4.1. Therapeutic indications

Nortriptyline is indicated for the treatment of Major Depressive Episodes in adults.

4.2. Posology and method of administration

Posology

Adults

The usual adult dose is 25 mg three or four times daily. Dosage should begin at a low level e.g. 10 mg three or four times daily, and be increased as required. Alternatively, the total daily dose may be given once a day, usually given at night. When doses above 100 mg daily are administered, plasma levels of nortriptyline should be monitored and maintained in the optimum range of 50 to 150 ng/ml. Doses above 150 mg per day are not recommended.

Lower than usual dosages are recommended for elderly patients. Lower dosages are also recommended for outpatients than for hospitalised patients who will be under close supervision. The physician should initiate dosage at a low level and increase it gradually, noting carefully the clinical response and any evidence of intolerance.

Following remission, maintenance medication may be required for a longer period of time at the lowest dose that will maintain remission.

If a patient develops minor side-effects, the dosage should be reduced. The drug should be discontinued promptly if adverse effects of a serious nature or allergic manifestations occur.

Elderly

30 to 50 mg/day in divided doses. Dosage should begin at a low level (10 – 20 mg daily) and be increased as required to the maximum dose of 50 mg. If it is considered necessary to use higher dosing in an elderly patient an ECG should be checked and plasma levels of nortriptyline should be monitored.

Older patients have been reported to have higher plasma concentrations of the active nortriptyline metabolite 10-hydroxynortriptyline. In one case, this was associated with apparent cardiotoxicity, despite the fact that nortriptyline concentrations were within the 'therapeutic range'. Clinical findings should predominate over plasma concentrations as primary determinants of dosage changes.

Plasma levels

Optimal responses to nortriptyline have been associated with plasma concentrations of 50 to 150 ng/ml. Higher concentrations may be associated with more adverse experiences. Plasma concentrations are difficult to measure, and physicians should consult the laboratory professional staff.

Cytochrome P450 isoenzyme CYP2D6 and poor metabolisers

Many antidepressants (tricyclic antidepressants, including nortriptyline, selective serotonin re-uptake inhibitors and others) are metabolised by the hepatic cytochrome P450 isoenzyme CYP2D6. Three to ten per cent of the population have reduced isoenzyme activity ('poor metabolisers') and may have higher than expected plasma concentrations at usual doses. The percentage of 'poor metabolisers' in a population is also affected by its ethnic origin.

Reduced renal function

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

Reduced hepatic function

In case of reduced liver function careful dosing and, if possible, a serum level determination is advisable.

Paediatric population

Nortriptyline should not be used in children and adolescents aged less than 18 years, as safety and efficacy have not been established (see section 4.4).

Duration of treatment

The antidepressant effect usually sets in after two to four weeks. Treatment with antidepressants is symptomatic and must therefore be continued for an appropriate length of time usually up to 6 months after recovery in order to prevent relapse.

Discontinuation of treatment

When stopping therapy nortriptyline should be gradually withdrawn over several weeks.

Method of administration

For oral administration.

4.3. Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Concomitant treatment with MAOIs (monoamine oxidase inhibitors) is contraindicated (see section 4.5).

Simultaneous administration of nortriptyline and MAOIs may cause serotonin syndrome (a combination of symptoms, possibly including agitation, confusion, tremor, myoclonus and hyperthermia).

Treatment with nortriptyline may be instituted 14 days after discontinuation of irreversible non-selective MAOIs and minimum one day after discontinuation of the reversible moclobemide. Treatment with MAOIs may be introduced 14 days after discontinuation of nortriptyline.

Recent myocardial infarction, any degree of heart block or disorders of cardiac rhythm and coronary artery insufficiency.

4.4. Special warnings and precautions for use

Suicide/suicidal thoughts or clinical worsening

Depression is associated with an increased risk of suicidal thoughts, Self-harm and suicide (suicide-related events). This risk persists until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored until such improvement occurs. It is general clinical experience that the risk of suicide may increase in the early stages of recovery.

Patients with a history of suicide-related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment are known to be at greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment. A meta-analysis of placebo-controlled clinical trials of antidepressant drugs in adult patients with psychiatric disorders showed an increased risk of suicidal behaviour with antidepressants compared to placebo in patients less than 25 years old.

Close supervision of patients and in particular those at high risk should accompany drug therapy in early treatment and following dose changes. Patients (and caregivers of patients) should be alerted about the need to monitor for any clinical worsening, suicidal behaviour or thoughts and unusual changes in behaviour and to seek medical advice immediately if these symptoms present.

Withdrawal symptoms, including insomnia, irritability and excessive perspiration, may occur on abrupt cessation of therapy.

The use of nortriptyline in schizophrenic patients may result in an exacerbation of the psychosis or may activate latent schizophrenic symptoms. If administered to overactive or agitated patients, increased anxiety and agitation may occur. In manic depressive patients, nortriptyline may cause symptoms of the manic phase to emerge in which case the treatment with nortriptyline should be discontinued.

Cross sensitivity between nortriptyline and other tricyclic antidepressants is a possibility.

Caution should be exercised when treating patients with advance liver disease.

Patients with cardiovascular disease should be given nortriptyline only under close supervision because of the tendency of the drug to produce sinus tachycardia and to prolong the conduction time. Myocardial infarction, arrhythmia and strokes have occurred. Great care is necessary if nortriptyline is administered to hyperthyroid patients or to those receiving thyroid medication, since cardiac arrhythmias may develop.

Cardiac arrhythmias are likely to occur with high dosage. They may also occur in patients with pre-existing heart disease taking normal dosage.

Unmasking of Brugada syndrome has been reported in patients treated with nortriptyline. Brugada syndrome is a rare hereditary disease of the cardiac sodium channel with characteristic ECG changes (ST segment elevation and T wave abnormalities in the right precordial leads), which may lead to cardiac arrest and/or sudden death. Nortriptyline should generally be avoided in patients with Brugada syndrome or those suspected of having Brugada syndrome. Caution is advised in patient with risk factors such as a family history of cardiac arrest or sudden death (see sections 4.8 and 4.9).

QT interval prolongation

Cases of QT interval prolongation and arrhythmia have been reported during the postmarketing period. Caution is advised in patients with significant bradycardia, in patients with uncompensated heart failure, or in patients concurrently taking QT-prolonging drugs. Electrolyte disturbances (hypokalaemia, hyperkalaemia, hypomagnesaemia) are known to be conditions increasing the proarrhythmic risk.

The use of nortriptyline should be avoided, if possible, in patients with a history of epilepsy. If it is used, however, the patients should be observed carefully at the beginning of treatment, for nortriptyline is known to lower the convulsive threshold.

The elderly are particularly liable to experience adverse reactions, especially agitation, confusion and postural hypotension.

Troublesome hostility in a patient may be aroused by the use of nortriptyline.

If possible, the use of nortriptyline should be avoided in patients with narrow angle glaucoma or symptoms suggestive of prostatic hypertrophy.

When it is essential, nortriptyline may be administered with electroconvulsive therapy, although the hazards may be increased.

Both elevation and lowering of blood sugar levels have been reported. Significant hypoglycaemia was reported in a Type II diabetic patient maintained on chlorpropamide (250 mg/day), after the addition of nortriptyline (125 mg/day).

Anaesthetics given during tricyclic antidepressant therapy may increase the risk of arrhythmias and hypotension. If possible, discontinue this medicinal product several days before surgery; if emergency surgery is unavoidable, the anaesthetist should be informed that the patient is being so treated (see section 4.5).

Nortriptyline should be used with caution in patients with urinary retention, pylorus stenosis or paralytic ileus.

Hyperpyrexia has been reported with tricyclic antidepressants when administered with anticholinergic or with neuroleptic medications, especially in hot weather.

Serotonin syndrome

Concomitant administration of tricyclic antidepressants including nortriptyline and other serotonergic agents such as MAO inhibitors (see section 4.3) or buprenorphine may result in serotonin syndrome, a potentially life-threatening condition (see section 4.5).

If concomitant treatment with other serotonergic agents is clinically warranted, close monitoring of the patient is advised, especially at initiation of treatment and dose increases.

Symptoms of serotonin syndrome may include mental-status changes, autonomic instability, neuromuscular abnormalities, and/or gastrointestinal symptoms.

If serotonin syndrome is suspected, dose reduction or treatment discontinuation should be considered, depending on the severity of symptoms.

Paediatric population

Nortriptyline should not be used in the treatment of depression in children and adolescents under the age of 18 years. Studies in depression of this age group did not show a beneficial effect for class of tricyclic antidepressants. Studies with other classes of antidepressants (SSRI's and SNRI's) have shown risk of suicidality, self-harm and hostility to be related to these compounds. This risk cannot be excluded with nortriptyline. In addition, nortriptyline is associated with a risk of cardiovascular adverse events in all age groups.

Furthermore, long-term safety data in children and adolescents concerning growth, maturation and cognitive and behavioural development are not available (see also section 4.8 Undesirable effects and Section 4.9 Overdose.)

Warnings: as improvement may not occur during the initial weeks of therapy, patients, especially those posing a high suicidal risk, should be closely monitored during this period.

Excipients

The tablets contain lactose. Patients with rare hereditary problems such as galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

4.5. Interaction with other medicinal products and other forms of interaction

Contraindicated combinations

MAOIs (non-selective as well as selective A (moclobemide) and B (selegiline)) - risk of 'serotonin syndrome' (see section 4.3).

Combinations that are not recommended

Sympathomimetic agents

Nortriptyline should not be given with sympathomimetic agents such as adrenaline, ephedrine, isoprenaline, noradrenaline, phenylephrine and phenylpropanolamine (e.g. as contained in local and general anaesthetics and nasal decongestants).

Adrenergic neurone blockers/antihypertensives

Nortriptyline may decrease the antihypertensive effect of guanethidine, debrisoquine, bethanidine, methyldopa and possibly clonidine. Concurrent administration of reserpine has been shown to produce a 'stimulating' effect in some depressed patients. It would be is advisable to review all antihypertensive therapy during treatment with tricyclic antidepressants.

Anticholinergic agents

Tricyclic antidepressants may potentiate the effects of these medicinal products on the eye, central nervous system, bowel and bladder; concomitant use of these should be avoided due to an increased risk of paralytic ileus, hyperpyrexia, etc.

Drugs which prolong the QT-interval, including antiarrhythmics such as quinidine, the antihistamines astemizole and terfenadine, some antipsychotics (notably pimozide and sertindole), cisapride, halofantrine, and sotalol, may increase the likelihood of ventricular arrhythmias when taken with tricyclic antidepressants.

Use caution when using nortriptyline and methadone concomitantly due to a potential for additive effects on the QT interval and increased risk of serious cardiovascular effects.

Caution is also advised for co-administration of nortriptyline and diuretics inducing hypokalaemia (e.g. furosemide).

Thioridazine

Co-administration of nortriptyline and thioridazine (CYP2D6 substrate) should be avoided due to inhibition of thioridazine metabolism and consequently increased risk of cardiac side effects

Tramadol

Concomitant use of tramadol (a CYP2D6 substrate) and tricyclic antidepressants (TCAs), such as nortriptyline increases the risk for seizures and serotonin syndrome. Additionally, this combination can inhibit the metabolism of tramadol to the active metabolite and thereby increasing tramadol concentrations potentially causing opioid toxicity.

Antifungals such as fluconazole and terbinafine increase serum concentrations of tricyclics and accompanying toxicity. Syncope and torsade de pointes have occurred.

Combinations requiring precautions for use

Serotonergic medicines, such as buprenorphine, which increase the risk of serotonin syndrome, a potentially life-threatening condition (see section 4.4).

CNS depressants

Nortriptyline may enhance the sedative effects of alcohol, barbiturates and other CNS depressants.

Tricyclic antidepressants (TCA) including nortriptyline are primarily metabolised by various hepatic cytochrome P450 isozymes (e.g., CYP1A2, CYP2C, CYP2D6, CYP3A4).

CYP2D6 inhibitors

The CYP2D6 isozyme can be inhibited by a variety of medicinal products, e.g. neuroleptics, serotonin reuptake inhibitors, beta blockers, and antiarrhythmics. Examples of strong CYP2D6 inhibitors include bupropion, fluoxetine, paroxetine and quinidine. These drugs may produce substantial decreases in TCA metabolism and marked increases in plasma concentrations. Consider monitoring TCA plasma levels, whenever a TCA is to be co-administered with another medicinal product known to be an inhibitor of CYP2D6. Dose adjustment of nortriptyline may be necessary (see section 4.2).

Other Cytochrome P450 inhibitors

Cimetidine, methylphenidate and calcium-channel blockers (e.g. diltiazem and verapamil) may increase plasma levels of tricyclic antidepressants and accompanying toxicity.

Tricyclic antidepressants and neuroleptics mutually inhibit the metabolism of each other; this may lead to a lowered convulsion threshold, and seizures. It may be necessary to adjust the dosage of these drugs.

Cytochrome P450 inducers

Oral contraceptives, rifampicin, phenytoin, barbiturates, carbamazepine and St. John's Wort (Hypericum perforatum) may increase the metabolism of tricyclic antidepressants and result in lowered plasma levels of tricyclic antidepressants and reduced antidepressant response.

In the presence of ethanol nortriptyline plasma concentrations were increased.

The CYP3A4 and CYP1A2 isozymes metabolise nortriptyline to a lesser extent. However, fluvoxamine (strong CYP1A2 inhibitor) was shown to increase nortriptyline plasma concentrations and this combination should be avoided. Clinically relevant interactions may be expected with concomitant use of nortriptyline and strong CYP3A4 inhibitors such as ketoconazole, itraconazole and ritonavir.

Valproic Acid

Nortriptyline plasma concentration can be increased by valproic acid. Clinical monitoring is therefore recommended.

Buprenorphine

Nortriptyline should be used cautiously when co-administered with buprenorphine as the risk of serotonin syndrome, a potentially life-threatening condition, is increased (see section 4.4).

4.6. Fertility, pregnancy and lactation

Pregnancy

There is a moderate amount of data from the use of nortriptyline in pregnant women.

Animal studies are insufficient with respect to reproductive toxicity (see section 5.3). Therefore, the drug should not be administered to pregnant patients or women of childbearing age unless the potential benefits clearly outweigh any potential risk.

Following administration in the final weeks of pregnancy, neonatal withdrawal symptoms may occur including irritability, hypertonia, tremors, irregular breathing, weak suckling and possibly anticholinergic symptoms (urine retention, obstipation).

Breast-feeding

Nortriptyline is excreted in limited amounts in breastmilk (corresponding to 0.6 % - 1 % of the maternal dose). Adverse effects for infants have not been reported thus far. Breastfeeding can be continued during nortriptyline therapy if the benefit of the mother outweighs the potential risk for the infant. Observation of the infant is advised, especially during the first four weeks after birth.

Fertility

The reproductive toxicity of nortriptyline has not been investigated in animals. For its parent substance amitriptyline, association with an effect on fertility in rats, namely a lower pregnancy rate was observed. (see section 5.3).

4.7. Effects on ability to drive and use machines

Nortriptyline has moderate influence on the ability to drive and use machines.

Nortriptyline may impair the mental and/or physical abilities required for the performance of hazardous tasks, such as operating machinery or driving a car; therefore the patient should be warned accordingly.

4.8. Undesirable effects

In the listing below the MedDRA system organ system and frequency convention is used.

The frequencies are represented as follows: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).

System Organ Class

Frequency

Undesirable effects

Blood and lymphatic system disorders

Rare

Bone marrow depression, agranulocytosis, leukopenia, eosinophilia, thrombocytopenia

Endocrine disorders

Not known

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Metabolism and nutrition disorders

Rare

Decreased appetite

Not known

Changes of blood sugar levels, hyponatraemia

Psychiatric disorders

Very common

Aggression

Common

Confusional state, libido decreased, agitation

Uncommon

Hypomania, mania, anxiety, insomnia, nightmares

Rare

Delirium (in elderly patients), hallucinations (in schizophrenic patients)

Not known

Suicidal ideation and suicidal behaviour*, paranoia

Nervous system disorders

Very common

Tremor, dizziness, headache

Common

Disturbance in attention, dysgeusia, paraesthesia, ataxia

Uncommon

Convulsion

Rare

Akathisia, dyskinesia

Not known

Extrapyramidal disorder, serotonin syndrome**

Eye disorders

Very common

Accommodation disorder

Common

Mydriasis

Very rare

Acute glaucoma

Ear and labyrinth disorders

Uncommon

Tinnitus

Cardiac disorders

Very common

Palpitations, tachycardia

Common

Atrioventricular block, bundle branch block

Uncommon

Collapse conditions, worsening of cardiac failure

Rare

Arrhythmia

Very rare

Cardiomyopathies, torsades de pointes

Not known

Hypersensitivity myocarditis, brugada syndrome (unmasking)

Vascular disorders

Common

Orthostatic hypotension

Uncommon

Hypertension

Not known

Hyperthermia

Respiratory, thoracic and mediastinal disorders

Very common

Congested nose

Very rare

Allergic inflammation of the pulmonary alveoli and of the lung tissue, respectively (alveolitis, Löffler's syndrome)

Gastrointestinal disorders

Very common

Dry mouth, constipation, nausea

Uncommon

Diarrhoea, vomiting, tongue oedema

Rare

Salivary gland enlargement, ileus paralytic

Hepatobiliary disorders

Uncommon

Hepatic impairment (e.g. cholestatic liver disease)

Rare

Jaundice

Not known

Hepatitis

Skin and subcutaneous tissue disorders

Very common

Hyperhidrosis

Uncommon

Rash, urticaria, face oedema

Rare

Alopecia, photosensitivity reaction

Renal and urinary disorders

Uncommon

Urinary retention

Common

Micturition disorders

Reproductive system and breast disorders

Common

Erectile dysfunction

Uncommon

Galactorrhoea

Rare

Gynaecomastia

General disorders and administration site conditions

Common

Fatigue, feeling thirst

Rare

Pyrexia

Investigations

Common

Electrocardiogram abnormal, electrocardiogram QT prolonged, electrocardiogram QRS complex prolonged, hyponatremia

Uncommon

Intraocular pressure increased

Rare

Weight decreased, liver function test abnormal, blood alkaline phosphatase increased, transaminases increased

* Cases of suicidal ideation and suicidal behaviours have been reported during nortriptyline therapy or early after treatment discontinuation (see section 4.4)

** This event has been reported for serotonergic medicines such as the therapeutic class of tricyclic antidepressants (see sections 4.4 and 4.5).

Withdrawal symptoms

Abrupt cessation of treatment after prolonged therapy may produce nausea, headache and malaise.

Class Effects

Epidemiological studies, mainly conducted in patients 50 years of age and older, show an increased risk of bone fractures in patients receiving SSRs and TCAs. The mechanism leading to this risk is unknown.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at:www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Signs and symptoms

50 mg of a tricyclic antidepressant can be an overdose in a child.

Of patients who are alive at presentation, mortality of 0-15% has been reported. Symptoms may begin within several hours and may include blurred vision, confusion, restlessness, dizziness, hypothermia, hyperthermia, agitation, vomiting, hyperactive reflexes, dilated pupils, fever, rapid heart rate, decreased bowel sounds, dry mouth, inability to void, myoclonic jerks, seizures, respiratory depression, myoglobinuric renal failure, nystagmus, ataxia, dysarthria, choreoathetosis, coma, hypotension and cardiac arrhythmias. Cardiac conduction may be slowed, with prolongation of QRS complex and QT intervals, right bundle branch and AV block, ventricular tachyarrhythmias (including Torsade de pointes and fibrillation) and death. Prolongation of QRS duration to more than 100msec is predictive of more severe toxicity. The absence of sinus tachycardia does not ensure a benign course. Hypotension may be caused by vasodilatation, central and peripheral alpha adrenergic blockade and cardiac depression. In a healthy young person, prolonged resuscitation may be effective; one patient survived 5 hours of cardiac massage.

Brugada syndrome (unmasking) and Brugada ECG pattern (BEP) have been reported in post-marketing surveillance in association with nortriptyline overdose.

Treatment

The treatment is symptomatic and supportive. Patients must be continuously monitored and closely followed up, even in apparently uncomplicated situations.

The airways, breathing and circulation (ABC) must be evaluated and treated, if necessary. Patency of the airway is maintained by intubation, where required. Treatment with artificial respiration is recommended in order to prevent a possible respiratory arrest. Continuous ECG-monitoring of cardiac function should continue, at least until the QRS duration is normal. Ventricular arrhythmias, especially when accompanied by lengthened QRS intervals, may respond to alkalinisation by hyperventilation or administration of sodium bicarbonate. Quinidine and procainamide usually should not be used because they may exacerbate arrhythmias and conduction already slowed by the overdose. Urea and electrolyte levels must be monitored, especially for low potassium. Urinary output must be monitored. Arterial blood gases must be monitored, especially for acidosis. Consider gastric lavage only if it can be performed within one hour of a potentially fatal overdose. Give 50 g of activated charcoal (1 g/ kg body weight if given to a child) if within one hour of ingestion. Activated charcoal may be more effective than emesis or lavage to reduce absorption. Diuresis and dialysis have little effect. Haemoperfusion is unproven.

Treatment of the following should be decided on a case-by-case basis:

– Wide QRS-intervals, cardiac failure and ventricular arrhythmias

– Circulatory failure

– Hypotension

– Hyperthermia

– Convulsions

– Metabolic acidosis

Agitation and convulsions may be treated with diazepam.