nortriptyline hydrochloride

nor·trip·ty·line hydrochloride (nôr-trpt-ln)

n.

A tricyclic compound used as an antidepressant.

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nortriptyline hydrochloride

Allegron (UK), Aventyl, Norventyl (CA), Pamelor, PMS-Nortriptyline (CA)

Pharmacologic class: Tricyclic compound

Therapeutic class: Antidepressant

Pregnancy risk category D

FDA Boxed Warning

• Drug may increase risk of suicidal thinking and behavior in children and adolescents with major depressive disorder and other psychiatric disorders. Risk must be balanced with clinical need, as depression itself increases suicide risk. With patient of any age, observe closely for clinical worsening, suicidality, and unusual behavior changes when therapy begins. Advise family and caregivers to observe patient closely and communicate with prescriber as needed.
• Drug isn't approved for use in pediatric patients.

Action

Increases serotonin and norepinephrine release by blocking their reuptake by presynaptic neurons; also possesses anticholinergic properties

Availability

Capsules: 10 mg, 25 mg, 50 mg, 75 mg

Oral solution: 10 mg/5 ml

⊘Indications and dosages

➣ Depression

Adults: 25 mg P.O. t.i.d. or q.i.d., up to a maximum of 150 mg daily

Dosage adjustment

• Elderly patients
• Adolescents

Off-label uses

• Postherpetic neuralgia
• Neurologic pain

Contraindications

• Hypersensitivity to drug or dibenzazepines
• Acute recovery phase of myocardial infarction
• MAO inhibitor use within past 14 days

Precautions

Use cautiously in:
• asthma, cardiovascular disease, cardiac or hepatic disease, hyperthyroidism, increased intraocular pressure, angle-closure glaucoma, urinary retention, severe depression
• history of seizures
• elderly patients (especially elderly men with prostatic hyperplasia)
• pregnant or breastfeeding patients
• children (use not recommended).

Administration

• Give as prescribed, either in divided doses three or four times daily or as single dose at bedtime.
• Administer with meals or snack to minimize stomach upset.
☞ Don't give within 14 days of MAO inhibitors.

Route	Onset	Peak	Duration
P.O.	2-3 wk	6 wk	Unknown

Adverse reactions

CNS: dizziness, drowsiness, fatigue, headache, lethargy, insomnia, agitation, confusion, extrapyramidal reactions, hallucinations, seizures, suicidal behavior or ideation (especially in child or adolescent)

CV: hypotension, ECG changes, palpitations, heart block, arrhythmias, myocardial infarction, cerebrovascular accident

EENT: blurred vision, dry eyes

GI: nausea, constipation, anorexia, dry mouth, paralytic ileus

GU: urinary retention, gynecomastia

Hematologic: blood dyscrasias

Hepatic: jaundice, hepatotoxicity

Skin: photosensitivity

Other: unpleasant taste, weight gain

Interactions

Drug-drug. Anticholinergics, anticholinergic-like drugs (including antidepressants, antihistamines, atropine, disopyramide, haloperidol, phenothiazines, quinidine): additive anticholinergic effects

Antihypertensives: poor therapeutic response to antihypertensives

Antithyroid drugs: increased risk of agranulocytosis

Cimetidine, fluoxetine, hormonal contraceptives: increased nortriptyline blood level and possible toxicity

Clonidine: hypertensive crisis

CNS depressants (including antihistamines, opioids, sedative-hypnotics): additive CNS depression

Decongestants, vasoconstrictors: additive adrenergic effects

MAO inhibitors: hypertension, hyperpyrexia, seizures, death

Drug-diagnostic tests. Alkaline phosphatase, bilirubin: increased levels

Glucose: increased or decreased level

Drug-herbs. Angel's trumpet, belladonna, henbane, jimson weed, scopolia: increased anticholinergic effects

Chamomile, hops, kava, skullcap, scopolia, valerian: increased CNS depression

St. John's wort: decreased drug blood level and efficacy

Drug-behaviors. Alcohol use: increased drowsiness, impaired motor skills

Patient monitoring

• Check vital signs and ECG.
• Monitor bladder and bowel function. Stay alert for urine retention and constipation.
• Assess neurologic status and document mood swings.
• Monitor liver function tests.
☞ Watch for suicidal tendency, especially in child or adolescent.

Patient teaching

• Explain that drug's full effect may take 4 weeks.
• Tell patient drug may cause drowsiness or dizziness, but these effects should subside within a few weeks.
☞ Advise patient (and family as appropriate) to immediately report worsening depression or suicidal ideation, especially in child or adolescent.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects him.
• Tell patient to avoid alcohol and to consult prescriber before using herbs.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.