- Tricyclic antidepressant
- Capsules: 10 mg, 25 mg, 50 mg, and 75 mg
- Oral solution: 10 mg, 5 mg
- Tablets: 10mg, 25 mg
- Depression: Mostly effective on endogenous depression
- Smoking Cessation
- Post-Herpetic Neurolgia
- Migraine Headache = Maintenance Therapy
- Absorption: Oral administration results in maximum plasma concentrations in approximately 5 hours.
- Distribution: 93% bins to plasma proteins.
- Metabolism: Drugs Metabolized by P450 2D6 (debrisoquin hydroxylase). Demethylation and hydroxylation followed by conjugation with glucuronic acid.
- The half-life: 26 hours
- Excreted 98% through kidneys
- Note: Renal failure: no significant effect on Nortriptyline kinetics.
- Usual adult dose: 25 mg 3 or 4 times daily (Gradual Increase)
- MAX dose: 100mg/day
- Elderly patients: 25 mg- 50 mg /day in divided doses.
- Adolescent depression: Not recommended in 13-18 years of age
Drug inhibition effect: (Concomitant use will increase the plasma level of Nortriptylin HCL):
- Type 1C Antiarrhythmics :
Drug Inducer effect: (Concomitant use will decrease the plasma level of Nortriptylin HCL):
Reserpine (kind of alkaloid agent in pharmaceutics) + Tricyclic antidepressant (TCA) has “stimulating” effect in depressed patients.
Monoamine oxidase inhibitor (MAOI):
- Increased risk of Serotonin syndrome
Antihistamines: such as Astemizole and Terfenadine
Some antipsychotics mainly Pimozide and Sertindole
antiarrhythmics class 1
Calcium channel blockers: Especially Verapamil
Tramadol: TCAs increase the risk of seizure in patients using Tramadol
- Myocardial infarction
- Arrhythmias (QT interval Prolongation)
- Heart block
- Confusional states (especially in the elderly) with hallucinations
- Exacerbation of psychosis
- Paresthesias of extremities
- Peripheral neuropathy
- Extrapyramidal symptoms
- Alteration in EEG patterns
- Dry mouth
- Blurred vision
- Disturbance of accommodation
- Paralytic ileus
- Urinary retention
- Delayed micturitio
- Skin rash
- Photosensitization (avoid excessive exposure to sunlight)
- Edema (general or of face and tongue)
- Bone marrow depression
- Nausea and vomiting
- Epigastric distress
- peculiar taste
- Abdominal cramps
- Gynecomastia in the male
- Breast enlargement and galactorrhea in the female
- Sexual dysfunction (increased or decreased libido, impotence)
- Testicular swelling
- Elevation or depression of blood sugar levels
- Syndrome of inappropriate ADH (antidiuretic hormone) secretion.
- Patients <= 12 Years of age
- Nocturnal enuresis
- Concurrent use of nortriptyline hydrochloride or other tricyclic antidepressants with a monoamine oxidase inhibitor (MAOI) .
- During the acute recovery period after myocardial infarction.
- Pregnancy: D – category
- Lactation: Do Not Nurse
- Clinical Worsening and Suicide Risk:
- Adult and paediatric with major depressive disorder (MDD) may experience worsening of their depression and/or the emergence of suicidal ideation and behaviour or unusual changes in behaviour. This risk may persist until significant remission occurs. Observe very carefully during this period!
- Physicians, Family members and caregivers= All ought to monitor patient during the initiation of Nortriptylinr HCL for any unusual behavioral change.
- Concomitant use with Alcohol may have a potentiating effect = Increase suicidal ideation.
- Patients with Bipolar Disorder:
- Warning: Use of Nortriptyline HCL alone can increase the likelihood of increase in precipitation of manic episode.
- Determine patients with bipolar disorder prior to initiation of Nortriptyline HCL!
- Patients with Seizure disorders: Use with caution!
- Patients with Cardiovascular diseases: only under close supervision:
- Q-T interval Prolongation, Sinus tachycardia, Myocardial infarction, and/or ventricular arrhythmia, and strokes have occurred, especially in concurrent use with:
- Antihistamines (such as Astemizole and Terfenadine)
- Some antipsychotics (mainly Pimozide and Sertindole)
- antiarrhythmics class 1
- Beta-receptor blockers
- Calcium antagonists (Especially Verapamil)
- Anticholinergic activity: Caution in concomitant use with anti-cholinergics/ sympathomimetics
- Patients with Hyperthyroidism: Great care needed due to risk of cardiac arrhythmias.
- In hypothyroidism: levothyroxine combine with antidepressants can give rise to hyperthyroidism and
- Levothyroxine may strengthen the antidepressant effect!
- May impair the mental and/or physical abilities required for the performance of hazardous tasks:
- Caution is indicated in the co-administration of TCAs with any of the SSRIs and also in switching from one class to the other.
- Safety and effectiveness in the pediatric population have not been established.
- Caution in use in patients > 65 years of age.
- Withdrawal Symptoms: Abrupt cessation: After prolonged therapy, may produce nausea, headache, and malaise.
- Do not prescribe simultaneously with monoamine oxidase inhibitor (MAOI): Risk of Serotonine Syndrom:
- If surgery is necessary: Discontinue Nortriptyline HCL, if possible, for several days prior to the procedure. Anaesthetics given during tricyclic antidepressant therapy may increase the risk of arrhythmias and hypotension.
- Caution in parkinsonism patients who are on Levodopa: The metabolism of levodopa in the intestine may be accelerated, possibly through delay of peristalsis.
- TCAs increase the risk of seizure in patients using Tramadol
- Do not use with serotonin enhancing medications. Risk of Serotonin Syndrome.
- Moderate to severe liver disease: Reducees hepatic clearance resulting in higher plasma levels.
- Renal failure: no significant effect on Nortriptyline kinetics.