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{{MedTemplate
{{MedTemplate
| generic           = Nortriptyline
| generic           = Nortriptyline (hydrochloride)
| brand             = Pamelor
| brand             = Pamelor (US brand discontinued; generic widely available), Aventyl
| structure         =  
| structure         =
| classes           = TCA, Antidepressant
| classes           = [[:Category:Tricyclic antidepressants|Tricyclic antidepressant (TCA, secondary amine)]], [[:Category:Antidepressants|Antidepressant]], [[:Category:Neuropathic pain medicines|Neuropathic pain medicine]], [[:Category:Migraine prophylactics|Migraine prophylactic]]
| mechanism          = Norepinephrine reuptake inhibitor
| uses             = <vote slug="major-depressive-disorder-use">Major depressive disorder (FDA)</vote>, <vote slug="neuropathic-pain-broad-use">Neuropathic pain, often first-line (off-label; diabetic peripheral neuropathy, postherpetic neuralgia)</vote>, <vote slug="migraine-prophylaxis-use">Migraine prophylaxis (off-label)</vote>, <vote slug="chronic-pain-syndromes-use">Chronic pain syndromes (off-label)</vote>, <vote slug="smoking-cessation-adjunct-use">Smoking cessation adjunct (off-label, modest evidence)</vote>
| uses               =  
| starting_dose     = Depression: 25 mg PO TID-QID or 75 mg at bedtime, titrate to 75-150 mg/day. Neuropathic pain: 10-25 mg at bedtime, titrate to 50-100 mg/day. Elderly: 10 mg at bedtime (Beers-list cautions, though less than amitriptyline)
| starting_dose     =  
| preparations     = Capsules 10, 25, 50, 75 mg; oral solution 10 mg/5 mL
| preparations       =  
| fda_max          = 150 mg/day; therapeutic plasma-level monitoring recommended (target 50-150 ng/mL window)
| routes            =  
| pill_id           =
| onset              =
| routes            = Oral
| duration           =  
| onset            = Pain and migraine prophylaxis effect 1-4 weeks; antidepressant effect 4-6 weeks
| halflife          =  
| duration         = 24 hours (HS dosing)
| bioavailability    =  
| halflife          = 18-44 hours<ref name="pamelor-label">FDA Prescribing Information, Pamelor (nortriptyline hydrochloride), Mallinckrodt/various, current revision. https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/018012s029,018013s059lbl.pdf</ref>
| pregnancy         =  
| bioavailability   = ~50% (oral)<ref name="pamelor-label" />
| legal              =  
| pregnancy        = TCA class signal; limited human data specific to nortriptyline.{{citation needed}}
| intro              =  
| legal             = [[USLegal:Prescription only|Rx-only]] in US. Carries the antidepressant '''Boxed Warning''' for suicidality in children, adolescents, and young adults<ref name="pamelor-label" />
| pharmacokinetics   =  
| mechanism        = <vote slug="nortriptyline-mech-claim">'''Secondary amine TCA''', the active metabolite of amitriptyline, with substantially less anticholinergic, antihistaminergic, and α1-adrenergic activity than the parent compound. This makes nortriptyline the "cleaner" TCA, generally preferred over amitriptyline in elderly patients and in chronic pain where the tertiary-amine side-effect burden is undesirable. Selective norepinephrine reuptake inhibition predominates over serotonin reuptake inhibition.</vote> Therapeutic plasma-level monitoring is standard practice for TCAs given the narrow therapeutic index and the established plasma-level-efficacy correlation. CYP2D6 substrate; CPIC PGx guidance applies for dose individualization<ref name="cpic-tca">CPIC Guideline for CYP2D6 and CYP2C19 Genotypes and Dosing of Tricyclic Antidepressants, 2016. https://cpicpgx.org/guidelines/guideline-for-tricyclic-antidepressants-and-cyp2d6-and-cyp2c19/</ref>.
| pharmacodynamics  =  
| indications        =  
| dosing             =  
| effects            =  
| contraindications  =  
| interactions      =  
| pregnancy_details  =
| monitoring         =
| counseling        =
| anecdotes          =
| seealso            =
| references        =  
}}
}}


== References ==
<references />
[[Category:Tricyclic antidepressants]]
[[Category:Antidepressants]]
[[Category:Antidepressants]]
 
[[Category:Neuropathic pain medicines]]
[[Category:Migraine prophylactics]]

Latest revision as of 07:20, 23 May 2026

Tricyclic antidepressant (TCA, secondary amine), Antidepressant, Neuropathic pain medicine, Migraine prophylactic
Nortriptyline (hydrochloride)
Pamelor (US brand discontinued; generic widely available), Aventyl

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Summary
Classes
Tricyclic antidepressant (TCA, secondary amine), Antidepressant, Neuropathic pain medicine, Migraine prophylactic
Common uses
Major depressive disorder (FDA)0, Neuropathic pain, often first-line (off-label; diabetic peripheral neuropathy, postherpetic neuralgia)0, Migraine prophylaxis (off-label)0, Chronic pain syndromes (off-label)0, Smoking cessation adjunct (off-label, modest evidence)0
Pharmacy
Starting dose
Depression: 25 mg PO TID-QID or 75 mg at bedtime, titrate to 75-150 mg/day. Neuropathic pain: 10-25 mg at bedtime, titrate to 50-100 mg/day. Elderly: 10 mg at bedtime (Beers-list cautions, though less than amitriptyline)
Preparations
Capsules 10, 25, 50, 75 mg; oral solution 10 mg/5 mL
US FDA Max
150 mg/day; therapeutic plasma-level monitoring recommended (target 50-150 ng/mL window)
Pharmacology
Routes
Oral
Onset
Pain and migraine prophylaxis effect 1-4 weeks; antidepressant effect 4-6 weeks
Duration
24 hours (HS dosing)
Half-life
18-44 hours[2]
Bioavailability
~50% (oral)[2]
Pregnancy
TCA class signal; limited human data specific to nortriptyline.[citation needed]
Legal status
Rx-only in US. Carries the antidepressant Boxed Warning for suicidality in children, adolescents, and young adults[2]
Purported mechanism
Secondary amine TCA, the active metabolite of amitriptyline, with substantially less anticholinergic, antihistaminergic, and α1-adrenergic activity than the parent compound. This makes nortriptyline the "cleaner" TCA, generally preferred over amitriptyline in elderly patients and in chronic pain where the tertiary-amine side-effect burden is undesirable. Selective norepinephrine reuptake inhibition predominates over serotonin reuptake inhibition.0 Therapeutic plasma-level monitoring is standard practice for TCAs given the narrow therapeutic index and the established plasma-level-efficacy correlation. CYP2D6 substrate; CPIC PGx guidance applies for dose individualization[1].

References

  1. ↑ CPIC Guideline for CYP2D6 and CYP2C19 Genotypes and Dosing of Tricyclic Antidepressants, 2016. https://cpicpgx.org/guidelines/guideline-for-tricyclic-antidepressants-and-cyp2d6-and-cyp2c19/
  2. ↑ 2.0 2.1 2.2 FDA Prescribing Information, Pamelor (nortriptyline hydrochloride), Mallinckrodt/various, current revision. https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/018012s029,018013s059lbl.pdf
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