Clinical Information

Nortriptyline is a tricyclic antidepressant used for treatment of endogenous depression. It also is a metabolite of the antidepressant amitriptyline. Nortriptyline is used when its stimulatory side effect is considered to be of clinical advantage; amitriptyline is used when the side effect of mild sedation is desirable.

Nortriptyline is unique among the antidepressants in that its blood level exhibits the classical therapeutic window effect, as blood concentrations above or below the therapeutic window correlate with poor clinical response. Thus, therapeutic monitoring to ensure that the blood level is within the therapeutic window is critical to accomplish successful treatment with this drug.

Like amitriptyline, nortriptyline can cause major cardiac toxicity when the concentration is above 500 ng/mL, characterized by QRS widening (intraventricular conduction delay), which leads to ventricular tachycardia and asystole. In some patients, toxicity may manifest at lower concentrations.