Nortriptyline

What is nortriptyline (Pamelor)?

Nortriptyline is a medication that belongs to a drug class called tricyclic antidepressants (TCAs). As its class name implies, nortriptyline is approved by the US Food and Drug Administration (FDA) for the treatment of depression.¹

What You Need To Know About Depression

An imbalance in some of the brain’s neurotransmitters (the chemical messengers nerves use to communicate with each other) may be one of the primary causes of depression. Nortriptyline boosts norepinephrine and serotonin, two neurotransmitters that play roles in regulating mood. It also blocks the action of acetylcholine, another chemical messenger. The drug alleviates the symptoms of depression by restoring balance among these neurotransmitters. 

Sometimes, doctors use nortriptyline off-label to treat conditions characterized by chronic pain and nerve pain, such as diabetic neuropathy, trigeminal neuralgia, and postherpetic neuralgia. It also has other nonanalgesic uses, such as smoking cessation, migraine prevention, anxiety disorders, bedwetting in children, and neurogenic cough.¹

How do you take nortriptyline?

When your pharmacist dispenses nortriptyline, they’ll provide a guide on how to take it. Read through the entire guide, and ask your doctor for clarification if anything is unclear.

Capsules come in a range of doses that you’ll take according to your doctor’s directions. Your doctor may advise you to take nortriptyline once daily or several times per day. But regardless of how often you take it, you should try to take it around the same time(s) each day. 

You can take the drug with or without food. If you struggle with swallowing pills, you can break open the capsule and stir its contents into a soft food, such as applesauce or pudding. Be sure to consume the whole mixture immediately.

If you’re taking nortriptyline as an oral solution, always use a medication measuring spoon, syringe, or medicine cup to measure your dose. Household spoons are not suitable for measuring medication.

Dosage forms and strengths

The dosage of this medicine varies from patient to patient. Your doctor will tell you how much to take and how often. The following information details the available forms and typical dosages; however, you should always take your medications exactly as your doctor prescribes, even if your doses fall outside the usual range.

Nortriptyline capsules

Capsules are available in the following strengths:²

• 10mg

• 25mg

• 50mg

• 75mg

Nortriptyline oral solution

The oral solution is available in a single strength:²

• 10mg/5mL

The amount of medicine you take, how often you take it, and the treatment duration all depend on your condition. Your doctor will customize your treatment plan to meet your unique needs.

Dosing

Regardless of the form, adults typically take 50–150mg of nortriptyline daily, usually at bedtime. Doctors generally start with a low dose and adjust it as needed. However, the total daily amount shouldn’t exceed 150mg.³

Depending on the condition being treated and the patient’s age, older adults and adolescents usually take a lower dose.

This drug is not recommended for the treatment of depression in young children.

Seeing results

You may not see results right away. Your depression symptoms will likely start improving within a few weeks. However, it often takes 4–6 weeks to see the full effect.

Don’t stop taking nortriptyline if you don’t feel better within a week or two. Your doctor can advise you whether you should stop or continue taking the drug. If you decide to stop, your doctor can help you do it gradually, reducing the risk of withdrawal symptoms.

Warnings and potential side effects of nortriptyline

Nortriptyline has US FDA boxed warnings. Like other antidepressant drugs, nortriptyline increases the risk of suicidal thinking and behavior in younger patients (children, adolescents, and adults under 25). When a doctor decides that antidepressant drugs are the best course of action for any patient, they’ll review the risks and benefits of treatment before prescribing medication. Once a patient begins pharmacologic therapy, prescribers will closely monitor them for signs of suicidality, worsening symptoms, and behavioral changes. While these drugs aren’t known to increase the risk of suicidal thinking and behavior in adults 25 and older, people with close relationships to the patient must stay vigilant in watching for any of these signs.²

Nortriptyline may cause side effects. Most are common and resolve without intervention within a few days to a few weeks. If you experience any severe side effects, seek urgent medical attention.³ ⁴

Common side effects of nortriptyline include:

• Nausea, vomiting

• Drowsiness

• Weakness

• Nightmares

• Dry mouth

• Changes in appetite or unexplained weight loss or gain

• Constipation

• Difficulty urinating or changes in frequency

• Changes in sex drive or functioning

• Excessive sweating

• Numbness, tingling of the arms or legs

Occasionally, people taking nortriptyline experience severe side effects that require medical attention, including:

• Changes in mood or behavior, including agitation, aggressiveness, hostility, and impulsivity

• Jaw, neck, and back muscle spasms

• Slowed speech or difficulty speaking

• Difficulty swallowing

• Shuffling walk

• Uncontrollable shaking of a part of the body

• Fever

• Trouble breathing

• Rash

• Yellowing of the skin or eyes

• Irregular heartbeat, heart palpitations

• Changes in blood sugar levels

• Low blood pressure

• Confusion

Nortriptyline can cause angle-closure glaucoma, a sudden, severe increase in ocular pressure that may lead to blindness. Your doctor may recommend routine eye exams to check for pressure changes. Additionally, you’ll need to stay vigilant in monitoring for signs of glaucoma, including severe headaches or eye pain, blurred vision, redness of the eye, or distortion around bright lights at night. If you experience symptoms of angle-closure glaucoma, seek immediate emergency care.⁴

People taking nortriptyline also face a higher risk of developing serotonin syndrome, a condition marked by excessive levels of serotonin within the body. This may occur in anyone taking this medication, but the risk is higher among people who take other substances affecting serotonin levels while taking nortriptyline, including monoamine oxidase inhibitors (MAOIs), triptans, other tricyclic antidepressants, lithium, linezolid, tramadol, fentanyl, and St. John’s wort.

Signs and symptoms of serotonin syndrome include the following:²

• Rapid heart rate

• Dizziness, lack of coordination

• Muscle stiffening or tremor

• Sweating, flushing

• Fever

• Seizures

• Nausea, vomiting, or diarrhea

• Low blood pressure

• Hallucinations

• Irritability

• Coma

This information on warnings and potential side effects is not complete. If you experience anything unusual while taking nortriptyline, speak with your doctor as soon as possible.

Long-term use of nortriptyline

Nortriptyline is generally safe, but it’s not known if the risk of suicidality increases with long-term use.³

When prescribing nortriptyline, doctors start with a low dose and increase the strength as needed. Once the desired level of effect has been achieved, the drug may be used as a maintenance medication for longer periods. For maintenance, doctors prescribe the lowest dose that effectively maintains symptom remission. 

Missed doses

If you miss a dose, take it as soon as you remember. However, if it’s nearly time for your next dose, skip the missed dose and resume your regular schedule. Don’t double your dose to make up for a missed one.

Overdoses

A nortriptyline overdose is dangerous. Signs and symptoms develop quite rapidly after taking a toxic dose. Seek emergency medical treatment if you or someone in your care experiences signs of an overdose while taking nortriptyline.

Signs and symptoms of an overdose may include:³

• Irregular heartbeat, palpitations

• Extreme drowsiness

• Visual hallucinations

• Dilated pupils

• Poor concentration

• Confusion, agitation

• Vomiting

• Overactive reflexes and twitching

• Muscle stiffness

• Hypothermia

• Difficulty breathing

• Severely low blood pressure, shock

• Seizures

• Coma

Allergy information

It’s possible to be allergic to nortriptyline. 

Signs of an allergic reaction include:

• Swelling in or around the throat, lips, tongue, or face

• Difficulty breathing

• Hives

• Vomiting

• Low blood pressure

• Loss of consciousness

An allergic reaction can be serious. Reach out to your doctor immediately or call 911 if you suspect you may be having an allergic reaction.

What to discuss with your doctor before taking nortriptyline

Nortriptyline is available by prescription only, so you’ll need to schedule an appointment with your doctor before taking it. At your appointment, there are a few topics you should address. Let your doctor know if you:⁴

• Have any drug allergies, especially to tricyclic antidepressants

• Are taking or have recently taken MAOIs, such as selegiline (Eldepryl, Zelapar), isocarboxazid (Marplan), phenelzine (Nardil), and tranylcypromine (Parnate)

• Are taking prescription or nonprescription drugs, vitamins, herbs, or supplements

• Have had a heart attack

• Are pregnant, trying to conceive, or breastfeeding

• Are planning to have surgery, including dental procedures

• Drink alcohol regularly or use cannabis

• Have ever had thoughts of or attempted suicide

• Have a family history of abnormal heart rhythms or sudden cardiac death

Additionally, inform your doctor if you have any of the following medical conditions:⁴

• An enlarged prostate

• Difficulty urinating

• Abnormal heart rhythm, QT prolongation

• Diabetes

• Seizures

• Schizophrenia

• Overactive thyroid

• Liver, kidney, or heart disease

• Glaucoma

Your doctor may advise you to avoid prolonged sun exposure and wear protective clothing and sunscreen while taking nortriptyline, as the drug can increase your skin’s sensitivity to sunlight.

Stopping nortriptyline

Even if you feel much improved, continue taking nortriptyline as prescribed. If you stop taking the drug, your symptoms may return. 

If you decide you want to stop taking nortriptyline, you’ll need guidance from your doctor to do it safely. Suddenly discontinuing the medication may trigger withdrawal symptoms, such as nausea, vomiting, diarrhea, dizziness, chills, tremors, headache, and malaise, which can be severe.⁵

Nortriptyline in pregnancy and breastfeeding

Pregnancy

There are no adequate human studies establishing the safety of this drug in pregnancy. However, if you're pregnant and taking nortriptyline for depression, your doctor will weigh the benefits and risks of continuing it during your pregnancy.³

If you’re planning to become pregnant, speak with your doctor ahead of time to ensure you have plenty of time to work out a treatment plan. Don’t stop taking nortriptyline before speaking with your doctor. 

Breastfeeding

Nortriptyline may be used cautiously while breastfeeding, but you’ll need to consult your doctor.

Small amounts of nortriptyline may be passed through breast milk, but studies have not shown any harmful effects on infants.⁶

Interactions with other drugs

Nortriptyline may interact with other medications or supplements you’re taking. A drug interaction is when a substance changes how a drug works. Tell your doctor about all vitamins, supplements, and medications you’re taking, even if you only take them occasionally. 

Drugs are known to interact with nortriptyline include:³

• MAOIs, including selegiline (Eldepryl), isocarboxazid (Marplan), phenelzine (Nardil), safinamide (Xadago), and tranylcypromine (Parnate)

• Cytochrome P450 2D6 inhibitors, such as quinidine, sertraline (Zoloft), paroxetine (Paxil), and fluoxetine (Prozac)

• Drugs with anticholinergic effects, such as diphenhydramine (Benadryl), loratadine (Claritin), oxybutynin (Ditropan), and solifenacin (VESIcare)

• Cimetidine (Tagamet)

• Diuretics, such as chlorpropamide

• Antiarrhythmic drugs, such as disopyramide (Norpace), Dronedarone (Multaq), ibutilide (Corvert), and sotalol (Betapace)

• Antibiotics, such as pentamidine (Nebupent) and linezolid (Zyvox)

• Antipsychotics, such as pimozide (Orap), thioridazine (Mellaril), and olanzapine (Zyprexa)

Additionally, taking nortriptyline alongside certain other medications may increase the risk of severe side effects. These medications include:

• Selective serotonin reuptake inhibitors (SSRIs), such as citalopram (Celexa), fluoxetine (Prozac), and sertraline (Zoloft)

• Selective norepinephrine reuptake inhibitors (SNRIs), including duloxetine (Cymbalta) and venlafaxine (Effexor)

• Triptans, such as sumatriptan (Imitrex, Treximet), zolmitriptan (Zomig), and rizatriptan (Maxalt)

Approval history

The US FDA approved nortriptyline as a treatment for adults with depression in 1964. The drug is not FDA-approved for use in children. Other uses of the drug (such as the treatment of pain) are off-label.³ ⁷

Tips and advice for taking nortriptyline

The following information can help you take nortriptyline safely while minimizing side effects:

• Taking nortriptyline with food may reduce stomach upset

• If you take nortriptyline once daily, your doctor may recommend taking it before bed to reduce the impact of side effects

• Nortriptyline may make you dizzy or tired, so assess your body’s response to the drug before engaging in activities that demand coordination or alertness

• This medication may make your skin more sensitive to the sun — limit sun exposure and wear sunscreen

• Inform your doctor immediately if you notice negative mood changes, suicidal thoughts, agitation, or other worsening symptoms of depression

• You won’t feel better right away — give nortriptyline a few weeks or more to work, but let your doctor know if your symptoms do not improve in that time