Patient/caregiver was instructed on contraindications for using nortriptyline as follows:
- Nortriptyline is extensively metabolized in the liver and the metabolites are mainly excreted in the urine. If liver function is deficient, the metabolism of Nortriptyline can be compromised. In individuals with history of compromised renal function, the excretion of nortriptyline metabolites can be compromised. In either case, nortriptyline and metabolites stay in the body for prolonged duration of time in comparison to normal leading to increased blood levels of the medication and metabolites for longer periods of time. This can lead to increased risk for side-effects and consequent toxicity. So, Nortriptyline could be cautiously administered in individuals with hepatic and/or renal dysfunction. Periodical labs for liver and/or renal function could be ordered and individuals monitored for development of any toxic symptoms. Discuss with your physician regarding history of compromised liver or kidney function, if any.
- Nortriptyline use can significant risk for obstruction to the drainage of fluid (aqueous humor) inside the eye. This blockage of fluid in the eye can result in increase in the intraocular pressure, leading to glaucoma. Individuals with glaucoma can present with eye pain, headache, and blurred vision with haloes around light. So, nortriptyline use is contraindicated in individuals with history of glaucoma or cautiously used with periodical eye exam.
- Serotonin is one chemical in the brain, which in permissible amounts, is believed to reduce anxiety and promote happiness and well-being. Very excessive concentrations of serotonin in the brain can lead to serotonin syndrome. Individuals with serotonin syndrome can present with mania, excitement, hallucinations, agitation, insomnia, pounding heartbeat, very rapid heart rate, overactive reflexes, and diarrhea. Nortriptyline use, especially along with a few other antidepressants, such as, citalopram, fluoxetine, and sertraline, can significantly increase the serotonin levels in the body, lead to development of serotonin syndrome, and so, is contraindicated. Caution must be exercised even when discontinuing on any of the above mentioned antidepressant medications with potential to increase serotonin levels and starting on nortriptyline, by observing a window period of atleast 2 weeks, before the transition to nortriptyline is made. Using nortriptyline with these medications closely can result in dangerously elevated serotonin in the blood, leading to development of serotonin syndrome.
