combination increases the risk of central nervous system intoxication and the potentially fatal state of the serotonin syndrome. Epidemiological studies, conducted mainly in patients older than 50 years and above, show an increased risk of bone fractures in patients simultaneously receiving tricyclic antidepressants (amitriptyline) and selective serotonin reuptake inhibitors.

Antiviral drugs

The combination of amitriptyline with antiviral drugs can increase plasma concentrations of amitriptyline with the development of toxic effects, which makes it necessary to carefully monitor the therapeutic and side effects when they are simultaneously prescribed.

Nitrates

Decreased saliva secretion and dry mouth (blocking the action of acetylcholine) with amitriptyline may reduce the effect of the sublingual form of nitrates.

Muscle relaxants of central action

Concomitant use with amitriptyline increases their effect.

Special instructions:

The use of amitriptyline in patients of all age groups is associated with a risk of side effects from the cardiovascular system. When high doses are used, it is possible to develop rhythm disturbances and a severe decrease in blood pressure. In patients suffering from heart disease, these phenomena can occur when the usual dose is prescribed. Depression is associated with an increased risk of suicidal thoughts, self-injury and suicide. This risk persists until a stable remission occurs. Since the improvement may not occur during the first few weeks of treatment or more, patients should be carefully monitored before the onset of improvement. Patients from the high-risk group also require close monitoring. especially at the beginning of treatment or after a dose change.A higher risk of suicidal thoughts or attempts is characteristic of patients who have a history of suicidal behavior, or with pronounced suicidal ideation before initiating therapy. May cause suicide in persons younger than 25 years of age (class-effect of antidepressants). Patients (and caregivers) should be warned about the need to monitor any signs of clinical deterioration, suicidal behavior or thoughts, unusual behavior and the need to seek immediate medical attention if these symptoms appear. With special care, it is necessary to appoint amitriptyline patients with hyperthyroidism or patients receiving drugs that control the function of the thyroid gland, in connection with the possible development of violations of the heart rhythm. In patients with diabetes, treatment with amitriptyline may alter the action of insulin and the concentration of glucose in the blood, which may require correction of the dose of insulin and / or oral hypoglycemic drugs. Elderly patients are particularly at risk of orthostatic hypotension.The use of amitriptyline in bipolar disorder can provoke the development of the manic phase, in this case amitriptyline necessary cancel. If amitriptyline is used to treat a depressive component of schizophrenia, possibly exacerbating psychotic symptoms. In this case amitriptyline should be used in combination with antipsychotics. In patients with such rare conditions as narrowing of the anterior chamber of the eye or angle-closure glaucoma, acute attacks of glaucoma are possible in connection with the dilatation of the pupil. In patients using contact lenses, reducing the formation of tears and the accumulation of mucous secretions due to the m-holinoblokiruyuschey action of tricyclic antidepressants can lead to damage to the epithelium of the cornea. Dry mouth can lead to changes in mucous membrane, inflammatory reactions, burning sensation and caries. Regular visits to the dentist are recommended. Amitriptyline It should be used with extreme caution in patients with convulsive disorders, since amitriptyline reduces the threshold of convulsive readiness, which may lead to a decrease in the effectiveness of treatment with antiepileptic drugs.The use of anesthetics during treatment with tri / tetracyclic antidepressants may increase the risk of arrhythmia and lowering blood pressure. It should be possible to stop taking amitriptyline several days before surgery; If an emergency operation is required, the anesthetist should be informed of the therapy the patient is receiving. When using tricyclic antidepressants in combination with anticholinergic drugs or antipsychotics, especially in hot weather, the development of hyperpyrexia is possible. Amitriptyline should be used with caution in patients receiving SSRIs. There have been reports of an increased risk of bone fractures with SSRIs and tricyclic antidepressants in patients aged 50 years and older. The use of high doses of tricyclic antidepressants in the third trimester of pregnancy can affect the newborn, including behavioral disorders and neurological functions. In newborns, there are cases of drowsiness as a result of the influence of amitriptyline, and cases of urinary retention, as a result of the influence of nortriptyline (metabolite of amitriptyline),if the drug was administered to women immediately before childbirth. Amitriptyline penetrates into breast milk and may cause drowsiness in infants. The ratio of concentrations of breast milk / plasma is 0.4-1.5. A child who is breastfed may experience undesirable reactions described in the "Side effects" section.

Effect on the ability to drive transp. cf. and fur:

In view of the sedative effect of amitriptyline during its use, vehicle management and potentially hazardous activities requiring increased attention and speed of psychomotor reactions should be avoided. Patients assigned amitriptyline, should be warned in advance by the doctor about this aspect of the drug.

Form release / dosage:

Tablets 0.0250 g.

Packaging:For 10 tablets in a contour mesh box made of PVC film and aluminum foil printed lacquered. For 5 contour squares with instructions for use in cardboard pack.

Storage conditions:

In a dry, the dark place at a temperature of no higher than 25 ° C. Keep out of the reach of children.

Shelf life:

3 years.Do not use after the expiration date.

Terms of leave from pharmacies:On prescription

Registration number:P N003754 / 01

Date of registration:28.09.2009 / 06.10.2014

Expiration Date:Unlimited

The owner of the registration certificate:ZIO-HEALTH, JSC ZIO-HEALTH, JSC Russia

Manufacturer: & nbsp

ZIO-HEALTH, JSC Russia

Information update date: & nbsp13.08.2017

Illustrated instructions

Instructions

Amitriptyline (Amitriptyline)