Introduction
Tricyclic antidepressant (TCA) poisoning, including nortriptyline (NT) and amitriptyline, is among the highly prevalent toxicities. They are second-line drugs next to Selective serotonin reuptake inhibitors (SSRIs) in the management of depression. They carry a higher case fatality, of 7.1% deaths per overdose, with more toxic effects than most other antidepressants [1]. Despite the potentially dangerous toxicity of TCAs, they remained commonly prescribed for various forms of depression, anxiety conditions, and chronic neuropathic pains. Common adverse effects of TCA therapy include blurred vision, dry mouth, tachycardia, orthostatic hypotension, cardiac arrhythmia, sedation, constipation, and urinary retention [2].
Silymarin with the trade name of Livergol® is a Silybum marianum seed derivative with antioxidant properties. Silymarin has been highlighted because of its various biological activities such as immune modulator, hypolipidemic, anti-depressant, antifibrotic, anti-inflammatory, sedative, and antitumor properties. Additionally, it is widely used for its well-known hepatoprotective effect. There are very limited reports on the toxicity of silymarin in human studies, so this substance is accepted as a safe herbal product. The most common adverse effects reported on its use include gastrointestinal symptoms, headaches, and dermatological reactions, but little is known about its potential for drug interaction [3, 4].