Nortriptyline

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Nortriptyline
Nortriptyline.svg
Nortriptyline-from-4M48-ball-and-stick.png
Clinical data
Trade names Pamelor, Noritren, Nortrilen, others
Other namesDesitriptyline; ELF-101; E.L.F. 101; N-7048
AHFS/Drugs.com Monograph
MedlinePlus a682620
License data
Pregnancy
category
Routes of
administration 		By mouth
Drug class Tricyclic antidepressant (TCA)
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability 32–79% [3]
Protein binding 92% [3]
Metabolism Liver
Metabolites 10-E-Hydroxynortriptyline
Elimination half-life 18–44 hours (mean 30 hours) [3]
Excretion Urine: 40% [3]
Feces: minor [3]
Identifiers
  • 3-(10,11-Dihydro-5H-dibenzo[a,d]cyclohepten-5-ylidene)-N-methyl-1-propanamine
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard 100.000.717 OOjs UI icon edit-ltr-progressive.svg
Chemical and physical data
Formula C19H21N
Molar mass 263.384 g·mol−1
3D model (JSmol)
  • c3cc2c(/C(c1c(cccc1)CC2)=C/CCNC)cc3
  • InChI=1S/C19H21N/c1-20-14-6-11-19-17-9-4-2-7-15(17)12-13-16-8-3-5-10-18(16)19/h2-5,7-11,20H,6,12-14H2,1H3 Yes check.svgY
  • Key:PHVGLTMQBUFIQQ-UHFFFAOYSA-N Yes check.svgY
   (verify)

Nortriptyline, sold under the brand name Pamelor, among others, is a medication used to treat depression. This medicine is also sometimes used for neuropathic pain, attention deficit hyperactivity disorder (ADHD), smoking cessation and anxiety. [4] [5] As with many antidepressants, its use for young people with depression and other psychiatric disorders may be limited due to increased suicidality in the 18–24 population initiating treatment. [5] Nortriptyline is a less preferred treatment for ADHD and stopping smoking. [5] It is taken by mouth. [5]

Contents

Common side effects include dry mouth, constipation, blurry vision, sleepiness, low blood pressure with standing, and weakness. [5] Serious side effects may include seizures, an increased risk of suicide in those less than 25 years of age, urinary retention, glaucoma, mania, and a number of heart issues. [5] Nortriptyline may cause problems if taken during pregnancy. [5] Use during breastfeeding appears to be relatively safe. [4] It is a tricyclic antidepressant (TCA) and is believed to work by altering levels of serotonin and norepinephrine. [5] [lower-alpha 1]

Nortriptyline was approved for medical use in the United States in 1964. [5] It is available as a generic medication. [4] In 2021, it was the 139th most commonly prescribed medication in the United States, with more than 4 million prescriptions. [6] [7]

Medical uses

Nortriptyline is used to treat depression. [8] This medication is in capsule or liquid and is taken by the mouth one to four times a day, with or without food. [8] Usually people are started on a low dose and it is gradually increased. [8] A level between 50 and 150 ng/mL of nortriptyline in the blood generally corresponds with an antidepressant effect. [9]

In the United Kingdom, it may also be used for treating nocturnal enuresis, with courses of treatment lasting no more than three months. It is also used off-label for the treatment of panic disorder, irritable bowel syndrome, migraine prophylaxis and chronic pain or neuralgia modification, particularly temporomandibular joint disorder. [10]

Neuropathic pain

Although not approved by the FDA for neuropathic pain, many randomized controlled trials have demonstrated the effectiveness of TCAs for the treatment of this condition in both depressed and non-depressed individuals. In 2010, an evidence-based guideline sponsored by the International Association for the Study of Pain recommended nortriptyline as a first-line medication for neuropathic pain. [11] However, in a 2015 Cochrane systematic review the authors did not recommend nortriptyline as a first-line agent for neuropathic pain. [12]

Irritable bowel syndrome

Nortriptyline has also been used as an off-label treatment for irritable bowel syndrome (IBS). [13]

Contraindications

Nortriptyline should not be used in the acute recovery phase after myocardial infarction (viz, heart attack). [14] Use of tricyclic antidepressants along with a monoamine oxidase inhibitor (MAOI), linezolid, or IV methylene blue are contraindicated as it can cause an increased risk of developing serotonin syndrome. [15]

Closer monitoring is required for those with a history of cardiovascular disease, [16] stroke, glaucoma, or seizures, as well as in persons with hyperthyroidism or receiving thyroid hormones.

Side effects

The most common side effects include dry mouth, sedation, constipation, increased appetite, blurred vision and tinnitus. [17] [18] An occasional side effect is a rapid or irregular heartbeat. Alcohol may exacerbate some of its side effects. [17]

Overdose

The symptoms and the treatment of an overdose are generally the same as for the other TCAs, including anticholinergic effects, serotonin syndrome and adverse cardiac effects. TCAs, particularly nortriptyline, have a relatively narrow therapeutic index, which increase the chance of an overdose (both accidental and intentional). Symptoms of overdose include: irregular heartbeat, seizures, coma, confusion, hallucination, widened pupils, drowsiness, agitation, fever, low body temperature, stiff muscles and vomiting. [8]

Interactions

Excessive consumption of alcohol in combination with nortriptyline therapy may have a potentiating effect, which may lead to the danger of increased suicidal attempts or overdosage, especially in patients with histories of emotional disturbances or suicidal ideation.

It may interact with the following drugs: [19]

Pharmacology

Nortriptyline is a strong norepinephrine reuptake inhibitor and a moderate serotonin reuptake inhibitor. Its pharmacologic profile is as the table shows with (inhibition or antagonism of all sites). [20] [21]

Pharmacodynamics

Nortriptyline [20]
SiteKi (nM)SpeciesRef
SERT Tooltip Serotonin transporter15–18Human [22] [23]
NET Tooltip Norepinephrine transporter1.8–4.4Human [22] [23]
DAT Tooltip Dopamine transporter1,140Human [22]
5-HT1A 294Human [24]
5-HT2A 5.0–41Human/rat [25] [24]
5-HT2C 8.5Rat [25]
5-HT3 1,400Rat [26]
5-HT6 148Rat [27]
α1 55Human [24]
α2 2,030Human [24]
β >10,000Rat [28]
D2 2,570Human [24]
H1 3.0–15Human [29] [24] [30]
H2 646Human [29]
H3 45,700Human [29]
H4 6,920Human [29]
mACh Tooltip Muscarinic acetylcholine receptor37Human [24]
   M1 40Human [31]
   M2 110Human [31]
   M3 50Human [31]
   M4 84Human [31]
   M5 97Human [31]
σ1 2,000Guinea pig [32]
Values are Ki (nM). The smaller the value, the more strongly the drug binds to the site.

Nortriptyline is an active metabolite of amitriptyline by demethylation in the liver. Chemically, it is a secondary amine dibenzocycloheptene and pharmacologically it is classed as a first-generation antidepressant. [33]

Nortriptyline may also have a sleep-improving effect due to antagonism of the H1 and 5-HT2A receptors. [34] In the short term, however, nortriptyline may disturb sleep due to its activating effect.

In one study, nortriptyline had the highest affinity for the dopamine transporter among the TCAs (KD = 1,140 nM) besides amineptine (a norepinephrine–dopamine reuptake inhibitor), although its affinity for this transporter was still 261- and 63-fold lower than for the norepinephrine and serotonin transporters (KD = 4.37 and 18 nM, respectively). [22]

Pharmacokinetics

Pharmacogenetics

Nortriptyline is metabolized in the liver by the hepatic enzyme CYP2D6, and genetic variations within the gene coding for this enzyme can affect its metabolism, leading to changes in the concentrations of the drug in the body. [35] Increased concentrations of nortriptyline may increase the risk for side effects, including anticholinergic and nervous system adverse effects, while decreased concentrations may reduce the drug's efficacy. [36] [37] [38]

Individuals can be categorized into different types of CYP2D6 metabolizers depending on which genetic variations they carry. These metabolizer types include poor, intermediate, extensive, and ultrarapid metabolizers. Most individuals (about 77–92%) are extensive metabolizers, [38] and have "normal" metabolism of nortriptyline. Poor and intermediate metabolizers have reduced metabolism of the drug as compared to extensive metabolizers; patients with these metabolizer types may have an increased probability of experiencing side effects. Ultrarapid metabolizers use nortriptyline much faster than extensive metabolizers; patients with this metabolizer type may have a greater chance of experiencing pharmacological failure. [36] [37] [38]

The Clinical Pharmacogenetics Implementation Consortium recommends avoiding nortriptyline in persons who are CYP2D6 ultrarapid or poor metabolizers, due to the risk of a lack of efficacy and side effects, respectively. A reduction in starting dose is recommended for patients who are CYP2D6 intermediate metabolizers. If use of nortriptyline is warranted, therapeutic drug monitoring is recommended to guide dose adjustments. [38] The Dutch Pharmacogenetics Working Group recommends reducing the dose of nortriptyline in CYP2D6 poor or intermediate metabolizers, and selecting an alternative drug or increasing the dose in ultrarapid metabolizers. [39]

Chemistry

Nortriptyline is a tricyclic compound, specifically a dibenzocycloheptadiene, and possesses three rings fused together with a side chain attached in its chemical structure. [40] Other dibenzocycloheptadiene TCAs include amitriptyline (N-methylnortriptyline), protriptyline, and butriptyline. [40] [41] Nortriptyline is a secondary amine TCA, with its N-methylated parent amitriptyline being a tertiary amine. [42] [43] Other secondary amine TCAs include desipramine and protriptyline. [44] [45] The chemical name of nortriptyline is 3-(10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5-ylidene)-N-methyl-1-propanamine and its free base form has a chemical formula of C19H21N1 with a molecular weight of 263.384 g/mol. [46] The drug is used commercially mostly as the hydrochloride salt; the free base form is used rarely. [46] [47] The CAS Registry Number of the free base is 72-69-5 and of the hydrochloride is 894-71-3. [46] [47] [48]

History

Nortriptyline was developed by Geigy. [49] It first appeared in the literature in 1962 and was patented the same year. [49] The drug was first introduced for the treatment of depression in 1963. [49] [50]

Society and culture

50 mg (left) and 25 mg generic nortriptyline HCl capsules made by Teva Pharmaceutical Industries. Nortriptyline HCL capsules - 50mg and 25mg.JPG
50 mg (left) and 25 mg generic nortriptyline HCl capsules made by Teva Pharmaceutical Industries.

Generic names

Nortriptyline is the English and French generic name of the drug and its INN Tooltip International Nonproprietary Name, BAN Tooltip British Approved Name, and DCF Tooltip Dénomination Commune Française, while nortriptyline hydrochloride is its USAN Tooltip United States Adopted Name, USP Tooltip United States Pharmacopeia, BANM Tooltip British Approved Name, and JAN Tooltip Japanese Accepted Name. [46] [47] [51] [52] Its generic name in Spanish and Italian and its DCIT Tooltip Denominazione Comune Italiana are nortriptilina, in German is nortriptylin, and in Latin is nortriptylinum. [46] [47] [51] [52]

Brand names

Brand names of nortriptyline include Allegron, Aventyl, Noritren, Norpress, Nortrilen, Norventyl, Norzepine, Pamelor, and Sensoval, among many others. [46] [47] [52]

Footnotes

  1. ↑ Nortriptyline actually belongs to a class of drugs called serotonin–norepinephrine reuptake inhibitors (SNRIs). They work at synapse level, and do not allow reuptake of both serotonin and norepinephrine by the neurons. This increases the amount of these neurotransmitters at synpase. In a way, that is not completely clear, this reduces the transmission of pain signals to the brain. It is for this reason, that SNRIs would work in neuropathic pain, but not in nociceptive pain.

Related Research Articles

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