Drug reference

Nortriptyline

BNF 80 (2020–2021)

Source: BNF 80 (2020–2021)
PDF pages: 417, 418

Review source pages for extracted sections and age labels. BNF dose snippets show only their first line.

Overview

Indications And Dose

Depressive illness ▶BY MOUTH ▶Adult: To be initiated at a low dose, then increased if necessary to 75–100 mg daily in divided doses, alternatively increased if necessary to 75–100 mg once daily; maximum 150 mg per day ▶Elderly: To be initiated at a low dose, then increased if necessary to 30–50 mg daily in divided doses continued → Neuropathic pain ▶BY MOUTH ▶Adult: Initially 10 mg once daily, to be taken at night, increased if necessary to 75 mg daily, dose to be increased gradually; higher doses to be given under specialist supervision Nervous system l UNLICENSED USE Not licensed for use in neuropathic pain.

PDF pages 417, 418

Contra Indications

Arrhythmias. during the manic phase of bipolar disorder. heart block. immediate recovery period after myocardial infarction

PDF page 418

Cautions

Cardiovascular disease. chronic constipation. diabetes. epilepsy. history of bipolar disorder. history of psychosis. hyperthyroidism (risk of arrhythmias). increased intra-ocular pressure. patients with a signiﬁcant risk of suicide. phaeochromocytoma (risk of arrhythmias). prostatic hypertrophy. susceptibility to angle-closure glaucoma. urinary retention CAUTIONS, FURTHER INFORMATION Treatment should be stopped if the patient enters a manic phase. Elderly patients are particularly susceptible to many of the side-effects of tricyclic antidepressants; low initial doses should be used, with close monitoring, particularly for psychiatric and cardiac side-effects.

PDF page 418

Prescribing And Dispensing Information

Limited quantities of tricyclic antidepressants should be prescribed at any one time because their cardiovascular and epileptogenic effects are dangerous in overdosage.

PDF page 418

Safety

Interactions

→Appendix 1: tricyclic antidepressants

PDF page 418

Side Effects

Agranulocytosis. alopecia. anxiety. appetite decreased. arrhythmias. asthenia. atrioventricular block. bone marrow disorders. breast enlargement. confusion. constipation. delusions. diarrhoea. dizziness. drowsiness. drug cross-reactivity. drug fever. dry mouth. eosinophilia. fever. ﬂushing. galactorrhoea. gastrointestinal discomfort. gynaecomastia. hallucination. headache. hepatic disorders. hyperhidrosis. hypertension. hypomania. hypotension. increased risk of fracture. increased risk of infection. malaise. movement disorders. mydriasis. myocardial infarction. nausea. oedema. oral disorders. palpitations. paralytic ileus. peripheral neuropathy. photosensitivity reaction. psychosis exacerbated. seizure. sensation abnormal. sexual dysfunction. SIADH. skin reactions. sleep disorders. stroke. suicidal tendencies. taste altered. testicular swelling. thrombocytopenia. tinnitus. tremor. urinary disorders. urinary tract dilation. vision disorders. vomiting. weight changes SIDE-EFFECTS, FURTHER INFORMATION The risk of side- effects is reduced by titrating slowly to the minimum effective dose (every 2–3 days). Consider using a lower starting dose in elderly patients. Overdose Tricyclic and related antidepressants cause dry mouth, coma of varying degree, hypotension, hypothermia, hyperreﬂexia, extensor plantar responses, convulsions, respiratory failure, cardiac conduction defects, and arrhythmias. Dilated pupils and urinary retention also occur. For details on the management of poisoning see Tricyclic and related antidepressants under Emergency treatment of poisoning p. 1430.

PDF page 418

Pregnancy

Use only if potential beneﬁt outweighs risk.

PDF page 418

Breast Feeding

The amount secreted into breast milk is too small to be harmful.

PDF page 418

Hepatic Impairment

Manufacture advises avoid in severe impairment.

PDF page 418

Monitoring Requirements

▶Manufacturer advises plasma-nortriptyline concentration monitoring if dose above 100 mg daily, but evidence of practical value uncertain.

PDF page 418

Dose and formulations

Medicinal Forms

There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: oral suspension, oral solution Oral solution ▶Nortriptyline (Non-proprietary) Nortriptyline (as Nortriptyline hydrochloride) 2 mg per 1 ml Nortriptyline 10mg/5ml oral solution sugar free sugar-free | 250 ml P £246.00 Nortriptyline (as Nortriptyline hydrochloride) 5 mg per 1 ml Nortriptyline 25mg/5ml oral solution sugar free sugar-free | 250 ml P £324.00 Tablet CAUTIONARY AND ADVISORY LABELS 2 ▶Nortriptyline (Non-proprietary) Nortriptyline (as Nortriptyline hydrochloride) 10 mg Nortriptyline 10mg tablets | 28 tablet P £1.85–£2.14 | 30 tablet P £6.87– £11.79 | 84 tablet P £5.54–£6.42 | 100 tablet P £39.30 DT = £6.60 Nortriptyline (as Nortriptyline hydrochloride) 25 mg Nortriptyline 25mg tablets | 28 tablet P £2.27–£2.46 | 30 tablet P £6.81– £12.43 | 84 tablet P £6.80–£7.38 | 100 tablet P £41.44 DT = £8.09 Nortriptyline (as Nortriptyline hydrochloride) 50 mg Nortriptyline 50mg tablets | 30 tablet P £42.00 DT = £33.75

PDF page 418

Clinical care

Treatment Cessation

Withdrawal effects may occur within 5 days of stopping treatment with antidepressant drugs; they are usually mild and self-limiting, but in some cases may be severe. The risk of withdrawal symptoms is increased if the antidepressant is stopped suddenly after regular administration for 8 weeks or more. The dose should preferably be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge (6 months in patients who have been on long-term maintenance treatment). If possible tricyclic and related antidepressants should be withdrawn slowly.

PDF page 418

Patient And Carer Advice

Drowsiness may affect the performance of skilled tasks (e.g. driving). Effects of alcohol enhanced.

PDF page 418

Dose text by age group

Adult

To be initiated at a low dose, then increased if

First-line fragment. Read the complete Indications and Dose section above.

PDF page 417

Adult

Initially 10 mg once daily, to be taken at night,

First-line fragment. Read the complete Indications and Dose section above.

PDF page 418

Age labels are extracted for navigation. Check the complete source section and current local guidance before clinical use.

Drug reference

Nortriptyline

BNF 80 (2020–2021)

Source: BNF 80 (2020–2021)
PDF pages: 417, 418

Review source pages for extracted sections and age labels. BNF dose snippets show only their first line.

Overview

Indications And Dose

PDF pages 417, 418

Contra Indications

Arrhythmias. during the manic phase of bipolar disorder. heart block. immediate recovery period after myocardial infarction

PDF page 418

Cautions

PDF page 418

Prescribing And Dispensing Information

Limited quantities of tricyclic antidepressants should be prescribed at any one time because their cardiovascular and epileptogenic effects are dangerous in overdosage.

PDF page 418

Safety

Interactions

→Appendix 1: tricyclic antidepressants

PDF page 418

Side Effects

PDF page 418

Pregnancy

Use only if potential beneﬁt outweighs risk.

PDF page 418

Breast Feeding

The amount secreted into breast milk is too small to be harmful.

PDF page 418

Hepatic Impairment

Manufacture advises avoid in severe impairment.

PDF page 418

Monitoring Requirements

▶Manufacturer advises plasma-nortriptyline concentration monitoring if dose above 100 mg daily, but evidence of practical value uncertain.

PDF page 418

Dose and formulations

Medicinal Forms

PDF page 418

Clinical care

Treatment Cessation

PDF page 418

Patient And Carer Advice

Drowsiness may affect the performance of skilled tasks (e.g. driving). Effects of alcohol enhanced.

PDF page 418

Dose text by age group

Adult

To be initiated at a low dose, then increased if

First-line fragment. Read the complete Indications and Dose section above.

PDF page 417

Adult

Initially 10 mg once daily, to be taken at night,

First-line fragment. Read the complete Indications and Dose section above.

PDF page 418

Age labels are extracted for navigation. Check the complete source section and current local guidance before clinical use.