Nortriptyline HCl

(nor-TRIP-tih-leen HIGH-droe-KLOR-ide)

Aventyl HCl, Aventyl HCl Pulvules, Pamelor,  Apo-Nortriptyline, Gen-Nortriptyline, Novo-Nortriptyline, Nu-Nortriptyline, PMS-Nortriptyline

Class: Tricyclic antidepressant

 Action Inhibits reuptake of norepinephrine and serotonin in CNS.

 Indications Relief of symptoms of depression. unlabeled use(s): Treatment of panic disorder, premenstrual depression, dermatologic disorders (eg, chronic urticaria, angioedema, nocturnal pruritis in atopic eczema).

 Contraindications Hypersensitivity to any tricyclic antidepressant. Generally, not to be given in combination with or within 14 days of treatment with MAO inhibitors or during acute recovery phases of MI.

 Route/Dosage

ADULTS: PO 25 mg tid to qid. Doses > 150 mg/day are not recommended. ELDERLY & ADOLESCENTS: PO 30 to 50 mg/day in divided doses.

 Interactions

Anticoagulants: Dicumaral actions may increase. Carbamazepine: Carbamazepine levels may increase; nortriptyline levels may decrease. Cimetidine, fluoxetine: Concomitant administration may increase nortriptyline blood levels and effects. CNS depressants: Depressant effects may be additive. Clonidine: May result in hypertensive crisis. Guanethidine: Hypotensive action may be inhibited. MAO Inhibitors: Hyperpyretic crisis, convulsions and death may occur. Sympathomimetics: Pressor response may decrease.

 Lab Test Interferences None well documented.

 Adverse Reactions

CV: Orthostatic hypotension; hypertension; tachycardia; palpitations; arrhythmias; ECG changes; stroke; heart block; CHF. RESP: Pharyngitis; rhinitis; sinusitis; laryngitis; coughing. CNS: Confusion; hallucinations; delusions; nervousness; restlessness; agitation; panic; insomnia; nightmares; mania; exacerbation of psychosis; drowsiness; dizziness; weakness; fatigue; emotional lability; seizures; tremors; extrapyramidal symptoms (eg, pseudoparkinsonism, movement disorders, akathisia). EENT: Nasal congestion; tinnitus; conjunctivitis; mydriasis; blurred vision; increased IOP; peculiar taste in mouth. GI: Nausea; vomiting; anorexia; GI distress; diarrhea; flatulence; dry mouth; constipation. GU: Impotence; sexual dysfunction; nocturia; urinary frequency; urinary tract infection; vaginitis; cystitis; dysmenorrhea; amenorrhea; urinary retention and hesitancy. HEMA: Bone marrow depression including agranulocytosis; eosinophilia; purpura; thrombocytopenia; leukopenia. DERM: Rash; pruritus; photosensitivity reaction; dry skin; acne. HEPA: Hepatitis; jaundice. META: Elevation or depression of blood sugar. OTHER: Numbness; breast enlargement.

 Precautions

Pregnancy: Category D. Safety not established. Limb reduction anomalies have been reported with nortriptyline. Lactation: Excreted in breast milk. Children: Safety and efficacy not established. Special-risk patients: Use drug with caution in patients with history of seizures, urinary retention, urethral or ureteral spasm, angle-closure glaucoma or increased IOP, cardiovascular disorders, hyperthyroid patients or those receiving thyroid medication, patients with hepatic or renal impairment, schizophrenia or paranoia.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

• Give with food or milk.
• Store at room temperature in tight container.
• If prescribed as single daily dose, give at bedtime to reduce side effects.

 Assessment/Interventions

• Obtain patient history, including drug history and any known allergies.
• Obtain baseline renal function tests, liver function tests, CBC and ECG, and monitor throughout therapy.
• Drug levels may be obtained to determine if patient is in optimal range (50 to 150 ng/mL).
• Assess emotional status (eg, appearance, speech patterns, mood, level of interest), and monitor level of consciousness and suicidal ideation.
• Monitor daily elimination pattern, BP, and pulse, and notify physician of potential problems.
• Assess for bladder distention and constipation.

OVERDOSAGE: SIGNS & SYMPTOMS   Confusion, vomiting, muscle rigidity, ECG abnormalities, seizures, agitation, fever, hyperactive reflexes, CHF, coma, respiratory depression, death

 Patient/Family Education

• Advise patient to avoid sudden position changes to prevent orthostatic hypotension.
• Explain that it may take up to 2 wk for therapeutic effects to become evident.
• Caution patient to avoid exposure to sunlight and to use sunscreen or wear protective clothing to avoid photosensitivity reaction.
• Instruct patient to notify physician of visual disturbances.
• Advise patient to take sips of water frequently, suck on ice chips or sugarless hard candy or chew sugarless gum if dry mouth occurs.
• Caution patient that drug may cause drowsiness and to use caution while driving or performing other tasks requiring mental alertness.
• Instruct patient not to double dose if one is missed and to notify physician if > 1 dose is missed.
• Advise that side effects will be decreased if taken at bedtime if prescribed as once-daily dose.

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