Nortriptyline

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.