Perioperative Management of Pamelor (Nortriptyline)
Continue Pamelor (nortriptyline) through the morning of surgery, including on the day of the surgical procedure. Tricyclic antidepressants like nortriptyline should not be held perioperatively due to the risk of withdrawal symptoms and the potential for worsening depression, which could increase morbidity and negatively impact quality of life 1.
Rationale for Continuation
Withdrawal risk outweighs surgical concerns: The general principle in perioperative medication management is that medications with withdrawal potential should be continued perioperatively to avoid disease progression and maintain short-term quality of life 1, 2.
No specific contraindication exists: While the provided guidelines extensively cover perioperative management of analgesics, muscle relaxants, and other medications, tricyclic antidepressants are not listed among medications that should be held on the day of operation 3.
Abrupt discontinuation risks: Stopping antidepressants can lead to withdrawal symptoms including anxiety, agitation, irritability, and worsening of depression—all of which can complicate perioperative care and recovery 4.
Important Perioperative Considerations
Drug Interactions to Monitor
Anticholinergic effects: Nortriptyline has significant anticholinergic properties that can cause dry mouth, urinary retention, blurred vision, and constipation—effects that may be exacerbated by anesthetic agents 4.
Sympathomimetic interactions: Close supervision is required when nortriptyline is used with sympathomimetic drugs, as the response may be potentiated 4.
Alcohol and sedatives: The patient's response to alcohol and other CNS depressants may be exaggerated, requiring careful titration of anesthetic agents 4.
Cytochrome P450 interactions: Nortriptyline is metabolized by P450IID6, and concomitant use with other drugs metabolized by this enzyme (including many anesthetic adjuncts) may require dose adjustments 4.
Specific Anesthetic Precautions
Increased anesthetic sensitivity: Patients on tricyclic antidepressants may have enhanced responses to anesthetic agents due to norepinephrine potentiation 3.
Cardiovascular monitoring: Watch for potential hypotension, tachycardia, or arrhythmias, as tricyclics can affect cardiovascular stability 4.
Avoid abrupt changes: If discontinuation were ever necessary (which it is not for routine surgery), the drug should be tapered over several days rather than stopped abruptly 4, 1.
Common Pitfalls to Avoid
Do not hold "just to be safe": The instinct to discontinue all non-essential medications perioperatively is misguided for antidepressants, as the psychiatric risks of withdrawal exceed the surgical risks of continuation 1, 2.
Communicate with anesthesia: Ensure the anesthesiologist is aware the patient is taking nortriptyline so they can adjust anesthetic agents accordingly and monitor for drug interactions 4.
Monitor for serotonin syndrome: Although nortriptyline primarily affects norepinephrine, be cautious if the patient is also receiving other serotonergic agents perioperatively (such as certain opioids like tramadol, meperidine, or fentanyl) 3.