What is the recommended dose of Nordaline?

Recommended Dosage of Nortriptyline

The recommended initial dosage of nortriptyline (Nordaline) is 10-25 mg once daily, typically administered at bedtime, with gradual titration up to a maximum of 150 mg per day based on clinical response and tolerability. 1

Dosing Guidelines

Initial Dosing

• Start with 10-25 mg once daily, preferably at bedtime, for most adult patients 1
• For elderly patients or those with increased sensitivity to anticholinergic effects, begin with 10 mg daily to minimize adverse effects 1

Dose Titration

• Increase dose gradually using increments of initial dose every 5-7 days until therapeutic benefits or significant side effects become apparent 1
• After 9 months of treatment, consider dosage reduction to reassess the need for continued medication 1

Maximum Dosage

• Maximum recommended dose is 150 mg per day for adults 1
• For elderly patients, the daily dosage should not exceed 100 mg due to increased risk of adverse effects 1, 2

Special Populations

Elderly Patients

• Lower starting dose of 10 mg daily is recommended 1
• Maximum dose should be limited to 100 mg daily due to increased sensitivity to anticholinergic effects 1

Patients with Renal Impairment

• No significant alteration in nortriptyline metabolism has been observed in patients with chronic renal failure 3
• However, use with caution and monitor closely due to marked inter-individual differences in drug clearance 3

Therapeutic Monitoring

• Therapeutic blood level "window" of 50-150 ng/mL (190-570 nmol/L) is recommended for optimal efficacy 1
• Consider obtaining plasma levels if response is inadequate or toxicity is suspected 4
• A single 24-hour blood sample can help determine individual patient dosage requirements 4

Clinical Considerations

Efficacy Profile

• Nortriptyline tends to be activating (reduces apathy) compared to other tricyclic antidepressants 1
• May be particularly useful in patients with depression accompanied by fatigue or psychomotor retardation 1, 2

Side Effect Profile

• Lower risk for cardiotoxic, hypotensive, and anticholinergic effects compared to other tricyclic antidepressants 1
• May cause tachycardia, orthostatic hypotension, sedation, dry mouth, constipation, and urinary retention 1, 2

Common Pitfalls and Precautions

• Avoid abrupt discontinuation; taper gradually over 10-14 days to limit withdrawal symptoms 1
• Monitor for orthostatic hypotension, especially with higher initial doses 2
• Use with caution in patients with cardiovascular disease, as data from a large retrospective study showed increased risk of sudden cardiac death with TCA doses >100 mg/day 1
• Consider obtaining an electrocardiogram before initiating therapy in patients with cardiovascular risk factors 1

Alternative Medications

• If nortriptyline is not tolerated, consider alternative antidepressants such as SSRIs (fluoxetine, paroxetine, sertraline) which have different side effect profiles 1, 5
• For patients requiring both antidepressant and analgesic effects, duloxetine (60-120 mg/day) may be an alternative option 1, 5