How to Wean Nortriptyline
Discontinue nortriptyline over 10 to 14 days to limit withdrawal symptoms, reducing the dose gradually rather than stopping abruptly. 1
Tapering Protocol
The standard approach is to taper over 10-14 days, which represents the evidence-based timeframe for tricyclic antidepressant discontinuation. 1 This guideline applies specifically to nortriptyline as a tricyclic antidepressant (TCA).
Specific Dosing Strategy
- Start by reducing the current dose by approximately 10-25% every 3-7 days until complete discontinuation is achieved 1
- For patients on higher doses (e.g., 75-100 mg/day), begin with 25 mg decrements every 3-7 days 1
- For patients on lower doses (e.g., 25-50 mg/day), reduce by 10 mg increments every 3-7 days 1
- The final step should reach the lowest available dose before complete discontinuation 2
Important Timing Considerations
- Do NOT use alternate-day dosing when tapering nortriptyline - this approach causes pronounced fluctuations in drug levels and significantly increases withdrawal symptom risk 3
- Maintain daily dosing throughout the taper, simply reducing the daily dose amount 3
Monitoring During Taper
Withdrawal Symptoms to Watch For
- Gastrointestinal distress (most common with nortriptyline) 4
- Flu-like symptoms, insomnia, nausea 2
- Anxiety, irritability, restlessness 5
- Sensory disturbances and imbalance 2
These symptoms typically emerge within 1-3 days of dose reduction and may last 1-2 weeks 2
Management of Withdrawal Symptoms
- If withdrawal symptoms occur, hold at the current dose for several additional days before continuing the taper 1
- Consider slowing the taper rate to 10% reductions every 7-10 days if symptoms are problematic 1
- Adjunctive medications can help manage specific symptoms: gabapentin for anxiety/irritability, trazodone for insomnia, or mirtazapine for sleep disturbances 1
Special Populations and Circumstances
Longer Duration Therapy
- Patients who have been on nortriptyline for many months or years may require a more extended tapering schedule beyond the standard 10-14 days 2, 6
- Consider extending the taper to 4-8 weeks for patients on long-term therapy (>6 months) 6
Pediatric Patients
- Gradual tapering in children and adolescents effectively prevents withdrawal symptoms in most cases 4
- Use the same general principles but may require closer monitoring 4
Patients with Cardiac Disease
- Exercise particular caution given nortriptyline's potential for cardiotoxic effects 1
- Monitor for any cardiac symptoms during the taper 1
Critical Pitfalls to Avoid
- Never stop nortriptyline abruptly - this significantly increases withdrawal symptom risk 1
- Avoid alternate-day dosing strategies - these cause dangerous fluctuations in receptor occupancy 3
- Do not confuse withdrawal symptoms with depression recurrence - withdrawal emerges quickly (1-3 days) and diminishes over time, while depression recurrence develops gradually and persists 2
- Do not taper multiple psychotropic medications simultaneously - if the patient is on other medications, wean one at a time 7
When to Seek Additional Support
- If signs of depression recurrence emerge (gradual onset, persistent symptoms), prompt medical evaluation is needed 2
- Suicidal thoughts or severe mood disturbances during tapering warrant immediate medical attention 2
- Consider slower tapering or temporary dose stabilization if withdrawal symptoms are severe 1