nortriptyline hydrochloride

(nor trip' ti leen)

Aventyl, Norventyl (CAN), Pamelor, PMS-Nortriptyline (CAN)

Pregnancy Category C

Drug class
Tricyclic antidepressant (TCA) (secondary amine)

Therapeutic actions
Mechanism of action unknown; the TCAs are structurally related to the phenothiazine
antipsychotic drugs (eg, chlorpromazine), but inhibit the presynaptic reuptake of the
neurotransmitters norepinephrine and serotonin; anticholinergic at CNS and peripheral
receptors; sedating; the relationship of these effects to clinical efficacy is unknown.

Indications
• Relief of symptoms of depression (endogenous depression most responsive)
• Unlabeled uses: Treatment of panic disorders (25–75 mg/day), premenstrual
depression (50–125 mg/day), dermatologic disorders (75 mg/day), chronic pain,
headache prophylaxis

Contraindications and cautions

• Contraindicated with hypersensitivity to any tricyclic drug; concomitant therapy
with an MAOI; recent MI; myelography within previous 24 hr or scheduled
within 48 hr; pregnancy (limb reduction abnormalities); lactation.
• Use cautiously with EST (increased hazard with TCAs); preexisting CV disorders
(possibly increased risk of serious CVS toxicity); angle-closure glaucoma,
increased IOP; urinary retention, ureteral or urethral spasm (anticholinergic
effects may exacerbate these conditions); seizure disorders; hyperthyroidism
(predisposes to CVS toxicity, including cardiac arrhythmias); impaired hepatic,
renal function; psychiatric patients (schizophrenic or paranoid patients may
exhibit a worsening of psychosis); manic-depressive disorder (may shift to
hypomanic or manic phase); elective surgery (discontinued as long as possible
before surgery).

Available forms
Capsules—10, 25, 50, 75 mg; solution—10 mg/5 mL

Dosages
ADULTS
25 mg tid–qid PO. Begin with low dosage and gradually increase as required and
tolerated. Doses > 150 mg/day are not recommended.
PEDIATRIC PATIENTS
< 12 yr: Not recommended.
> 12 yr: 30–50 mg/day PO in divided doses.
GERIATRIC PATIENTS
30–50 mg/day PO in divided doses.
Pharmacokinetics
Route Onset Peak Duration
Oral Varies 2–4 hr 2–4 wk

Metabolism: Hepatic; T1/2: 18–28 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine

Adverse effects
• CNS: Sedation and anticholinergic (atropine-like) effects (dry mouth, blurred
vision, disturbance of accommodation for near vision, mydriasis, increased IOP),
confusion (especially in elderly), disturbed concentration, hallucinations,
disorientation, decreased memory, feelings of unreality, delusions, anxiety,
nervousness, restlessness, agitation, panic, insomnia, nightmares, hypomania,
mania, exacerbation of psychosis, drowsiness, weakness, fatigue, headache,
numbness, tingling, paresthesias of extremities, incoordination, motor
hyperactivity, akathisia, ataxia, tremors, peripheral neuropathy, extrapyramidal
symptoms, seizures, speech blockage, dysarthria
• CV: Orthostatic hypotension, hypertension, syncope, tachycardia, palpitations,
MI, arrhythmias, heart block, precipitation of CHF, stroke
• Endocrine: Elevated or depressed blood sugar; elevated prolactin levels;
inappropriate ADH secretion
• GI: Dry mouth, constipation, paralytic ileus, nausea, vomiting, anorexia,
epigastric distress, diarrhea, flatulence, dysphagia, peculiar taste, increased
salivation, stomatitis, glossitis, parotid swelling, abdominal cramps, black tongue,
hepatitis; elevated transaminase, altered alkaline phosphatase
• GU: Urinary retention, delayed micturition, dilation of the urinary tract,
gynecomastia, testicular swelling; breast enlargement, menstrual irregularity and
galactorrhea; increased or decreased libido; impotence
• Hematologic: Bone marrow depression, including agranulocytosis; eosinophilia;
purpura; thrombocytopenia; leukopenia
• Hypersensitivity: Rash, pruritus, vasculitis, petechiae, photosensitization, edema
(generalized, facial, tongue), drug fever
• Withdrawal: Symptoms with abrupt discontinuation of prolonged therapy:
nausea, headache, vertigo, nightmares, malaise
• Other: Nasal congestion, excessive appetite, weight gain or loss; sweating,
alopecia, lacrimation, hyperthermia, flushing, chills

Interactions
Drug-drug
• Increased TCA levels and pharmacologic (especially anticholinergic) effects with
cimetidine, fluoxetine
• Altered response, including arrhythmias and hypertension with sympathomimetics
• Risk of severe hypertension with clonidine
 • Hyperpyretic crises, severe convulsions, hypertensive episodes, and deaths when
MAOIs are given with TCAs
• Decreased hypotensive activity of guanethidine
Note: MAOIs and TCAs have been used successfully in some patients resistant to therapy
with single agents; however, case reports indicate that the combination can cause serious
and potentially fatal adverse effects.

Nursing considerations
Assessment
• History: Hypersensitivity to any tricyclic drug; concomitant therapy with an
MAOIs; recent MI; myelography within previous 24 hr or scheduled within 48 hr;
pregnancy; lactation; EST; preexisting CV disorders; angle-closure glaucoma,
increased IOP, urinary retention, ureteral or urethral spasm; seizure disorders;
hyperthyroidism; impaired hepatic, renal function; psychiatric patients; manic-
depressive patients; elective surgery
• Physical: Weight; T; skin color, lesions; orientation, affect, reflexes, vision and
hearing; P, BP, orthostatic BP, perfusion; bowel sounds, normal output, liver
evaluation; urine flow, normal output; usual sexual function, frequency of menses,
breast and scrotal examination; liver function tests, urinalysis, CBC, ECG

Interventions
• Limit drug access to depressed and potentially suicidal patients.
• Give major portion of dose hs if drowsiness, severe anticholinergic effects occur.
• Reduce dosage if minor side effects develop; discontinue if serious side effects
occur.
• Arrange for CBC if patient develops fever, sore throat, or other sign of infection.

Teaching points
• Take drug exactly as prescribed; do not stop taking this drug abruptly or without
consulting your health care provider.
• Avoid alcohol, other sleep-inducing, over-the-counter drugs.
• Avoid prolonged exposure to sunlight or sunlamps; use a sunscreen or protective
garments if possible.
• These side effects may occur: Headache, dizziness, drowsiness, weakness, blurred
vision (reversible; use safety measures if severe; avoid driving or performing
tasks that require alertness); nausea, vomiting, loss of appetite, dry mouth (eat
frequent small meals, perform frequent mouth care, and suck sugarless candy);
nightmares, inability to concentrate, confusion; changes in sexual function.
• Report dry mouth, difficulty in urination, excessive sedation.

Adverse effects in Italic are most common; those in Bold are life-threatening.