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...

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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