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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.

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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet].

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Last Update: April 25, 2018.



Imipramine is a tricyclic antidepressant that continues to be widely used in the therapy of depression. Imipramine can cause mild and transient serum enzyme elevations and is rare cause of clinically apparent acute cholestatic liver injury.


Imipramine (im ip' ra meen) is a dibenzazepine derived tricyclic antidepressant which acts by inhibition of serotonin and norepinephrine reuptake within synaptic clefts in the central nervous system, thus increasing brain levels of these neurotransmitters. Imipramine is indicated for therapy of depression and was approved for this indication in the United States in 1959; it is still widely used, with more than 1 million prescriptions being filled yearly. Imipramine is also used for childhood enuresis. Imipramine is available in generic forms and under the brand names of Tofranil in 10, 25, and 50 mg tablets and as capsules of 75, 100, 125 and 150 mg for nighttime dosing. The typical recommended dose for depression in adults is 75 to 100 mg daily in divided doses, increasing gradually to a maximum of 200 mg daily. Imipramine can also be given as a single nighttime dose. The recommended dose in children (ages 6 years or above) is 25 to 75 mg daily 1 hour before bedtime. Common side effects include dizziness, headache, drowsiness, restlessness, confusion, gastrointestinal upset, increased appetite, weight gain, blurred vision, dry mouth and urinary retention.


Liver test abnormalities have been reported to occur in up to 20% of patients on long term therapy with imipramine, but elevations are uncommonly above 3 times the upper limit of normal. The aminotransferase abnormalities are usually mild, asymptomatic and transient, reversing even with continuation of medication. Rare instances of clinically apparent acute liver injury as well as prolonged jaundice have been reported due to imipramine. The onset of jaundice is usually with 1 to 8 weeks of starting therapy. The pattern of enzyme elevations varies from hepatocellular to mixed or cholestatic. Signs and symptoms of hypersensitivity (fever, rash, eosinophilia) are common, but usually not very prominent. Rapid recurrence with rechallenge is common. Autoantibody formation is rare. Rare instances of acute liver failure and death attributed to imipramine have been reported.

Likelihood score: B (likely rare cause of clinically apparent liver injury).

Mechanism of Injury

The mechanism by which imipramine causes serum aminotransferase elevation is not known. It undergoes extensive hepatic metabolism and a possible cause of liver injury is production of an intermediate of metabolism that triggers a hypersensitivity reaction.

Outcome and Management

The serum aminotransferase elevations that occur on imipramine therapy are usually self-limited and do not require dose modification or discontinuation of therapy. The acute hepatitis caused by imipramine is typically self-limited and benign, but can be severe and even fatal. Instances of prolonged jaundice compatible with vanishing bile duct syndrome have been reported. Rechallenge with imipramine usually causes a prompt recurrence of the liver injury and should be avoided. While cross reactivity of hepatic injury with other tricyclic antidepressants has rarely been described, switching to another form of antidepressants such as the selective serotonin reuptake inhibitors is more prudent and is likely to be safe.

Drug Class: Antidepressant Agents

Other Drugs in the Subclass, Tricyclics: Amitriptyline, Amoxapine, Clomipramine, Desipramine, Doxepin, Nortriptyline, Protriptyline, Trimipramine



Imipramine – Tofranil®


Antidepressant Agents


Product labeling at DailyMed, National Library of Medicine, NIH


Imipramine 50-49-7 C19-H24-N2
Image of Imipramine Chemical Structure


References updated: 25 April 2018

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    (Review of tricylic antidepressant hepatotoxicity published in 2013; imipramine is listed as causing hepatocellular, mixed and cholestatic liver injury at a frequency of 0.5-1% with a latency ranging from 1 week to 1 year).
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    (65 year old woman developed fatigue and serum enzyme elevations [ALT ~1300 U/L; Alk P ~380 U/L] 1 month after starting trimipramine; 3 years later she developed nausea and ALT elevations 10 days after starting desipramine [ALT ~250 U/L], and 2 years later developed abdominal pain and fever and enzyme elevations [ALT ~1100 U/L, Alk P ~ 510 U/L] 8 days after starting cyamemazine; each time with rapid recovery and no jaundice).
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    (48 year old man developed jaundice 4 months after starting imipramine [bilirubin 30.4 mg/dL, ALT 3998 U/L, Alk P 250 U/L], progressing to hepatic failure but spontaneous recovery within 3 months of stopping).
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    (Systematic review of 81 articles on weight change with antipsychotics; using change after 10 weeks to compare: clozapine +5.7, olanzapine +4.2, chlorpromazine +4.2, risperidone +1.7, loxapine +0.6, haloperidol +0.5, ziprasidone +0.3, molindone -0.1, and pimozide -2.7 kilograms).
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    (Analysis of cases of hepatotoxicity from antidepressants in Spanish Pharmacovigilance System from 1989-1999 identified 99 cases; among SSRIs, 26 were due to fluoxetine, 14 paroxetine, 6 fluvoxamine, 5 sertraline, 3 venlafaxine and 2 citalopram; among tricyclics, 16 clomipramine 7 amitriptyline, 6 imipramine; among miscellaneous, 3 nefazodone and 1 trazodone; but all similar in rate ~1-3 per 100,000 patient-years of exposure, except for nefazodone with 29/100,000).
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    (Review of hepatotoxicity of antidepressants; antidepressant use has increased markedly between 1992 and 2002, accounting for 5% of cases of hepatotoxicity; tricyclics are less likely to cause injury than MAO inhibitors; predominantly cholestatic patterns of liver injury with onset in first 2-3 weeks; occasional reports of prolonged cholestasis).
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    (53,042 patients treated with antidepressants in 35 psychiatric hospitals in Germany from 1993-2000 were monitored for adverse drug reactions; increased liver enzymes reported in 16% on tricyclics, 5.5% on SSRIs and 12% of monamine oxidase inhibitors).
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    (Among 126 cases of drug induced liver injury seen in Spain between 1993-2000, 3 were due to amitriptyline with a relative risk of 14.2: estimated frequency of 6 per 100,000 person-year exposures).
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    (Review of drug induced liver injury and summary analysis of reports of injury from MAO inhibitors, SSRIs, tricyclics and atypical agents).
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    (Among 300 cases of drug induced liver disease in the US collected from 2004 to 2008, 1 case was attributed to amitriptyline, but no other tricyclic was mentioned).
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    (Among 1198 patients with acute liver failure enrolled in a US prospective study between 1998 and 2007, 133 were attributed to drug induced liver injury, but none were linked to tricyclic antidepressants).
  • Molleston JP, Fontana RJ, Lopez MJ, Kleiner DE, Gu J, Chalasani N; Drug-induced Liver Injury Network. Characteristics of idiosyncratic drug induced liver injury in children: results from the DILIN prospective study. J Pediatr Gastroenterol Nutr 2011; 53: 182-9. [PMC free article: PMC3634369] [PubMed: 21788760]
    (Among 30 children with suspected drug induced liver injury, half [n=15] were due to antimicrobials [minocycline 4, INH 3, azithromycin 3] and the rest largely due to CNS agents and anticonvulsants; one case was attributed to amitriptyline, but no other tricyclic antidepressant was listed).
  • Park SH, Ishino R. Liver injury associated with antidepressants. Curr Drug Saf 2013; 8: 207-23. [PubMed: 23914755]
    (Review of antidepressant induced liver injury).
  • Björnsson ES, Bergmann OM, Björnsson HK, Kvaran RB, Olafsson S. Incidence, presentation and outcomes in patients with drug-induced liver injury in the general population of Iceland. Gastroenterology 2013; 144: 1419-25. [PubMed: 23419359]
    (In a population based study of drug induced liver injury from Iceland, 96 cases were identified over a 2 year period, none of which were attributed to imipramine or other tricyclic antidepressant).
  • Hernández N, Bessone F, Sánchez A, di Pace M, Brahm J, Zapata R, A Chirino R, et al. Profile of idiosyncratic drug induced liver injury in Latin America. An analysis of published reports. Ann Hepatol 2014; 13: 231-9. [PubMed: 24552865]
    (Systematic review of literature of drug induced liver injury in Latin American countries published from 1996 to 2012 identified 176 cases, one was attributed to amitriptyline but none to imipramine or other tricyclic antidepressants).
  • Voican CS, Corruble E, Naveau S, Perlemuter G. Antidepressant-induced liver injury: a review for clinicians. Am J Psychiatry 2014; 171: 404-15. [PubMed: 24362450]
    (Review of hepatotoxicity of antidepressants, mentions cases of cholestatic jaundice and vanishing bile duct syndrome, but that hepatocellular injury can also occur due to imipramine).
  • Chalasani N, Bonkovsky HL, Fontana R, Lee W, Stolz A, Talwalkar J, Reddy KR, et al.; United States Drug Induced Liver Injury Network. Features and outcomes of 899 patients with drug-induced liver injury: The DILIN Prospective Study. Gastroenterology 2015; 148: 1340-52.e7. PubMed Citation. [PMC free article: PMC4446235] [PubMed: 25754159]
    (Among 899 cases of drug induced liver injury enrolled in a US prospective study between 2004 and 2013, 20 cases [2%] were attributed to antidepressants only one of which was due to a tricylic, imipramine: a 33 year old woman developed jaundice with a mixed enzyme pattern 1 month after starting imipramine which resolved within a month of stopping).
  • Friedrich ME, Akimova E, Huf W, Konstantinidis A, Papageorgiou K, Winkler D, Toto S, et al. Drug-induced liver injury during antidepressant treatment: results of AMSP, a drug surveillance program. Int J Neuropsychopharmacol 2016; 19. pii: pyv126. PubMed Citation. [PMC free article: PMC4851269] [PubMed: 26721950]
    (Among 184,234 psychiatric inpatients from 80 European hospitals, 149 cases [0.08%] of drug induced liver injury were reported, of whom 18 [13%] were taking trimipramine, although none were receiving imipramine]).
  • Ferrajolo C, Scavone C, Donati M, Bortolami O, Stoppa G, Motola D, Vannacci A, et al.; DILI-IT Study Group. Antidepressant-induced acute liver injury: a case-control study in an Italian inpatient population. Drug Saf 2018; 41: 95-102. PubMed Citation. [PubMed: 28770534]
    (Among 179 cases of hospitalizations for unexplained acute liver injury enrolled in an prospective study between 2010 and 2014, 17 had been exposed to antidepressants including only 1 who received a tricyclic [amitriptyline]).


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