Nortriptyline interactions

Food & lifestyle

• alcohol

  Moderate

  Metabolism

  Concomitant use of ethanol and a tricyclic antidepressant (TCA) may result altered TCA plasma levels and efficacy, and additive impairment of motor skills, especially driving skills. Acute ethanol ingestion may inhibit TCA metabolism, while chronic ingestion of large amounts of ethanol may induce hepatic TCA metabolism.

  What to do: Patients should be advised to avoid alcohol during TCA therapy. Alcoholics who have undergone detoxification should be monitored for decreased TCA efficacy. Dosage adjustments may be required.

  7 sources

  1. Dorian P, Sellers EM, Reed KL, et al. "Amitriptyline and ethanol: pharmacokinetic and pharmacodynamic interaction." Eur J Clin Pharmacol 25 (1983): 325-31
  2. Warrington SJ, Ankier SI, Turner P "Evaluation of possible interactions between ethanol and trazodone or amitriptyline." Neuropsychobiology 15 (1986): 31-7
  3. Sandoz M, Vandel S, Vandel B, Bonin B, Allers G, Volmat R "Biotransformation of amitriptyline in alcoholic depressive patients." Eur J Clin Pharmacol 24 (1983): 615-21
  4. Ciraulo DA, Barnhill JG, Jaffe JH "Clinical pharmacokinetics of imipramine and desipramine in alcoholics and normal volunteers." Clin Pharmacol Ther 43 (1988): 509-18
  5. Seppala T, Linnoila M, Elonen E, Mattila MJ, Makl M "Effect of tricyclic antidepressants and alcohol on psychomotor skills related to driving." Clin Pharmacol Ther 17 (1975): 515-22
  6. Ciraulo DA, Barnhill JG, Jaffe JH, Ciraulo AM, Tarmey MF "Intravenous pharmacokinetics of 2-hydroxyimipramine in alcoholics and normal controls." J Stud Alcohol 51 (1990): 366-72
  7. Ciraulo DA, Alderson LM, Chapron DJ, Jaffe JH, Subbarao B, Kramer PA "Imipramine disposition in alcoholics." J Clin Psychopharmacol 2 (1982): 2-7

Conditions

Conditions in which Nortriptyline needs care, as documented in this source.

• Acute Myocardial Infarction Recovery

  Major

  The use of most tricyclic antidepressants is contraindicated in patients that are going through the acute recovery period after a myocardial infarction.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Anticholinergic Syndrome

  Major

  Tricyclic and tetracyclic antidepressants (TCAs) have anticholinergic activity, to which elderly patients are particularly sensitive. Tertiary amines such as amitriptyline and trimipramine tend to exhibit greater anticholinergic effects than other agents in the class. Therapy with TCAs should be administered cautiously in patients with preexisting conditions that are likely to be exacerbated by anticholinergic activity, such as urinary retention or obstruction; angle-closure glaucoma, untreated intraocular hypertension, or uncontrolled primary open-angle glaucoma; and gastrointestinal obstructive disorders. In patients with angle-closure glaucoma, even average doses can precipitate an attack. Glaucoma should be treated and under control prior to initiation of therapy with TCAs, and intraocular pressure monitored during therapy.

  33 sources

  1. Remick RA, Campos PE, Misri S, Miles JE, Van Wyck, Fleet J "A comparison of the safety and efficacy of buproprion HCL and amitriptyline HCL in depressed outpatients." Prog Neuropsychopharmacol Biol Psychiatry 6 (1982): 523-7
  2. Guy W, McEvoy JM, Ban TA, Wilson WH, Pate K "A double-blind clinical trial of mianserin versus amitriptyline: differentiation by adverse symptomatology." Pharmacotherapy 3 (1983): 45-51
  3. Bryant SG, Fisher S, Kluge RM "Long-term versus short-term amitriptyline side effects as measured by a postmarketing surveillance system." J Clin Psychopharmacol 7 (1987): 78-82
  4. Pedersen JH, Sorensen JL "Therapeutic effect and side effects in patients with endogenous depression treated with oral nortriptyline once a day." Neuropsychobiology 6 (1980): 42-7
  5. Georgotas A, McCue RE, Hapworth W, et al. "Comparative efficacy and safety of MAOIs versus TCAs in treating depression in the elderly." Biol Psychiatry 21 (1986): 1155-66
  6. Rudorfer MV, Young RC "Anticholinergic effects and plasma desipramine levels." Clin Pharmacol Ther 28 (1980): 703-6
  7. Nelson JC, Jatlow PI, Bock J, Quinlan DM, Bowes MB "Major adverse reactions during desipramine treatment." Arch Gen Psychiatry 39 (1982): 1055-61
  8. Remick RA, Keller FD, Buchanan RA, Gibson RE, Fleming JA "A comparison of the efficacy and safety of alprazolam and desipramine in depressed outpatients." Can J Psychiatry 33 (1988): 590-4

  Show all 33 sourcesShow fewer sources

  9. Ayd FJ, Jr "Long-term treatment of chronic depression: 15-year experience with doxepin HCl." J Clin Psychiatry 45 (1984): 39-46
  10. Warnes H, Lehmann HE, Ban TA "Adynamic ileus during psychoactive medication: a report of three fatal and five severe cases." Can Med Assoc J 96 (1967): 1112-3
  11. Gershon S "Comparative side effect profiles of trazodone and imipramine: special reference to the geriatric population." Psychopathology 17 (1984): 39-50
  12. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  13. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  14. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  15. "Product Information. Sinequan (doxepin)." Roerig Division (2002):
  16. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  17. Judd FK, Moore K, Norman TR, Burrows GD, Gupta RK, Parker G "A multicentre double blind trial of fluoxetine versus amitriptyline in the treatment of depressive illness." Aust N Z J Psychiatry 27 (1993): 49-55
  18. Feighner JP, Cohn JB, Fabre LF, Jr Fieve RR, Mendels J, Shrivastava RK, Dunbar GC "A study comparing paroxetine placebo and imipramine in depressed patients." J Affect Disord 28 (1993): 71-9
  19. Rosen J, Pollock BG, Altieri LP, Jonas EA "Treatment of nortriptyline's side effects in elderly patients: a double-blind study of bethanechol." Am J Psychiatry 150 (1993): 1249-51
  20. Pigott TA, Pato MT, Bernstein SE, Grover GN, Hill JL, Tolliver TJ, Murphy DL "Controlled comparisons of clomipramine and fluoxetine in the treatment of obsessive-compulsive disorder. Behavioral and biological results." Arch Gen Psychiatry 47 (1990): 926-32
  21. Guillibert E, Pelicier Y, Archambault JC, Chabannes JP, Clerc G, Desvilles M, Guibert M, Pagot R, Poisat JL, Thobie Y "A double-blind, multicentre study of paroxetine versus clomipramine in depressed elderly patients." Acta Psychiatr Scand Suppl 350 (1989): 132-4
  22. Hermesh H, Aizenberg D, Weizman A, Lapidot M, Munitz H "Clomipramine-induced urinary dysfunction in an obsessive-compulsive adolescent." Drug Intell Clin Pharm 21 (1987): 877-9
  23. Ananth J, Assalian P, Links PS "Intolerable side effects of clomipramine." J Clin Psychopharmacol 2 (1982): 215-6
  24. Jenike MA, Baer L, Greist JH "Clomipramine versus fluoxetine in obsessive-compulsive disorder: a retrospective comparison of side effects and efficacy." J Clin Psychopharmacol 10 (1990): 122-4
  25. Claghorn JL, Feighner JP "A double-blind comparison of paroxetine with imipramine in the long-term treatment of depression." J Clin Psychopharmacol 13 (1993): S23-7
  26. Ritch R, Krupin T, Henry C, Kurata F "Oral imipramine and acute angle closure glaucoma." Arch Ophthalmol 112 (1994): 67-8
  27. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  28. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  29. "Product Information. Ludiomil (maprotiline)." Ciba-Geigy Pharmaceuticals (2001):
  30. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  31. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):
  32. Settle EC "Antidepressant drugs: disturbing and potentially dangerous adverse effects." J Clin Psychiatry 59 Suppl 16 (1998): 25-30
  33. Talbert RL, Yee GC, DiPiro JT, Matzke GR, Posey LM, Wells BG "Pharmacotherapy: A Pathophysiologic Approach" Stamford, CT: Appleton & Lange (1999):

• Cardiovascular Diseases

  Major

  Tricyclic and tetracyclic antidepressants (TCAs) may cause orthostatic hypotension, reflex tachycardia, syncope, and dizziness, particularly during initiation of therapy or rapid escalation of dosage. Imipramine appears to have the greatest propensity to induce these effects, while secondary amines such as nortriptyline may do so less frequently. Tolerance to the hypotensive effects often develops after a few doses to a few weeks. Rarely, collapse and sudden death have occurred secondary to severe hypotension. Other reported adverse cardiovascular effects include tachycardia, arrhythmias, heart block, hypertension, thrombosis, thrombophlebitis, myocardial infarction, strokes, congestive heart failure, and ECG abnormalities such as PR and QT interval prolongation. Therapy with TCAs should be avoided during the acute recovery phase following myocardial infarction, and should be administered only with extreme caution in patients with hyperthyroidism, a history of cardiovascular or cerebrovascular disease, or a predisposition to hypotension. Close monitoring of cardiovascular status, including ECG changes, is recommended at all dosages. Many of the newer antidepressants, including bupropion and the selective serotonin reuptake inhibitors (SSRIs), are considerably less or minimally cardiotoxic and may be appropriate alternatives.

  39 sources

  1. Robinson DS, Nies A, Corcella J, Cooper TB, Spencer C, Kefover R "Cardiovascular effects of phenelzine and amitriptyline in depressed outpatients." J Clin Psychiatry 43 (1982): 8-15
  2. Veith RC, Bloom V, Bielski R, Friedel RO "ECG effects of comparable plasma concentrations of desipramine and amitriptyline." J Clin Psychopharmacol 2 (1982): 394-8
  3. Dunn FG "Malignant hypertension associated with use of amitriptyline hydrochloride." South Med J 75 (1982): 1124-5
  4. Christensen P, Thomsen HY, Pedersen OL, et al. "Cardiovascular effects of amitriptyline in the treatment of elderly depressed patients." Psychopharmacology (Berl) 87 (1985): 212-5
  5. Pedersen JH, Sorensen JL "Therapeutic effect and side effects in patients with endogenous depression treated with oral nortriptyline once a day." Neuropsychobiology 6 (1980): 42-7
  6. Roose SP, Glassman AH, Siris SG, Walsh BT, Bruno RL, Wright LB "Comparison of imipramine- and nortriptyline-induced orthostatic hypotension: a meaningful difference." J Clin Psychopharmacol 1 (1981): 316-9
  7. Young RC, Alexopoulos GS, Shamoian CA, Dhar AK, Kutt H "Heart failure associated with high plasma 10-hydroxynortriptyline levels." Am J Psychiatry 141 (1984): 432-3
  8. Georgotas A, McCue RE, Hapworth W, et al. "Comparative efficacy and safety of MAOIs versus TCAs in treating depression in the elderly." Biol Psychiatry 21 (1986): 1155-66

  Show all 39 sourcesShow fewer sources

  9. Gross JS, Zwerin G "Left bundle branch block developing in a patient with sub-therapeutic nortriptyline levels: a case report." J Am Geriatr Soc 39 (1991): 1006-7
  10. Rudorfer MV, Young RC "Desipramine: cardiovascular effects and plasma levels." Am J Psychiatry 137 (1980): 984-6
  11. Nelson JC, Jatlow PI, Bock J, Quinlan DM, Bowes MB "Major adverse reactions during desipramine treatment." Arch Gen Psychiatry 39 (1982): 1055-61
  12. Carpenter P, Gobel FL, Hulsing DJ "Desipramine cardiac toxicity." Minn Med 65 (1982): 231-4
  13. Luchins DJ "Review of clinical and animal studies comparing the cardiovascular effects of doxepin and other tricyclic antidepressants." Am J Psychiatry 140 (1983): 1006-9
  14. Roose SP, Dalack GW, Glassman AH, Woodring S, Walsh BT, Giardina EG "Is doxepin a safer tricyclic for the heart?" J Clin Psychiatry 52 (1991): 338-41
  15. Burrows GD, Vohra J, Hunt D, Sloman JG, Scoggins BA, Davies B "Cardiac effects of different tricyclic antidepressant drugs." Br J Psychiatry 129 (1976): 335-41
  16. Linnoila M, Jobson KO, Gilliam JH, Paine RL "Effects of doxepin on blood pressure and heart rate in patients with primary major affective disorder ." J Clin Psychopharmacol 2 (1982): 433-4
  17. Strasberg B, Coelho A, Welch W, Swiryn S, Bauernfeind R, Rosen K "Doxepin induced torsade de pointes." Pacing Clin Electrophysiol 5 (1982): 873-7
  18. Appelbaum PS, Kapoor W "Imipramine-induced vasospasm: a case report." Am J Psychiatry 140 (1983): 913-5
  19. Kantor SJ, Glassman AH, Bigger JT, Jr Perel JM, Giardina EV "The cardiac effects of therapeutic plasma concentrations of imipramine." Am J Psychiatry 135 (1978): 534-8
  20. Ramanathan KB, Davidson C "Cardiac arrhythmia and imipramine therapy." Br Med J 1 (1975): 661-2
  21. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  22. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  23. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  24. "Product Information. Sinequan (doxepin)." Roerig Division (2002):
  25. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  26. Bluhm RE, Wilkinson GR, Shelton R, Branch RA "Genetically determined drug-metabolizing activity and desipramine- associated cardiotoxicity: a case report." Clin Pharmacol Ther 53 (1993): 89-95
  27. Laird LK, Lydiard RB, Morton WA, Steele TE, Kellner C, Thompson NM, Ballenger JC "Cardiovascular effects of imipramine, fluvoxamine, and placebo in depressed outpatients." J Clin Psychiatry 54 (1993): 224-8
  28. Feighner JP, Cohn JB, Fabre LF, Jr Fieve RR, Mendels J, Shrivastava RK, Dunbar GC "A study comparing paroxetine placebo and imipramine in depressed patients." J Affect Disord 28 (1993): 71-9
  29. Van Sweden B "Rebound antidepressant cardiac arrhythmia." Biol Psychiatry 24 (1988): 363-4
  30. Faravelli C, Brat A, Marchetti G, Franchi F, Padeletti L, Michelucci A, Pastorino A "Cardiac effects of clomipramine treatment. ECG and left ventricular systolic time intervals." Neuropsychobiology 9 (1983): 113-8
  31. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  32. Roos JC "Cardiac effects of antidepressant drugs. A comparison of the tricyclic antidepressants and fluvoxamine." Br J Clin Pharmacol 15 Suppl 3 (1983): s439-45
  33. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  34. "Product Information. Ludiomil (maprotiline)." Ciba-Geigy Pharmaceuticals (2001):
  35. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  36. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):
  37. Settle EC "Antidepressant drugs: disturbing and potentially dangerous adverse effects." J Clin Psychiatry 59 Suppl 16 (1998): 25-30
  38. Talbert RL, Yee GC, DiPiro JT, Matzke GR, Posey LM, Wells BG "Pharmacotherapy: A Pathophysiologic Approach" Stamford, CT: Appleton & Lange (1999):
  39. Upward JW, Edwards JG, Goldie A, Waller DG "Comparative effects of fluoxetine and amitriptyline on cardiac function." Br J Clin Pharmacol 26 (1988): 399-402

• Depressive Disorder

  Major

  Adult and pediatric patients with depression may experience worsening of their symptoms and may have the emergence of suicidal thoughts and behavior. Patients should be monitored appropriately and observed closely for worsening of their symptoms, suicidality or changes in their behavior, especially during the first few months of treatment, and at times of dose changes. Families and caregivers should be advised of the need for close observation and communication with the treating physician. Discontinuing the medication should be considered if symptoms are persistently worse, or abrupt in onset. It may be prudent to refrain from dispensing large quantities of medication to these patients.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Epilepsy

  Major

  Tricyclic antidepressants (TCAs), can lower the seizure threshold and trigger seizures. These drugs should be used with extreme caution in patients with a history of seizures, or other predisposing factors, such as head trauma, CNS abnormalities, and alcoholism. Daily dose restrictions might apply for specific antidepressants. Physicians are encouraged to get additional dosing recommendations on the manufacturer's prescribing information.

  9 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

  Show all 9 sourcesShow fewer sources

  9. Settle EC "Antidepressant drugs: disturbing and potentially dangerous adverse effects." J Clin Psychiatry 59 Suppl 16 (1998): 25-30

• Pheochromocytoma

  Major

  Tricyclic and tetracyclic antidepressants (TCAs) may potentiate the effects of circulating catecholamines. Enhanced sympathetic activity can provoke hypertensive crises in patients with pheochromocytoma or other tumors of the adrenal medulla, such as some neuroblastomas. Therapy with TCAs should be administered cautiously in patients with these tumors.

  12 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Sinequan (doxepin)." Roerig Division (2002):
  5. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  6. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  7. "Product Information. Remeron (mirtazapine)." Organon (2001):
  8. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):

  Show all 12 sourcesShow fewer sources

  9. "Product Information. Ludiomil (maprotiline)." Ciba-Geigy Pharmaceuticals (2001):
  10. Braunwald E, Hauser SL, Kasper DL, Fauci AS, Isselbacher KJ, Longo DL, Martin JB, eds., Wilson JD "Harrison's Principles of Internal Medicine." New York, NY: McGraw-Hill Health Professionals Division (1998):
  11. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  12. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Alcoholic Intoxication

  Moderate

  Tricyclic antidepressants can enhance the response to alcohol. In patients who may use alcohol excessively, it should be borne in mind that the potentiation may increase the danger inherent in any suicide attempt or overdosage.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Bipolar Disorder

  Moderate

  A major depressive episode can be the initial presentation of bipolar disorder. Patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder prior to initiating treatment with a tricyclic antidepressant. This screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. It should be noted that tricyclic antidepressants are not approved for use in treating bipolar depression.

  9 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

  Show all 9 sourcesShow fewer sources

  9. Settle EC "Antidepressant drugs: disturbing and potentially dangerous adverse effects." J Clin Psychiatry 59 Suppl 16 (1998): 25-30

• Bone Marrow Failure Disorders

  Moderate

  The use of tricyclic and tetracyclic antidepressants (TCAs) has rarely been associated with bone marrow suppression. Leukopenia, agranulocytosis, thrombocytopenia, anemia, eosinophilia, purpura, and pancytopenia have been reported with some TCAs. Patients with preexisting bone marrow suppression or blood dyscrasias receiving TCAs should be monitored closely during therapy for further decreases in blood counts.

  16 sources

  1. Draper BM, Manoharan A "Neutropenia with cross-intolerance between two tricyclic antidepressant agents." Med J Aust 146 (1987): 452-3
  2. Wolf B, Conradty M, Grohmann R, Ruther E, Witzgall H, Londong V "A case of immune complex hemolytic anemia, thrombocytopenia, and acute renal failure associated with doxepin use." J Clin Psychiatry 50 (1989): 99-100
  3. Albertini RS, Penders TM "Agranulocytosis associated with tricyclics." J Clin Psychiatry 39 (1978): 483-5
  4. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  5. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  6. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  7. "Product Information. Sinequan (doxepin)." Roerig Division (2002):
  8. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):

  Show all 16 sourcesShow fewer sources

  9. Hunt KA, Resnick MP "Clomipramine-induced agranulocytosis and its treatment with G-CSF." Am J Psychiatry 150 (1993): 522-3
  10. Magni G, Urbani A, Silvestro A, Grassetto M "Clomipramine-induced pancytopenia." J Nerv Ment Dis 175 (1987): 309-10
  11. Souhami RL, Ashton CR, Lee-Potter JP "Agranulocytosis and systemic candidiasis following clomipramine therapy." Postgrad Med J 52 (1976): 472-4
  12. Gravenor DS, Leclerc JR, Blake G "Tricyclic antidepressant agranulocytosis." Can J Psychiatry 31 (1986): 661
  13. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  14. "Product Information. Ludiomil (maprotiline)." Ciba-Geigy Pharmaceuticals (2001):
  15. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  16. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Diabetes Mellitus

  Moderate

  Both elevation and lowering of blood sugar levels have been reported with the use of some tricyclic antidepressants (TCAs). Rarely, these effects have also occurred with maprotiline, a tetracyclic antidepressant. Patients with diabetes should be monitored for worsening control of blood glucose when treated with these agents, particularly during dosage escalation or whenever dosage has been altered.

  11 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Sinequan (doxepin)." Roerig Division (2002):
  5. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  6. Zogno MG, Tolfo L, Draghi E "Hypoglycemia caused by maprotiline in a patient taking oral antidiabetics." Ann Pharmacother 28 (1994): 406
  7. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  8. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):

  Show all 11 sourcesShow fewer sources

  9. "Product Information. Ludiomil (maprotiline)." Ciba-Geigy Pharmaceuticals (2001):
  10. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  11. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Diabetes Mellitus

  Moderate

  There have been reports of both elevation and lowering of blood sugar levels in patients receiving tricyclic antidepressants. These drugs should be used with caution in patients with hypoglycemia, hyperglycemia or diabetes. Monitoring sugar levels is recommended.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Glaucoma

  Moderate

  Tricyclic antidepressants as other type of antidepressants have an effect on pupil size causing dilation. This effect can potentially narrow the eye angle resulting in increased intraocular pressure and angle closure glaucoma, especially in predisposed patients. These drugs should be used with caution in patients with anatomically narrow angle or history of glaucoma. Doxepin hydrochloride capsules are contraindicated in patients with glaucoma.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Liver Diseases

  Moderate

  Tricyclic and tetracyclic antidepressants (TCAs) are known to undergo metabolism in the liver. Some of the metabolites, such as those of imipramine, clomipramine and desipramine, may be pharmacologically active. Many of the metabolites are also excreted by the kidney. There are very limited data concerning the use of TCAs in patients with renal and/or liver disease. Therapy with TCAs should be administered cautiously in patients with significantly impaired renal or hepatic function. Dosage adjustments may be necessary.

  27 sources

  1. Gram LF, Overo KF "First-pass metabolism of nortriptyline in man." Clin Pharmacol Ther 18 (1975): 305-14
  2. Nelson JC, Jatlow PI "Nonlinear desipramine kinetics: prevalence and importance." Clin Pharmacol Ther 41 (1987): 666-70
  3. Schulz P, Turner-Tamiyasu K, Smith G, Giacomini KM, Blaschke TF "Amitriptyline disposition in young and elderly normal men." Clin Pharmacol Ther 33 (1983): 360-6
  4. Midha KK, Hubbard JW, McKay G, et al. "Stereoselective pharmacokinetics of doxepin isomers." Eur J Clin Pharmacol 42 (1992): 539-44
  5. Sandoz M, Vandel S, Vandel B, et al. "Metabolism of amitriptyline in patients with chronic renal failure." Eur J Clin Pharmacol 26 (1984): 227-32
  6. Jorgensen A, Hansen V "Pharmacokinetics of amitriptyline infused intravenously in man." Eur J Clin Pharmacol 10 (1976): 337-41
  7. Henry JF, Altamura C, Gomeni R, Hervy MP, Forette F, Morselli PL "Pharmacokinetics of amitriptyline in the elderly." Int J Clin Pharmacol Ther Toxicol 19 (1981): 1-5
  8. Ciraulo DA, Barnhill JG, Jaffe JH "Clinical pharmacokinetics of imipramine and desipramine in alcoholics and normal volunteers." Clin Pharmacol Ther 43 (1988): 509-18

  Show all 27 sourcesShow fewer sources

  9. Brosen K, Gram LF "First-pass metabolism of imipramine and desipramine: impact of the sparteine oxidation phenotype." Clin Pharmacol Ther 43 (1988): 400-6
  10. Lieberman JA, Cooper TB, Suckow RF, et al. "Tricyclic antidepressant and metabolite levels in chronic renal failure." Clin Pharmacol Ther 37 (1985): 301-7
  11. Faulkner RD, Pitts WM, Lee CS, Lewis WA, Fann WE "Multiple-dose doxepin kinetics in depressed patients." Clin Pharmacol Ther 34 (1983): 509-15
  12. Ziegler VE, Biggs JT, Wylie LT, Rosen SH, Hawf DJ, Coryell WH "Doxepin kinetics." Clin Pharmacol Ther 23 (1978): 573-9
  13. Virtanen R, Scheinin M, Iisalo E "Single dose pharmacokinetics of doxepin in healthy volunteers." Acta Pharmacol Toxicol (Copenh) 47 (1980): 371-6
  14. Dawlilng S, Lynn K, Rosser R, Braithwaite R "The pharmacokinetics of nortriptyline in patients with chronic renal failure." Br J Clin Pharmacol 12 (1981): 39-45
  15. Dawling S, Crome P, Braithwaite R "Pharmacokinetics of single oral doses of nortriptyline in depressed elderly hospital patients and young healthy volunteers." Clin Pharmacokinet 5 (1980): 394-401
  16. Alexanderson B "Pharmacokinetics of nortriptyline in man after single and multiple oral doses: the predictability of steady-state plasma concentrations from single-dose plasma-level data." Eur J Clin Pharmacol 4 (1972): 82-91
  17. Gram LF, Andreasen PB, Overo KF, Christiansen J "Comparison of single dose kinetics of imipramine, nortriptyline and antipyrine in man." Psychopharmacology (Berl) 50 (1976): 21-7
  18. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  19. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  20. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  21. "Product Information. Sinequan (doxepin)." Roerig Division (2002):
  22. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  23. Linnoila M, Insel T, Kilts C, Potter WZ, Murphy DL "Plasma steady-state concentrations of hydroxylated metabolites of clomipramine." Clin Pharmacol Ther 32 (1982): 208-11
  24. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  25. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  26. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  27. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Liver Diseases

  Moderate

  In general, tricyclic antidepressants should be used with caution in patients with liver or renal disease, as these drugs are metabolized and excreted through the liver and kidneys. Dose selection, especially in the elderly patients that might have liver or renal dysfunction, should usually be limited to the smallest effective total daily dose. Some tricyclic antidepressants such as clomipramine and nortriptyline have occasionally been associated with elevations in SGOT (AST) and SGPT (ALT), and other hepatic adverse events such as jaundice. Although serious liver injury has only been reported rarely, therapy with these drugs should be administered cautiously in patients with preexisting liver disease and periodic monitoring of liver enzyme levels is recommended.

  9 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. Larrey D, Rueff B, Pessayre D, Danan G, Algard M, Geneve J, Benhamou JP "Cross hepatotoxicity between tricyclic antidepressants." Gut 27 (1986): 726-7
  6. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  7. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  8. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):

  Show all 9 sourcesShow fewer sources

  9. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Neutropenia

  Moderate

  The use of some tricyclic antidepressants has been associated with neutropenia (ANC < 500/mm3) and agranulocytosis (ANC < 500/mm3). Leukocyte and differential blood counts should be performed in patients that develop fever and sore throat during treatment. Therapy should be discontinued if there is evidence of pathologic neutrophil depression.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Schizophrenia

  Moderate

  Tricyclic antidepressants (TCAs) may aggravate symptoms of psychosis in schizophrenic patients, particularly those with paranoid symptomatology. Depressed patients, usually those with bipolar disorder, may experience a switch from depression to mania or hypomania. These occurrences have also been reported rarely with the tetracyclic antidepressant, maprotiline. Therapy with these agents should be administered cautiously in patients with schizophrenia, bipolar disorder, or a history of mania.

  24 sources

  1. Hemmingsen R, Rafaelsen OJ "Hypnagogic and hypnopompic hallucinations during amitriptyline treatment." Acta Psychiatr Scand 62 (1980): 364-8
  2. Preskorn SH, Simpson S "Tricyclic-antidepressant-induced delirium and plasma drug concentration." Am J Psychiatry 139 (1982): 822-3
  3. Holmes VF, Fricchione GL "Hypomania in an AIDS patient receiving amitriptyline for neuropathic pain." Neurology 39 (1989): 305
  4. Nelson JC, Jatlow PI, Bock J, Quinlan DM, Bowes MB "Major adverse reactions during desipramine treatment." Arch Gen Psychiatry 39 (1982): 1055-61
  5. Norman TR, Judd F, Holwill BJ, Burrows GD "Doxepin and visual hallucinations." Aust N Z J Psychiatry 16 (1982): 295-6
  6. Hardoby W "Imipramine and suicidal thoughts ." Am J Psychiatry 149 (1992): 412-3
  7. Godwin CD "Case report of tricyclic-induced delirium at a therapeutic drug concentration." Am J Psychiatry 140 (1983): 1517-8
  8. Rampling D "Aggression: a paradoxical response to tricyclic antidepressants." Am J Psychiatry 135 (1978): 117-8

  Show all 24 sourcesShow fewer sources

  9. Kupfer DJ, Carpenter LL, Frank E "Possible role of antidepressants in precipitating mania and hypomania in recurrent depression." Am J Psychiatry 145 (1988): 804-8
  10. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  11. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  12. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  13. "Product Information. Sinequan (doxepin)." Roerig Division (2002):
  14. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  15. van Kammen DP, van Scheyen JD, Murphy DL "Platelet monoamine oxidase activity and clomipramine-induced mania in unipolar depressed patients." Biol Psychiatry 15 (1980): 565-73
  16. Vallada HP, Gentil V "Musical hallucinations triggered by clomipramine?" Br J Psychiatry 159 (1991): 888-9
  17. Harper G "Suicidality with clomipramine." J Am Acad Child Adolesc Psychiatry 31 (1992): 369-70
  18. Cruz R "Clomipramine side effects." J Am Acad Child Adolesc Psychiatry 31 (1992): 1168-9
  19. Peet M "Induction of mania with selective serotonin re-uptake inhibitors and tricyclic antidepressants." Br J Psychiatry 164 (1994): 549-50
  20. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  21. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  22. "Product Information. Ludiomil (maprotiline)." Ciba-Geigy Pharmaceuticals (2001):
  23. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  24. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Schizophrenia

  Moderate

  Some tricyclic antidepressants have shown to cause activation or exacerbation of psychosis in schizophrenic patients. A dosage reduction might be required.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Tardive Dyskinesia

  Moderate

  Tricyclic and tetracyclic antidepressants (TCAs) have anticholinergic activity, to which elderly patients are particularly sensitive. Tertiary amines such as amitriptyline and trimipramine tend to exhibit greater anticholinergic effects than other agents in the class. As with other drugs that possess anticholinergic activity, TCAs may aggravate tardive dyskinesia or induce previously suppressed symptoms. Patients with tardive dyskinesia requiring therapy with TCAs should be monitored for exacerbation of the condition.

  18 sources

  1. Woogen S, Graham J, Angrist B "A tardive dyskinesia-like syndrome after amitriptyline treatment." J Clin Psychopharmacol 1 (1981): 34-6
  2. Finder E, Lin K-M, Ananth J "Dystonic reaction to amitriptyline." Am J Psychiatry 139 (1982): 1220
  3. Nelson JC, Jatlow PI, Bock J, Quinlan DM, Bowes MB "Major adverse reactions during desipramine treatment." Arch Gen Psychiatry 39 (1982): 1055-61
  4. Lee HK "Dystonic reactions to amitriptyline and doxepin ." Am J Psychiatry 145 (1988): 649
  5. Gersten SP "Tardive dyskinesia-like syndromes with clomipramine ." Am J Psychiatry 150 (1993): 165-6
  6. Schatzberg AF, Cole JO, Blumer DP "Speech blockage: a tricyclic side effect." Am J Psychiatry 135 (1978): 600-1
  7. Dekret JJ, Maany I, Ramsey TA, Mendels J "A case of oral dyskinesia associated with imipramine treatment." Am J Psychiatry 134 (1977): 1297-8
  8. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):

  Show all 18 sourcesShow fewer sources

  9. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  10. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  11. "Product Information. Sinequan (doxepin)." Roerig Division (2002):
  12. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  13. Sandyk R "Persistent akathisia associated with early dyskinesia." Postgrad Med J 60 (1984): 916
  14. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  15. "Product Information. Ludiomil (maprotiline)." Ciba-Geigy Pharmaceuticals (2001):
  16. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  17. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):
  18. Talbert RL, Yee GC, DiPiro JT, Matzke GR, Posey LM, Wells BG "Pharmacotherapy: A Pathophysiologic Approach" Stamford, CT: Appleton & Lange (1999):

• Thyroid Diseases

  Moderate

  Most tricyclic antidepressants should be administered with caution in hyperthyroid patients or those receiving thyroid medication as they may develop arrhythmias when these drugs are given.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

• Urinary Retention

  Moderate

  Due to their anticholinergic properties, tricyclic antidepressants should be administered with caution in patients with history of urinary retention. Particularly doxepin hydrochloride capsules are contraindicated in patients with tendency to urinary retention.

  8 sources

  1. "Product Information. Pamelor (nortriptyline)." Sandoz Pharmaceuticals Corporation (2002):
  2. "Product Information. Elavil (amitriptyline)." Stuart Pharmaceuticals (2002):
  3. "Product Information. Norpramin (desipramine)." Hoechst Marion Roussel (2002):
  4. "Product Information. Tofranil (imipramine)." Novartis Pharmaceuticals (2002):
  5. "Product Information. Anafranil (clomipramine)." Basel Pharmaceuticals (2001):
  6. "Product Information. Asendin (amoxapine)." Lederle Laboratories (2001):
  7. "Product Information. Surmontil (trimipramine)." Wyeth-Ayerst Laboratories (2001):
  8. "Product Information. Vivactil (protriptyline)." Merck & Co., Inc (2001):

Therapeutic duplication

Drug classes that overlap with Nortriptyline, so taking both doubles up the same effect. This source publishes no per-row citations for duplication.

• antidepressants

  The recommended maximum number of medicines in the 'antidepressants' category to be taken concurrently is usually one.Your list includes two medicines belonging to the 'antidepressants' category.

  Example product in the source data (US market): Bupropion/dextromethorphan

• antidepressants

  The recommended maximum number of medicines in the 'antidepressants' category to be taken concurrently is usually one.Your list includes two medicines belonging to the 'antidepressants' category.

  Example product in the source data (US market): Fluoxetine/olanzapine

• antidepressants

  The recommended maximum number of medicines in the 'antidepressants' category to be taken concurrently is usually one.Your list includes two medicines belonging to the 'antidepressants' category.

  Example product in the source data (US market): Limbitrol ds

• antidepressants

  The recommended maximum number of medicines in the 'antidepressants' category to be taken concurrently is usually one.Your list includes two medicines belonging to the 'antidepressants' category.

  Example product in the source data (US market): Amitriptyline/perphenazine

• antidepressants

  The recommended maximum number of medicines in the 'antidepressants' category to be taken concurrently is usually one.Your list includes two medicines belonging to the 'antidepressants' category.

  Example product in the source data (US market): Bupropion/naltrexone