More than 8 percent of adults in the US reportedly have had at least one episode of major depression. Accounting for more than 21 million Americans, depression triggers various problems for individuals diagnosed with the condition, in addition to issues in the family. Antidepressant medications, of various categories and mechanisms of action, are prescribed as per the assessment of the condition. Nortriptyline is one of the frequently prescribed medications for depression, with various off-label uses, including chronic pain management. The following subsections offer an in-depth explanation of the medication, and possible side effects of nortriptyline, to help users prevent and mitigate undesirable effects.

Overview of Nortriptyline

Belonging to the category of tricyclic antidepressants, nortriptyline is an active metabolite of amitriptyline. It is prescribed for treating major depression in patients, in addition to the following conditions.

Some of the treatments are essentially off-label uses of the medication but are known to be effective enough to be a preferred option. The medication is a prescription-only formulation and is available as tablets.

Mechanism of action of the antidepressant

The mechanism of action of the antidepressant is primarily attributed to the inhibition of the reuptake of serotonin. The reuptake of the neurotransmitter is inhibited at the neuronal membrane and is also assumed to be inhibited at the beta-adrenergic receptors. Antidepressants of this category are known to have a selective inhibition action for the reuptake of noradrenaline. The medication does not inhibit or have any action on monoamine oxidase or dopamine. As a result of this selective inhibition, the medication delivers the desired outcomes as an antidepressant and also as medication for pain management.

Time required for medication to deliver effects

When taken to help manage pain, the medication requires about a week for the results to be experienced, with lesser pain. When the medication is taken to treat MDD and major depressive disorder, it requires anywhere between four weeks to six weeks, before the complete effects of the medication are experiencing.

Commonly reported side effects of nortriptyline

Without exception, all medications come with the possibility of undesirable effects. This may include adverse effects, mild effects, or moderate effects. Additionally, there is also the possibility of drug interactions with other medications or substances. It is important to note that side effects are possible, but not necessarily experienced by all users. Certain users may not experience any side effects whatsoever, while some may experience effects. Among individuals who experience effects, the intensity or the duration may differ from person to person and depends on various factors, such as age, health, and other pre-existing conditions.

Commonly reported effects include constipation among individuals who start the medication. This typically resolves naturally without the need for a specific medication, other than symptomatic relief. Another condition that may be experienced initially is dry mouth and this is another effect that is known to resolve naturally in a few weeks after commencement of the medication.

It is to be borne in mind that patients on the medication for pain management are likely to take lower dosages and this may expose them to lesser risks of side effects. Patients on the drug for depression are likely to take higher dosages and this may expose the patient to elevated risks of side effects. As mentioned, the drug is not to be discontinued abruptly, and this applies even when there are mild or moderate effects attributed to the medication. The patient is expected to seek medical assistance to cope with the effects while continuing the treatment. The patient is likely to experience difficulties when passing urine, apart from experiencing headaches.

Effects that are of concern and require medical intervention

Certain effects require urgent medical attention to prevent the effects from turning serious or uncontrollable. For instance, an irregular heartbeat rate requires swift medical attention. Similarly, patients who witness the wites of the eyes turning yellow in color are to bring this to the attention of the treating specialist. This may also extend to the color of the skin, and actually indicates an impact on the liver. Other serious conditions include high sodium levels in the blood, swelling in the eyes, and persistent stomach aches.

Precautionary measures

Patients are advised to follow certain precautionary measures, due to the side effects of the drug. For instance, the medication is known to cause a drowsy feeling or sleepiness. It is therefore advisable to take the medication before bedtime and to avoid taking up responsibilities during the day that involve a high state of alertness and reflexes.

The dose is to be gradually tapered off before being fully stopped. This is required to help individuals cope with possible withdrawal effects, due to abrupt discontinuation of treatment. For instance, pain relief medications help patients manage pain, and when the medication is stopped abruptly, there is a likelihood of difficulty in adjusting to the pain stimuli (though medications are stopped after the pain reduces, the possibility of experiencing some pain exists.

Categories of individuals not suitable for the medication

The medication is generally suitable for all adults and for teens between the ages of 12 to 17. Children below this age are also sometimes prescribed the medication, but it is not considered the first line of treatment for bedwetting in patients between the ages of 6 and 12.

The drug is not recommended for use by certain categories of individuals. For instance, patients with a history of allergy either to nortriptyline or other medications are to consult a specialist before taking the medication. Patients with heart complications and diseases are also advised to avoid the medication to prevent aggravation of certain conditions. Patients with liver or renal problems are also to stay off the medication as it could trigger undesirable effects. Other categories of individuals who are unsuitable to take the medication include patients with epilepsy, or patients undergoing a treatment regimen that includes electroconvulsive treatment (ECT).

Patients on other antidepressant medications are also to seek specific medical recommendations, as drugs are known to have an impact on nortriptyline.  This may also be experienced for a period after the medication has been stopped. It may be therefore necessary to ensure a suitable gap between the two treatment regimens. Pregnant women, women planning a pregnancy, and nursing mothers are all advised to avoid the medication to prevent the side effects of nortriptyline. By virtue of the mechanism of action, the drug is known to cause an increase in eye pressure, and therefore patients diagnosed with glaucoma are to stay off the drug.

Patients who have had a history of suicidal tendencies, are not to be administered the medication as this may aggravate the intent. Similarly, patients with diabetes, are also to avoid taking the drug as nortriptyline is known to have an impact on blood sugar levels. In the event that doctor considers it necessary to take the medication, the frequency of testing blood sugar levels is likely to be increased to help monitor blood sugar levels effectively and periodically.

Ideal dosage to prevent undesirable outcomes of nortriptyline

The actual dosage of the medication will be as per the assessment of the treating specialist who will consider various parameters before determining the dosage. The tablets are available in three strengths of 10, 25, and 50 mg formulations. Typically, patients diagnosed with pain in the nerves are recommended a daily dose of 10 mg, with an appropriate increase in dosage as determined. However, the upper limit of the medication when prescribed for pain is 75 mg daily, which essentially means that the maximum permissible dose is not to be breached.

In the case of patients with depression, the maximum dose can be gradually increased to anywhere between 75 mg to 100 mg daily. The upper limit in such instances is not to exceed 150 mg daily, and the maximum dosage is also only as per explicit medical advice.

Missed doses can be taken immediately after noticing the fact that the dose has been missed. However, there needs to be a clear gap between two consecutive doses, and therefore, if the time of noticing the missed dose is close to the next dose, the only option is to skip the missed dose entirely. The usual schedule of medication may then be followed, and this will avoid the possibility of undesirable effects due to excessive dosages.

Intake instructions

Typically, the medication is recommended to be taken once daily, and as mentioned above, the ideal time to take the drug is before bedtime. Nortriptyline can be consumed with food or without food. Certain drugs are known to cause an upset stomach, warranting intake along with food. However, in the case of this medication, there are no known or reported stomach upsets experienced by patients, and therefore it is safe to take as preferred. The best mode of intake of all tablets is to swallow them whole, with water. Most medications are likely to taste bitter when chewed, and this distaste may make it difficult to intake the tablets. This may also cause an aversion to the pills among young children; it is best to ensure that the tablets are swallowed whole.

Overdose indications

Overdose of nortriptyline can trigger unpleasant and unwanted consequences, including effects that are considered as serious in nature. Possible effects include an abrupt and abnormal change in heartbeat rate. Another possible outcome of overdose is a seizure. It is, therefore, necessary to stick diligently to the recommended dosage only and to avoid the urge to take a double dose to make up for the missed dosage

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