Text Size :
A A A

Nortriptyline

Brands and Forms

  • Pamelor
    • Capsule: 10mg, 25mg, 50mg, 75mg
    • Liquid: 10mg/5ml
  • Aventyl

Uses of Nortriptyline

Nortriptyline can be used for treating Major Depressive Disorder and Dysthymia, Anxiety Disorders, and it is also used at times for alleviating neuropathic pain and for treating nicotine dependence.

How Nortriptyline Works

Nortriptyline is a Tricyclic Antidepressant. It blocks norepinephrine reuptake in the central nervous system and thus boosts norepinephrine neurotransmissions. At high doses it also boosts serotonin neurotransmission. Its anticholinergic and antihistimine properties account for some of the side-effects of this medication.

Cautions when Using Nortriptyline

Nortriptyline can induce Manic or Mixed Episodes and Rapid Cycling in people with Bipolar Disorder.

Children and adolescents who use antidepressants like Nortriptyline may develop self-injurious or suicidal behaviors (for more information, see here).

Use caution in people with a known seizure disorder, heart disease, urinary retention, or hyperthyroidism.

Tricyclic Antidepressants such as Nortriptyline have been shown to increase the risk of cardiovascular disease [ref]. Furthermore, because of the risk of cardiac arrhythmias and other cardiovascular side-effects, the risk/benefit ratio may not justify the use of this medication in individuals with heart disease.

Long-term use of Nortriptyline may increase the risk of osteoporosis and bone fractures in individuals over age 50.

Nortriptyline should not be used during or within 14 days following the administration of an MAOI, because a hypertensive crisis may result.

Dosing of Nortriptyline

The usual therapeutic range of Nortriptyline is 75-150mg/day. The maximum dose is 300mg/day. It can be given once daily at bedtime, as it tends to be sedating, but can also be given in up to 4 divided doses per day.

Initial dose is usually 25mg/day, and it can be increased by 25mg no quicker than every 3 days. Once at 75-100mg/day, it is generally recommended to wait at least 4 weeks to see if therapeutic effects occur before increasing the dose further.

When wanting to stop this medication, the dose should be decreased gradually over a period of 6-8 weeks. A sudden cessation of the medication can result in a discontinuation syndrome.

Onset of action

Therapeutic effects are not expected before 2-4 weeks at a dose of 75-100mg/day. If no significant effects are seen after 6-8 weeks of use, including at least 2 weeks at a dose above 100mg/day, then the medication may not work at all.

Kidney impairment

Use with caution. May need to lower dose and to monitor blood levels of the medication.

Liver impairment

Use with caution. May need to lower dose and to monitor blood levels of the medication.

Elderly

May be more sensitive to the anticholinergic, cardiovascular, hypotensive and sedative effects. Initial dose is 25-50mg/day, and maximum dose is 150mg/day.

Side-effects of Nortriptyline

Below is a list of most of the reported side-effects of Nortriptyline. Most of these side-effects occur in only a minority of individuals, and many also resolve with time while the medication is continued.

Cardiovascular: arrhythmias; flushing; hypertension; hypotension; palpitations; tachycardia; stroke; heart block; congestive heart failure.

Central Nervous System: agitation; unsteadiness; confusion; drowsiness; fatigue; headache; incoordination; dizziness; insomnia; nightmares; numbness; paresthesias of extremities; peripheral nephropathy; restlessness; seizures; tingling; tremors; weakness; extrapyramidal symptoms; serotonin syndrome.

Dermatologic: itching; excessive sweating; petechiae; photosensitivity; skin rash; hair loss; dry skin; acne.

Endocrine/Metabolic: elevation or depression of blood glucose levels; SIADH; weight gain or loss; abnormal breast milk secretion; breast enlargement in men and women; breast pain.

Eyes, Ears, Nose and Throat: nasal congestion; tinnitus; conjunctivitis; mydriasis; blurred vision; increased intraocular pressure; peculiar taste in mouth.

Gastrointestinal: nausea; vomiting; loss of appetite; diarrhea; flatulence; dry mouth; constipation; paralytic ileus; elevated liver enzymes; hepatitis.

Genitourinary: impotence; sexual dysfunction; nocturia; urinary frequency; urinary tract infection; vaginitis; cystitis; dysmenorrhea; amenorrhea; urinary retention and hesitancy.

Hematologic: bone marrow depression, including agranulocytosis; eosinophilia; purpura; thrombocytopenia.

Muskuloskeletal: risk of osteoporosis and bone fractures with long-term use.

Psychiatric: anxiety; agitation; apathy; irritability; worsening depression; depersonalization; suicidal thoughts; self-injurious behaviors among children and adolescents; can induce Manic or Mixed Episodes and Rapid Cycling in people with Bipolar Disorder.

Respiratory: pharyngitis; rhinitis; sinusitis; laryngitis; coughing.

Common side-effects of Nortriptyline

Dizziness, sedation/fatigue, tremor, headache, blurred vision, constipation, urinary retention, sexual dysfunction; increased appetite, weight gain, dry mouth, nausea, diarrhea, heartburn, anxiety, restlessness, sweating.

Rare but serious side-effects of note of Nortriptyline

  • Children and adolescents who use antidepressants like Nortriptyline may develop self-injurious or suicidal behaviors (for more information, see here).
  • Seizures
  • QTc prolongation, which can lead to serious heart arrhythmias
  • Acute angle glaucoma
  • Paralytic ileus
  • Liver failure
  • Bone marrow depression

Nortriptyline discontinuation syndrome

Individuals who suddenly stop using Nortriptyline after taking the medication at moderate or high doses over a significant period of time are at risk of developing a discontinuation syndrome, which can include the following symptoms: dizziness, electric shock-like sensations, sweating, nausea, insomnia, tremor, anxiety, restlessness, agitation, depressed mood, irritability, confusion, lethargy, and vertigo. These symptoms usually start anywhere from one day to one week after the medication was stopped, and can persists for days or even weeks.

This syndrome can be treated by restarting the medication at its prior dose. It can be prevented by decreasing the dose gradually over a period of 6-8 weeks when wanting to stop the medication. In rare cases, individuals may experience the discontinuation syndrome even when the medication is being tapered gradually; in such cases, an extremely slow and gradual taper will be necessary.

Nortriptyline overdose

Confusion, vomiting, muscle rigidity, ECG abnormalities, seizures, agitation, fever, hyperactive reflexes, congestive heart failure, coma, respiratory depression, death.

Nortriptyline and pregnancy

Category C: some animal studies show adverse effects at very high doses, but no controlled human studies have been done; should only be used in pregnancy if clearly needed and if benefits outweigh potential risks. For further information, see the section on treating Depression in pregnancy.

Medical Monitoring for Nortriptyline

Monitor blood counts (CBC with differential), body mass index; blood sugars (in patients with diabetes), electrocardiogram, and liver function tests as needed.

Drug Interactions with Nortriptyline

  • Combining Imipramine with other anticholinergic drugs can increase the risk of paralytic ileus or hyperthermia.
  • Cisapride and Sparfloxacin are contraindicated in patients receiving Nortriptyline because of the increased risk of life-threatening cardiac arrhythmias resulting from QTc prolongation.
  • Gatifloxacin, Levofloxacin, and Moxifloxacin should also be combined with caution, as these may also cause QTc prolongation.
  • Nortriptyline blood concentrations can be increased by Bupropion, Cimetidine, Duloxetine, Fluoxetine, Haloperidol, Paroxetine, Phenothiazines.
  • Nortriptyline can decrease the actions of Dicumaral and Guanethidine.
  • Combining Nortriptyline with Clonidine can cause a hypertensive crisis.
  • Nortriptyline should not be used during or within 14 days following the administration of an MAOI, because a hypertensive crisis may result.