NORTRIPTYLINE

1. NORTRIPTYLINE Suzanne Barron, SN NUR 308 Psychiatric Nursing

2. Goals & Objectives • Goals • To give 1st year nursing students a deeper knowledge and understanding of the psychiatric drug nortriptyline. • Objectives • Learner will be able to: • Identify 3 contraindications for nortriptyline. • Identify 3 adverse signs and symptoms of nortriptyline. • List 5 symptoms of nortriptyline toxicity.

3. Nortriptyline Generic Name: Nortriptyline Trade Name: Pamelor Drug Category: Tricyclic Antidepressent

4. Indications • Nortriptyline is mainly prescribed for Major Depression • It does have several unlabeled uses including: • Chronic pain management • Premenstrual dysphoric disorder (PMDD) • Social phobia • Neuropathy • Panic disorder • Migraine prophylaxis

5. Dosage & Route Nortriptyline comes as both pill and liquid and is given by mouth. It can be given in divided doses or daily at bedtime. Adult dosing at 25 mg and may increase to 150 mg/day Adolescent dosing 1-3 mg/kg/day, max dose 150 mg/day Geriatric dosing 10-25 mg at bedtime, increase by 10-25 mg at weekly intervals to desired dose; usual maintenance 75 mg/day, max 150 mg/day

6. Mechanism of action of nortriptyline Action Blocks reuptake of norepinephrine and serotonin into nerve endings, thereby increasing action of norepinephrine and serotonin in nerve cells.

7. Pharmacokinetics Route PO Onset 2-3 wk Peak 6 wk Duration Ukn Nortriptyline is taken orally Metabolized by the liver Excreted by the kidneys Crosses the Placenta Excreted in breast milk Half life 18-28 hours Protein binding 93% to 95%

8. Contraindications Black Box Warning: Children, suicidal ideation • Do not use within 14 days of MAOIs • Pregnancy (D) • Hypersensensitity to tricyclic's • Recovery Phase of MI • Seizure disorders • Prostatic Hypertrophy • Precautions • Breastfeeding, suicidal patients, severe depression, increased intraocular pressure, closed-angle glaucoma, urinary retention, cardiac/hepatic disease, hyperthyroidism, electroshock therapy, elective surgery

9. Side Effects Cardiovascular: Orthostatic hypotension, ECG changes, tachycardia, hypertension, palpitations, dysrthymias Psychiatric: Confusion, disorientation, delusions, anxiety, restlessness, agitation, insomnia, panic, nightmares Neurologic: Numbness, tingling, paresthesias of extremities, incoordination, ataxia, tremors, seizures, alteration in EEG patterns, tinnitus Allergy: Rash, urticaria, itching, photosensitization, edema, drug fever, cross-sensitivity with other tricyclic drugs. Endocrine: Increased/decreased libido, breast enlargement, gynecomastia

10. Side Effects Continued Anticholinergic: Dry mouth, blurred vision, constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract Gastrointestinal: Nausea and vomiting, anorexia, epigastric distress, diarrhea, peculiar taste, stomatitis, abdominal cramps Hematologic: Agranulocytosis, thrombocytopenia, eosinophilia, leukopenia Other: Jaundice, altered liver function, weight gain or loss, perspiration; flushing, urinary frequency, nocturia, drowsiness, dizziness, weakness, fatigue, headache, parotid swelling

11. Nortriptyline Toxicity • Warning signs: confusion, restlessness, disturbed concentration, transient visual hallucinations, agitation, muscle rigidity, vomiting, hypothermia, hyperactive reflexes • Critical manifestations: cardiac dysrhythmias, sever hypotension, shock, congestive heart failure, pulmonary edema, convulsions, and CNS depression including coma • Treatment of overdose: • Patient should receive gastrointestinal decontamination. This should include large volume gastric lavage and activated charcoal. A Stimulant cathartic should be given. • Patients respiratory, cardiac function, and temperature should be monitored and maintained. ECG will need to be monitored for at least 5 days. • May required administration of digoxin for heart failure, antiarrhythmics, and anticonvulsants.

12. Nursing Considerations Assess and Monitor Mental status must be monitored to include orientation, mood, and behavior Weight and BMI Blood Pressure and pulse ECG’s in geriatric patients or those with heart disease Fasting blood sugar Cholesterol levels especially in overweight patients Suicidal tendencies (especially early in therapy) Signs of toxicity

13. Nursing Considerations May Increase Bone Marrow Depression Serum glucose may increase or decrease Bilirubin & Alkaline phosphatase May Cause Assess and Periodically Monitor Labs Leukocyte and differential blood counts Liver function Serum glucose Serum nortriptyline levels may be monitored (usually patients placed on higher than recommended doses for therapeutic reasons) Some Lab Considerations

14. Nursing Considerations Implementation • Nortriptyline can be administered with meals to minimize gastrointestinal effects • Administer at bedtime to minimize daytime sedation • Any dose increases should be administered at bedtime to avoid sedation • When stopping nortriptyline, taper dose to avoid withdrawal effects • Dose should be decreased at 50% for 3 days, then 50% for three more days, then drug can be discontinued

15. Nursing Considerations Take as directed. Take missed doses as soon as possible unless close to next dose. Do not stop medication without consulting provider. Abrupt discontinuation may cause illness. Watch for suicidality. especially in early therapy Notify provider immediately if this occurs. Make position changes slowly. You may become dizzy if you stand to quickly. May cause drowsiness or blurred vision. Avoid driving and other activities requiring alertness until affect of drug is known. Avoid alcohol and other CNS depressant drugs. Maintain avoidance for 7 days after discontinuation. Monitor food intake. Weight gain can occur from increase in appetite. Patient Teaching

16. Nursing Considerations Notify provider if urinary retention occurs or if symptoms of constipation persist. Notify your provider if you suspect pregnancy. Medication could effect your baby if you become pregnant. Use sunscreen and protective clothing when in the sun to avoid complications from photosensitivity Dry mouth can be diminished by with sugarless gum or candy. Increase fluid consumption. Report if dry mouth persists for more than 2 weeks. . Notify all health care professionals of medications before treatment or surgery. Monitor food intake. Weight gain can occur from increase in appetite. Patient Teaching

17. Nursing Considerations Outcomes and Evaluations • Patient should experience: • Increase in sense of well being • New interest in surroundings • Refreshing sleep • More energy • Increased appetite

18. Summary Nortriptylineis a tricyclic antidepressant that works by increasing the amounts of norepinephrine and serotonin in the brain. It is prescribed mostly for patients with major depression but it is prescribed for other uses. It is comes in the form of a capsule or a liquid and is taken by mouth. It can be taken in split doses up to four times a day or one large dose at bedtime and may be taken with or without food. It is approved for adults, adolescents, and geriatric patients. It is not recommended for children. Dose needs to be increased slowly to avoid side effects and needs to be decreased slowly to avoid withdrawal symptoms. Two of the major risks involved in prescribing nortriptyline include suicidality early in treatment and toxicity.

19. Questions Name at least 3 contraindications for nortriptyline. Do not use within 14 days of MAOIs Pregnancy (D) Hypersensensitity to tricyclic's Recovery Phase of MI Seizure disorders Prostatic Hypertrophy

20. Questions Name 3 adverse signs and symptoms of nortriptyline. • Orthostatic hypotension, ECG changes, tachycardia, hypertension, palpitations, dysrthymias • Psychiatric: Confusion, disorientation, delusions, anxiety, restlessness, agitation, insomnia, panic, nightmares • Neurologic: Numbness, tingling, paresthesias of extremities, incoordination, ataxia, tremors, seizures, alteration in EEG patterns, tinnitus • Allergy: Rash, urticaria, itching, photosensitization, edema, drug fever, cross-sensitivity with other tricyclic drugs. • Endocrine: Increased/decreased libido, breast enlargement, gynecomastia • Anticholinergic: Dry mouth, blurred vision, constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract • Gastrointestinal: Nausea and vomiting, anorexia, epigastric distress, diarrhea, peculiar taste, stomatitis, abdominal cramps • Hematologic: Agranulocytosis, thrombocytopenia, eosinophilia, leukopenia • Other: Jaundice, altered liver function, weight gain or loss, perspiration; flushing, urinary frequency, nocturia, drowsiness, dizziness, weakness, fatigue, headache, parotid swelling

21. Questions List 5 symptoms of nortriptylinetoxicity. • Warning signs: confusion, restlessness, disturbed concentration, transient visual hallucinations, agitation, muscle rigidity, vomiting, hypothermia, hyperactive reflexes • Critical manifestations: cardiac dysrhythmias, sever hypotension, shock, congestive heart failure, pulmonary edema, convulsions, and CNS depression including coma

22. References Deglin, J. H., Vallerand, A. H., & Sanoski, C. (2013). Davis's drug guide for nurses (13th ed.). Philadelphia, Penn.: F.A. Davis Company. Lehne, R. A. (2013). Pharmacology for Nurses (8th ed.). St. Louis: Elsevier Saunders. Nortriptyline. (n.d.). ATI Testing. Retrieved April 5, 2014 from http://www.atitesting.com/ati_next_gen/Student/DrugGui deSearchPage.aspx?TermHint=nortriptyline Nortriptyline(n.d.). Epocrates Online. Retrieved March 15, 2014 from https://online.epocrates.com/u/10a57/nortriptyline.