Nortriptyline HCl

(nor-TRIP-tih-leen HIGH-droe-KLOR-ide)

  Action:
Inhibits reuptake of norepinephrine and serotonin in CNS.

  Indications:
Relief of symptoms of depression. Unlabeled use(s): Treatment of panic disorder, premenstrual depression, dermatologic disorders (eg, chronic urticaria, angioedema, nocturnal pruritis in atopic eczema).

  Contraindications:
Hypersensitivity to any tricyclic antidepressant. Generally, not to be given in combination with or within 14 days of treatment with MAO inhibitors or during acute recovery phases of MI.

  Route/Dosage:

Adults:
PO 25 mg tid to qid. Doses > 150 mg/day are not recommended.

Elderly and Adolescents:
PO 30 to 50 mg/day in divided doses.

  Interactions:

Anticoagulants: Dicumaral actions may increase.

Carbamazepine: Carbamazepine levels may increase; nortriptyline levels may decrease.

Cimetidine, fluoxetine: Concomitant administration may increase nortriptyline blood levels and effects.

CNS depressants: Depressant effects may be additive.

Clonidine: May result in hypertensive crisis.

Guanethidine: Hypotensive action may be inhibited.

MAO Inhibitors: Hyperpyretic crisis, convulsions and death may occur.

Sympathomimetics: Pressor response may decrease.

  Lab Test Interferences:
None well documented.

  Adverse Reactions:

CV:

Orthostatic hypotension; hypertension; tachycardia; palpitations; arrhythmias; ECG changes; stroke; heart block; CHF.

RESP:

Pharyngitis; rhinitis; sinusitis; laryngitis; coughing.

CNS:

Confusion; hallucinations; delusions; nervousness; restlessness; agitation; panic; insomnia; nightmares; mania; exacerbation of psychosis; drowsiness; dizziness; weakness; fatigue; emotional lability; seizures; tremors; extrapyramidal symptoms (eg, pseudoparkinsonism, movement disorders, akathisia).

EENT:

Nasal congestion; tinnitus; conjunctivitis; mydriasis; blurred vision; increased IOP; peculiar taste in mouth.

GI:

Nausea; vomiting; anorexia; GI distress; diarrhea; flatulence; dry mouth; constipation.

GU:

Impotence; sexual dysfunction; nocturia; urinary frequency; urinary tract infection; vaginitis; cystitis; dysmenorrhea; amenorrhea; urinary retention and hesitancy.

HEMA:

Bone marrow depression including agranulocytosis; eosinophilia; purpura; thrombocytopenia; leukopenia.

DERM:

Rash; pruritus; photosensitivity reaction; dry skin; acne.

HEPA:

Hepatitis; jaundice.

META:

Elevation or depression of blood sugar.

OTHER:

Numbness; breast enlargement.

  Precautions:

Pregnancy: Category D. Safety not established. Limb reduction anomalies have been reported with nortriptyline.

Lactation: Excreted in breast milk.

Children: Safety and efficacy not established.

Special risk patients: Use drug with caution in patients with history of seizures, urinary retention, urethral or ureteral spasm, angle-closure glaucoma or increased IOP, cardiovascular disorders, hyperthyroid patients or those receiving thyroid medication, patients with hepatic or renal impairment, schizophrenia or paranoia.

  Administration/Storage:

• Give with food or milk.
• Store at room temperature in tight container.
• If prescribed as single daily dose, give at bedtime to reduce side effects.

  Assessment/Interventions:

• Obtain patient history, including drug history and any known allergies.
• Obtain baseline renal function tests, LFTs, CBC, and ECG, and monitor throughout therapy.
• Drug levels may be obtained to determine if patient is in optimal range (50 to 150 ng/mL).
• Assess emotional status (eg, appearance, speech patterns, mood, level of interest), and monitor level of consciousness and suicidal ideation.
• Monitor daily elimination pattern, BP, and pulse, and notify health care provider of potential problems.
• Assess for bladder distention and constipation.

  Patient/Family Education:

• Advise patient to avoid sudden position changes to prevent orthostatic hypotension.
• Explain that it may take up to 2 wk for therapeutic effects to become evident.
• Caution patient to avoid exposure to sunlight and to use sunscreen or wear protective clothing to avoid photosensitivity reaction.
• Instruct patient to notify health care provider of visual disturbances.
• Advise patient to take sips of water frequently, suck on ice chips or sugarless hard candy or chew sugarless gum if dry mouth occurs.
• Caution patient that drug may cause drowsiness and to use caution while driving or performing other tasks requiring mental alertness.
• Instruct patient not to double dose if one is missed and to notify health care provider if > 1 dose is missed.
• Advise that side effects will be decreased if taken at bedtime if prescribed as once-daily dose.

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