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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.
Pharmacologic: tricyclic antidepressants
Time/action profile (antidepressant effect)
|PO||2–3 wk||6 wk||unknown|
Adverse Reactions/Side Effects
Central nervous system
- suicidal thoughts (life-threatening)
- drowsiness (most frequent)
- fatigue (most frequent)
- lethargy (most frequent)
- extrapyramidal reactions
Ear, Eye, Nose, Throat
- blurred vision (most frequent)
- dry eyes (most frequent)
- dry mouth (most frequent)
- arrhythmias (life-threatening)
- hypotension (most frequent)
- ECG changes
- constipation (most frequent)
- paralytic ileus
- unpleasant taste
- weight gain
- urinary retention
- blood dyscrasias
Drug-Drug interactionConcurrent use with MAO inhibitors may result in serious potentially fatal reactions (MAO inhibitors should be stopped at least 14 days before nortriptyline therapy. Nortriptyline should be stopped at least 14 days before MAO inhibitor therapy).Concurrent use with MAO-inhibitor like drugs, such as linezolid or methylene blue may ↑ risk of serotonin syndrome; concurrent use contraindicated; do not start therapy in patients receiving linezolid or methylene blue ; if linezolid or methylene blue need to be started in a patient receiving nortriptyline, immediately discontinue nortriptyline and monitor for signs/symptoms of serotonin syndrome for 2 wk or until 24 hr after last dose of linezolid or methylene blue, whichever comes first (may resume nortriptyline therapy 24 hr after last dose of linezolid or methylene blue)May prevent the therapeutic response to most antihypertensives.Hypertensive crisis may occur with clonidine.↑ CNS depression with other CNS depressants, including alcohol, antihistamines, opioids, and sedative/hypnotics.Adrenergic effects may be ↑ with other adrenergic agents, including vasoconstrictors and decongestants.↑ anticholinergic effects with other drugs possessing anticholinergic properties, including antihistamines, antidepressants, atropine, haloperidol, phenothiazines, quinidine, and disopyramide.Cimetidine, fluoxetine, or hormonal contraceptives ↑ blood levels and risk of toxicity.↑ risk of agranulocytosis with antithyroid agents.Drugs that affect serotonergic neurotransmitter systems, including SSRIs, SNRIs, fentanyl, buspirone, tramadol and triptans ↑ risk of serotonin syndrome.Concomitant use of kava-kava, valerian, or chamomile can ↑ CNS depression.Use with St. John's wort ↑ of serotonin syndrome.↑ anticholinergic effects with jimson weed and scopolia.
Availability (generic available)
- Monitor mental status (orientation, mood, behavior).
- Assess weight and BMI initially and throughout treatment. For overweight/obese individuals, monitor fasting blood glucose and cholesterol levels.
- Monitor BP and pulse rate before and during initial therapy. Report significant decreases in BP or a sudden increase in pulse rate.
- Monitor baseline and periodic ECGs in geriatric patients or patients with heart disease. May cause prolonged PR and QT intervals and may flatten T waves.
- Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults ≤24 yrs. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for next 4 wk, and on advice of health care professional thereafter.
- Pain: Assess type, location, and severity of pain before and periodically during therapy. Use pain scale to monitor effectiveness of medication.
- Lab Test Considerations: Assess leukocyte and differential blood counts, liver function, and serum glucose periodically. May cause ↑ serum bilirubin and alkaline phosphatase. May cause bone marrow depression. Serum glucose may be ↑ or ↓.
- Serum levels may be monitored in patients who fail to respond to usual therapeutic dose. Therapeutic plasma concentration range is 50–150 ng/mL.
Symptoms of acute overdose include disturbed concentration, confusion, restlessness, agitation, seizures, drowsiness, mydriasis, arrhythmias, fever, hallucinations, vomiting, and dyspnea.
- May cause alterations in blood glucose levels.
- Treatment of overdose includes gastric lavage, activated charcoal, and a stimulant cathartic. Maintain respiratory and cardiac function (monitor ECG for at least 5 days) and temperature. Medications may include digoxin for HF, antiarrhythmics, and anticonvulsants.
Potential Nursing DiagnosesIneffective coping (Indications)
Risk for injury (Side Effects)
Sexual dysfunction (Side Effects)
- Do not confuse Pamelor (nortriptyline) with Tambocor (flecainide).
- Taper to avoid withdrawal effects. Reduce dose 50% for 3 days, then by 50% for 3 more days, then discontinue.
- Oral: Administer medication with meals to minimize gastric irritation.
- May be given as a single dose at bedtime to minimize sedation during the day. Dose increases should be made at bedtime because of sedation.
- Instruct patient to take medication as directed. Take missed doses as soon as possible unless almost time for next dose; if regimen is a single dose at bedtime, do not take in the morning because of side effects. Advise patient that drug effects may not be noticed for at least 2 wk. Abrupt discontinuation may cause nausea, vomiting, diarrhea, headache, trouble sleeping with vivid dreams, and irritability.
- May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is known.
- Instruct patient to notify health care professional if visual changes occur. Inform patient that periodic glaucoma testing may be required during long-term therapy.
- Caution patient to make position changes slowly to minimize orthostatic hypotension. (This side effect is less pronounced with this medication than with other tricyclic antidepressants.)
- Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur.
- Advise patient to avoid alcohol or other CNS depressant drugs during therapy and for at least 3–7 days after therapy has been discontinued.
- Instruct patient to notify health care professional if urinary retention occurs or if dry mouth or constipation persists. Sugarless candy or gum may diminish dry mouth, and an increase in fluid intake or bulk may prevent constipation. If symptoms persist, dose reduction or discontinuation may be necessary. Consult health care professional if dry mouth persists for more than 2 wk.
- Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
- Alert patient that urine may turn blue-green in color.
- Inform patient of need to monitor dietary intake. Increase in appetite may lead to undesired weight gain. Refer as appropriate for nutritional, weight, or medical management.
- May have teratogenic effects. Instruct patient to notify health care professional immediately if pregnancy is planned or suspected.
- Advise patient to notify health care professional of medication regimen before treatment or surgery.
- Therapy for depression is usually prolonged. Emphasize the importance of follow-up exams.
- Increased sense of well-being.
- Renewed interest in surroundings.
- Increased appetite.
- Improved energy level.
- Improved sleep.
- Decrease in severity of chronic neurogenic pain. Patients may require 2–6 wk of therapy before full therapeutic effects of medication are seen.