Nortriptyline: Difference between revisions

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{{MedTemplate

| generic = Nortriptyline

| generic = Nortriptyline (hydrochloride)

| brand = Pamelor

| brand = Pamelor (US brand discontinued; generic widely available), Aventyl

| classes = TCA, Antidepressant

| structure =

| mechanism = ~~Norepinephrine~~ reuptake ~~inhibitor~~

| classes = [[:Category:Tricyclic antidepressants|Tricyclic antidepressant (TCA, secondary amine)]], [[:Category:Antidepressants|Antidepressant]], [[:Category:Neuropathic pain medicines|Neuropathic pain medicine]], [[:Category:Migraine prophylactics|Migraine prophylactic]]

| 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>

| 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

| fda_max = 150 mg/day; therapeutic plasma-level monitoring recommended (target 50-150 ng/mL window)

| pill_id =

| routes = Oral

| onset = Pain and migraine prophylaxis effect 1-4 weeks; antidepressant effect 4-6 weeks

| duration = 24 hours (HS dosing)

| 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>

| bioavailability = ~50% (oral)<ref name="pamelor-label" />

| pregnancy = TCA class signal; limited human data specific to nortriptyline.{{citation needed}}

| 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" />

| 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>.

}}

== References ==

[[Category:Tricyclic antidepressants]]

[[Category:Antidepressants]]

[[Category:Neuropathic pain medicines]]

[[Category:Migraine prophylactics]]

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