nortriptyline hydrochloride: clinical use

Prescribing considerations

• Review cardiovascular disease, hypotension, seizure history, hepatic impairment, urinary retention, narrow-angle glaucoma, prostatic symptoms, diabetes and risk of self-harm.
• Older people are more susceptible to confusion, agitation, postural hypotension and anticholinergic effects.
• Avoid abrupt withdrawal because discontinuation symptoms can occur.
• Overdose can rapidly cause seizures, respiratory depression and life-threatening cardiac conduction disturbances.
• CYP2D6 poor metabolism or inhibition can produce unexpectedly high exposure.

Contraindications and cautions

• Hypersensitivity to nortriptyline or product excipients.
• Recent myocardial infarction, heart block, cardiac arrhythmia or coronary insufficiency.
• Concomitant monoamine oxidase inhibitor treatment; observe product-specific washout requirements.
• Severe liver disease.
• Concomitant sympathomimetic agents are contraindicated in selected oral-solution SmPCs.
• Breastfeeding is contraindicated by selected oral-solution SmPCs, although independent UK specialist guidance supports use when clinically appropriate.

Monitoring

• Monitor clinical response, adverse effects and emergence or worsening of suicidal thoughts, particularly early in treatment and following treatment changes.
• Assess pulse, blood pressure and symptoms of arrhythmia or postural hypotension; consider ECG assessment where cardiac risk is increased.
• Consider plasma nortriptyline measurement where specifically indicated, including suspected altered metabolism, interactions or toxicity.
• Monitor glucose more closely in people with diabetes.
• Review anticholinergic burden, confusion, urinary retention, constipation and falls, especially in older people.

Clinical pharmacology

Nortriptyline is a secondary-amine tricyclic antidepressant and the principal active metabolite of amitriptyline. It inhibits noradrenaline reuptake more strongly than serotonin reuptake and also antagonises muscarinic, histamine H1 and alpha-adrenergic receptors. It is metabolised mainly through CYP2D6, with substantial variation between individuals.

Formulation and product differences

• The selected tablet is film coated and contains lactose monohydrate.
• Selected oral solutions are clear, colourless liquids containing sodium benzoate and sucralose and supplied with a double-ended measuring spoon.
• Selected oral solutions should be protected from light and used within three months of first opening.
• Check product-specific pregnancy, breastfeeding, excipient and administration information when changing formulation.

Tablet

Route: Oral

Strengths: 10 mg, 25 mg, 50 mg