Buy Pamelor Online

Nortriptyline (nortriptyline hydrochloride)

BOXED WARNING

Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children, adolescents, and young adults with major depressive disorder and other psychiatric disorders. Monitor and observe closely for clinical worsening, suicidality, or unusual changes in behavior in patients who are started on antidepressant therapy. Not approved for use in pediatric patients.

OTHER BRAND NAMES

Pamelor

THERAPEUTIC CLASS

Tricyclic antidepressant (TCA)

DEA CLASS

RX

INDICATIONS

Relief of symptoms of depression.

ADULT DOSAGE

Depression

Usual: 25mg tid or qid; initiate at a low level and increase as required
Alternate Regimen: Total daily dose may be given qd
Max: 150mg/day

Monitor plasma levels w/ doses >100mg/day and maintain in the optimum range of 50-150ng/mL

Following remission, maintenance medication may be required for a longer period of time at the lowest dose that will maintain remission

Dosing Considerations with MAOIs

Switching to/from an MAOI for Psychiatric Disorders:
Allow at least 14 days between discontinuation of an MAOI and initiation of treatment, and allow at least 14 days between discontinuation of treatment and initiation of an MAOI

Use w/ Other MAOIs (eg, Linezolid, IV Methylene Blue):
Do not start nortriptyline in a patient being treated w/ linezolid or IV methylene blue
In patients already receiving nortriptyline, if acceptable alternatives are not available and benefits outweigh risks, d/c nortriptyline and administer linezolid or IV methylene blue; monitor for serotonin syndrome for 2 weeks or until 24 hrs after the last dose of linezolid or IV methylene blue, whichever comes 1st. May resume nortriptyline therapy 24 hours after the last dose of linezolid or IV methylene blue

PEDIATRIC DOSAGE

Depression

Cap:
Adolescents:
30-50mg/day in single or divided doses

Following remission, maintenance medication may be required for a longer period of time at the lowest dose that will maintain remission

Dosing Considerations with MAOIs

Switching to/from an MAOI for Psychiatric Disorders:
Allow at least 14 days between discontinuation of an MAOI and initiation of treatment, and allow at least 14 days between discontinuation of treatment and initiation of an MAOI

Use w/ Other MAOIs (eg, Linezolid, IV Methylene Blue):
Do not start nortriptyline in a patient being treated w/ linezolid or IV methylene blue
In patients already receiving nortriptyline, if acceptable alternatives are not available and benefits outweigh risks, d/c nortriptyline and administer linezolid or IV methylene blue; monitor for serotonin syndrome for 2 weeks or until 24 hrs after the last dose of linezolid or IV methylene blue, whichever comes 1st. May resume nortriptyline therapy 24 hours after the last dose of linezolid or IV methylene blue

DOSING CONSIDERATIONS

Elderly
30-50mg/day in single or divided doses

Adverse Reactions
Reduce dose if a patient develops minor side effects and promptly d/c if adverse effects of a serious nature or allergic manifestations occur

ADMINISTRATION

Oral route

HOW SUPPLIED

Cap: 10mg, 25mg, 50mg, 75mg; Sol: 10mg/5mL [16 fl oz]

CONTRAINDICATIONS

Use of an MAOI for psychiatric disorders either concomitantly or within 14 days of stopping treatment. Treatment within 14 days of stopping an MAOI for psychiatric disorders. Starting treatment in a patient being treated with other MAOIs (eg, linezolid, IV methylene blue). During the acute recovery period following MI.

WARNINGS/PRECAUTIONS

Not approved for the treatment of bipolar depression. May precipitate mixed/manic episode in patients at risk for bipolar disorder. May produce sinus tachycardia and prolong conduction time; MI, arrhythmia, and strokes reported. Caution with cardiovascular disease (CVD), glaucoma, history of urinary retention, and hyperthyroidism. May lower seizure threshold, exacerbate psychosis or activate schizophrenia, or alter glucose levels. D/C several days prior to elective surgery. May impair mental/physical abilities. Serotonin syndrome reported; d/c immediately and initiate supportive symptomatic treatment. Pupillary dilation that occurs following use may trigger an angle-closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy.

ADVERSE REACTIONS

Arrhythmias, hypotension, HTN, tachycardia, MI, heart block, stroke, confusion, hallucination, insomnia, tremors, ataxia, dry mouth, blurred vision, skin rash.

DRUG INTERACTIONS

See Contraindications. May cause serotonin syndrome with other serotonergic drugs (eg, triptans, TCAs, fentanyl) and with drugs that impair metabolism of serotonin; d/c immediately if this occurs. May block antihypertensive effect of guanethidine and similar agents. Caution in patients on thyroid medications. Alcohol may potentiate effects. May produce "stimulating" effect with reserpine. Monitor and adjust dose with anticholinergic and sympathomimetic drugs. Increased plasma levels with cimetidine. Hypoglycemia reported with chlorpropamide. Drugs that inhibit CYP2D6 (eg, quinidine, cimetidine, many CYP2D6 substrates [eg, other antidepressants, phenothiazines, propafenone, flecainide]) may increase plasma concentrations and may require lower doses for either TCA or the other drug and monitoring of TCA plasma levels. Caution with SSRI coadministration and when switching between TCAs and SSRIs; sufficient time must elapse before starting therapy when switching from fluoxetine (at least 5 weeks may be necessary). Longer T1/2, higher exposure, and decreased clearance with quinidine.

PREGNANCY AND LACTATION

Safety not known in pregnancy/nursing.

MECHANISM OF ACTION

TCA; inhibits activity of histamine, 5-hydroxytryptamine, and acetylcholine. Increases pressor effect of norepinephrine, blocks pressor response of phenethylamine, and interferes with transport, release, and storage of catecholamines.

ASSESSMENT

Assess for recent MI, known hypersensitivity to drug, bipolar disorder risk, susceptibility to angle-closure glaucoma, CVD, hyperthyroidism, history of urinary retention/seizure disorder/mania/schizophrenia, any other conditions where treatment is cautioned or contraindicated, pregnancy/nursing status, and possible drug interactions.

MONITORING

Monitor for signs/symptoms of clinical worsening, suicidality, unusual changes in behavior, mixed manic episodes, arrhythmias, psychosis, serotonin syndrome, angle-closure glaucoma, changes in blood glucose levels, seizures, cognitive/motor impairment, and other adverse reactions.

PATIENT COUNSELING

Advise to avoid alcohol. Instruct to seek medical attention for symptoms of activation of mania, seizures, clinical worsening, cardiovascular events, increasing psychosis, increasing anxiety/agitation, and hypo/hyperglycemia. Inform that physical/mental abilities may be impaired. Advise about the risk of angle-closure glaucoma in susceptible individuals.

STORAGE

20-25°C (68-77°F).

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