From the Guidelines
Nortriptyline should be tapered when discontinuing rather than stopped abruptly to minimize the risk of withdrawal symptoms. A gradual taper over 2-4 weeks is typically recommended, with dose reductions of approximately 25% every few days to a week depending on the starting dose and patient response 1. For example, if a patient is taking 75mg daily, the dose might be reduced to 50mg for one week, then 25mg for another week before stopping completely. Abrupt discontinuation of nortriptyline can lead to withdrawal symptoms including nausea, headache, dizziness, sleep disturbances, anxiety, irritability, and flu-like symptoms. These withdrawal effects occur because the body has adapted to the medication's effects on neurotransmitters like serotonin and norepinephrine, and needs time to readjust when the medication is removed. Patients with higher doses or longer treatment duration may require more gradual tapering schedules. During the tapering process, patients should be monitored for both withdrawal symptoms and potential recurrence of the condition being treated with nortriptyline. Some key points to consider when tapering nortriptyline include:
- The risk of withdrawal symptoms is higher in patients who have been taking the medication for a longer period or at higher doses 1.
- Patients may experience a range of severe withdrawal symptoms, including severe anxiety, agitation, low mood, and somatic and other symptoms 1.
- Determining optimal tapering procedures to minimize withdrawal symptoms for patients who wish to discontinue antidepressants is a current topic of debate among clinicians 1.
- Patients frequently feel that their experiences of withdrawal symptoms are either discounted by clinicians or attributed only as an indication of relapse to depression 1. It is essential to prioritize the patient's safety and well-being during the tapering process, and to be aware of the potential risks and benefits of discontinuing nortriptyline 1.
From the Research
Nortriptyline Discontinuation
- Nortriptyline, a tricyclic antidepressant, may require a taper when discontinuing to minimize withdrawal symptoms 2.
- A prospective study of scheduled withdrawal from nortriptyline in children and adolescents found that gradual tapering precluded withdrawal symptoms in most pediatric patients 2.
- However, the study on SSRI withdrawal syndrome suggests that tapering over a period of months and down to doses much lower than minimum therapeutic doses may be more effective in reducing withdrawal symptoms 3.
- There is evidence that nortriptyline can cause withdrawal symptoms, including irritability, dream and sleep disturbance, and restlessness, when discontinued abruptly 4.
- A study on the recurrence of depression after discontinuation of long-term amitriptyline treatment found that some patients experienced a mild withdrawal syndrome within the first 2 weeks after discontinuation 4.
- The decision to taper nortriptyline should be based on individual patient factors, including the duration of treatment and the dose being taken 2, 4.
- It is essential to monitor patients for withdrawal symptoms and adjust the tapering schedule as needed to minimize discomfort and prevent relapse 2, 4.