Pharmacologic class: Tricyclic compound
Therapeutic class: Antidepressant
Pregnancy risk category D
FDA Box 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.
Increases serotonin and norepineph-rine release by blocking their reuptake by presynaptic neurons; also possesses anticholinergic properties
Capsules: 10 mg, 25 mg, 50 mg, 75 mg
Oral solution: 10 mg/5 ml
Indications and dosages
Adults: 25 mg P.O. t.i.d. or q.i.d., up to a maximum of 150 mg daily
• Elderly patients
• Postherpetic neuralgia
• Neurologic pain
• Hypersensitivity to drug or dibenza-zepines
• Acute recovery phase of myocardial infarction
• MAO inhibitor use within past 14 days
Use cautiously in:
• asthma, cardiovascular disease, cardiac or hepatic disease, hyperthy-roidism, 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).
• 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.
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
Other: unpleasant taste, weight gain
Drug-drug. Anticholinergics, anti-cholinergic-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, hyper-pyrexia, seizures, death
Drug-diagnostic tests. Alkaline phos-phatase, bilirubin: increased levels Glucose: increased or decreased level
Drug-herbs. Angel's trumpet, belladonna, henbane, jimson weed, scopo-lia: 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
• 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.
• 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.