Tricyclic Antidepressant (TCA) Pregnancy: The safety of nortriptyline in pregnancy has not been established, nor is there evidence from animal studies that it is free from hazard; it should not be administered to pregnant patients or women of childbearing age unless the potential benefits clearly outweigh any potential risk. Contraindicated for the nursing mother.

Nortriptyline

Brand names: Allegron

Nortriptyline is a secondary-amine tricyclic antidepressant also used for neuropathic pain; this page covers its use in older people, in whom it is one of the better-tolerated tricyclics but still carries notable risk.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: The elderly: 30 to 50 mg/day in divided doses, beginning at a low level (10-20 mg daily) and increased as required. Usual adult dose: 25 mg three or four times daily, beginning at e.g. 10 mg three or four times daily and increased as required

Route: Oral

Frequency: In divided doses; alternatively the total daily dose may be given once a day, usually at night

Max: Elderly: maximum 50 mg daily. Adults: doses above 150 mg per day are not recommended; when doses above 100 mg daily are administered, plasma nortriptyline levels should be monitored and maintained in the optimum range of 50 to 150 ng/ml

Lower than usual dosages are recommended for elderly patients, and lower dosages for outpatients than for hospitalised patients under close supervision. If it is considered necessary to use higher dosing in an elderly patient, an ECG should be checked and plasma levels of nortriptyline monitored. Older patients have been reported to have higher plasma concentrations of the active metabolite 10-hydroxynortriptyline, in one case associated with apparent cardiotoxicity despite nortriptyline concentrations within the therapeutic range; clinical findings should predominate over plasma concentrations as primary determinants of dosage change. The elderly are particularly liable to experience adverse reactions, especially agitation, confusion and postural hypotension. Initiate at a low level and increase gradually, noting the clinical response and any evidence of intolerance; if minor side-effects develop, reduce the dosage, and discontinue promptly if serious adverse effects or allergic manifestations occur. The antidepressant effect usually sets in after 2-4 weeks and treatment must be continued for an appropriate length of time, usually up to 6 months after recovery, to prevent relapse. When stopping therapy, withdraw gradually over several weeks. CYP2D6 poor metabolisers (3-10% of the population) may have higher than expected plasma concentrations at usual doses. Reduced hepatic function: careful dosing and, if possible, a serum level determination is advisable. Should not be used in children and adolescents aged less than 18 years. Note: eMC §4.5 (interactions) was not captured in this source bundle; the interaction entries below are drawn from the US prescribing information.

Dose adjustments

Renal

Renal failure does not affect the kinetics of nortriptyline; this medicinal product can be given in usual doses to patients with renal failure.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance or to any of the excipients
Recent myocardial infarction
Any degree of heart block or other cardiac arrhythmias
Severe liver disease
Mania
Nursing mothers
Children under the age of six years

Side effects

Anticholinergic effects — dry mouth, blurred vision and disturbance of accommodation, mydriasis, constipation, paralytic ileus
Urinary retention, delayed micturition, dilation of the urinary tract
Cardiovascular — hypotension, hypertension, tachycardia, palpitation, arrhythmias, heart block, myocardial infarction, stroke
Psychiatric — confusional states (especially in the elderly) with hallucinations, disorientation and delusions; anxiety, restlessness, agitation, insomnia, nightmares
Drowsiness, dizziness, weakness, fatigue, headache, tremor and sweating; bone-marrow depression including agranulocytosis; increased risk of bone fractures in patients aged 50 years and over

Interactions

Monoamine oxidase inhibitors (MAOIs) intended to treat psychiatric disorders — contraindicated concurrently and within 14 days of stopping either drug, because of the increased risk of serotonin syndrome (US label CONTRAINDICATIONS)
Linezolid and intravenous methylene blue (MAOIs) — do not start nortriptyline in a patient being treated with these; if urgent treatment with them is required, stop nortriptyline promptly and monitor for serotonin syndrome for two weeks or until 24 hours after the last dose, whichever comes first (US label)
Thyroid medication / hyperthyroid patients — great care is necessary as cardiac arrhythmias may develop (SPC §4.4)
Other tricyclic antidepressants — cross-sensitivity with nortriptyline is a possibility (SPC §4.4)

Clinical monograph

How it works

It inhibits reuptake of noradrenaline (and to a lesser extent serotonin) at the synapse, and is relatively less sedating and less anticholinergic than amitriptyline.

Prescribing in practice

In older people start low and titrate slowly, as anticholinergic effects, postural hypotension, sedation and cardiac conduction effects raise the risk of falls, confusion and arrhythmia.
Avoid or use with great caution in those with cardiac conduction disease, recent myocardial infarction or significant arrhythmia, and consider a baseline ECG where indicated.
It is dangerous in overdose; assess suicide risk and consider limiting quantities supplied.

Monitoring

Monitor mood and suicidal ideation early in treatment, plus blood pressure, anticholinergic burden and cardiac status in older patients.

Counselling the patient

It may take several weeks to improve mood or pain, and the dose is built up gradually.
Report fainting, palpitations, marked dry mouth, constipation or urinary difficulty.
Rise slowly from sitting or lying to reduce dizziness.

Evidence & guidelines

NICE recommends tricyclics such as nortriptyline among first-line options for neuropathic pain, with cautious use and slow titration in older adults.

Reference: NICE CG173 (Neuropathic Pain); AGS Beers Criteria 2023; ACB Scale; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways