Names and pronunciation
(nor-trip′ti-leen) Arentyl , Aventyl , Pamelor
Source page 964
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Individual generic drug information
Extracted information for nortriptyline only.
(nor-trip′ti-leen) Arentyl , Aventyl , Pamelor
Source page 964
Func. class.: Antidepressant, tricyclic
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Chem. class.: Dibenzocycloheptene— secondary amine
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Do not confuse: nortriptyline/amitriptyline
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ACTION: Blocks reuptake of norepi- nephrine and serotonin into nerve end- ings, thereby increasing action of nor- epinephrine and serotonin in nerve cells
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USES: Major depression
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Unlabeled uses: Postherpetic neural- gia, IBS, enuresis, panic disorder, social anxiety disorder
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Extracted information for nortriptyline only.
CONTRAINDICATIONS: Hyper- sensitivity to tricyclics, carBAMazepine; recovery phase of MI Precautions: Breastfeeding, suicidal patients, severe depression, increased intraocular pressure, closed-angle glau- coma, urinary retention, cardiac/hepatic disease, hyperthyroidism, electroshock therapy, elective surgery, pregnancy, sei- zure disorders, prostatic hypertrophy
Source page 964
Black Box Warning: Children, suicidal ideation Black Box Warning: Suicidal thoughts/ behaviors in children/young adults: not approved for children; monitor for suicidal ideation in depression, adoles- cents, young adults • Monitor for glaucoma exacerbation and paralytic ileus • B/P (lying, standing), pulse q4hr; if systolic B/P drops 20 mm Hg, hold prod- uct, notify prescriber; VS q4hr in patients with CV disease • Blood studies: thyroid function tests, LFTs, serum nortriptyline level/target 50-150 mg/ mL if patient is receiving long-term therapy • Weight weekly; appetite may increase with product • PR, QT prolongation: dysrhythmias in cardiac patients; assess for chest pain, palpitations, dyspnea • EPS primarily in geriatric patients: ri- gidity, dystonia, akathisia, preferred tricy- clic in geriatric patients • Mental status changes: mood, senso- rium, affect, suicidal tendencies, increase in psychiatric symptoms, depression, panic • Urinary retention, constipation; consti- pation is more likely to occur in children • Withdrawal symptoms: headache, nausea, vomiting, muscle pain, weakness; do not usually occur unless product was discontinued abruptly • Alcohol intake; if alcohol is consumed, hold dose until AM • Serotonin syndrome, neuroleptic malignant syndrome: assess for in- creased heart rate, shivering, sweating, dilated pupils, tremors, high B/P, hyper- thermia, headache, confusion; if these occur, stop product, administer serotonin antagonist if needed (rare) • Assistance with ambulation during be- ginning therapy because drowsiness/diz- ziness occurs; safety measures including side rails, primarily for geriatric patients • Beers: avoid in older adults; highly anticholinergic, sedating, and may cause orthostatic hypotension • Pregnancy/breastfeeding: use only if benefits outweigh fetal risk; cautious use in breastfeeding
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SIDE EFFECTS CNS: Dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation, weakness, insomnia, nightmares, EPS (geriatric patients), increased psychiat- ric symptoms, seizures CV: Orthostatic hypotension, ECG changes, tachycardia, hypertension, pal- pitations, dysrhythmias EENT: Blurred vision, tinnitus, mydria- sis, dry eyes ENDO: SIADH, hyponatremia, hypothy- roidism GI: Constipation, dry mouth, nausea, vomiting, paralytic ileus, increased appe- tite, cramps, epigastric distress, jaun- dice, hepatitis, stomatitis, weight gain GU: Urinary retention, acute renal fail- ure, sexual dysfunction HEMA: Agranulocytosis, thrombocytope- nia, eosinophilia, leukopenia INTEG: Rash, urticaria, sweating, pruri- tus, photosensitivity SYST: Serotonin syndrome
Source page 965
INTERACTIONS Increase: QT prolongation—class IA/III antidysrhythmics, some phenothiazines, β agonists, local anesthetics, tricyclics, haloperidol, chloroquine, droperidol, pen- tamidine; CYP3A4 inhibitors (amiodarone, clarithromycin, erythromycin, telithromy- cin, troleandomycin), arsenic trioxide, levomethadyl; CYP3A4 substrates (meth- adone, pimozide, QUEtiapine, quiNIDine, risperiDONE, ziprasidone) • Heavy smoking: decreased product effect • Hyperpyretic crisis, seizures, hyper- tensive episode: MAOI Increase: effects of direct-acting sympa- thomimetics (EPINEPHrine), alcohol, bar- biturates, benzodiazepines, CNS depres- sants, products increasing QT interval, other anticholinergics Increase: serotonin syndrome, neurolep- N tic malignant syndrome—SSRIs, SNRIs, serotonin receptor agonists, linezolid; methylene blue (IV) Decrease: effects of guanethidine, cloNI- Dine, indirect-acting sympathomimetics (ePHEDrine) Drug/Herb Increase: CNS effect—evening primrose oil, kava, valerian Decrease: nortriptyline level—St. John’s wort, SAM-e, yohimbe Drug/Lab Test Increase: serum bilirubin, blood glu- cose, alk phos Decrease: VMA, 5-HIAA False increase: urinary catecholamines
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TREATMENT OF OVERDOSE: ECG monitoring; lavage; administer anti- convulsant
Source page 966
Extracted information for nortriptyline only.
DOSAGE AND ROUTES • Adult: PO 25 mg tid or qid; may in- crease to 150 mg/day; may give daily dose at bedtime • Adolescent/elderly: PO 30-50 mg in 1 or 2 divided doses
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Available forms: Caps 10, 25, 50, 75 mg; oral sol 10 mg/5 mL
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Administer: • Store in tight, light-resistant container at room temperature • Increased fluids, bulk in diet if consti- pation occurs • Without regard to meals • Dosage at bedtime to avoid overseda- tion during day; may take entire dose at bedtime; geriatric patients may not toler- ate once-daily dosing • Gum, hard candy, frequent sips of wa- ter for dry mouth • Oral solution: with fruit juice, water, or milk to disguise taste
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Extracted information for nortriptyline only.
Assess:
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Evaluate: • Therapeutic response: decreased de- pression
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • That therapeutic effects may take 2-3 wk; only small quantities may be dispersed • To use caution when driving, during other activities requiring alertness be- cause of drowsiness, dizziness, blurred vision • To avoid alcohol ingestion, other CNS depressants; to avoid MAOIs within 14 days • Not to discontinue medication quickly after long-term use; may cause nausea, headache, malaise • To wear sunscreen or large hat be- cause photosensitivity occurs • To immediately report urinary retention, worsening depression, suicidal thoughts/ behaviors
Source page 966
Extracted information for nortriptyline only.
PHARMACOKINETICS PO: Steady-state 4-19 days; metabolized by liver; excreted by kidneys; crosses placenta; excreted in breast milk; half-life 18-28 hr, protein binding 93%-95%
Source page 965
Filter the extracted dose blocks for this individual drug.
• Adult: PO 25 mg tid or qid; may in- crease to 150 mg/day; may give daily dose at bedtime
Candidate age grouping · source page 965
• Adolescent/elderly: PO 30-50 mg in 1 or 2 divided doses
Candidate age grouping · source page 965