nortriptyline

Adjunctive therapy

Brands: Pamelor

Last reviewed 2025-12-29

Reviewed by PsychMed Editorial Team.

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Quick answers

What is nortriptyline?
Nortriptyline (Pamelor) is a secondary amine TCA used for treatment-resistant depression and neuropathic pain with lower anticholinergic burden than tertiary amines.
What is Pamelor?
Pamelor is a brand name for nortriptyline.
What is Pamelor (nortriptyline) used for?
Label indications include: Depression; use with caution in adolescents and patients with cardiac disease.
What drug class is Pamelor (nortriptyline)?
Tricyclic antidepressant (TCA); predominantly norepinephrine reuptake inhibition.
What strengths does Pamelor (nortriptyline) come in?
Capsules 10–75 mg; oral solution 10 mg/5 mL.

Snapshot

Class: Adjunctive therapy
Common US brands: Pamelor
Therapeutic drug monitoring recommended; reference range 50–150 ng/mL.
Last reviewed: 2025-12-29

Label indications

Depression; use with caution in adolescents and patients with cardiac disease.

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Clinical Highlights

Nortriptyline (Pamelor) is a secondary amine TCA used for treatment-resistant depression and neuropathic pain with lower anticholinergic burden than tertiary amines. Therapeutic drug monitoring (TDM) helps maintain concentrations within a narrow therapeutic window.

Benefits often build over 2–4 weeks, while early side effects (dry mouth, constipation, sleepiness) can appear in the first days—follow-up and symptom tracking are often planned.
Despite a somewhat “cleaner” side-effect profile than amitriptyline, nortriptyline still carries meaningful anticholinergic and cardiac conduction risk—lowest-effective dosing and planned monitoring are common.
The compare tool and nortriptyline evidence feed can help balance anticholinergic load, QTc risks, and neuropathic pain data when adjusting therapy.
Often preferred TCA in older adults due to lower anticholinergic load but still requires cardiac monitoring.
TCAs are dangerous in overdose; prescribe smaller quantities when risk is elevated and include safe storage counseling (children, pets).
Depression (FDA 1964)
Generic: All formulations available generically.

Dosing & Formulations

Capsules 10–75 mg; oral solution 10 mg/5 mL. Typical start is 25 mg HS with titration to 75–100 mg/day (single HS or divided).

Target plasma level 50–150 ng/mL; obtain TDM after steady state (7–10 days).
If adverse effects emerge early, consider slower titration or checking levels sooner in suspected CYP2D6 poor metabolizers or high-risk polypharmacy.
Tapering is typically gradual to avoid withdrawal symptoms.

Monitoring & Risks

Boxed warning: Antidepressants increase suicidality risk in young adults; closer monitoring is common. Anticholinergic effects: Dry mouth, constipation, urinary retention.

Sedation: Less than amitriptyline but present.
Orthostatic hypotension: Slow position changes are commonly recommended.
Weight gain: Weight/BMI and metabolic profile monitoring is common.
Cardiac conduction abnormalities—baseline ECG is commonly obtained in patients >40 years.
Red flags: new palpitations, fainting, severe dizziness, or confusion warrant urgent evaluation, especially during titration or after adding interacting medications.

Drug Interactions

CYP2D6 inhibitors markedly increase levels—dose adjustment and plasma concentration monitoring are often used. MAOIs contraindicated; a 14-day washout is typically used to avoid serotonin syndrome.

Additive anticholinergic effects with other agents (antipsychotics, antihistamines).
Additive conduction and orthostasis risk with other QT-active or α1-blocking medications; baseline ECG is commonly obtained in higher-risk patients.

Practice Notes

Therapeutic drug monitoring aids in optimizing efficacy and minimizing toxicity. Secure storage essential due to overdose lethality.

Practical supports help adherence: bedtime dosing, hydration/fiber, bowel regimen when needed, and a slow taper plan to avoid rebound insomnia, nausea, or anxiety.
When treating bipolar depression, pair nortriptyline with a mood stabiliser; closer monitoring for mania/hypomania can be coordinated via the bipolar disorder hub.
For pain-focused use, benefit is often reassessed at lower dose ranges, and escalation into toxicity is generally avoided when the target outcome is sleep or pain rather than full antidepressant effect.

References

Nortriptyline prescribing information — DailyMed (2025)
Preskorn1991 TDM Antidepressants
Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology: Update 2017 — Pharmacopsychiatry (2018)