Nortriptyline Dosing Schedule for Insomnia
For insomnia treatment, nortriptyline should be initiated at 10 mg at bedtime and may be increased to a maximum of 40 mg per day, with careful monitoring for side effects. 1
Dosing Recommendations
- Initial dose: 10 mg at bedtime
- Maximum dose: 40 mg per day (can be given as a single bedtime dose or divided twice daily)
- Elderly patients: Lower dosing is recommended, starting at 10 mg at bedtime
Mechanism and Efficacy
Nortriptyline, a tricyclic antidepressant (TCA), has sedating properties that make it useful for patients with insomnia. It is particularly beneficial for patients with agitated depression and sleep maintenance issues 1. Unlike some other medications used for insomnia, nortriptyline may be especially helpful when insomnia co-occurs with pain or depression.
Monitoring and Considerations
- Therapeutic window: When doses exceed 40 mg daily, plasma levels should be monitored and maintained in the optimal range of 50-150 ng/mL 2
- Doses above 150 mg per day are not recommended 2
- Elderly patients: Require lower doses (30-50 mg/day in divided doses) due to increased risk of side effects 2
- Plasma level monitoring: Higher concentrations may be associated with more adverse experiences, including cardiotoxicity even when within the therapeutic range 2
Common Side Effects
- Sedation (which is beneficial for insomnia)
- Anticholinergic effects (dry mouth, urinary hesitancy)
- Orthostatic hypotension
- Next-day somnolence (reported in 6.06% of TCA users vs 3.21% with placebo) 3
Important Considerations
- Nortriptyline tends to be more sedating than desipramine, making it appropriate for insomnia treatment 1
- Secondary amines like nortriptyline are generally better tolerated than tertiary amines (amitriptyline, imipramine) 1
- Clinical findings should predominate over plasma concentrations when determining dosage changes 2
Alternative Options
For insomnia treatment, guidelines recommend considering:
- Non-pharmacological approaches first (CBT-I) 4
- FDA-approved medications for insomnia (doxepin 3-6 mg, zolpidem, etc.) 4
- Other sedating antidepressants like mirtazapine (7.5-30 mg) or trazodone (25-100 mg) 4
Caution
While nortriptyline can be effective for insomnia, it is not FDA-approved specifically for this indication. TCAs as a class have been shown to improve total sleep time compared to placebo 3, but they also carry risks of adverse effects that should be carefully considered, especially in elderly patients.
Follow-up
Assess response to treatment within 2-4 weeks of initiation, monitoring for effectiveness and side effects such as daytime sedation, orthostatic hypotension, and cognitive changes 4.