Indications and Dosage

Depressive Illness

• • By Mouth (Adults): Start at a low dose, increase to 75–100 mg daily in divided doses or as a single daily dose; maximum 150 mg per day.
  • By Mouth (Elderly): Start at a low dose, increase to 30–50 mg daily in divided doses.

Neuropathic Pain (Unlicensed Use)

• • By Mouth (Adults): Initially 10 mg once daily at night, increase if necessary up to 75 mg daily; higher doses require specialist supervision.

Contraindications

• Acute recovery after myocardial infarction, arrhythmias, heart block, manic phase of bipolar disorder.

Cautions

• Cardiovascular disease, chronic constipation, diabetes, epilepsy, history of bipolar disorder, hyperthyroidism, increased intra-ocular pressure, significant risk of suicide, phaeochromocytoma, prostatic hypertrophy, angle-closure glaucoma, urinary retention.

Side Effects

• Common/Very Common: Anxiety, decreased appetite, arrhythmias, asthenia, cardiac conduction disorders, confusion, constipation, delirium, depression, dizziness, drowsiness, dry mouth, eosinophilia, fever, flushing, gastrointestinal discomfort, hallucinations, headache, hepatic disorders, hypotension, nausea, palpitations, peripheral neuropathy, psychosis, seizures, skin reactions, sleep disorders, taste alteration, tremor, urinary disorders, vomiting, weight changes.
• Uncommon to Rare: Psychosis, aggression, bone marrow depression, galactorrhea, gynecomastia, myocardial infarction, oedema, oral disorders, paralytic ileus, photosensitivity reactions, SIADH, thrombocytopenia, tinnitus, vision disorders.

Special Considerations

• Pregnancy: Use only if potential benefits outweigh risks.
• Breastfeeding: Amount secreted into breast milk considered too small to be harmful.
• Hepatic Impairment: Avoid in severe impairment; caution advised otherwise.
• Withdrawal: Gradual reduction recommended to minimize withdrawal symptoms.

Monitoring Requirements

• Monitoring of plasma-nortriptyline concentration recommended for doses above 100 mg daily, although the practical value of this is uncertain.

Treatment Cessation

• Withdrawal effects can occur within 5 days of stopping; reduce dose gradually over about 4 weeks or longer if symptoms emerge.

Patient and Carer Advice

• Drowsiness may impair the ability to perform skilled tasks; caution with driving.
• Alcohol effects may be enhanced.

Medicinal Forms

Oral Solution

• Nortriptyline (Non-proprietary):

• • Available as Nortriptyline hydrochloride in sugar-free oral solution:

• • • 2 mg per 1 ml (10 mg/5 ml)
    • 5 mg per 1 ml (25 mg/5 ml)

• • Volume: 250 ml for both concentrations.

Tablets

• Nortriptyline (Non-proprietary):

• • Nortriptyline hydrochloride tablets available in:

• • • 10 mg
    • 25 mg
    • 50 mg