Nortriptyline Withdrawal Symptoms
Abrupt discontinuation of nortriptyline after prolonged use produces nausea, headache, and malaise, as explicitly stated in the FDA drug label. 1
Primary Withdrawal Symptoms
The FDA-approved prescribing information for nortriptyline specifically identifies three core withdrawal symptoms that occur when treatment is stopped abruptly after prolonged therapy: 1
- Nausea - gastrointestinal distress is the most commonly reported withdrawal symptom 1
- Headache - occurs as part of the discontinuation syndrome 1
- Malaise - general feeling of discomfort, illness, or unease 1
The FDA emphasizes that while these withdrawal symptoms occur, they are not indicative of addiction. 1
Additional Anticholinergic Withdrawal Effects
Because nortriptyline has significant anticholinergic properties, abrupt discontinuation can trigger an anticholinergic discontinuation syndrome characterized by cholinergic rebound: 2
- Sweating - excessive perspiration from cholinergic rebound 2
- Urinary urgency - increased bladder activity 2
- Nausea - overlapping with the primary withdrawal symptoms 2
Timing and Duration
Withdrawal symptoms from tricyclic antidepressants like nortriptyline typically: 3, 4
- Begin within 24-48 hours after discontinuation 4
- Reach maximum intensity around day 5 4
- Usually resolve within 2-3 weeks 4
Critical Risk Factors
The intensity and likelihood of withdrawal symptoms depend on: 4
- Daily dose - higher doses increase withdrawal severity 4
- Duration of treatment - longer treatment periods increase risk 4
- Speed of discontinuation - abrupt cessation versus gradual taper 4
Management Algorithm
If withdrawal symptoms occur, reinstitute the original nortriptyline dose and implement a gradual taper. 3, 4
For Mild Symptoms:
- Provide reassurance that symptoms are transient and self-limiting 3
- Monitor for progression over 2-3 weeks 4
For Moderate to Severe Symptoms:
- Restart nortriptyline at the previous therapeutic dose 3, 4
- Once symptoms resolve, taper the dose gradually over several weeks 2, 3
- Avoid abrupt discontinuation during the taper 2
Prevention Strategy
Always taper nortriptyline gradually rather than stopping abruptly. 2, 3
The gradual tapering approach minimizes or completely avoids discontinuation symptoms by allowing the body's cholinergic and adrenergic systems to readjust slowly. 2
Common Diagnostic Pitfall
Do not misdiagnose withdrawal symptoms as physical illness or depression relapse. 3
Misdiagnosing these symptoms may lead to unnecessary medical testing and inappropriate treatment interventions. 3 The key distinguishing feature is the temporal relationship: symptoms emerge within 24-48 hours of stopping the medication and resolve with reinstitution of the drug. 4