Nortriptyline

Nortriptyline is a prescription drug used to treat depression. It may also be used to help patients quit smoking.

• Nortriptyline is available under the following different brand names: Pamelor and Aventyl.

Adult and pediatric dosages:

Capsule

• 10 mg
• 25 mg
• 50 mg
• 75 mg

Oral solution

• 10 mg/5 ml

Dosage Considerations – Should be Given as Follows:

Depression

Adults

• 25 mg orally every 6-8 hours, not to exceed more than 150 mg per day

Dosing considerations:

• The total daily dose can be given at bedtime
• To discontinue therapy, gradually taper the dose to minimize the incidence of withdrawal symptoms and allow for detection of re-emerging symptoms

Pediatric

• Children under 6 years: safety and efficacy not established
• Children 6-12 years: 1-3 mg/kg per day orally every 6-8 hours, or 10-20 mg per day orally divided 6-8 hours
• Children 12 years: 30-50 mg orally each day, divided or single dose
• See black box warning

Geriatric

• Initial: 30-50 mg orally once per day or in divided doses, may increase to 75-100 mg per day if tolerated

Chronic Urticaria, Nocturnal Pruritus, Angioedema (off-label)

• 75 mg per day orally

Smoking Cessation (off-label)

• 25 mg orally each day, start 1-2 weeks before the quit date, may adjust to 75-100 mg/day 10-28 days prior to the selected quit date, adjust the dose to 75-100 mg/day, continue therapy for 12 weeks or more after quit day

ADHD (off-label)

Adults

• 25 mg orally every 6-8 hour

Pediatric

• 0.5 mg/kg per day orally, adjusted to a maximum 2 mg/kg per day or 100 mg, whichever is less

Postherpetic Neuralgia (off-label)

• Mild to moderate: monitor patients for adverse effects
• Severe: dosage adjustment not necessary, do not repeat more frequently than every 2 weeks, consider alternative therapy if repeated courses are required
• 10-25 mg orally at bedtime, may increase every 3-5 days in 10 mg increments each day up to 160 mg at bedtime or divided every 12 hours if tolerated

Nocturnal Enuresis (off-label)

Pediatric

• Children 6-7 years (20-25 kg): 10 mg orally at bedtime
• Children 8-10 years (26-35 kg): 10-20 mg orally at bedtime
• Children over 11 (36-54 kg): 25-35 mg orally at bedtime

Side effects associated with the use of Nortriptyline, include the following:

• fatigue
• lethargy
• drowsiness
• weakness
• dry mouth
• constipation
• blurred vision
• agitation
• anxiety
• headache
• difficulty sleeping (insomnia)
• nausea
• vomiting
• sweating
• dizziness when standing
• ECG changes
• fast heart rate
• confusion
• extrapyramidal symptoms (continuous spasms and muscle contractions, motor restlessness, rigidity, slow movement, shaking, and irregular jerky movements)
• dizziness
• numbness and tingling
• ringing in the ears (tinnitus)
• rash
• increased liver functions
• sexual dysfunction
• seizure
• decreased white blood cells (agranulocytosis)
• increase of white blood cells (eosinophilia)
• decease of white blood cells (leukopenia)
• decrease of platelets (thrombocytopenia)
• water retention (Syndrome Of Inappropriate Anti-Diuretic Hormone, SIADH)

This document does not contain all possible side effects and others may occur. Check with your physician for additional information about side effects.

If your medical doctor is using this medicine to treat your pain, your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor, health care provider, or pharmacist first.

• Severe Interactions of Nortriptyline include:
  • astemizole
  • cisapride
  • disopyramide
  • dronedarone
  • ibutilide
  • indapamide
  • iobenguane I 123
  • isocarboxazid
  • pentamidine
  • phenelzine
  • pimozide
  • procainamide
  • procarbazine
  • quinidine
  • safinamide
  • selegiline
  • sotalol
  • terfenadine
  • thioridazine
  • tranylcypromine
• Nortriptyline has serious interactions with at least 125 different drugs.
• Nortriptyline has moderate interactions with at least 358 different drugs.
• Nortriptyline has mild interactions with at least 77 different drugs.

This information does not contain all possible interactions or adverse effects. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share this information with your doctor and pharmacist. Check with your health care professional or doctor for additional medical advice, or if you have health questions, concerns, or for more information about this medicine.

Warnings

• In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (under 24 years) taking antidepressants for major depressive disorders or other psychiatric illnesses
• This increase was not seen in patients aged over age 24 years; a slight decrease in suicidal thinking was seen in adults over age 65 years
• In children and young adults, risks must be weighed against the benefits of taking antidepressants
• Patients should be monitored closely for changes in behavior, clinical worsening, and suicidal tendencies; this should be done during the initial 1-2 months of therapy and dosage adjustments
• The patient's family should communicate any abrupt changes in behavior to the healthcare provider
• Worsening behavior and suicidal tendencies that are not part of the presenting symptoms may require discontinuation of therapy
• This drug is not approved for use in pediatric patients
• This medication contains nortriptyline. Do not take Pamelor or Aventyl if you are allergic to nortriptyline or any ingredients contained in this drug
• Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center immediately

Contraindications

• Hypersensitivity
• Any drugs or conditions that prolong QT interval
• Acute recovery post-myocardial Infarction
• Coadministration with serotonergic drugs
  • Concomitant with or within 14 days of MAOIs (serotonin syndrome)
  • Starting nortriptyline in a patient who is being treated with linezolid or intravenous methylene blue is contraindicated because of an increased risk of serotonin syndrome
  • If linezolid or intravenous methylene blue must be administered, discontinue nortriptyline immediately and monitor for central nervous system toxicity; may resume nortriptyline 24 hours after last linezolid or methylene blue dose or after 2 weeks of monitoring, whichever comes first

Effects of Drug Abuse

• No information provided

Short-Term Effects

• May cause sedation, which may impair physical or mental abilities; use caution when performing tasks that require mental alertness (operating heavy machinery)
• See "What Are Side Effects Associated with Using Nortriptyline?"

Long-Term Effects

• Bone fractures have been associated with antidepressant treatment; consider the possibility of bone fractures in patients if an antidepressant treated patient presents with unexplained bone pain, swelling, bruising, or point tenderness
• See "What Are Side Effects Associated with Using Nortriptyline?"

Cautions

• Use caution in patients with prostate enlargement, urinary/GI retention, overactive thyroid (hyperthyroidism), seizure disorder, brain tumor, respiratory impairment, or bipolar/mania (may worsen psychosis)
• Clinical worsening and suicidal ideation may occur despite medication in adolescents and young adults (18-24 years)
• Potentially life-threatening serotonin syndrome reported when coadministered with drugs that impair serotonin metabolism (in particular, monoamine oxidase inhibitors (MAOIs), including nonpsychiatric monoamine oxidase inhibitors (MAOIs), such as linezolid and intravenous methylene blue)
• Risk of anticholinergic side effects, such as diarrhea, overactive bladder, and incontinence, asthma, chronic obstructive pulmonary disease (COPD)
• May cause bone marrow suppression (rare)
• May cause low blood pressure when you stand up (orthostatic hypotension)
• May cause sedation, which may impair physical or mental abilities; use caution when performing tasks that require mental alertness (operating heavy machinery)
• Risk of dilation of the pupil of the eye (mydriasis), which may trigger angle closure attack in patients with angle-closure glaucoma with anatomically narrow angles without a patent iridectomy
• May cause sedation and impair physical or mental abilities
• Withdraw gradually
• Bone fractures have been associated with antidepressant treatment; consider the possibility of bone fractures in patients if an antidepressant treated patient presents with unexplained bone pain, swelling, bruising, or point tenderness
• Use with caution in patients who would not tolerate frequent episodes of low blood pressure, including patients with cardiovascular disease, decreased blood volume (hypovolemia), or with concurrent medication that predisposes for low blood pressure or slow heart rate
• Use caution in patients with cardiovascular disease, diabetes mellitus (may alter glucose regulation), liver or kidney impairment, and the elderly
• Abrupt discontinuation or interruption of antidepressant therapy has been associated with a discontinuation syndrome, which may include vomiting, diarrhea, headaches, dizziness, chills, shaking, numbness and tingling, sleepiness, fatigue, and sleep disturbances
• May increase the risk of adverse effects associated with electroconvulsive therapy; discontinue therapy before electroconvulsive therapy if possible
• Due to the risk of drug interaction with anesthesia and cardiac arrhythmia, discontinuation of therapy before elective surgery recommended

Pregnancy and Lactation

• Use nortriptyline during pregnancy only in LIFE-THREATENING emergencies when no safer drug is available. There is positive evidence of human fetal risk
• Nortriptyline is excreted in breast milk, do not breastfeed. The American Association of Pediatrics states the effect on nursing infants is unknown but may be of concern