What is the recommended tapering schedule for an adult patient to safely discontinue a 20mg daily dose of nortriptyline?

Tapering Nortriptyline 20mg: Recommended Protocol

For a 20mg daily dose of nortriptyline, taper gradually over 4-8 weeks by reducing the dose by approximately 10-25% every 1-2 weeks, ultimately reaching very low doses (2.5-5mg) before complete discontinuation. 1, 2

Specific Tapering Schedule

Standard Approach for 20mg Starting Dose

• Week 1-2: Reduce to 15mg daily (25% reduction) 1, 2
• Week 3-4: Reduce to 10mg daily 1, 2
• Week 5-6: Reduce to 5mg daily 1, 2
• Week 7-8: Reduce to 2.5mg daily or every other day before stopping 2, 3

The total taper duration should be at least 4-8 weeks minimum for this dose, though patients on long-term treatment may require slower tapers extending to 2-4 months. 1, 2

Why Hyperbolic (Non-Linear) Tapering Matters

Tricyclic antidepressants like nortriptyline require hyperbolic dose reductions to linearly reduce their biological effect at receptors, similar to SSRIs and serotonin transporter occupancy. 3 This means the final dose reductions (from 10mg to 5mg to 2.5mg) are proportionally as important as the initial reductions, despite being smaller absolute amounts. 3

Monitoring During the Taper

• Assess withdrawal symptoms at each dose reduction before proceeding to the next step, including: 1, 2

  • Gastrointestinal distress (nausea, vomiting, diarrhea) 4
  • Anxiety, restlessness, or irritability 1
  • Sleep disturbances 1
  • Cognitive impairment or difficulty concentrating 1

• Monitor for anticholinergic withdrawal including rebound cholinergic effects 1

• Watch for orthostatic hypotension and fall risk, particularly in older adults 1, 2

When to Slow Down or Pause

If withdrawal symptoms emerge during any step, hold at the current dose for an additional 1-2 weeks before attempting further reduction. 1, 2 If symptoms are severe or intolerable, return to the previous higher dose and resume tapering at a slower rate (10% reductions per month rather than every 1-2 weeks). 1, 2

Critical Pitfalls to Avoid

• Do not stop abruptly from 20mg—even this relatively low dose requires gradual tapering 1
• Do not skip the final low-dose steps (5mg, 2.5mg)—these are essential to minimize withdrawal despite being small absolute amounts 3
• Do not rush the taper if the patient has been on nortriptyline long-term (>1 year), as they may need the slower 10% per month approach 2
• Do not mistake withdrawal symptoms for depression relapse—withdrawal typically includes physical symptoms like GI distress that are not characteristic of depression recurrence 1, 4

Evidence Quality Note

While prospective studies in pediatric populations show that gradual tapering of nortriptyline prevents withdrawal symptoms in most patients 4, specific adult tapering protocols are extrapolated from general tricyclic antidepressant guidelines 1, 2 and principles established for other antidepressants requiring hyperbolic dose reduction. 3