Nortriptyline

(nor-trip-tuh-leen)

Trade/other name(s): Pamelor, Aventyl, nortriptyline hydrochloride

Why would this drug be used?

Nortriptyline is part of a class of drugs called tricyclic antidepressants. It is often used to treat depression or anxiety. It may also be used to help treat certain types of pain (usually along with other medicines), as well as some other problems.

How does this drug work?

Nortriptyline seems to help relieve depression by raising levels of certain chemicals (norepinephrine and serotonin) in the brain. It is not clear if this is also how it helps with certain types of pain or other conditions.

Before taking this medicine

Tell your doctor…

• If you are allergic to any medicines, dyes, additives, or foods.
• If you have ever thought of or attempted suicide. Treatment with an antidepressant may raise the risk of suicidal thoughts, especially during the first few months of treatment.
• If you drink alcohol or are taking any type of sedative. This drug may increase their effects on the nervous system, which in some cases could be dangerous.
• If you have a history of kidney disease or liver disease (including hepatitis or cirrhosis). This drug is cleared from the body by these organs. Reduced liver or kidney function may result in more drug than expected staying in the body. This could lead to unwanted side effects. Your doctor will want to monitor you closely and may need to adjust your dose accordingly.
• If you have recently had a heart attack or have ever had heart disease. This drug may raise the risk of heart problems.
• If you are planning on having surgery in the near future. This drug can affect blood pressure during surgery.
• If you have trouble passing urine or have ever had asthma, glaucoma, diabetes, high blood pressure, thyroid problems, seizures, bipolar disorder (manic depressive illness), or schizophrenia. This drug could make these conditions worse.
• If you have any other medical conditions such as congestive heart failure, lung disease, gout, or infections. You may need closer monitoring of these conditions while being treated.
• If you have taken monoamine oxidase inhibitors (such as isocarboxazid, phenelzine, selegiline, and tranylcypromine) within the past 2 weeks. Nortriptyline may raise the blood pressure and body temperature, and cause seizures, coma, and even death.
• If you are pregnant, trying to get pregnant, or if there is any chance of pregnancy. It is not known if this drug might cause problems if either the male or female is taking it at the time of conception or during pregnancy. It is important to check with your doctor about whether birth control should be used with this medicine.
• If you are breast-feeding. While no studies have been done, this drug may pass into breast milk and affect the baby. Talk with your doctor about the possible risks of breast-feeding while taking this drug.
• About any other prescription or over-the-counter medicines you are taking, including vitamins and herbs. In fact, keeping a written list of each of these medicines (including the doses of each and when you take them) with you in case of emergency may help prevent complications if you get sick.

Interactions with other drugs

Nortriptyline may interact with a large number of other drugs. Be sure your doctor knows if you are taking any of those listed below.

Drugs that could possibly lower the effectiveness or increase the side effects of nortriptyline including:

• Sedatives, anxiety medicines, sleeping pills, or alcohol
• Cold medicines (antihistamines or decongestants)
• Anti-seizure drugs (carbamazepine, phenytoin, phenobarbital)
• Other antidepressants (such as sertraline, paroxetine, fluoxetine, fluvoxamine, bupropion)
• Antipsychotic drugs such as haloperidol (Haldol), risperidone (Risperdal), and clozapine (Clozaril)
• Hormone therapies (including birth control pills and estrogen replacement)
• Thyroid medicines
• Heart rhythm drugs such as propafenone (Tambocor) or flecainide (Rhythmol)
• The calcium-reducing drug cinacalcet
• Stimulant drugs such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine)
• Cimetidine (Tagamet)

Nortriptyline could lower the effectiveness or raise the risk of side effects from some other drugs, including:

• Warfarin (Coumadin)
• Sedatives, anxiety medicines, sleeping pills, or alcohol
• Anti-seizure drugs (carbamazepine, phenytoin, phenobarbital)
• Antipsychotic drugs such as haloperidol (Haldol), risperidone (Risperdal), and clozapine (Clozaril)
• Clonidine (Catapres)
• Amantadine

Antidepressants known as monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), or selegiline (Emsam) may raise the risk of serotonin syndrome (see “Precautions” section) and should not be taken within 2 weeks of taking nortriptyline. The antibiotic linezolid (Zyvox) and the dye methylene blue, which are both given in the vein, also act as MAOIs, and increase the risk of serotonin syndrome (see “Precautions”).

Medicines that affect serotonin in your body, such as antidepressants, lithium, or tramadol can increase your risk of serotonin syndrome (see “Precautions”) if they are taken while you are on this drug. Supplements such as tryptophan or St. John’s wort can cause the same problem.

Note that the liquid form of this medicine contains alcohol and may interact with disulfuram (Antabuse) or metronidazole (Flagyl.)

There may be other drug interactions not on the lists above. Check with your doctor, nurse, or pharmacist about all of your medicines, herbs, and supplements.

Interactions with foods

Alcohol may have more potent effects on the nervous system while taking nortriptyline. Its use should be minimized or avoided while taking this drug. No other serious interactions with foods are known at this time. Check with your doctor, nurse, or pharmacist about whether some foods may be a problem.

Tell all the doctors, dentists, nurses, and pharmacists you visit that you are taking this drug.

How is this drug taken or given?

Nortriptyline can be taken as a capsule or as a liquid. It can be taken with food to lower the chance it will upset your stomach. It is usually started at a low dose 1 to 4 times a day, which may be increased over time if needed. Once you are on a regular dose, it may be taken once a day. Taking it at bedtime may lessen daytime side effects and help you sleep at night.

The dose and schedule may depend on a number of factors, including the reason you are taking the medicine, how well you respond to it, and your general health. Lower starting doses are usually recommended in elderly patients and adolescents.

Your doctor may do blood tests to monitor the levels of this drug in your body. Your dose may need to be adjusted based on these levels.

Keep the medicine in a tightly closed container and out of the reach of children or pets.

Precautions

This drug can interact with a number of other medicines and should be used cautiously (if at all) in people with a number of different medical conditions. See the "Before Taking This Medicine" section of this document for more detailed information.

This drug may make you feel drowsy when you first start taking it or if the dose is increased. Do not drive or operate heavy machinery until you know how the drug affects you. If possible, you may want to take the medicine at bedtime, as it may not affect you as much during the day and may help you sleep better at night. Use caution if taking cold or allergy medicines, sedatives, anxiety medicines, or sleeping pills or if drinking alcohol while taking this medicine. Talk to your doctor or nurse if you feel too drowsy or it does not go away.

The antidepressant effects of this medicine may take 2 weeks or longer to work. Other effects, such as helping relieve pain or helping you sleep, are likely to start much quicker.

Do not stop taking this drug without first speaking to your doctor or nurse. If you are going to stop taking this drug, it should usually be tapered down over the course of several weeks, as directed by your doctor. Suddenly stopping the drug can cause anxiety, dizziness, irritability, headache, insomnia, and confusion in some people.

If you are taking this drug to help relieve cancer pain, taking it and other medicines on a regular schedule can help keep pain from worsening. If you wait until the pain is bad, it may take more medicine to get it under control. If your pain is not well controlled, talk to your doctor about the possibility of adjusting your doses or changing your medicine. Most cancer pain can be controlled.

This drug can cause problems with blood pressure during surgery, so your doctor may recommend lowering the dose or even stopping it before a scheduled operation

As with other antidepressants, this drug may raise the risk of suicidal thoughts and actions, mostly in people under age 25. This is more common during the first few months of treatment. If you notice any strange or unusual thoughts or behavior, such as irritability, sleep problems, aggressiveness, restlessness, panic attacks, or thoughts of suicide while on this medicine, call your doctor. Tell family members, loved ones, and caregivers that you are taking this drug, so that they can help you if they notice behavior changes.

This drug may lessen saliva production, which can lead to dry mouth and an increased risk of dental cavities or gum disease, especially in older people. Your doctor or nurse should be able to offer suggestions on how to deal with this if needed.

This drug may cause a quick drop in blood pressure when you go from lying down to sitting up, or from sitting to standing up (orthostatic hypotension). This may cause you to feel dizzy or faint, which can cause falls or injuries. Changing position slowly can reduce the risk of these problems. Let your doctor know if this happens to you.

This drug may make you more sensitive to sunlight, which can lead to severe sunburns. Do not spend long periods in the sun until you know how your skin is reacting to sunlight. Your doctor may advise you to avoid being outdoors between the hours of 10 and 4, use sunscreen, and/or to wear sunglasses, a hat, and protective clothes when outside, even on hazy days.

Nortriptyline can cause a rare problem similar to neuroleptic malignant syndrome, with symptoms like fever, rigid muscles, tremors, sweating, and confusion. It can become life-threatening if not treated quickly. If you have symptoms like these, call the doctor right away.

This drug can rarely cause a problem called serotonin syndrome, with symptoms such as nausea, vomiting, diarrhea, sweating, headache, fast heartbeat, dizziness, restlessness, fever, confusion, tremors, loss of coordination, muscle spasms, and even seizures. This syndrome can become life-threatening if not treated quickly. If you have symptoms like these, call your doctor right away.

Overdoses of nortriptyline can be fatal. If you think someone has taken too much of this drug, get emergency help. Signs of overdose may include agitation, vomiting, fever, stiff muscles, abnormal heart rhythm, drowsiness, confusion, seizures, hallucinations, coma, and cold body temperature.

Possible side effects

You will probably not have most of the following side effects, but if you have any talk to your doctor or nurse. They can help you understand the side effects and cope with them.

Common

• Feeling dizzy
• Feeling drowsy*
• Feeling tired
• Weakness
• Dry mouth*
• Headache
• Increased appetite
• Weight gain
• Nausea

Less common

• Confusion*
• Feeling restless
• Heartburn
• Diarrhea
• Constipation
• Trouble urinating
• Change in heart rate
• Low blood pressure (feeling dizzy or faint) when sitting or standing up*

Rare

• Sensitivity to sunlight*
• Suicidal thoughts or actions*
• Trouble speaking or swallowing
• Skin rash
• Allergic reaction
• Higher or lower blood sugar
• Serotonin syndrome*
• Fever, rigid muscles, tremors, confusion*

*See "Precautions" section for more detailed information.

Other side effects not listed above can also occur in some patients. Tell your doctor or nurse if you develop these or any other problems.

FDA approval

Yes – first approved before 1984 (FDA cannot verify dates of drugs approved before 1984.)

Disclaimer: This information does not cover all possible uses, actions, precautions, side effects, or interactions. It is not intended as medical advice, and should not be relied upon as a substitute for talking with your doctor, who is familiar with your medical needs.