Dosage should be initiated at a low level and increased gradually, noting carefully the clinical response and any evidence of intolerance. Medication should be given one hour before bedtime. Physostigmine is not recommended except to treat life-threatening symptoms that have been unresponsive to other therapies, and then only in consultation with a poison control center. Since methylphenidate hydrochloride may inhibit the metabolism of imipramine pamoate, downward dosage adjustment of imipramine pamoate may be required when given concomitantly with methylphenidate hydrochloride.Since imipramine pamoate may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks, such as operating an automobile or machinery, the patient should be cautioned accordingly.Tofranil-PM may enhance the CNS depressant effects of alcohol. Such monitoring should include daily observation by families and caregivers.The three strengths of Tofranil™ (imipramine hydrochloride USP) are available as follows:Dispense in tight container (USP) with a child-resistant closure.Antidepressant Medicines, Depression and other Serious Mental Illnesses,Talk to your, or your family member’s, healthcare provider about:What is the most important information I should know about antidepressant medicines, depression and other serious mental illnesses, and suicidal thoughts or actions?Antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, and young adults within the first few months of treatment.Depression and other serious mental illnesses are the most important causes of suicidal thoughts and actions. The clinical effect is hypothesized as being due to potentiation of adrenergic synapses by blocking uptake of norepinephrine at nerve endings. Multiple drug ingestion (including alcohol) is common in deliberate tricyclic overdose. Genetic Implication. Barbiturates are contraindicated in patients with known barbiturate sensitivity. There has been a long-standing concern, however, that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. As a general rule, a woman taking a drug should not nurse since the possibility exists that the drug may be excreted in breast milk and be harmful to the child.Safety and effectiveness in the pediatric population other than pediatric patients with nocturnal enuresis have not been established (The safety and effectiveness of the drug as temporary adjunctive therapy for nocturnal enuresis in pediatric patients less than 6 years of age has not been established.The safety of the drug for long-term, chronic use as adjunctive therapy for nocturnal enuresis in pediatric patients 6 years of age or older has not been established; consideration should be given to instituting a drug-free period following an adequate therapeutic trial with a favorable response.A dose of 2.5 mg/kg/day should not be exceeded in childhood. Critical manifestations of overdose include cardiac dysrhythmias, severe hypotension, convulsions, and CNS depression including coma. There may be circumstances when it is necessary to initiate treatment with an MAOI such as linezolid or intravenous methylene blue in a patient taking Tofranil-PM. Find out what health conditions may be a health risk when taken with Phenobarbital Oral The mode of action of the drug in controlling childhood enuresis is thought to be apart from its antidepressant effect.The concomitant use of monoamine oxidase inhibiting compounds is contraindicated. Monitoring of plasma drug levels should not guide management of the patient.In rare instances, hemoperfusion may be beneficial in acute refractory cardiovascular instability in patients with acute toxicity. Phenobarbital may also be used for purposes not listed in this medication guide. Therefore, hospital monitoring is required as soon as possible.Children have been reported to be more sensitive than adults to an acute overdosage of imipramine hydrochloride. Why Are Dementia Patients Getting Risky Psychiatric Drugs? Consideration should be given to instituting a drug free period following an adequate therapeutic trial with a favorable response. It is desirable to monitor TCA plasma levels whenever a TCA is going to be co-administered with another drug known to be an inhibitor of P450 2D6.The plasma concentration of imipramine may increase when the drug is given concomitantly with hepatic enzyme inhibitors (e.g., cimetidine, fluoxetine) and decrease by concomitant administration with hepatic enzyme inducers (e.g., barbiturates, phenytoin), and adjustment of the dosage of imipramine may therefore be necessary.In occasional susceptible patients or in those receiving anticholinergic drugs (including antiparkinsonism agents) in addition, the atropine-like effects may become more pronounced (e.g., paralytic ileus).