Nortriptyline is a prescription-only medication used to relieve the symptoms of depression. It is more effective in treating endogenous depression than other depressive states. Endogenous depression is a sub-class of major depressive disorder that occurs due to the presence of an internal factor (genetic and biological) instead of an external stressor (environment or social). Nortriptyline is an active metabolite of amitriptyline—a tricyclic antidepressant (TCA) of the dibenzocycloheptene type. This medication is also useful for smoking cessation and for treating various types of pain.
How it works
This TCA works by regulating the chemicals in the brain that may be unbalanced in people with mood disorders. The exact mechanism of action of nortriptyline is unknown. It is believed that nortriptyline blocks the reabsorption of the neurotransmitter norepinephrine and inhibits the activity of serotonin, histamine, and acetylcholine either by acting at the neuronal membrane or at beta-adrenergic receptors. Unlike other pharmacological treatment for depression, TCAs do not block monoamine oxidase (MAO) nor affect the reabsorption of dopamine. While it can help improve sleep, nortriptyline is less sedating than amitriptyline. Other off-label (unlicensed) uses of nortriptyline include:
- Premenstrual dysphoric disorder;
- Irritable bowel syndrome;
- Diabetic neuropathy;
- Orofacial pain;
- Myofascial pain;
- Nicotine addiction.
How to take Nortriptyline
The therapeutic dose for this drug is between 50 to 150ng/ml. The recommended dose for adults ranges from 30mg to 150mg/day in divided doses. Adolescents and the elderly should start with a lower dose of 25–50mg/day. Your doctor may prescribe an initial dose of 25mg three to four times a day. It may be taken with or without food. Your doctor or pharmacist will tell you how much medication to use and how often.
Your symptoms may not improve immediately; it may take up to four weeks before you experience the full effect of this medication. Tell your doctor if your symptoms persist or worsen, especially if your feelings of sadness get worse, or if you are having suicidal thoughts. Some young people are prone to having suicidal thoughts when they start taking antidepressants.
If you missed a dose, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and take the next dose as scheduled. Contact your prescriber if you are not sure what to do after missing a dose.
Recommended dose for adult patients
25–100mg (maximum dose for the elderly is 50mg)
Things to know before taking Nortriptyline
Safety and efficacy
Aside from treating depressive symptoms, nortriptyline is occasionally used as an aid for smoking cessation and for the treatment of chronic neuropathic pain (pain caused by nerve damage). It appears to be safer and well tolerated of the medication class. Side effects are better tolerated because it has less potent anticholinergic effect than amitriptyline.
In a study spanning six weeks, nortriptyline was found to be effective for over a third of 92 patients with treatment resistant major depression. When compared to fluoxetine, 71% of 205 outpatients with moderate major depression have improved in nortriptyline and 65% in fluoxetine. The most common side effect for fluoxetine is nausea, while nortriptyline was associated with dry mouth.
Warnings and contraindications
- It is dangerous to take this medication with monoamine oxidase (MAO) inhibitors, as fever, muscle rigidity, seizures, and even death may occur. Stop taking MAO inhibitors at least two weeks before starting treatment.
- Do not take this medicine if you are allergic to nortriptyline or amitriptyline.
- If you are recovering from myocardial infarction, you should not take this medication.
- Do not use this medicine with another tricyclic antidepressant
- Stopping this medication abruptly can result to withdrawal symptoms.
- Antipsychotic medications
- Anticholinergic medications
- St. John’s wort
- Topical decongestants
- Migraine medications