nortriptyline management

[randomdoc1]

inherited a 75 yo female on 100mg nortriptyline daily. level returned at 245ng/ml. She said her last psychiatrist said the "level doesn't matter" but she is feeling unsteady on her feet. Pt reluctant to decrease dose due to fear of depression. What would you guys do in this situation? I don't deal with nortriptyline that much, all I know is that I'm not comfortable with this kind of level in a 75 yo and she has not tried many other medications. Actually, I think she's been on the same dose for nearly 30 years. I don't see any other drug trials in her chart.

I did recommend she decrease at least to 75mg daily, recheck a level and get a recent EKG to start. However, if the EKG is not reassuring nor is the level, we may have to change the medication especially given there are safer alternatives.

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[MacDonaldTriad]

It matters if something bad happens and you ignore this. Stop it for at least 2 days and restart at 50 mg. Get an EKG just before restarting it to see if you want to restart it. Then check a level again with a second EKG. Unless she insists this is the only thing she will take and has failed other things, maybe it's time to move on.

 

[Attending1985]

This reminds of an elderly lady I inherited on clomipramine with a qtc of 504. Was a nightmare getting her off of it but now she’s doing fine on 30 mg of cymbalta after a few failed trials of other things. Good luck and agree get an ekg and go from there.

 

[WisNeuro]

Throw some oxybutynin, diphenhydramine for sleep, and a nice opiate dose at her in addition and this looks like a good deal of my referrals. Is she also having any cognitive issues to go along with that unsteadiness? Other meds with anticholinergic issues?

 

[Liquid8]

If she’s been on that dose for 30 years and the unsteadiness is something new, then I’d be looking at investigating other causes of this due to her age.

The other question is what other medications is she taking? Nortriptyline is inhibited by CYP2D6 and if she’s on other drugs that inhibit this, the nortriptyline level will be raised. Out of other commonly used non-psych drugs metoclopramide probably has the strongest inhibitory effect, but there’s quite a few others (eg. celecoxib, calcium channel blockers, reflux drugs) that could affect things in a smaller degree or in combination.

Whether I’d drop the medication also depends on what she’s been like longitudinally. If smaller drops have been tried before and she’s reported relapses, then it’s harder to justify a decrease unless the side effects are intolerable.

From what's been said it's not clear to me if the patient has other anticholinergic side effects or signs of TCA toxicity, but if that was the case and I thought the TCA was responsible, I’d drop it 75mg with the option of an increase back to 100mg if her mood deteriorates in the short term. You could also say that due to concerns about her levels, side effects etc. you won’t go above 100mg/day so if her mood isn’t controlled on that dose you’d be looking at changing her to something else.

 

[michaelrack]

I would drop to 75, get an EKG in about a week, along with a repeat level (aiming for 50-150, in her probably towards the higher end). In other words, I agree with what you (the OP) is planning on doing. No need for drastic action in a patient who has been on a stable dose for years.