Nortriptyline Dosage Guide

If you’re one of the tens of millions of American adults affected by depression, your healthcare provider may prescribe medication to help you stay in control of your symptoms.

Nortriptyline is an antidepressant medication that’s used to treat major depression. Although it isn’t a common first-line treatment for depression, your healthcare provider might still prescribe nortriptyline in certain circumstances.

Like other antidepressants, nortriptyline is prescribed in several different dosages, both to treat psychiatric disorders such as major depressive disorder (MDD) and as an off-label medication for certain other health issues.

Below, we’ve listed common dosages of nortriptyline, as well as information on how you should use this medication. We’ve also discussed potential side effects, interactions and safety issues associated with nortriptyline that you should be aware of before use. 

Nortriptyline is a prescription medication that’s used for the treatment of depression. It belongs to a class of medications called tricyclic antidepressants, or TCAs.

As with many other prescription medications, nortriptyline is sometimes prescribed for medical problems other than its approved purpose (referred to as off-label use). These include:

• Neuropathic pain conditions, such as diabetic neuropathy

• Chronic pain conditions, such as orofacial pain in adults

• Postherpetic neuralgia (nerve pain caused by shingles)

• Smoking cessation

Like other antidepressants, nortriptyline works by increasing the levels of natural chemicals in your brain and body, referred to as neurotransmitters. More specifically, nortriptyline works by increasing concentrations of the neurotransmitters serotonin and norepinephrine.

Serotonin regulates your moods, including feelings of happiness and anxiety. It also plays an important role in regulating your sleep and wake cycle. Low levels of serotonin are linked todepression, anxiety and suicidal behavior.

Norepinephrine, or noradrenaline, is involved in regulating your moods, ability to focus on tasks and memorize information, as well as many aspects of your physical health and function. Low levels of norepinephrine are associated with lethargy, poor concentration and depression.

Experts believe that many antidepressants, including TCAs such as nortriptyline, help to reduce the severity of depression symptoms and provide antidepressant effects by increasing levels of these neurotransmitters. 

These changes in neurotransmitter levels may also help people to deal with other health issues, such as cravings for nicotine.

As a tricyclic antidepressant, nortriptyline generally isn’t used as a first-line treatment for major depression. Instead, people with depression are typically treated first with newer medications, such as selective serotonin reuptake inhibitors (SSRIs).

Your mental health provider may suggest using nortriptyline if other medications aren’t suitable for you, or if they don’t fully control your depression symptoms. Learn more about the differences and similarities of nortriptyline vs amitriptyline, another TCA.

Nortriptyline is available as an oral capsule or liquid solution. Nortriptyline capsules come in a range of dosages including 10mg, 25mg, 50mg and 75mg, while the oral solution has a typical strength of 10mg/5mL.

For depression, a normal dosage of nortriptyline is 25 to 100mg per day, taken as three or four capsules throughout the day. Your mental health provider will tell you about when you should take nortriptyline for depression. 

In some cases, an entire day’s dose of nortriptyline may be administered once per day. Make sure to follow your mental health provider’s instructions and use nortriptyline as prescribed. 

The typical maximum dose of nortriptyline is 150mg per day. If your provider has prescribed a high dose of nortriptyline greater or equal to 100 mg, they will usually monitor your blood levels during treatment to check that the medication is within the optimal range.

It’s common to start nortriptyline at the lowest initial dose, then adjust your dose over the course of several weeks of treatment as recommended by your mental health provider. 

If you develop side effects while using nortriptyline, your healthcare provider may recommend a dose reduction to the lowest therapeutic dose that’s effective for you.

Make sure to inform your provider if you develop any side effects while you’re using nortriptyline, especially if you’re in the process of adjusting your dosage. 

Nortriptyline may be prescribed at a lower dosage (typically 25 to 50 mg per day) in adolescent and elderly patients. Nortriptyline is typically not recommended as a treatment for endogenous depression in children.

Your healthcare provider may provide specific instructions if you’re given nortriptyline to manage pain.

Nortriptyline is a simple medication to use, although you may need to stick to a set schedule if your mental health provider asks you to take this medication several times per day. There are also several nortriptyline uses, which we discuss in this guide. Follow the instructions below while using nortriptyline:

• Take nortriptyline as prescribed. Make sure to follow the dosage schedule provided by your mental health provider. This may require you to take three to four separate doses of nortriptyline, or a single dose one time per day.
  
  

• Use nortriptyline with or without food. Nortriptyline may be taken with or without any food. If you’re not sure about whether to use nortriptyline with food or not, talk to your mental health provider.
  
  

• If you forget a dose, take it as soon as you remember. However, if it’s almost time for your next dose, skip any missed doses and use your medication as normal. Do not ever take a double dose of nortriptyline.
  
  

• Inform your healthcare provider about other medications. Nortriptyline can interact with other medications. To reduce your risk of drug interactions, it’s important to inform your healthcare provider about any medications you use before starting treatment.
  
  We’ve provided more information about nortriptyline’s potential interactions further down the page.
  
  

• Do not adjust your dose of nortriptyline. Antidepressant treatments can take several weeks to start working. If you’ve just started nortriptyline and don’t notice any changes in your depression symptoms, do not adjust your dosage on your own.
  
  

• Do not abruptly stop using nortriptyline. Nortriptyline and other antidepressants can cause withdrawal side effects if they’re stopped abruptly. If you want to stop treatment with nortriptyline, talk to your mental health provider first.
  
  

• Store nortriptyline in a safe location. Like other prescription medications, nortriptyline should be kept in its original container. Store nortriptyline in a secure, room temperature, low-humidity location away from children or pets. 

Like other tricyclic antidepressants, nortriptyline can cause side effects. In fact, one of the key reasons nortriptyline is no longer used as a first-line treatment for depression is because of its higher risk of adverse events compared to newer antidepressant drugs.

Common side effects of nortriptyline include:

• Drowsiness

• Dizziness

• Xerostomia (dry mouth)

• Blurred vision

• Confusion

• Heart palpitations

• Constipation

• Nausea and vomiting

• Impaired coordination

• Anxiety and/or agitation

• Tachycardia (fast heart rate)

• Disorientation

• Diaphoresis (excessive sweating)

• Changes in blood sugar levels (hypo/hyperglycemia)

• Physical weakness

• Weight gain

• Changes in sex drive

• Erectile dysfunction (ED)

• Gynecomastia (male breast gland growth)

• Galactorrhea (nipple discharge)

• Restlessness

• Insomnia

• Urinary retention

• Photosensitivity (sensitivity to sunlight)

• Paraesthesia (“pins and needles” sensations)

• Tremor
  

Nortriptyline may also produce more severe adverse effects, including fever, spasms that affect your jaw, neck and back muscles, slow or difficult speech, shuffling gait, uncontrollable shaking of certain body parts, difficulty breathing or swallowing, rash and yellowing of skin or eyes. Learn more about nortriptyline side effects in this blog.

You may have a higher risk of experiencing side effects from nortriptyline if you have an existing health issue.

To keep yourself safe while using nortriptyline, make sure to tell your healthcare provider about any existing medical issues you have, including if you’ve previously experienced a heart attack, stroke or other cardiovascular event. 

Contact your healthcare provider or seek medical attention as soon as you can if you ever start to develop any severe or dangerous side effects, allergic reactions or other issues while you’re prescribed nortriptyline.

Nortriptyline is a safe medication for most people when used as directed. However, you should be aware that it can interact with other medications and cause some safety issues, including an elevated risk of suicide in teens and young adults.

We’ve provided more information about potential drug interactions and safety issues associated with nortriptyline below. 

Nortriptyline Drug Interactions

Like other medications, nortriptyline may cause interactions when used with certain other drugs, including other medications used in antidepressant therapy. 

When it’s used with other medications that increase serotonin, nortriptyline can contribute to an elevated risk for serotonin syndrome -- a dangerous, potentially life-threatening condition that’s caused by excessively high serotonin levels.

Symptoms of serotonin syndrome include hypertension (high blood pressure), an elevated body temperature, irregular heartbeat, agitation, hyperactive reflexes and muscle rigidity.

Serotonin syndrome can contribute to an elevated risk of seizures and, when severe, potentially lead to coma and death. 

Medications that may cause serotonin syndrome with nortriptyline include other antidepressants and their metabolites. This risk is particularly high with monoamine oxidase inhibitors (MAOIs) -- an older class of antidepressants that can remain in the body for several weeks after use.

To reduce your risk of serotonin syndrome, make sure to tell your mental health provider about any over-the-counter and prescription medications you currently use or have used at any time during the last 14 days.

It’s especially important to inform your healthcare provider if you use any other medications that can increase serotonin levels, which are referred to as serotonergic drugs.

If you stop using nortriptyline, your mental health provider will inform you to wait at least 14 days before switching to an antidepressant, such as MAOIs.

Other medications, including those that affect certain enzyme activity, may affect the efficacy of nortriptyline and increase its risk of causing side effects. Make sure to tell your mental health provider about all medications and supplements you take before using nortriptyline.

Finally, consuming alcohol with nortriptyline may increase the effects of alcohol. Avoid drinking alcoholic beverages while taking nortriptyline. Inform your mental health provider if you have an alcohol or drug use disorder before starting treatment.

“Black Box” FDA Warning

Like other antidepressants, nortriptyline has a “black box” warning from the FDA notifying users of an increased risk of suicidal ideation and behavior in children, adolescents and young adults up to 24 years of age.

If you’re in your teens or early 20s and use nortriptyline, your healthcare provider may warn you and your family members about signs of suicidal ideation to look out for. They may also request that you check in with them on a regular basis during treatment with this medication.

Use During Pregnancy & Breastfeeding

Women who are pregnant or plan to become pregnant should inform their healthcare provider before using nortriptyline. 

Although nortriptyline may offer benefits in some situations, such as if your depression doesn’t get better with a conventional treatment, it’s rarely used as a first-line treatment for depression these days due to its risk of side effects. 

Instead, if you have depression, your healthcare provider will usually prescribe a newer type of antidepressant drug, such as an SSRI, a serotonin-norepinephrine reuptake inhibitor (SNRI) or an atypical antidepressant such as bupropion (the active ingredient in Wellbutrin^®).

These medications offer many of the same benefits as nortriptyline, but generally have a lower risk of causing side effects.

Your healthcare provider may also suggest using a non-pharmacological form of treatment for your depression symptoms, such as cognitive behavioral therapy (CBT) or a different form of psychotherapy.

We offer several SSRIs online, including fluoxetine (the active ingredient in Prozac^®), sertraline (Zoloft^®), paroxetine (Paxil^®), citalopram (Celexa^®) and escitalopram (Lexapro^®).

We also offer numerous SNRIs and atypical antidepressants, including duloxetine (Cymbalta^®), venlafaxine (Effexor^®) and bupropion (Wellbutrin).

In addition to medication, we also offer individual online therapy, allowing you to connect with a licensed counselor and talk about whatever’s on your mind from the privacy and comfort of your own home. 

Nortriptyline isn’t a common first-line medication for depression. However, your mental health provider may suggest using it if it’s deemed appropriate, or if other antidepressants don’t help with your symptoms. 

Make sure to use nortriptyline at the dosage prescribed by your mental health provider, and to let them know if you develop any side effects.

While antidepressants like nortriptyline can help to treat depression, they’re not the only option for relieving your symptoms and feeling better. Our guide to depression treatments talks about your options, from psychotherapy to healthy habits and lifestyle changes.

If you think that you’re depressed and would like to seek help, you can connect with a licensed provider online using our mental health services, including our online psychiatry service.

You can also learn more about dealing with depression, anxiety and other mental health issues with our free online mental health resources and content.