Nortriptyline (Pamelor)
Tricyclic antidepressant (norepinephrine reuptake inhibitor)
- Major Depression3
- Prevention of depression after ECT in combo with lithium1
- Melancholic depression2
- Deepens sleep quality
- Treatment resistant depression (as augmentation; caution with drug interactions)3
- Migraine prevention
- Low orthostasis risk
Features
Dosing
50-200 mg/d but is guided by blood level (50-150). Start 25mg/d.
Management
First-line tricyclic, particularly if hypotension risk.
TOLERABILITY: ANTICHOLINERGIC: Constipation (treat docusate 100 mg BID + sennosides 8.6 mg; bethanechol 10-25 mg tid if severe), urinary retention (treat bethanechol 25mg tid), dry mouth (treat spry gum tid, biotene; or pilocarpine swish), blurry vision, confusion.
RISKS: HEART: Orthostatic hypotension (treat elastic abdominal binders or support stockings; if severe, fludrocortisone 0.1-0.2 mg qd or midrodine 0.5 mg tid), falls, cardiac arrhythmias; HEPATOTOXICITY: Extremely rare (4 per 100,000 patient-years).
EMR Text
Depression
Nortriptyline use based on FDA approval in major depressive disorder.
Nortriptyline side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.