Nortriptyline 25mg is used to treat mental or mood problems such as depression. It is being marketed under the brand names Pamelor and Aventyl. This medication is a tricyclic antidepressant, specifically of dibenzocycloheptene type, and is the active metabolite of the tertiary amine—amitriptyline. Tricyclic antidepressants work by inhibiting the reabsorption of the biogenic amine neurotransmitters: norepinephrine (NE) and serotonin (5HT). Tertiary amines inhibit the reuptake of both neurotransmitters, but secondary amines like nortriptyline are more selective of inhibiting NE over 5HT.
Tricyclic antidepressants (TCA) are rarely used as first-line or even second-line treatment for depression because of its extensive side effect profile and high overdose risk. However, it is still one of the most effective pharmacological therapies for severe depression or major depressive disorder of melancholic type, demonstrating greater efficacy over selective serotonin reuptake inhibitors (SSRIs). Your doctor may prescribe this drug for other reasons. Nortriptyline is being used off-label for treating various conditions such as premenstrual dysphoric disorder, bedwetting, social anxiety disorder, insomnia, migraine, and neuropathic pains, and as an aid for smoking cessation.
TCAs are used as third- or fourth-line treatment for major depressive disorder (MDD). The recommended dose for nortriptyline is 25–50mg per day in adult patients with MDD, with a maximum dose of 150mg. It can be taken in divided doses or once at bedtime for those who are bothered of its sedative effects. Adolescent and elderly patients must take 10–25mg once at bedtime, not exceeding 50mg per day.
Nortriptyline for depressed children and adolescents
Tricyclic antidepressants are contraindicated in depressed children. There are limited data supporting the use of nortriptyline and other TCAs in the treatment of depression in adolescents. In the early 1960s, tricyclic drugs were first used to treat depression in children and adolescents, but they were more commonly prescribed for treating nocturnal enuresis or bedwetting in children. According to a review of 14 trials testing the effectiveness of TCA against placebo:
- Based on nine trials with 454 participants, no significant evidence that TCAs lead to higher rates of remission than placebo.
- Based on 13 trials with 533 participants, there was evidence that MDD patients treated with a tricyclic agent had lower severity score compared to placebo, but the difference was small.
- Based on six trials with 239 adolescent participants and two trials with 77 children participants, there was no evidence of differential rates of remission or response between the age groups.
- Based on eight trials involving 414 adolescent participants, there was notable lowering of depression scores.
- Based on three trials involving 64 children participants, there was no lowering of depression scores.
The authors concluded that tricyclic drugs, such as amitriptyline, nortriptyline, desipramine, and imipramine are not useful for treating depression in prepubertal children. The use of TCAs for adolescent depression will likely provide modest effects. Prescribing a tricyclic as a second-line treatment for depressed adolescents who failed to respond to other pharmacotherapy or psychotherapy is also unwarranted, as one trial who used TCAs in this context also failed to demonstrate significant treatment benefit.
Nortriptyline for smoking cessation
A Cochrane systematic review, investigating the safety and efficacy of antidepressants for smoking cessation, yield the following results:
- When used alone, nortriptyline produced a significant increase in long-term cessation based on six trials with 975 participants.
- There was insufficient evidence that adding nortriptyline to nicotine replacement therapy provides an additional long-term effect.
- Bupropion and nortriptyline appeared to be equally effective and similar efficacy to nicotine replacement therapy, although there was limited amount of data from direct comparisons.
- While nortriptyline has the potential for serious side effects, none was demonstrated in the few small trials for smoking cessation.
Nortriptyline for patients with major depression and heart disease
There’s a complex interactive relationship between depression and heart disease. Patients who became depressed after a heart attack had a fivefold increase in mortality during the first six months, according to a 1994 study. It has been thought that SSRIs are safer for patients with heart disease. In a study comparing Paroxetine and Nortriptyline for moderately depressed patients with ischemic heart disease, the two drugs seemed to have similar efficacy.
Nortriptyline has greater efficacy (92% vs 73%) in patients who completed treatment. However, more cardiovascular adverse events, including tachycardia, have been reported in nortriptyline and there were more cases of discontinuance compared to paroxetine. The researchers came to a conclusion that Paroxetine was as effective as nortriptyline but less likely to produce cardiovascular side effects.