nortriptyline (Rx)

Brand and Other Names:Pamelor, Aventyl
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

capsule

  • 10mg
  • 25mg
  • 50mg
  • 75mg

oral solution

  • 10mg/5mL
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Depression

25mg PO q6-8hr

No more than 150 mg/day

Dosing considerations

  • Total daily dose can be given HS
  • To discontinue therapy, gradually taper dose to minimize incidence of withdrawal symptoms and allow for detection of re-emerging symptoms

Chronic Urticaria, Nocturnal Pruritus, Angioedema (Off-label)

75mg/day PO

Smoking Cessation (Off-label)

25 mg PO qDay; start 1-2 weeks before quit date; may titrate to 75-100 mg/day 10-28 days prior to selected quit date; titrate dose to 75-100 mg/day; continue therapy for 12 weeks or more after quit day

ADHD (Off-label)

25 mg PO q6-8hr

Postherpetic Neuralgia (Off-label)

10-25 mg PO qHS; may increase q3-5days in 10 mg increments qDay up to 160 mg qHS or divided q12hr if tolerated

Dosing Modifications

Hepatic impairment: Administer lower dose and titrate at a slower rate

Dosage Forms & Strengths

capsule

  • 10mg
  • 25mg
  • 50mg
  • 75mg

oral solution

  • 10mg/5mL
more...

Depression (Off-label)

<6 years: Safety and efficacy not established

6-12 years: 1-3 mg/kg/day PO divided q6-8hr, OR 10-20 mg/day PO divided q6-8hr 

>12 years: 30-50 mg PO qDay, divided or single dose

See Black Box Warning

Nocturnal Enuresis (Off-label)

6-7 years (20-25 kg): 10 mg PO qHS

8-11 years (26-35 kg): 10-20 mg PO qHS

>11 years (36-54 kg): 25-35 mg PO qHS

ADHD (Off-label)

0.5 mg/kg/day PO, titrated to maximum 2 mg/kg/day or 100 mg, whichever is less

Depression

Initial: 30-50 mg PO qDay or in divided doses

May increase to 75-100 mg/day if tolerated

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Interactions

Interaction Checker

and nortriptyline

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            Adverse Effects

            Frequency Not Defined

            Fatigue

            Lethargy

            Sedation

            Weakness

            Dry mouth

            Constipation

            Blurred vision

            Agitation

            Anxiety

            Headache

            Insomnia

            Nausea

            Vomiting

            Sweating

            Orthostatic hypotension, ECG changes, tachycardia

            Confusion, extrapyramidal symptoms, dizziness, paresthesia, tinnitus

            Rash

            Increased LFTs

            Sexual dysfunction

            Seizure

            Agranulocytosis

            Eosinophilia

            Leukopenia

            Thrombocytopenia

            SIADH

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            Warnings

            Black Box Warnings

            In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (<24 years) taking antidepressants for major depressive disorders or other psychiatric illnesses

            This increase was not seen in patients aged over age 24 years; a slight decrease in suicidal thinking was seen in adults over age 65 years

            In children and young adults, risks must be weighed against the benefits of taking antidepressants

            Patients should be monitored closely for changes in behavior, clinical worsening, and suicidal tendencies; this should be done during the initial 1-2 months of therapy and dosage adjustments

            The patient’s family should communicate any abrupt changes in behavior to the healthcare provider

            Worsening behavior and suicidal tendencies that are not part of the presenting symptoms may require discontinuation of therapy

            This drug is not approved for use in pediatric patients

            Contraindications

            Hypersensitivity

            Any drugs or conditions that prolong QT interval

            Acute recovery post-MI

            Coadministration with serotonergic drugs

            • Concomitant with or within 14 days of MAOIs (serotonin syndrome)
            • Starting nortriptyline in a patient who is being treated with linezolid or IV methylene blue is contraindicated because of an increased risk of serotonin syndrome
            • If linezolid or IV methylene blue must be administered, discontinue nortriptyline immediately and monitor for CNS toxicity; may resume nortriptyline 24 hours after last linezolid or methylene blue dose or after 2 weeks of monitoring, whichever comes first

            Cautions

            Use cautioni in patients with BPH, urinary/GI retention, hyperthyroidism, seizure disorder, brain tumor, respiratory impairment, bipolar/mania (may worsen psychosis)

            Clinical worsening and suicidal ideation may occur despite medication in adolescents and young adults (18-24 years)

            Potentially life-threatening serotonin syndrome reported when coadministered with drugs that impair serotonin metabolism (in particular, MAOIs, including nonpsychiatric MAOIs, such as linezolid and IV methylene blue)

            Risk of anticholinergic side effects

            May cause bone marrow suppression (rare)

            May cause orthostatic hypotension

            May cause sedation, which may impair physical or mental abilities; use caution when performing tasks that require mental alertness (eg, operating heavy machinery)

            Risk of mydriasis; may trigger angle closure attack in patients with angle closure glaucoma with anatomically narrow angles without a patent iridectomy

            May cause sedation and impair physical or mental abilities

            Withdraw gradually

            Bone fractures have been associated with antidepressant treatment; consider possibility of bone fractures in patients if antidepressant treated patient presents with unexplained bone pain, swelling, bruising or point tenderness

            Use with caution in patients who would not tolerate frequent hypotensive episodes, including patients with cardiovascular disease, hypovolemia or with concurrent medication that predisposes for hypotension/bradycardia

            Use caution in patients with cardiovascular disease, diabetes mellitus (may alter glucose regulation), hepatic/renal impairment, and the elderly

            Abrupt discontinuation or interruption of antidepressant therapy has been associated with a discontinuation syndrome, which may include vomiting, diarrhea, headaches, dizziness, chills, tremors, paresthesias, somnolence, fatigue, and sleep disturbances

            May increase the risk of adverse effects associated with electroconvulsive therapy; discontinue therapy prior to electroconvulsive therapy if possible

            Due to risk of drug interaction with anesthesia and of cardiac arrhythmia, discontinuation of therapy prior to elective surgery recommended

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            Pregnancy & Lactation

            Pregnancy category: D

            Lactation: Excreted in breast milk; do not nurse (AAP states effect on nursing infants is unknown but may be of concern)

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Neurotransmitter (especially norepinephrine and serotonin) reuptake inhibitor; increases concentration of neurotransmitter in the CNS

            Absorption

            Onset of action: 1-3 weeks

            Peak plasma time: 7-8.5 hr

            Steady-state therapeutic plasma concentration: 50-150 ng/mL

            Distribution

            Protein bound: 93-95%

            Vd: 21 L/kg

            Metabolism

            Hepatic CYP2D6

            Elimination

            Half-life: 28-31 hr

            Excretion: Urine, feces

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            Images

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

            Adding plans allows you to:

            • View the formulary and any restrictions for each plan.
            • Manage and view all your plans together – even plans in different states.
            • Compare formulary status to other drugs in the same class.
            • Access your plan list on any device – mobile or desktop.

            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.