Tricyclic Antidepressant (TCA) Pregnancy: Avoid in pregnancy if possible

Nortriptyline

Brand names: Allegron

Adult dose

Dose: 10-75 mg/day

Route: Oral

Frequency: Once daily (nocte) or in divided doses

Max: 150 mg/day

Start at 10 mg nocte in elderly; titrate slowly. For neuropathic pain: 10-75 mg/day

Paediatric dose

Dose: Seek specialist opinion N/A/kg

Route: Oral

Frequency: Seek specialist opinion

Max: Seek specialist opinion

Seek specialist opinion

Dose adjustments

Renal

Use with caution

Hepatic

Avoid in severe hepatic impairment

Paediatric weight-based calculator

Patient weight (kg)

Seek specialist opinion

Clinical pearls

Preferred TCA in elderly over amitriptyline — lower anticholinergic burden (ACB score 2 vs 3) and less sedation
Active metabolite of amitriptyline — retains antidepressant and analgesic properties with better tolerability profile
NICE CG173: consider TCAs for neuropathic pain when first-line agents (duloxetine, amitriptyline, pregabalin, gabapentin) have failed; nortriptyline may be better tolerated
Still avoid if possible in elderly with glaucoma, prostatic hypertrophy, or cardiac conduction defects
Therapeutic drug monitoring available — target 50-150 nanograms/mL for antidepressant effect

Contraindications

Recent myocardial infarction
Heart block
Mania
Concurrent MAOI use

Side effects

Dry mouth
Constipation
Urinary hesitancy
Sedation (less than amitriptyline)
Postural hypotension
QT prolongation

Interactions

MAOIs (severe — avoid)
Tramadol / SSRIs (serotonin syndrome)
Antiarrhythmics (QT prolongation)

Monitoring

ECG before starting in patients with cardiac risk factors
Postural blood pressure
Urinary symptoms
Cognitive function

Reference: BNFc; BNF 90; NICE CG173 (Neuropathic Pain); AGS Beers Criteria 2023; ACB Scale. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways