nortriptyline PAMELOR

Class: TCA/​2° Amine Dibenzocycloheptene
FDA Indications: MDD
Off-Label Use: IBS, Panic Disorder, Neuropathic Pain, Migraines, Enuresis, TMJD
Prescribing
Forms: 10, 25, 50, 75mg capsule; 10mg/5mL po soln
Dose Range: 75-300 mg/day
Starting: 10-25 mg qd qhs, ↑ by 25 mg q3-7 days, max dose 300 mg qd
Stopping: ↓ 50% x3 days, then ↓ another 50% x3 days, then D/C entirely.
Monitoring: Suggested plasma level 150-500 nmol/L (recommended for MDD)

NAMI drug fact sheet

Precautions
Contraindications: Concomitant use of MAOIs; patient s/p MI; coadministration of other QT-prolonging agents; h/o QT ↑ or arrhythmia; caution in patients with hypo-K+ or hypo-Mg2+
Serious Side Effects: 5HT syndrome; ↓ seizure threshold; QT↑, arrhythmias, tachycardia, orthostatic hypotension
Side Effects: weight gain, sexual dysfunction, anticholinergic side effects
Pharmacodynamics
1° MOA: Tricyclic antidepressant
Target: SERT, NET, H1, α1, M1, 5HT2A
Pharmacokinetics
t½: 30 (18-44)° TMAX: 2-6°
Substrate of: 2D6; 1A2, 3A4, 2C19
Inhibits: 2D6 (weak), 2C19; Induces:
Active Metabolites:
DDIs
  • - DO NOT CO-PRESCRIBE WITH MAOIs (need a 14-day washout period)
  • - caution combining with other CNS depressants & anticholingerics
  • - 2D6 inhibitors can ↑ serum levels; 2D6 inducers can ↓ serum levels
Misc
  • - major 2° metabolite of amitriptyline
  • - plasma level monitoring has been well-studied
Special Populations

Category C—A case-control study showed ∅ ↑ congenital malformations with 1st trimester use & a review (n=209) showed ∅ assoc with congenital malformations or developmental delay.

RID 1.7-3.1%


Avoid due to its anticholinergicity and high sedation, especially when combining with other CNS depressants and/or anticholingerics. Caution regarding orthostatic hypotension (fall risk!). Can impair cognition.

No dosage adjustment necessary.


All TCAs are hepatically metabolzed, highly protein bound and will accumulate, and associated with ↑ LFTs.

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Last updated August 27 2018 18:45:06. Disclaimer: This website does not provide medical advice, nor is it a substitute for clinical judgment.