How to Wean Nortriptyline
Discontinue nortriptyline over 10 to 14 days to limit withdrawal symptoms. 1
Tapering Protocol
The American Family Physician guidelines provide clear direction for tricyclic antidepressant discontinuation:
- Taper over 10-14 days as the standard approach for all antidepressants, including nortriptyline 1
- Reduce by increments of the initial dose every 5-7 days until complete discontinuation 1
- For nortriptyline specifically, since the initial dose is typically 10 mg, reduce by approximately 10 mg every 5-7 days 1
Practical Implementation
Step-by-step approach:
- If the patient is on 40 mg daily (maximum dose), reduce to 30 mg for 5-7 days, then 20 mg for 5-7 days, then 10 mg for 5-7 days, then discontinue 1
- If the patient is on lower doses, follow the same principle of reducing by the initial dosing increment every 5-7 days 1
- After 9 months of treatment, dosage reduction should be used to reassess the need to continue medication 1
Monitoring for Withdrawal Symptoms
Watch for these specific symptoms during the taper:
- Gastrointestinal distress (most common withdrawal effect with nortriptyline) 2
- Somatic symptoms: dizziness, light-headedness, nausea, fatigue, myalgia, flu-like symptoms 3
- Psychological symptoms: anxiety, agitation, crying spells, irritability 3
Managing Withdrawal If It Occurs
If withdrawal symptoms emerge:
- Reinstitute the previous dose and slow the rate of taper 3
- Reassure the patient that symptoms are usually transient and self-limiting 3
- Do not mistake withdrawal symptoms for physical illness or depression relapse, which could lead to unnecessary testing 3
Important Caveats
Key clinical considerations:
- The 10-14 day taper is significantly faster than what is recommended for SSRIs, which may require months of tapering 4
- Pediatric studies show that scheduled tapering of nortriptyline prevents withdrawal symptoms in most patients 2
- Unlike SSRIs, tricyclic antidepressants like nortriptyline have not been associated with severe, prolonged withdrawal syndromes requiring hyperbolic tapering 4
- The relatively short taper duration for nortriptyline (10-14 days) is appropriate given its pharmacological profile and lower risk of severe discontinuation symptoms compared to shorter half-life SSRIs 1, 3