In patients starting low-dose amitriptyline for IBS, when do you obtain a baseline ECG?

A baseline ECG is not routine for low-dose amitriptyline in IBS. Neither the ACG nor AGA guidelines require one. The ATLANTIS trial also did not use a routine pretreatment ECG; it excluded patients with cardiac contraindications or QT-prolonging co-medications instead (Lacy et al., PMID 33315591; Ford et al., PMID 37858323).

Reserve a baseline ECG for patients at risk of QT prolongation or torsades, as outlined in the AHA statement on drug-induced arrhythmias (Tisdale et al., PMID 32929996):

• Known QT prolongation or long QT syndrome
• Concurrent QT-prolonging drugs or CYP inhibitors that raise TCA levels
• Structural or ischemic heart disease, conduction disease, or bradycardia
• Age over 65, female sex, electrolyte disturbance, or prior drug-indu...