What is nortriptyline used for?

• Treating depression in adults. Nortriptyline is not licensed for treating depression in children and adolescents under 18 years of age. However, some specialists may still prescribe it if they feel it is essential.
• Treating nerve pain (neuralgia or neuropathic pain) in adults, for example caused by nerve damage as a result of diabetes, stroke, injuries, chemotherapy, amputation (phantom limb limb) or shingles (postherpetic neuralgia). This is an unlicensed use of nortriptyline.

How does nortriptyline work?

• Nortriptyline hydrochloride is a type of medicine called a tricyclic antidepressant (TCA). It works by enhancing the activity of the neurotransmitters serotonin and noradrenaline in the brain.
• Neurotransmitters are natural body chemicals that act as chemical messengers between the nerve cells. Serotonin and noradrenaline are neurotransmitters known to be involved in regulating emotions, mood and behaviour, among other things. In depressive illness less serotonin and noradrenaline than normal is released from nerve cells in the brain.
• Nortriptyline works by stopping the serotonin and noradrenaline that has been released from being reabsorbed back into the nerve cells in the brain. This helps to prolong their effects and over time this helps to lighten mood and relieve depression.
• Nortriptyline won't change your personality or make you feel instantly happy and relaxed. It works over time to correct the chemical changes in your brain that have made you become depressed, and helps you get back to feeling like your old self.
• It's not fully understood how nortriptyline relieves nerve pain. It's thought to work by enhancing the nerve signals within the central nervous system that naturally reduce pain messages arriving in the brain.

How long does nortriptyline take to work?

• In depression it may take between two to four weeks before nortriptyline starts to work and you begin to feel better, so it's very important that you keep taking it, even if it doesn't seem to make much difference at first. You'll usually need to keep taking nortriptyline every day for several months, and for at least six months after you feel better. You should keep taking it for as long as your doctor asks you to. If you feel your depression has got worse, or if you have any distressing thoughts, or feelings about suicide or harming yourself in these first few weeks, or indeed at any point during treatment or after stopping treatment, then it is very important to talk to your doctor.
• With nerve pain nortriptyline may start to help in a few days for some people, while others don't see much difference for two three to weeks. It can take several weeks for you to see the maximum benefit of this medicine, so it's important to persevere with taking it. You should then keep taking it for as long as your doctor recommends.

How do I take nortriptyline?

• Always follow the instructions given by your doctor regarding the nortriptyline dose you should take. Remember that it takes a while for nortriptyline to start working, so keep taking it as prescribed even if it doesn't seem to make much difference at first. Do not take more than the dose prescribed by your doctor.
• Nortriptyline is usually taken three or four times a day, although it can also be prescribed as a single dose to be taken at bedtime. Follow the instructions given by your doctor. Try to always take your doses at the same times each day - this will help you to remember to take them.
• Nortriptyline tablets can be taken either with or without food, on a full or empty stomach.
• If you forget to take a dose at your usual time take it as soon as you remember, unless it's nearly time for your next dose. In this case just leave out the missed dose and take your next dose as usual when it is due. Do not take a double dose to make up for a missed dose.
• You should keep taking nortriptyline regularly until your doctor tells you to stop. When treating depression, current recommendations are that antidepressants are continued for at least six months after recovery to help prevent the depression coming back after the medicine is stopped.
• Nortriptyline is not addictive. However, do not suddenly stop taking nortriptyline, because this can cause withdrawal symptoms such as feeling sick, shivering, headache, difficulty sleeping, sweating, irritability, restlessness or anxiety. Withdrawal symptoms are temporary and are not due to dependence on the medicine. They can usually be avoided by stopping nortriptyline gradually, usually over a period of weeks or months, depending on your individual situation. Follow the instructions given by your doctor when it's time to stop treatment.

Who shouldn't take nortriptyline?

• People with severe liver disease.
• People with an irregular heartbeat (arrhythmia), heart block, or who have recently had a heart attack.
• People in a manic phase of bipolar disorder (manic depression).
• People who have taken a monoamine oxidase inhibitor antidepressant (MAOI) in the last two weeks.
• People who are allergic or intolerant to any ingredient of the medicine. Check the ingredients listed in the leaflet that comes with the medicine if you know you have specific allergies or intolerances.

Who might need a lower nortriptyline dose or extra monitoring?

• Elderly people.
• People with liver problems.
• People with heart disease or high blood pressure.
• People with an overactive thyroid gland (hyperthyroidism).
• People with a tumour of the adrenal gland (phaeochromocytoma).
• People with chronic constipation.
• People who have difficulty passing urine, such as men with an enlarged prostate gland.
• People with raised pressure in the eye or glaucoma.
• People with diabetes.
• People who suffer from epilepsy or are at risk of having seizures (fits), eg due to alcohol/drug withdrawal, brain damage, or other medicines.
• People receiving electroconvulsive therapy (ECT).
• People with psychotic illness, eg schizophrenia.
• People with a history of bipolar affective disorder (manic depression). This medicine should be stopped in people entering a manic phase.

If your child is prescribed nortriptyline it is very important that they are encouraged to report any distressing feelings, thoughts about suicide or self-harm, irritability, aggressive behaviour, mood changes or other unusual change in behaviour that they may experience while taking the medicine. If you notice a change in your child's behaviour, or are worried about them at any point, it is important to talk to your doctor immediately.

Can I take nortriptyline while pregnant or breastfeeding?

• It is important to get medical advice from your doctor if you think you could be pregnant or want to plan a pregnancy while taking nortriptyline. Nortriptyline should preferably not be used during pregnancy, particularly in the first and third trimesters, because its safety has not been fully established. However, it's important to talk to your doctor about the risks and benefits of taking the medicine compared with stopping treatment or using other treatments. For example, if nortriptyline is taken during the third trimester it could cause side effects or withdrawal symptoms in the baby after birth, and the baby may need extra monitoring because of this.
• If you get pregnant and decide to stop taking nortriptyline, don't do this suddenly. Your doctor will give you instructions on how to stop treatment gradually to avoid getting withdrawal symptoms.
• Get advice from your doctor if you want to breastfeed while you're taking nortriptyline. Nortriptyline passes into breast milk, but only in very small amounts that are unlikely to be harmful to a nursing infant. If you're taking nortriptyline it's usually fine for you to breastfeed providing your baby is healthy, wasn't born prematurely, and is monitored for potential problems such as drowsiness. However, do always check with your doctor first, because various factors need to be taken into account.

What are the possible side effects of nortriptyline?

• Dry mouth.
• Blurred vision.
• Constipation.
• Feeling sick.
• Dizziness, particularly when getting up.
• Headache.
• Tremor.
• Fast heartbeat or palpitations.
• Flushing or sweating.
• Feeling weak or tired.
• Confusion or problems concentrating.
• Pins and needles sensations.
• Involuntary muscle movements such as twitching.
• Sexual problems, such as reduced sex drive or erectile dysfunction.
• Change in the way things taste.
• Weight gain.
• Rare or unknown frequency
• Drowsiness.
• Difficulty passing urine.
• Hair loss.
• Breast enlargement, production of breast milk.
• Irregular heartbeats (arrhythmias).
• Reduced numbers of red blood cells, white blood cells or platelets in the blood. Tell your doctor if you experience a sore throat, high temperature (fever) or unusual bruising or bleeding while taking nortriptyline, because these could be a sign of a problem with your blood cells.
• Convulsions (fits or seizures).
• Liver problems, such as liver inflammation (hepatitis) or jaundice.
• Drop in the amount of sodium in the blood - a condition called hyponatraemia. This can cause symptoms such as drowsiness, confusion, muscle twitching or convulsions. Elderly people may be particularly susceptible to this effect. You should consult your doctor if you develop any of these symptoms while taking this medicine so that your blood sodium level can be checked if necessary.

Read the leaflet that comes with the medicine or talk to your doctor or pharmacist if you want any more information about the possible side effects of nortriptyline.

Can I take other medicines with nortriptyline?

• It's important to tell your doctor or pharmacist if you're already taking any medicines, including those bought without a prescription and herbal medicines, before you start treatment with nortriptyline.

Can I take over-the-counter medicines with nortriptyline?

You should always check with your pharmacist before taking any new medicines once you've started taking nortriptyline, to make sure that the combination is safe for you. However these are the main things to be aware of:

• If you need to take a painkiller it's fine to take paracetamol, aspirin or ibuprofen with nortriptyline, assuming these are appropriate for you. If you find nortriptyline makes you drowsy or constipated, it's best to avoid taking co-codamol, because this painkiller could make these problems worse.
• You shouldn't take cold and flu remedies that contain a decongestant such as pseudoephedrine or phenylephrine while you're taking nortriptyline.
• Avoid taking excessive amounts of stimulant laxatives like senna or bisacodyl while you're taking nortriptyline. If you need to treat constipation ask your pharmacist for advice.
• If you need an antihistamine it's best to avoid those that can make you sleepy, like chlorphenamine, diphenhydramine and promethazine - go for a non-sedating one like cetirizine or loratadine instead.
• Don't take the herbal remedy St John's wort (Hypericum perforatum) with nortriptyline.

What about prescribed medicines?

You're more likely to feel sleepy on nortriptyline if you also take other medicines that can cause drowsiness, such as the following:

• antipsychotics, eg haloperidol
• barbiturates, eg phenobarbital, amobarbital (these may also make the antidepressant less effective)
• benzodiazepines, eg diazepam, temazepam
• sedating antihistamines, eg promethazine, hydroxyzine
• sleeping tablets, eg zopiclone
• strong opioid painkillers, such as morphine, codeine, tramadol, fentanyl
• other tricyclic antidepressants, eg amitriptyline.
• You may be more likely to feel dizzy or faint if you take nortriptyline alongside medicines that lower blood pressure, including medicines used to treat high blood pressure and medicines that can lower blood pressure as a side effect, for example benzodiazepines. If you're taking medicines that lower blood pressure, tell your doctor if you feel dizzy or faint after starting treatment with nortriptyline, as your doses may need adjusting.

You may be more likely to get a dry mouth, constipation, difficulty passing urine or blurred vision if you take medicines that have anticholinergic effects with nortriptyline. These include the following:

• anticholinergics for urinary incontinence, eg tolterodine, oxybutynin
• anticholinergics for Parkinson's symptoms, eg procyclidine, trihexyphenidyl
• some antihistamines, eg promethazine, chlorphenamine
• antispasmodics, eg hyoscine, atropine
• some antipsychotics, eg chlorpromazine, clozapine
• certain other antidepressants
• some antisickness medicines, eg meclozine, cyclizine.

If you take other medicines or drugs that enhance serotonin activity in the brain while you're taking nortriptyline, you may be more likely to get a side effect called the 'serotonin syndrome', with symptoms such as agitation, tremor, shivering, increased heart rate and diarrhoea. Other medicines that increase serotonin activity include the following:

• dapoxetine
• dexamfetamine
• fentanyl
• illegal drugs such as cocaine, amphetamine (speed) and ecstasy (MDMA)
• lithium
• linezolid
• methadone
• selegiline, rasagiline or safinamide for Parkinson's
• SSRI, tricyclic or related antidepressants, eg paroxetine, citalopram, amitriptyline, duloxetine, venlafaxine
• tramadol
• triptans for migraine, eg sumatriptan
• tryptophan.

Nortriptyline may alter the anti-blood-clotting effect of coumarin anticoagulant medicines such as warfarin. Your doctor may want to check your blood clotting time (INR) more frequently if you are taking these two medicines together.

The following medicines may increase the blood level of nortriptyline and could increase the risk of its side effects:

• bupropion
• cimetidine
• fluconazole
• methylphenidate
• protease inhibitors for HIV such as ritonavir
• quinidine
• SSRI antidepressants such as fluvoxamine and fluoxetine
• terbinafine.

If you get a dry mouth while taking nortriptyline you may find that medicines that are designed to dissolve and be absorbed from under the tongue, eg sublingual glyceryl trinitrate (GTN) tablets for angina, become less effective. This is because the tablets do not dissolve properly in a dry mouth. To resolve this, drink a mouthful of water before taking sublingual tablets.

The following medicines should preferably not be used with nortriptyline, because they might increase the risk of developing an abnormal heart rhythm:

• medicines to treat abnormal heart rhythms (anti-arrhythmics), eg amiodarone, procainamide, quinidine, disopyramide, dronedarone
• certain antimalarials, eg quinine, halofantrine, Riamet, mefloquine
• certain antimicrobials, eg erythromycin given by injection, clarithromycin, moxifloxacin, voriconazole or pentamidine
• certain antipsychotics, eg amisulpride, thioridazine, chlorpromazine, sertindole, haloperidol, pimozide, zuclopenthixol, sulpiride
• certain other antidepressants, eg citalopram, escitalopram
• arsenic trioxide
• domperidone
• droperidol
• fingolimod
• hydroxyzine
• methadone
• mizolastine
• ondansetron
• ranolazine
• saquinavir
• sildenafil
• tolterodine
• vardenafil.

The medicines listed below can sometimes cause the amount of potassium in the blood to drop too low. If this happens in someone taking nortriptyline it could increase the risk of irregular heartbeats. Your doctor may want to check your potassium levels regularly if you are taking one of these medicines with nortriptyline:

• beta-2-agonists for asthma, eg salbutamol
• corticosteroids by mouth or injection, such as prednisolone
• diuretics such as furosemide, bendroflumethiazide, acetazolamide
• intravenous amphotericin
• stimulant laxatives, eg senna
• theophylline.

Nortriptyline should not be taken with a monoamine oxidase inhibitor antidepressant (MAOI), eg phenelzine, tranylcypromine, isocarboxazid, or moclobemide. Treatment with nortriptyline should not be started until at least two weeks after stopping an MAOI and vice versa.

References:

https://www.medicines.org.uk/emc/product/4090/smpc

https://www.webmd.com/drugs/2/drug-10710/nortriptyline-oral/details

https://www.netdoctor.co.uk/medicines/antidepressants/a6171/nortriptyline/

https://www.healthline.com/health/nortriptyline-oral-capsule

https://www.drugs.com/nortriptyline.html

https://medlineplus.gov/druginfo/meds/a682620.html

https://en.wikipedia.org/wiki/Nortriptyline