Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (296 page)
Canada only Side effects:
italics
= common;
bold
= life-threatening 
Nurse Alert
See
Appendix B
(nor-trip′ti-leen)
Arentyl
, Pamelor
Func. class.:
Antidepressant, tricyclic
Chem. class.:
Dibenzocycloheptene—secondary amine
Do not confuse:
nortriptyline
/amitriptyline
Blocks reuptake of norepinephrine and serotonin into nerve endings, thereby increasing action of norepinephrine and serotonin in nerve cells
Major depression
Unlabeled uses:
Chronic pain management, PMDD, social phobia, neuropathy, panic disorder, enuresis, migraine prophylaxis
Pregnancy (D), hypersensitivity to tricyclics, recovery phase of MI, seizure disorders, prostatic hypertrophy
Precautions:
Breastfeeding, suicidal patients, severe depression, increased intraocular pressure, closed-angle glaucoma, urinary retention, cardiac/hepatic disease, hyperthyroidism, electroshock therapy, elective surgery
Black Box Warning:
Children, suicidal ideation
Calculator
• Adult:
PO
25 mg tid or qid; may increase to 150 mg/day; may give daily dose at bedtime
• Adolescent:
PO
1-3 mg/kg/day in 3-4 divided doses or daily at bedtime, max 150 mg/day
• Child 6-12 yr (unlabeled):
PO
1-3 mg/kg/day in 3-4 divided doses, max 150 mg/day
• Geriatric:
PO
10-25 mg at bedtime, increase by 10-25 mg at weekly intervals to desired dose; usual maintenance 75 mg/day, max 150 mg/day
Available forms:
Caps 10, 25, 50, 75 mg; sol 10 mg/5 ml
•
Increased fluids, bulk in diet if constipation occurs
•
Without regard to meals
•
Dosage at bedtime for oversedation during day; may take entire dose at bedtime; geriatric patients may not tolerate once daily dosing
•
Gum, hard candy, frequent sips of water for dry mouth
•
Oral solution:
with fruit juice, water, or milk to disguise taste
CNS:
Dizziness, drowsiness
, confusion, headache, anxiety, tremors, stimulation, weakness, insomnia, nightmares, EPS (geriatric patients), increased psychiatric symptoms,
seizures
CV:
Orthostatic hypotension, ECG changes, tachycardia
,
hypertension,
palpitations,
dysrhythmias
EENT:
Blurred vision
, tinnitus, mydriasis
GI:
Constipation, dry mouth
, nausea, vomiting,
paralytic ileus,
increased appetite, cramps, epigastric distress, jaundice,
hepatitis,
stomatitis
GU:
Urinary retention
,
acute renal failure
HEMA:
Agranulocytosis, thrombocytopenia, eosinophilia, leukopenia
INTEG:
Rash, urticaria, sweating, pruritus, photosensitivity
PO:
Steady state 4-19 days; metabolized by liver; excreted by kidneys; crosses placenta; excreted in breast milk; half-life 18-28 hr, protein binding 93%-95%
Increase:
QT prolongation—class IA/III antidysrhythmics, some phenothiazines, β agonists, local anesthetics, tricyclics, haloperidol, chloroquine, droperidol, pentamidine; CYP3A4 inhibitors (amiodarone, clarithromycin, erythromycin, telithromycin, troleandomycin), ar
senic trioxide, levomethadyl; CYP3A4 substrates (methadone, pimozide, QUEtiapine, quiNIDine, risperiDONE, ziprasidone)
•
Heavy smoking: decreased product effect
Hyperpyretic crisis, seizures, hypertensive episode: MAOI
Increase:
effects of direct-acting sympathomimetics (EPINEPHrine), alcohol, barbiturates, benzodiazepines, CNS depressants, products increasing QT interval, other anticholinergics
Increase:
serotonin syndrome, neuroleptic malignant syndrome—SSRIs, SNRIs, serotonin receptor agonists, linezolid; methylene blue (IV)
Decrease:
effects of guanethidine, cloNIDine, indirect-acting sympathomimetics (ePHEDrine)
Increase:
CNS effect—kava, valerian
Decrease:
nortriptyline level—St. John’s wort
Increase:
serum bilirubin, blood glucose, alk phos
Decrease:
VMA, 5-HIAA
False increase:
urinary catecholamines
Black Box Warning:
Suicidal thoughts/behaviors in children/young adults:
not approved for children, monitor for suicidal ideation in depression, adolescents, young adults
•
B/P (lying, standing), pulse q4hr; if systolic B/P drops 20 mm Hg, hold product, notify prescriber; VS q4hr in patients with CV disease
•
Blood studies: CBC, leukocytes, differential, cardiac enzymes if patient is receiving long-term therapy
•
Hepatic studies: AST, ALT, bilirubin
•
Weight weekly; appetite may increase with product
PR, QT prolongation:
ECG for flattening of T wave, bundle branch block, AV block, QT prolongation, dysrhythmias in cardiac patients; assess for chest pain, palpitations, dyspnea
•
EPS primarily in geriatric patients: rigidity, dystonia, akathisia, preferred tricyclic in geriatric patients
•
Mental status changes: mood, sensorium, affect, suicidal tendencies, increase in psychiatric symptoms, depression, panic
•
Urinary retention, constipation; constipation is more likely to occur in children
Withdrawal symptoms:
headache, nausea, vomiting, muscle pain, weakness; do not usually occur unless product was discontinued abruptly
•
Alcohol intake; if alcohol is consumed, hold dose until
AM
•
Serotonin syndrome, neuroleptic malignant syndrome:
assess for increased heart rate, shivering, sweating, dilated pupils, tremors, high B/P, hyperthermia, headache, confusion; if these occur, stop product, administer serotonin antagonist if needed
(rare)
•
Storage in tight, light-resistant container at room temp
•
Assistance with ambulation during beginning therapy because drowsiness/dizziness occurs; safety measures including side rails, primarily for geriatric patients
•
Therapeutic response: decreased depression
•
That therapeutic effects may take 2-3 wk, only small quantities may be dispersed
•
To use caution when driving, during other activities requiring alertness because of drowsiness, dizziness, blurred vision
•
To avoid alcohol ingestion, other CNS depressants; to avoid MAOIs within 14 days
•
Not to discontinue medication quickly after long-term use; may cause nausea, headache, malaise
•
To wear sunscreen or large hat because photosensitivity occurs
To immediately report urinary retention, worsening depression, suicidal thoughts/behaviors
ECG monitoring; lavage, activated charcoal; administer anticonvulsant