Home Drug Guide Nortriptyline Hydrochloride

Drug Guide

Generic Name

Nortriptyline Hydrochloride

Brand Names Aventyl Hydrochloride, Aventyl, Pamelor

Classification

Therapeutic: Antidepressant, Tricyclic Antidepressant (TCA)

Pharmacological: Monoamine reuptake inhibitor

FDA Approved Indications

Depressive disorder

Mechanism of Action

Nortriptyline inhibits the reuptake of norepinephrine and serotonin in the central nervous system, leading to increased levels of these neurotransmitters in synaptic clefts, which helps alleviate depression.

Dosage and Administration

Adult: Initially 25 mg 3 times daily, titrating up as needed and tolerated; typical range 75-150 mg/day in divided doses or at bedtime.

Pediatric: Not generally recommended for pediatric use due to limited safety and efficacy data.

Geriatric: Start at a lower dose, such as 25 mg at bedtime, and titrate slowly based on response and tolerability.

Renal Impairment: Use with caution; dosage adjustment may be necessary.

Hepatic Impairment: Use cautiously; start at a lower dose due to reduced clearance.

Pharmacokinetics

Absorption: Well absorbed orally.

Distribution: Widely distributed in the body, crosses the blood-brain barrier.

Metabolism: Primarily hepatic via cytochrome P450 enzymes, especially CYP2D6 and CYP1A2.

Excretion: Excreted mainly in urine, with some fecal excretion.

Half Life: Approximately 20-90 hours, average around 35 hours.

Contraindications

Recent myocardial infarction
Use of monoamine oxidase inhibitors (MAOIs) within 14 days.
Known hypersensitivity to nortriptyline.

Precautions

History of seizures
Glaucoma (narrow-angle)
Urinary retention
Do not use in pregnancy unless clearly needed.

Adverse Reactions - Common

Dry mouth (Common)
Drowsiness (Common)
Dizziness (Common)
Constipation (Common)

Adverse Reactions - Serious

Cardiac conduction abnormalities (Serious)
Suicidal thoughts or behaviors (Serious)
Serotonin syndrome (rare) (Serious)

Drug-Drug Interactions

MAO inhibitors (risk of hypertensive crisis),
Other serotonergic drugs (risk of serotonin syndrome),
CNS depressants (additive sedative effect),
Cimetidine,
Alcohol

Drug-Food Interactions

Alcohol

Drug-Herb Interactions

N/A

Nursing Implications

Assessment: Monitor cardiac status (ECG), mental status, and assess for signs of overdose or toxicity.

Diagnoses:

Risk for suicide,
Risk for cardiac conduction disturbances.

Implementation: Administer medication as prescribed, usually at bedtime. Monitor for adverse effects, especially with dose titrations.

Evaluation: Assess for improvement in depressive symptoms, monitor for side effects, and check for signs of toxicity.

Patient/Family Teaching

Do not abruptly stop medication.
Avoid alcohol and CNS depressants.
Report signs of worsening depression, suicidal thoughts, or adverse reactions.
Take medication exactly as prescribed, preferably at the same time each day.

Special Considerations

Black Box Warnings:

Suicidality in children, adolescents, and young adults with depression.

Genetic Factors: Metabolized by CYP2D6; genetic variation may affect response and toxicity.

Lab Test Interference: May affect ECG readings due to its cardiac conduction effects.

Overdose Management

Signs/Symptoms: Tri-Cyclic Antidepressant toxicity includes severe hypotension, tachyarrhythmias, seizures, coma, and cardiac arrest.

Treatment: Supportive care, activated charcoal if within 1-2 hours of ingestion, sodium bicarbonate for cardiac arrhythmias, and intensive medical monitoring; consider consultation with poison control.

Storage and Handling

Storage: Store at room temperature, 15-30°C (59-86°F), away from moisture and light.

Stability: Stable if stored properly.