From the Guidelines
I would strongly advise against trying nortriptyline if you've experienced serotonin syndrome while taking sumatriptan. Both medications can increase serotonin levels in the brain, and having had serotonin syndrome once puts you at higher risk for developing it again. According to the provided evidence, tricyclic antidepressants like nortriptyline carry a risk of serotonin syndrome, especially with a history of cardiac disease or dysrhythmia 1. Nortriptyline is a tricyclic antidepressant that inhibits the reuptake of serotonin and norepinephrine, potentially raising serotonin levels further. If you've already experienced serotonin syndrome (characterized by symptoms like confusion, agitation, rapid heart rate, dilated pupils, muscle rigidity, and high fever), adding another serotonergic medication could be dangerous.
Some key points to consider:
- The risk of serotonin syndrome is a significant concern when using serotonergic medications, especially in patients with a history of this condition.
- Alternative treatments that work through different mechanisms should be considered, such as non-serotonergic medications for your condition.
- It's essential to consult with your healthcare provider about your history of serotonin syndrome before prescribing any new medication, as they can suggest the best course of treatment based on your specific condition and medical history.
- Other classes of drugs, such as certain anticonvulsants, beta-blockers, or selective serotonin–noradrenaline reuptake inhibitors like duloxetine, may be considered as alternative treatments, but their use should be carefully evaluated in the context of your medical history and the risk of serotonin syndrome 1.
From the FDA Drug Label
Serotonin syndrome may occur with sumatriptan tablets, particularly during co-administration with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors [see Drug Interactions (7.4)]. Nortriptyline is a tricyclic antidepressant (TCA).
If you had serotonin syndrome on sumatriptan, it is not recommended to try nortriptyline due to the increased risk of serotonin syndrome. The FDA drug label warns against the co-administration of sumatriptan with tricyclic antidepressants, such as nortriptyline, due to the risk of serotonin syndrome 2.
From the Research
Serotonin Syndrome and Medication Interactions
- Serotonin syndrome is a rare and potentially life-threatening condition caused by excessive serotonergic activity, often due to adverse drug interactions 3.
- The use of sumatriptan, a triptan, with selective serotonin reuptake inhibitors (SSRIs) or lithium has been reported to cause symptoms suggestive of serotonin syndrome, although most cases are mild and self-limited 4.
- The concurrent use of triptans and SSRIs or serotonin/norepinephrine reuptake inhibitors (SNRIs) may result in a potentially life-threatening problem known as serotonin syndrome, with an estimated 1.3% of patients prescribed a triptan or an SSRI or SNRI being prescribed this combination 5.
Nortriptyline and Serotonin Syndrome Risk
- Nortriptyline is a tricyclic antidepressant that can increase serotonin levels, potentially contributing to serotonin syndrome when used with other serotonergic agents.
- There is limited evidence specifically addressing the risk of serotonin syndrome with nortriptyline and sumatriptan, but the general principle of avoiding concurrent use of multiple serotonergic agents applies 6.
- If a patient has experienced serotonin syndrome on sumatriptan, it is essential to exercise caution when considering the use of other serotonergic agents, including nortriptyline, due to the potential increased risk of serotonin syndrome 3, 5.