(very low certainty evidence) and 0.47 (95% CI 0.06 to 0.89) (moderate certainty evidence), respectively. Benzodiazepines and Z-drugs generally showed larger effect sizes (e.g., SMDs of 0.45 to 0.83) than doxepin, whereas the effect sizes of orexin receptor antagonists, such as suvorexant, were more similar (SMDs of 0.23 to 0.44). Doses of doxepin used for sleep normally range from 3 to 6mg, but high doses of up to 25 to 50mg may be used as well. Other uses A 2010 review found that topical doxepin is useful to treat itchiness. A 2010 review of treatments for chronic hives found that doxepin had been superseded by better drugs but was still sometimes useful as a second-line treatment. Contraindications Known contraindications include: Hypersensitivities to doxepin, other TCAs, or any of the excipients inside the product used Glaucoma A predisposition to developing urinary retention such as in benign prostatic hyperplasia Use of monoamine oxidase inhibitors in last 14 days Pregnancy and lactation Its use in pregnant and lactating women is advised against, although the available evidence suggests it is unlikely to cause negative effects on fetal development. The lack of evidence from human studies, however, means it is currently impossible to rule out any risk to the fetus and it is known to cross the placenta. Doxepin is secreted in breast milk and neonatal cases of respiratory depression in association with maternal doxepin use have been reported. Side effects Doxepin's side effects profile may differ from the list below in some countries where it is licensed to be used in much smaller doses (viz., 3 mg and 6 mg). Central nervous system: fatigue, dizziness, drowsiness, lightheadedness, confusion, nightmares, agitation, increased anxiety, difficulty sleeping, seizures (infrequently), temporary confusion (delirium), rarely induction of hypomania and schizophrenia (stop medication immediately), extrapyramidal side effects (rarely), abuse in patients with polytoxicomania (rarely), ringing in the ears (tinnitus) Anticholinergic: dry mouth, constipation, even ileus (rarely), difficulties in urinating, sweating, precipitation of glaucoma Antiadrenergic: Low blood pressure, (if patient arises too fast from the lying/sitting position to standing—known as orthostatic hypotension), abnormal heart rhythms (e.g., sinus tachycardia, bradycardia, and atrioventricular block) Allergic/toxic: skin rash, photosensitivity, liver damage of the cholestatic type (rarely), hepatitis (extremely rare), leuko- or thrombocytopenia (rarely), agranulocytosis (very rarely), hypoplastic anemia (rarely) Others: frequently increased appetite and weight gain, rarely nausea, rarely high blood pressure. May increase or decrease liver enzyme levels in the blood of some