4.1. Therapeutic indications

Nortriptyline is indicated for the treatment of Major Depressive Episodes.

4.2. Posology and method of administration

For oral administration.

Adults: Dosage should begin at a low level (50mg once daily or 25mg 2-3 times daily). If necessary, dose could be gradually increased in 25mg increments no more than rapidly than every other day to be added to the morning dose. When doses above 100 mg daily are administered, plasma levels of nortriptyline should be monitored and maintained in the optimum range of 50 to 150ng/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. The maintenance dose should be the same as the optimal therapeutic dose.

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 50mg. If it is considered necessary to use higher dosing in an eldery patient an ECG should be checked and plasma levels of nortriptyline should be monitored.

Adolescent patients: The use of nortriptyline in children and adolescents to treat depression is not recommended due to a lack of evidence regarding its safety and efficacy.

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

Many antidepressants (tricyclic antidepressants, including nortriptyline, selective serotonin re-uptake inhibitors and others) are metabolised by the hepatic cytochrome P450 isoenzyme P450IID6. 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.

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.

A lower or less frequent dose should be considered in patients with hepatic impairment, concurrent diseases, or who are taking multiple medications (see “4.4 Special Warnings and Precautions for Use” and “4.5 Interactions with other Medicinal Products and other Forms of Interaction”).

Renal failure does not affect the kinetics of nortriptyline.

Duration of treatment: The antidepressive effect usually sets in after 2-4 weeks. Treatment with antidepressants is symptomatic and should therefore be continued for a sufficient period of time, usually 6 months or longer to prevent recurrence.

Discontinuation: Treatment should be discontinued gradually, otherwise withdrawal symptoms as headache, sleep disturbances, irritability and malaise could develop. These symptoms are not indicative of addiction.

4.3. Contraindications

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

• Recent myocardial infarction, any degree of heart block or other cardiac arrhythmias

• As for all tricyclic antidepressants, nortriptyline should not be administered to patients who are treated with monoamine oxidase inhibitors (MAOi; e.g. phelzine, tranylcypromine, etc.). Concomitant use of nortriptyline and MAOi might cause serotonin syndrome (a syndrome that can include symptoms as agitation, confusion, tremor, myoclonia and hyperthermia). Nortriptyline therapy can begin 14 days after the termination of a MAOi, and 1 day after the termination of the reversible MAOi moclobemide. Treatment with MAOis can begin 14 days after the terminations of treatment with nortriptyline (see section 4.5).

Please also refer to 'Drug interactions' section 4.5.

4.4. Special warnings and precautions for use

Use in children and adolescents under the age of 18

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.

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 this 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.

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 or hypotension 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.

Arrhytmias and hypotension can occur in patients without prior risk, especially when high doses are prescribed. Therefore patients who receive high doses should be followed up for arrhythmia's and hypotension.

Great care is necessary if nortriptyline is administered to hyperthyroid patients or to those receiving thyroid medication, since cardiac arrhythmias may develop.

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).

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, as 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, raised intra-ocular pressure or symptoms of urinary retention or prostatic hypertrophy.

The possibility of a suicide attempt by a depressed patient remains after the initiation of treatment. This possibility should be considered in relation to the quantity of drug dispensed at any one time.

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 (250mg/day), after the addition of nortriptyline (125mg/day).

Adjustment of anti-diabetic therapy may, therefore be necessary.

If patients developing throat pain, fever and fly symptoms during the first 10 weeks of treatment, it is recommended that a FBC is taken to exclude agranulocytosis.

Hyperpyrexia has been reported during treatment with tricyclic antidepressants together with anticholinergic or with neuroleptics, especially during hot weather.

The tablets contain lactose monohydrate. Patients with rare hereditary diseases such as galactose intolerance, Lapp lactose deficiency, or glucose-galactose malabsorbtion should not use this medication.

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

Drug interactions: Under no circumstances should nortriptyline be given concurrently with, or within two weeks of cessation of, therapy with monoamine oxidase inhibitors. Hyperpyretic crises, severe convulsions and fatalities have occurred when similar tricyclic antidepressants were used in such combinations.

Nortriptyline should not be given with sympathomimetic agents such as adrenaline, ephedrine, isoprenaline, noradrenaline, phenylephrine and phenylpropanolamine.

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

Barbiturates may increase the rate of metabolism of nortriptyline.

Anaesthetics given during tricyclic antidepressant therapy may increase the risk of arrhythmias and hypotension. If surgery is necessary, the drug should be discontinued, if possible, for several days prior to the procedure, or the anaesthetist should be informed if the patient is still receiving therapy.

Tricyclic antidepressants may potentiate the CNS depressant effect of alcohol.

The potentiating effect of excessive consumption of alcohol may lead to increased suicidal attempts or overdosage, especially in patients with histories of emotional disturbances or suicidal ideation.

Steady-state serum concentrations of the tricyclic antidepressants are reported to fluctuate significantly as cimetidine is either added to or deleted from the drug regimen. Higher than expected steady-state serum concentrations of the tricyclic antidepressant have been observed when therapy is initiated in patients already taking cimetidine. A decrease may occur when cimetidine therapy is discontinued.

Because nortriptyline's metabolism (like other tricyclic and SSRI antidepressants) involves the hepatic cytochrome P450IID6 isoenzyme system, concomitant therapy with drugs also metabolised by this system may lead to drug interactions. Lower doses than are usually prescribed for either the tricyclic antidepressant or the other drug may therefore be required.

Greater than two-fold increases in previously stable plasma levels of nortriptyline have occurred when fluoxetine was administered concomitantly. Fluoxetine and its active metabolite, norfluoxetine, have long half-lives (4-16 days for norfluoxetine).

Concomitant therapy with other drugs that are metabolised by this isoenzyme, including other antidepressants, phenothiazines, carbamazepine, propafenone, flecainide and encainide, or that inhibit this enzyme (eg, quinidine), should be approached with caution.

The combination of nortriptyline with medications that increase the QT interval: such as quinidine, antihistamines such as astemizole and terfenadine, some antipsychotics (mainly pimozide and sertindole), cisapride, halofrantine, and sotalolcan increase the risk for ventricular arrhythmia's in combination with TCA's. TCA's have some characteristics of class I anti-arrhytmics. Caution is warranted in combination with anti-arrhythmics from this class, with beta-receptor blockers and with calcium antagonists (especially verampanil) due to a potentiating effect on the AV-conduction time and negative inotropic effects. In combination with class I anti-arrhythmias and loop and thiazide diuretics attention should be paid to potential inhibitory effect on the QT time due to potassium loss.

Antifungal medication such as fluconazole and terbinafine increase the serum concentration of tricyclic antidepressants and the associated toxicity. Syncope and Torsade de Pointes have been reported.

In combination with levothyroxine antidepressants can give rise to hyperthyroidism and levothyroxine may strengthen the antidepressant effect.

The metabolism of levodopa in the intestine may be accelerated, possible through delay of peristalsis. TCAs may increase the risk of seizure in patients using tramadol.

The “serotonin syndrome” (changes in cognition, behaviour, function of the automatic nervous system and neuromuscular activity) have been reported when nortriptyline is administered together with serotonin enhancing medications.

Supervision and adjustment of dosage may be required when nortriptyline is used with other anticholinergic drugs.

4.6. Pregnancy and lactation

Use in pregnancy: A moderate amount of data in pregnant women indicate no malformative or feto/neonatal toxicity. Animal studies have shown reproductive toxicity (see section 5.3). Nortriptyline should only be used when strictly indicated.

The kinetics of nortriptyline changes during pregnancy, especially during the 2nd and 3rd trimesters. Therefore serum levels should be monitored and the dose should be adjusted if needed. After chronic use and administration near term neonatal withdrawal symptoms (irritability, hypertonism, tremors, irregular breathing, weak suckling) and anticholinergic symptoms (urine retention, constipation) may occur.

Use in lactation: Nortriptyline is excreted in limited amounts. The relative infant dose is low and serum levels have been reported as low or undetectable. Adverse effects on the suckling infant have not been reported to date. Nortriptyline can be used during lactation if the expected benefit for the mother outweighs the potential risk for the infant.

4.7. Effects on 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

Included in the following list are a few adverse reactions that have not been reported with this specific drug. However, the pharmacological similarities among the tricyclic antidepressant drugs require that each of the reactions be considered when nortriptyline is administered.

The following definitions are usually used to evaluate side effects:

Very common:

Common:

Uncommon:

Rare:

Very rare:

More than 1 out 10 patients

More than 1 but less than 10 out of 100 patients

More than 1 but less than 10 out of 1,000 patients

More than 1 but less than 10 out of 10,000 patients

Less than 1 out of 10,000 patients

Examinations:

Common: weight increase, abnormal ECG, QT prolongation, Qrs complex prolongation

Uncommon: increased intraocular pressure

Rare: weight loss, abnormal liver function, increased blood alkaline phosphatase, increased transaminase

Very rare: changes in blood sugar levels

Cardiovascular:

Very common: palpitation, irregular or heavy hearts beats and tachycardia

Common: artroventicular block, bundle branch block, high or low blood pressure

Rare: arrhytmias

Very rare: peripheral oedema

Unknown: Brugada Syndrome (unmasking)

Blood and lymphatic disorders:

Rare: bone marrow depression, agranulocytosis, leucopenia, eosinophilia, thrombocytopenia

Nervous system disorders:

Very common: dizziness, headache

Common: concentration disorders, taste disorders, paraethesia, ataxia, strange body movements and tremors

Uncommon: convulsions, numbness

Rare: clumsiness

Very rare: alterations in brain function (including perhaps seizures)

Eye disorders:

Very common: accommodation disorder including blurred vision

Common: mydriasis

Vestibular and ear disorders:

Uncommon: tinnitus

Gastrointestinal disorders:

Very common: dry mouth, constipation

Uncommon: diarrhoea, nausea, vomiting, tongue oedema

Rare: increased salivary glands, paralytic ileus, loss of appetite, diarrhoea and stomach cramps

Kidney and urinary tract disorders:

Uncommon: problems urinating (increased or decreased) and urinary retention

Skin and subcutaneous disorders:

Very common: sweating, flushing

Uncommon: rash, urticarial, facial oedema

Rare: alopecia, light sensitivity

Endocrine disorders:

Unknown: SIADH

Nutritional and metabolic disorders:

Rare: decreased appetite, weight gain or loss

Unknown: Hyponatraemia

Vascular diseases:

Very common: orthostatic hypotension

Uncommon: hypertension

General and application site disorders:

Common: weakness and fatigue

Rare: fever, peculiar taste, mouth or gum problems

Liver and bile disorders:

Rare: jaundice

Unknown: cholestasis

Reproductive system and breast disorders:

Common: erection disorders

Rare: gynaecomastia, changes in sexual performance may also rarely occur

Very rare: galactorrhoea, swelling of testicles

Psychiatric disorders:

Common: confusion, decreased libido

Uncommon: hypomania, mania, anxiety, insomnia (especially on sudden withdrawal), changes in sleep patterns (including nightmares)

Rare: confusional states/delirium (especially in older patients), hallucinations (in patients with schizophrenia), irritability

Unknown cases of suicidal ideation and suicidal behaviours have been reported during nortriptyline therapy or early treatment discontinuation (see section 4.4). Agitation, restlessness, aggressive outbursts, delusions, orgasm disorders in women, increased libido, disorientation

Withdrawal symptoms: Though these are not indicative of addiction, 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 or older, show an increased risk of bone fractures in patients receiving SSRI and TCA's. 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

Individual differences in metabolism may lead to symptoms and signs of overdose even after relatively modest excess ingestion, irrespective of age.

Signs and symptoms: 50mg 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.

Treatment: Symptomatic and supportive therapy is recommended. Early transfer to a hospital with an intensive care unit is recommended. Activated charcoal may be more effective than emesis or lavage to reduce absorption, although combination therapy may be appropriate depending on the time since ingestion.

Ventricular arrhythmias, especially when accompanied by lengthened QRS intervals, may respond to alkalinisation by hyperventilation or administration of sodium bicarbonate or the rapid infusion of hypertonic sodium chloride (100-200mmol). Serum electrolytes should be monitored and managed. Refractory arrhythmias may respond to propranolol, bretylium or lignocaine (usually 1-1.5mg/kg iv followed by 1-3mg/min). Quinidine and procainamide usually should not be used because they may exacerbate arrhythmias and conduction already slowed by the overdose.

Seizures may respond to diazepam. Phenytoin may treat seizures and cardiac rhythm disturbances. Physostigmine may antagonise atrial tachycardia, gut immotility, myoclonic jerks and somnolence. The effects of physostigmine may be short-lived.

Diuresis and dialysis have little effect. Haemoperfusion is unproven. Monitoring should continue, at least until the QRS duration is normal.

Doses as low as 50mg (especially in children) may lead to clinically significant symptoms.

Cardiotoxicity and convulsions are commoner in children and toxicological advice is recommended in all cases.

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