From the Guidelines
Nortriptyline is recommended as a first-line treatment for neuropathic pain, with a starting dose of 10-25 mg at bedtime, which can be increased every 3-7 days to a final dose of 25-100 mg at bedtime as tolerated 1.
Key Points
- Nortriptyline is a tricyclic antidepressant medication that is effective in treating neuropathic pain, with a reduction in pain in 66% of patients within 3 weeks 1.
- The medication works by increasing levels of serotonin and norepinephrine in the brain, which helps regulate mood and pain perception.
- Common side effects include dry mouth, constipation, blurred vision, drowsiness, and dizziness, which often improve with time as the body adjusts to the medication.
- Nortriptyline requires caution in patients with heart conditions, glaucoma, urinary retention, or seizure disorders, and should not be taken within 14 days of MAO inhibitors.
Dosage and Administration
- The typical starting dose for adults with neuropathic pain is 10-25 mg at bedtime, which can be gradually increased to 25-100 mg at bedtime as needed and tolerated 1.
- The dose should be increased every 3-7 days to allow the body to adjust to the medication.
- It's essential to take nortriptyline regularly at the same time each day, usually at bedtime to minimize daytime drowsiness.
Clinical Considerations
- Nortriptyline has been shown to be effective in treating various types of neuropathic pain, including postherpetic neuralgia (PHN) and neuropathic corneal pain 1.
- The medication has a superior side effect profile compared to other tricyclic antidepressants, such as amitriptyline 1.
- Nortriptyline can be used in combination with other medications, such as opioids or tramadol, for the treatment of neuropathic pain 1.
From the FDA Drug Label
INDICATIONS Nortriptyline hydrochloride is indicated for the relief of symptoms of depression. Endogenous depressions are more likely to be alleviated than are other depressive states. The primary use of nortriptyline is for the relief of symptoms of depression, specifically endogenous depressions 2.
From the Research
Nortriptyline Studies
- Nortriptyline is a tricyclic antidepressant used to treat depression, with guidelines for doses generally vague and recommending a wide dose range 3
- A study initiated nortriptyline treatment with a 75- to 125-mg dose in 26 depressed inpatients, resulting in a 45% decrease in Hamilton Rating Scale for Depression score within 1 week 3
- Orthostatic hypotension was a significant side effect, but only 2 patients required additional treatment, and none were dropped from the study due to side effects 3
Comparative Efficacy and Safety
- A subgroup analysis compared sertraline and nortriptyline in patients 70 and older, finding both treatments improved depression, but sertraline demonstrated a greater reduction in depression severity 4
- Sertraline was better tolerated than nortriptyline, with a lower attrition rate and side effect burden 4
- Another study compared sertraline and nortriptyline in older adults, finding similar efficacy, but sertraline had a significant advantage in secondary efficacy measures, such as cognitive function and quality of life 5
Treatment Outcomes
- A study compared mirtazapine and nortriptyline in depressed outpatients who had not responded to multiple treatment trials, finding low remission rates (<20%) for both treatments 6
- Neither response nor remission rates statistically differed by treatment, and the two treatments did not differ in tolerability or adverse events 6
- A review of selective serotonin reuptake inhibitors (SSRIs) found escitalopram to be more effective than other SSRIs in terms of response rate, remission rate, and withdrawal rate, but did not directly compare SSRIs to nortriptyline 7