and trazodone both decrease cholinergic effects/transmission. Use Caution/Monitor. nortriptyline and trazodone both increase sedation. Use Caution/Monitor.Serious - Use Alternative (2)nortriptyline and trazodone both increase QTc interval. Avoid or Use Alternate Drug. trazodone and nortriptyline both increase serotonin levels. Avoid or Use Alternate Drug.triazolamMonitor Closely (1)triazolam and nortriptyline both increase sedation. Use Caution/Monitor.triclofosMonitor Closely (1)triclofos and nortriptyline both increase sedation. Use Caution/Monitor.trifluoperazineMonitor Closely (1)trifluoperazine and nortriptyline both increase sedation. Use Caution/Monitor.Serious - Use Alternative (1)trifluoperazine and nortriptyline both increase QTc interval. Avoid or Use Alternate Drug.Minor (2)nortriptyline, trifluoperazine. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown. Additive anticholinergic effects. nortriptyline, trifluoperazine. Either increases levels of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive anticholinergic effects.trihexyphenidylMonitor Closely (1)trihexyphenidyl and nortriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor. Potential for additive anticholinergic effects.trimethoprimMonitor Closely (1)nortriptyline and trimethoprim both increase QTc interval. Modify Therapy/Monitor Closely.trimipramineMonitor Closely (2)nortriptyline and trimipramine both decrease cholinergic effects/transmission. Use Caution/Monitor. nortriptyline and trimipramine both increase sedation. Use Caution/Monitor.Serious - Use Alternative (2)nortriptyline and trimipramine both increase QTc interval. Avoid or Use Alternate Drug. nortriptyline and trimipramine both increase serotonin levels. Avoid or Use Alternate Drug.triprolidineMonitor Closely (1)triprolidine and nortriptyline both increase sedation. Use Caution/Monitor.tropisetronMonitor Closely (1)nortriptyline and tropisetron both increase QTc interval. Modify Therapy/Monitor Closely.trospium chlorideMonitor Closely (1)trospium chloride and nortriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor.umeclidinium bromide/vilanterol inhaledSerious - Use Alternative (2)nortriptyline increases toxicity of umeclidinium bromide/vilanterol inhaled by QTc interval. Avoid or Use Alternate Drug. Exercise extreme caution when vilanterol coadministered with drugs that prolong QTc interval; adrenergic agonist effects on the cardiovascular system may be potentiated. nortriptyline and umeclidinium bromide/vilanterol inhaled both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Avoid or Use Alternate Drug. Exercise extreme caution if vilanterol coadministered with MAOIs or TCAs, or within 2 weeks of discontinuation of these drugs; adrenergic agonist effects on the cardiovascular system may be potentiatedvalbenazineMonitor Closely (1)valbenazine and nortriptyline both increase QTc interval. Use Caution/Monitor.valerianMonitor Closely (1)valerian and nortriptyline both increase sedation. Use Caution/Monitor.vandetanibSerious - Use Alternative (1)nortriptyline, vandetanib. Either increases toxicity of the other by QTc interval. Avoid or Use Alternate Drug. Avoid coadministration with drugs known to prolong QT interval; if a drug known to prolong QT interval must be used, more frequent ECG monitoring is recommended.vasopressinMinor (1)nortriptyline increases effects of vasopressin by pharmacodynamic synergism. Minor/Significance Unknown.vecuroniumMonitor Closely (1)vecuronium and nortriptyline both decrease cholinergic effects/transmission. Use Caution/Monitor.vemurafenibSerious - Use Alternative (1)vemurafenib and nortriptyline both increase QTc interval. Avoid or Use Alternate Drug. Concomitant use of vemurafenib with drugs that prolong QT interval is not recommended.venlafaxineMonitor Closely (1)nortriptyline and venlafaxine both increase QTc interval. Modify Therapy/Monitor Closely.Serious - Use Alternative (2)venlafaxine and nortriptyline both increase serotonin levels. Avoid or Use Alternate Drug. venlafaxine will increase the level or effect of nortriptyline by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.verapamilMinor (1)verapamil increases levels of nortriptyline by decreasing metabolism. Minor/Significance Unknown.vilanterol/fluticasone furoate inhaledSerious - Use Alternative (2)nortriptyline and vilanterol/fluticasone furoate inhaled both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Avoid or Use Alternate Drug. Exercise extreme caution if vilanterol coadministered with MAOIs or TCAs, or within 2 weeks of discontinuation of these drugs; adrenergic agonist effects on the cardiovascular system may be potentiated nortriptyline increases toxicity of vilanterol/fluticasone furoate inhaled by QTc interval. Avoid or Use Alternate Drug. Exercise extreme caution when vilanterol coadministered with drugs that prolong QTc interval; adrenergic agonist effects on the cardiovascular system may be potentiated.vilazodoneSerious - Use Alternative (1)nortriptyline, vilazodone. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. Concomitant therapy should be discontinued immediately if signs or symptoms of serotonin syndrome emerge and supportive symptomatic treatment should be initiated. .vildagliptinMinor (1)nortriptyline increases effects of vildagliptin by pharmacodynamic synergism. Minor/Significance Unknown.voclosporinMonitor Closely (1)voclosporin, nortriptyline. Either increases effects of the other by QTc interval. Use Caution/Monitor.voriconazoleMonitor Closely (1)nortriptyline and voriconazole both increase QTc interval. Modify Therapy/Monitor Closely.vortioxetineSerious - Use Alternative (1)nortriptyline, vortioxetine. Either increases effects of the other by serotonin levels. Avoid or Use Alternate Drug.xylometazolineMonitor Closely (1)nortriptyline increases and xylometazoline decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.Serious - Use Alternative (1)nortriptyline, xylometazoline. Other (see comment). Avoid or Use Alternate Drug. Comment: Tricyclic antidepressants increase or decrease effects of sympathomimetics, by blocking reuptake of NE, or blocking uptake of indirect sympathomimetics into the adrenergic neuron.yohimbeSerious - Use Alternative (1)yohimbe, nortriptyline. Mechanism: unspecified interaction mechanism. Contraindicated. May cause increase or decrease in blood pressure.yohimbineMonitor Closely (1)nortriptyline increases and yohimbine decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.Serious - Use Alternative (1)nortriptyline, yohimbine. Other (see comment). Avoid or Use Alternate Drug. Comment: Tricyclic antidepressants increase or decrease effects of sympathomimetics, by blocking reuptake of NE, or blocking uptake of indirect sympathomimetics into the adrenergic neuron.ziconotideMonitor Closely (1)nortriptyline and ziconotide both increase sedation. Use Caution/Monitor.ziprasidoneMonitor Closely (1)ziprasidone and nortriptyline both increase sedation. Use Caution/Monitor.Serious - Use Alternative (1)nortriptyline and ziprasidone both increase QTc interval. Avoid or Use Alternate Drug.zolmitriptanMonitor Closely (1)zolmitriptan and nortriptyline both increase serotonin levels. Modify Therapy/Monitor Closely.zolpidemMinor (1)zolpidem, nortriptyline. Either increases effects of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive CNS depression. Frequency Not Defined Fatigue Lethargy Sedation Weakness Dry mouth Constipation Blurred vision Agitation Anxiety Headache Insomnia Nausea Vomiting Sweating Orthostatic hypotension, ECG changes, tachycardia Confusion, extrapyramidal symptoms, dizziness, paresthesia, tinnitus Rash Increased LFTs Sexual dysfunction Seizure Agranulocytosis Eosinophilia Leukopenia Thrombocytopenia SIADH Postmarketing Brugada syndrome Black Box Warnings In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (<24 years) taking antidepressants for major depressive disorders or other psychiatric illnesses This increase was not seen in patients aged over age 24 years; a slight decrease in suicidal thinking was seen in adults over age 65 years In children and young adults, risks must be weighed against the benefits of taking antidepressants Patients should be monitored closely for changes in behavior, clinical worsening, and suicidal tendencies; this should be done during the initial 1-2 months of therapy and dosage adjustments The patient’s family should communicate any abrupt changes in behavior to the healthcare provider Worsening behavior and suicidal tendencies that are not part of the presenting symptoms may require discontinuation of therapy This drug is not approved for use in pediatric patientsContraindications Hypersensitivity Any drugs or conditions that prolong QT interval Acute recovery post-MI Coadministration with serotonergic drugs Concomitant with or within 14 days of MAOIs (serotonin syndrome) Starting nortriptyline in a patient who is being treated with linezolid or IV methylene blue is contraindicated because of an increased risk of serotonin syndrome If linezolid or IV methylene blue must be administered, discontinue nortriptyline immediately and monitor for CNS toxicity; may resume nortriptyline 24 hours after last linezolid or methylene blue dose or after 2 weeks of monitoring, whichever comes first Cautions Use cautioni in patients with BPH, urinary/GI retention, hyperthyroidism, seizure disorder, brain tumor, respiratory impairment, bipolar/mania (may worsen psychosis) Clinical worsening and suicidal ideation may occur despite medication in adolescents and young adults (18-24 years) Potentially life-threatening serotonin syndrome reported when coadministered with drugs that impair serotonin metabolism (in particular, MAOIs, including nonpsychiatric MAOIs, such as linezolid and IV methylene blue) Risk of anticholinergic side effects May cause bone marrow suppression (rare) May cause orthostatic hypotension May cause sedation, which may impair physical or mental abilities; use caution when performing tasks that require mental alertness (eg, operating heavy machinery) Risk of mydriasis; may trigger angle closure attack in patients with angle closure glaucoma with anatomically narrow angles without a patent iridectomy May cause sedation and impair physical or mental abilities Withdraw gradually Bone fractures have been associated with antidepressant treatment; consider possibility of bone fractures in patients if antidepressant treated patient presents with unexplained bone pain, swelling, bruising or point tenderness Use with caution in patients who would not tolerate frequent hypotensive episodes, including patients with cardiovascular disease, hypovolemia or with concurrent medication that predisposes for hypotension/bradycardia Use caution in patients with cardiovascular disease, diabetes mellitus (may alter glucose regulation), hepatic/renal impairment, and the elderly Abrupt discontinuation or interruption of antidepressant therapy has been associated with a discontinuation syndrome, which may include vomiting, diarrhea, headaches, dizziness, chills, tremors, paresthesias, somnolence, fatigue, and sleep disturbances May increase the risk of adverse effects associated with electroconvulsive therapy; discontinue therapy prior to electroconvulsive therapy if possible Due to risk of drug interaction with anesthesia and of cardiac arrhythmia, discontinuation of therapy prior to elective surgery recommended Association between treatment and the unmasking of Brugada syndrome with some resulting in death reported; therapy should generally be avoided in patients with Brugada syndrome or those suspected of having Brugada syndrome Pregnancy category: D Lactation: Excreted in breast milk; do not nurse (AAP states effect on nursing infants is unknown but may be of concern)Pregnancy Categories A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk. B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available. Mechanism of Action Neurotransmitter (especially norepinephrine and serotonin) reuptake inhibitor; increases concentration of neurotransmitter in the CNS Absorption Onset of action: 1-3 weeks Peak plasma time: 7-8.5 hr Steady-state therapeutic plasma concentration: 50-150 ng/mL Distribution Protein bound: 93-95% Vd: 21 L/kg Metabolism Hepatic CYP2D6 Elimination Half-life: 28-31 hr Excretion: Urine, feces BRAND FORM. UNIT PRICE PILL IMAGE Pamelor oral- 25 mg capsulenortriptyline oral- 50 mg capsulenortriptyline oral- 25 mg capsulenortriptyline oral- 10 mg capsulenortriptyline oral- 25 mg capsulenortriptyline oral- 25 mg capsulenortriptyline oral- 75 mg capsulenortriptyline oral- 10 mg capsulenortriptyline oral- 50 mg capsulenortriptyline oral- 10 mg capsulenortriptyline oral- 25 mg capsulenortriptyline oral- 75 mg capsulenortriptyline oral- 50 mg capsulenortriptyline oral- 50 mg capsulenortriptyline oral- 75 mg capsulenortriptyline oral- 10 mg capsulenortriptyline oral- 75 mg capsulenortriptyline oral- 10 mg/5 mL solutionCopyright © 2010 First DataBank, Inc.Print Patient Educationnortriptyline oral NORTRIPTYLINE - ORAL (nor-TRIP-ti-leen) COMMON BRAND NAME(S): Aventyl, Pamelor WARNING: Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially people younger than 25) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. It is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for people younger than 25), even if treatment is not for a mental/mood condition. Tell the doctor right away if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed. USES: This medication is used to treat mental/mood problems such as depression. It may help improve mood and feelings of well-being, relieve anxiety and tension, and increase your energy level. This medication belongs to a class of medications called tricyclic antidepressants. It works by affecting the balance of certain natural chemicals (neurotransmitters) in the brain. HOW TO USE: Read the Medication Guide provided by your pharmacist before you start taking nortriptyline and each time you get a refill. If you have any questions, consult your doctor or pharmacist.Take this medication by mouth as directed by your doctor, usually 1 to 4 times daily. If you are using the liquid form, measure the dose carefully using a special measuring device/spoon. Do not use a household spoon because you may not get the correct dose.The dosage is based on your medical condition and response to treatment. To reduce your risk of side effects (such as dry mouth, dizziness), your doctor may direct you to start this medication at a low dose and gradually increase your dose. Follow your doctor's instructions carefully.Take this medication regularly in order to get