Pamelor (Nortriptyline) – Oral

What Is Pamelor?

Pamelor (nortriptyline) is a prescription medicine used to treat symptoms of depression. It is in a class of drugs called tricyclic antidepressants.

The exact way Pamelor works is not known. It may work by blocking the reuptake of substances in the body called norepinephrine and serotonin, allowing more of these substances to circulate. It also blocks acetylcholine and histamine receptors. 

It is available in 10 milligram (mg), 25 mg, 50 mg, and 75 mg capsules. It is also available as a liquid solution (generic only).

What Is Pamelor Used For?

The Food and Drug Administration (FDA) approved Pamelor to relieve symptoms of depression in adults.

Clinical depression, also sometimes called major depressive disorder (MDD), often causes symptoms that disrupt a person's ability to function daily. Although people with depression often feel sad, the condition goes beyond everyday sadness and can include other symptoms such as:

• Anxious or depressed mood
• Loss of interest in hobbies or activities
• Changes in appetite or weight
• Insomnia (inability to sleep) or hypersomnia (sleeping too much)
• Fatigue
• Difficulty concentrating, remembering, or making decisions
• Suicidal thoughts or behaviors

If left untreated, depression can significantly affect a person's mental and physical well-being. Treatment often consists of a combination of antidepressants and psychotherapy.

Pamelor is a tricyclic antidepressant, an older class of depression medications known as first-generation antidepressants. Tricyclic antidepressants are not prescribed as often as newer antidrepressants like selective serotonin reuptake inhibitors (SSRIs).

How to Take Pamelor

Use this medicine exactly as directed by your healthcare provider. It is usually taken one to four times a day.

Follow all directions on your prescription label and read all medication guides. Your healthcare provider may occasionally change your dose. Measure the liquid formulation with the supplied syringe or a dose-measuring device. Do not use a kitchen spoon.

You may have withdrawal symptoms if you stop taking nortriptyline suddenly. This is known as antidepressant discontinuation syndrome. Symptoms can begin within two to four days after stopping the drug and may continue for one to two weeks.

Symptoms can be vague, but often include:

• Flu-like symptoms, such as tiredness, fatigue, headache, muscle aches, and sweating
• Nausea and sometimes vomiting
• Insomnia (trouble sleeping) or vivid dreams and nightmares
• Balance issues, with dizziness, vertigo, and light-headedness
• Sensory disturbances, such as burning, tingling, or "shock-like" sensations
• Hyperarousal, which can manifest as anxiety, irritability, agitation, aggressive behavior, or mania

Talk to your healthcare provider before stopping this medicine.

You should not take this medication within two weeks of taking another class of drugs called monoamine oxidase inhibitors (MAOIs). MAOIs are potent antidepressants that regulate mood by breaking down serotonin, dopamine, and norepinephrine in the brain.

Avoid taking Pamelor and an MAOI within two weeks of each other, as doing so can increase the risk of a potentially life-threatening condition called serotonin syndrome.

Storage

Store Pamelor at room temperature (68–77 degrees Fahrenheit) and away from moisture and heat. Keep the bottle tightly closed when not in use.

Store out of the reach of children and pets. When traveling, transport Pamelor in your carry-on or your checked baggage with its original label attached.

Off-Label Uses

Healthcare providers may prescribe nortriptyline off-label for medical conditions that it is not approved to treat but has proven beneficial for. Do not share it with others.

Nortriptyline has been studied for the following off-label uses:

• Chronic pain
• Diabetic neuropathy
• Postherpetic neuralgia
• Smoking cessation
• Migraine prevention
• Bed-wetting in children
• Neurogenic cough
  

What Are the Side Effects of Pamelor?

This is not a complete list of side effects and others may occur. A healthcare provider can advise you on side effects. If you experience other effects, contact your healthcare provider. You may report side effects to the FDA at fda.gov/medwatch or 800-FDA-1088.

Common Side Effects

Common side effects of Pamelor include:

• Dizziness
• Increased blood pressure
• Nausea or vomiting
• Dry mouth (xerostomia)
• Weight gain or loss
• Blurred vision
• Rash, itching, or hives
• Numbness or tingling in your hands or feet
• Drowsiness or weakness
• Constipation
• Disorientation or confusion
• Restlessness or agitation
• Insomnia (trouble sleeping)
• Anxiety
• Inability to empty your bladder completely 
• Frequent urge to pee
• Libido changes or impotence
• Changes in blood sugar
• Sun sensitivity

Severe Side Effects

Call your healthcare provider immediately if you have serious side effects. Call 911 immediately if you think you or someone else is having a medical emergency.

Stopping nortriptyline suddenly can result in antidepressant discontinuation syndrome, which can be severe. Symptoms can begin within two to four days after stopping the drug and may continue for one to two weeks.

Symptoms can be vague but often include:

• Flu-like symptoms, such as tiredness, fatigue, headache, muscle aches, and sweating
• Nausea and sometimes vomiting
• Insomnia (trouble sleeping) or vivid dreams and nightmares
• Balance issues, with dizziness, vertigo, and light-headedness
• Sensory disturbances, such as burning, tingling, or "shock-like" sensations
• Hyperarousal, which can manifest as anxiety, irritability, agitation, aggressive behavior, or mania

These symptoms may overlap with a relapse of depression or anxiety, which can also occur after stopping the medication. However, signs of relapse typically appear more than a few days after stopping. It is recommended to consult with your healthcare provider before discontinuing any antidepressant.

Other serious side effects can include:

• Low blood pressure (hypotension) or feeling light-headed after standing up
• Fainting (syncope)
• Angioedema, a severe skin condition that causes swelling under the skin
• High blood pressure
• Abnormal heartbeat
• Stroke
• Brugada syndrome, a rare but serious heart-rhythm condition
• Seizures
• Involuntary or uncontrollable bodily or facial movements
• Paralytic ileus, a condition in which muscle contractions that move food through your intestines are temporarily paralyzed
• Glaucoma
• Low white blood cell or platelet counts
• Hallucinations or delusions
• Unusually elevated mood or mania
• Depression and suicidal thoughts
• Serotonin syndrome
• SIADH (syndrome of inappropriate secretion of antidiuretic hormone) (high levels of a hormone that causes the body to retain water)
• Hepatitis
• Hyperthermia (abnormally high body temperature) or heatstroke

Abruptly stopping nortriptyline may cause nausea, headache, or malaise (a general feeling of being unwell). Do not stop this medication without speaking to your healthcare provider.

Dosage: How Much Pamelor Should I Take?

Modifications

Due to the possible side effects of this medication, there may be changes to how it is used. Therefore, users need to be aware of the following when taking Pamelor:

• Pregnancy: Nortriptyline crosses the placenta and may cause irritability, jitteriness, and rarely, seizures, in the newborn. The American College of Obstetricians and Gynecologists (ACOG) recommends individualizing depression treatment during pregnancy. This risk of untreated depression in the pregnant person can actually result in worse outcomes for the fetus. If you are pregnant or become pregnant while taking this medication, talk to your healthcare team to weigh the risks vs. benefits.
• Breastfeeding: Many people wonder if they can breastfeed while taking certain medications. Pamelor is safe while breastfeeding, and there is no known risk to your nursing infant. Talk to your healthcare provider if you’re breastfeeding on this medication.
• Difficulty swallowing: Pamelor capsules can safely be opened and sprinkled onto food for children or adults with difficulty swallowing. Sprinkle the contents on soft foods like applesauce, pudding, or yogurt.

Missed Dose

Do not change your dose or stop taking Pamelor without talking to your healthcare provider. If you miss a dose, take it as soon as you can and then resume your next dose at its regular time. Skip the missed dose if it is almost time for your next dose. Do not take two doses at one time.

Overdose: What Happens If I Take Too Much Pamelor?

Pamelor overdose can happen when one takes too much of it. Taking nortriptyline with alcohol can also increase the risk of an overdose.

Overdose symptoms may include:

• Irregular heartbeat
• Severe drowsiness
• Vision problems
• Mental changes such as agitation, confusion, or hallucinations
• Stiff muscles
• Vomiting
• Feeling hot or cold
• Feeling like you might pass out
• Seizures
• Coma

Seek immediate medical help if you feel you or someone else has overdosed on Pamelor. Treatment in a hospital setting may be required.

Precautions

What Are the Reasons I Shouldn’t Take Pamelor?

In some cases, Pamelor may not be an appropriate medication for you. Tell your healthcare provider if:

• You are allergic to nortriptyline or similar medications: You are likely allergic to Pamelor if you’ve ever had an allergic reaction to any of the medicines in the same class of tricyclic antidepressants (e.g., amitriptyline, amoxapine, desipramine) Get emergency medical help immediately if you have signs of an allergic reaction like hives, difficulty breathing, or swelling of your face, lips, tongue, or throat.
• You are taking any MAOIs: Do not use nortriptyline if you have used any medication classified as an MAOI (e.g., isocarboxazid, linezolid) in the past 14 days. A dangerous drug interaction called serotonin syndrome could occur.
• You recently had a heart attack: Pamelor should not be taken when recovering from a heart attack.

What Medications Interact With Pamelor?

Avoid taking certain medications when also taking Pamelor, as they can affect how Pamelor works in the body. Some medicines can cause unwanted effects when used with nortriptyline, and some should not be used simultaneously. 

Pamelor can potentially interact with the following:

• Flumazenil: Tricyclic antidepressants like nortriptyline can lower the seizure threshold. Administration of flumazenil to reverse a benzodiazepine can potentially cause a seizure. Be sure to tell your healthcare provider if you are taking Pamelor. 
• MAOIs: Combination may increase the risk of serotonin syndrome, slowing down of the central nervous system, psychomotor impairment, and low blood pressure. Examples include Zelapar (selegiline), Marplan (isocarboxazid), and Zyvox (linezolid). Ask your healthcare provider if you are unsure whether you're taking an MAOI.
• Potassium: Combination may delay the passage of solid potassium through the gut. This delay might increase the exposure of the gut lining to potassium and cause lesions. Examples of solid potassium formulations are potassium acid phosphate, potassium chloride, potassium citrate, and potassium phosphate. Use alternative forms of potassium with Pamelor, like intravenous or liquid formulations.
• Yohimbe: Combination may increase the risk of serotonin syndrome and blood pressure changes. 
• Triptans: Combination may increase the risk of serotonin syndrome, slowing down of the central nervous system, and psychomotor impairment. Examples include Relpax (eletriptan), Frova (frovatriptan), and Imitrex (sumatriptan).
• Opioids: Using nortriptyline with opioids can make you tired, especially when you first start taking them together or increase the dose. The combination may increase the risk of serotonin syndrome, slowing down of the central nervous system, psychomotor impairment, severely low blood pressure, and constipation.
• Saint-John’s-wort

This is not a complete list of all medications that may affect how Pamelor works. Tell your healthcare provider or pharmacist about all your current medicines and supplements and any medicine you start or stop.

What Medications Are Similar?

Other tricyclic antidepressants used to treat symptoms of depression include:

• Elavil (amitriptyline)
• Silenor (doxepin)
• Norpramin (desipramine)

Amitriptyline

Unlike nortriptyline, which is only approved for adults, amitriptyline is approved for use in children 13 years and older.

Doxepin

Doxepin is used to treat symptoms of depression and anxiety. Doxepin tablets, marketed under the brand name Silenor, also treat insomnia in people who have trouble staying asleep, so they can serve as a treatment option for people with depression and insomnia.

Desipramine

Desipramine is also a tricyclic antidepressant used to treat symptoms of depression. It is approved for use in children 13 years and older. It may take up to three weeks before your symptoms improve with this medication.

This is a list of drugs also prescribed for depression. It is not a list of medicines recommended to take with nortriptyline. You should not take these drugs together.

How Can I Stay Healthy While Taking Pamelor?

Depression is a serious mood disorder and requires immediate attention. Nortriptyline is a medication that can help improve your symptoms. Use it regularly, as directed, to ensure it works properly.

If you have trouble remembering to take your doses, consider setting reminders on your cell phone. Be patient, and don't stop this medication without speaking to your healthcare provider. Stopping suddenly may make you feel sick. It may take a few weeks for your symptoms to improve.

When taking nortriptyline for depression, pay close attention to any changes in mood, behaviors, thoughts, or feelings. Call your healthcare provider if you have increased suicidal thoughts or actions.