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Nortriptyline

Nortriptyline hydrochloride is 1-Propanamine, 3-(10,11-dihydro, 5H-dibenzo cyclohepten- 5-ylidene)-N-methyl-,hydrochloride. It is a second generation tricyclic antidepressant marketed under the tradenames Aventyl® and Pamelor®. It is used in the treatment of depression and childhood nocturnal enuresis (bedwetting). In addition it is sometimes used for chronic pain modification. more...

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Clinical Pharmacology

Nortriptyline inhibits the reuptake of norepinephrine (noradrenalin) and, to a lesser extent, serotonin. Operant conditioning techniques in rats and pigeons suggest that nortriptyline has a combination of stimulant and depressant properties.

Indications

FDA-approved for treatment of depressive disorders. In UK also may be used for treating nocturnal enuresis with courses of treatment lasting no moer than 3 months. Also off-label used for the treatment of panic disorder, prevention of migraine headaches and chronic pain or neuralgia modification (particularly Temporomandibular joint disorder).

Metabolism

Nortriptyline is metabolised in the liver by hepatic enzyme CYP2D6. Approximately 7 to 10 percent of caucasians are poor metabolisers and might experience more adverse effects, thus, a lower dosage is often necessary in these individuals. Blood levels of nortriptyline should be obtained during long term treatment to avoid toxicity and optimise response.

Dosage

25 - 75mg at bedtime. The dosage may be higher or lower depending on your prescribing physician. Doses above 150 mg/day are not recommended.

Side Effects

Dry mouth, drowsiness, orthostatic hypotension, urinary retention, constipation, and rapid or irregular heartbeat. Some sexual side effects may be a problem as well. Less commonly, seizures and ECG/EKG changes have been reported, especially in overdose. However, the incidence of side effects with nortriptyline is somewhat lower than with the first generation tricyclics (e.g. imipramine (Tofranil®), amitriptyline (Elavil®)).

Warnings

Persons with a history of cardiovascular disease, stroke, glaucoma and/or seizures should be given nortriptyline only under close supervision as well as those who are hyperthyroid or receiving thyroid medication. Patients should be cautioned against the use of alcohol during nortriptyline therapy.

Precautions

Pregnancy and lactation. Children under the age of 18.

Contraindications

In the acute recovery phase after myocardial infarction (e.g. heart attack). Do not use MAO Inhibitors (e.g. phenelzine, tranylcypromine, etc) with nortriptyline as hyperpyretic crises, severe convulsions, and fatalities have occurred when similar tricyclic antidepressants were used in such combinations.

Do not use if you have had serious reactions to other tricyclic antidepressants unless under the close supervision of your prescribing physician.

Overdose

Deaths may occur from overdosage with tricyclic antidepressants. Serious cardiac arrhythmias and coma are also possible. Keep this medication away from infants and children in a child-proof container.

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Nortriptyline effective for smoking cessation - Patient-Oriented Evidence that Matters - Abstract
From Journal of Family Practice, 12/1/02 by Lori M. Dickerson

da Costa CL, Younes RN, Lourenco MT. Stopping smoking: a prospective, randomized, double-blind study comparing nortriptyline to placebo. Chest 2002; 122:403-8.

* BACKGROUND Despite public health campaigns and recommendations from national organizations for clinicians to encourage smoking cessation, only 2.5% of all smokers succeed in abstaining for 1 year. Currently, bupropion (Zyban) is an antidepressant approved by the FDA as an aid in smoking cessation. This study evaluated the safety and efficacy of another antidepressant, nortriptyline (Pamelor), in smokers enrolled in a smoking support group.

* POPULATION STUDIED Patients were participating in a hospital-based smoking support group in Brazil. They were in good general health, aged 18 to 65 years, and smoked more than 15 cigarettes per day. Degree of nicotine dependence was determined by the Fagerstrom questionnaire. Patients were excluded if they were depressed as determined by the Beck Depression Inventory or had a history of other psychiatric syndromes, cardiovascular disease, glaucoma, urinary retention, thyroid disease, or epilepsy, or were pregnant or breast-feeding. Patients could not be receiving nicotine replacement therapy or have taken antidepressants, benzodiazepines, or antipsychotic agents during the past month. Of 144 patients who completed the study, most were women.

* STUDY DESIGN AND VALIDITY Patients were randomly assigned to receive either placebo or nortriptyline, increased at weekly intervals from 25 to 75 mg daily. Patients and clinicians were blinded to assigned treatment. During the 6-week treatment, all patients participated in weekly group therapy supervised by the same psychiatrist. Group therapy was based on cognitive-behavioral therapy. Follow up abstinence rates were evaluated 6 months after the treatment period.

The authors disclosed the number of patients who withdrew from the study, but did not provide information on the number of dropouts, if any. Therefore, it is unknown if the total number of patients enrolled were represented in the report, or whether an intent-to-treat analysis was conducted. Six patients receiving nortriptyline withdrew from the study--4 after reaching the goal dose and 2 during study follow-up. In the placebo group, 6 patients withdrew after reaching the goal dose and 3 withdrew during study follow-up.

Participants must have been highly motivated, as they had chosen to participate in the hospital-based support group and attend weekly therapy. These patients probably do not mirror patients seen in usual daily practice who are merely contemplating smoking cessation. Another concern was that the determination of smoking cessation was based on a telephone interview with the patient, rather than laboratory testing. In addition, the study followed patients for only 6 months after treatment, rather than the standard evaluation period of 1 year in smoking cessation studies.

* OUTCOMES MEASURED Success was defined as cessation of smoking 1 week after the end of the treatment period. The rate of abstinence was also determined 6 months after the end of the study.

* RESULTS Patients receiving nortriptyline were less likely to report smoking in the week after the treatment period (55.9% vs 23.7% in the placebo group, P<.001, numbers needed to treat [NNT]=3). After 6 months of follow-up, 20.6% of patients receiving nortriptyline and 5.3% of patients receiving placebo reported to be free from nicotine use (P < .012, NNT=7). Patients most likely to respond had low nicotine dependence (Fagerstrom score less than 7 out of a possible 10) and were younger than 50 years.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Nortriptyline (Pamelor), in combination with weekly behavioral therapy, is effective in helping highly motivated smokers to quit. The medication may be an alternative for patients who cannot tolerate or do not benefit from bupropion. Given the high motivation of the group and the extensive behavioral therapy they also received, results are not likely to be as good in typical practice.

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