Nortriptyline in Pregnancy and Breastfeeding

Risk Factor: D
Class: Central nervous system drugs / Antidepressants

Contents of this page:
Fetal Risk Summary
Breast Feeding Summary
References
Questions and Answers

Fetal Risk Summary

Limb reduction anomalies have been reported with nortriptyline (1,2). However, one of these children was not exposed until after the critical period for limb development (3). The second infant was also exposed to sulfamethizole and heavy cigarette smoking (1). Evaluation of data from 86 patients with 1st-trimester exposure to amitriptyline, the active precursor of nortriptyline, does not support the drug as a major cause of congenital limb deformities (see Amitriptyline). Urinary retention in the neonate has been associated with maternal use of nortriptyline (4).

In a surveillance study of Michigan Medicaid recipients involving 229,101 completed pregnancies conducted between 1985 and 1992, 61 newborns had been exposed to nortriptyline during the 1st trimester (F. Rosa, personal communication, FDA, 1993). Two (3.3%) major birth defects were observed (two expected), both cardiovascular anomalies (0.5 expected).

Breast Feeding Summary

Nortriptyline is excreted into breast milk in low concentrations (5,6,7,8 and 9). A milk level in one patient was 59 ng/mL, representing a milk:serum ratio of 0.7 (6). A second patient was treated with nortriptyline 100 mg daily during the 2nd and 3rd trimesters, then stopped 2 weeks before an elective cesarean section (8). Treatment was restarted at 125 mg every night on the 1st postpartum day, then decreased to 75 mg nightly over the next 7 weeks. The mother was also receiving flupenthixol. Milk concentrations of nortriptyline, measured 1113.5 hours after a dose on postpartum days 6 (four samples), 20 (two samples), and 48 (two samples), ranged from 90 to 404 ng/mL, mean 230 ng/mL. The milk:serum ratios for these samples ranged from 0.87 to 3.71 (mean 1.62). No effects of the drug exposure were observed in the nursing infant, who had normal motor development for the first 4 months (8). Infant serum concentrations were not determined.

Nortriptyline was not detected in the serum of other breast-fed infants when their mothers were taking the drug (6,7,9); however, low levels (511 ng/mL) of the metabolite, 10-hydroxynortriptyline, were measured in the serum of two infants in one study (9). In this latter study, no evidence of accumulation in nursing infants after long-term (e.g., >50 days) maternal use of the antidepressant was observed (9).

The significance of chronic exposure of the nursing infant to the antidepressant is unknown, but concern has been expressed about the effects of long-term exposure on the infant's neurobehavioral mechanisms (8). The American Academy of Pediatrics has classified other antidepressants as agents whose effect on nursing infants is unknown, but may be of concern, especially after prolonged exposure (10).

References

  1. Bourke GM. Antidepressant teratogenicity? Lancet 1974;1:98.
  2. McBride WG. Limb deformities associated with iminobenzyl hydrochloride. Med J Aust 1972;1:492.
  3. Australian Drug Evaluation Committee. Tricyclic antidepressants and limb reduction deformities. Med J Aust 1973;1:7689.
  4. Shearer WT, Schreiner RL, Marshall RE. Urinary retention in a neonate secondary to maternal ingestion of nortriptyline. J Pediatr 1972;81:5702.
  5. Bader TF, Newman K. Amitriptyline in human breast milk and the nursing infant's serum. Am J Psychiatry 1980;137:8556.
  6. Erickson SH, Smith GH, Heidrich F. Tricyclics and breast feeding. Am J Psychiatry 1979;136:1483.
  7. Brixen-Rasmussen L, Halgrener J, Jorgensen A. Amitriptyline and nortriptyline excretion in human breast milk. Psychopharmacology (Berlin) 1982;76:945.
  8. Matheson I, Skjaeraasen J. Milk concentrations of flupenthixol, nortriptyline and zuclopenthixol and between-breast differences in two patients. Eur J Clin Pharmacol 1988;35;21720.
  9. Wisner KL, Perel JM. Serum nortriptyline levels in nursing mothers and their infants. Am J Psychiatry 1991;148:12346.
  10. Committee on Drugs, American Academy of Pediatrics. The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93:13750.

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Questions and Answers

Nortriptyline?, I'm currently taking Nortriptyline to prevent migrane headaches. I'm extremely nauseous and my chest hurts. Have any of you experienced these side effects and does it eventually go away as my body gets used to the drug?

This medication is great for chronic headaches but it can cause the side effects you mentioned. You did not say how long you had been on the medication. Sometimes the side effects will wear off after a few weeks. If you continue to have them, talk to the prescribing provider and ask them if you can reduce the dose. If you feel short of breath or like your heart is racing I would call them as soon as possible. It also helps if you take the medication at night. You also did not mention whether you take other medications-you always need to consider drug interaction.

Can a gastic bypass patience take nortriptyline?, Is nortriptyline safe to take if you have had gastric bypass? Due to the fact of no stomch anymore.

well, first, i'm not a doctor yet, but:
Nortriptyline has the role to increase the amount of norepinephrine in the synaptic cleft. Norepinephrine action on the alfa1 receptors in the stomach, causing contraction of the sphincters. Usually, the pilor muscle contracts and the gastric motility is reduced, causing enlargement of the stomach because of the food storage.
So, I think you should not take it...idk If it's totally correct but you can ask your doctor regarding what i said here.

What are your experiences with nortriptyline?, I was prescribed nortriptyline to help with recurring headaches and dizziness associated with back, neck and shoulder injuries.

It's an antidepressant which kind of scares me, what are your experiences with this medication? Have you ever heard of it being prescribed for something like this?

It's very common to prescribe tricyclic antidepressants for headaches and pain disorders. Even the newer SSRI/SNRI are prescribed for these reasons now, however, the pure SSRIs aren't as effective. Mainly it has to do with the action on serotonergic and noradrenergic receptors, as well as blocking activity at sodium channels.

Nortriptyline is one of the more effective TCAs for pain. Dosing for these disorders is usually less than for depression, although if you suffer from recalcitrant migraines, the dose may be as high as treating depression.

Overall, compared to SSRIs and SNRIs, it's relatively weak, although the incidence of side effects is probably higher. I won't mention those as to contaminate the process.

What are the effects of givng an infant 20mg nortriptyline?, I received 20 mg of Nortriptyline for five months as treatment for depression. I was 2 days short of my 3rd birthday when the medication started. The medical reports say the depressive symptoms lessened after 4 months and the dosage was gradually reduced during the 5th month. The information I have found relates to receiving the medication through breast milk, however I received Nortriptyline directly.

Why in the hell were you given an antidepressant as a small child????? That medication is not supposed to be given to children. And how do you diagnose a 2 year old as having depression???

is it safe to take nortriptyline 10mg while breastfeeding?, the doctor prescribed me the nortriptyline for back pain and said i could build up to 40mg before bed. my daughter is 1.5 years and is 23 lbs. i breastfeed mostly at night because she eats regular food during the day.

Safe use of nortriptyline hydrochloride during pregnancy and lactation has not been established; therefore, when the drug is administered to pregnant patients, nursing mothers, or women of childbearing potential, the potential benefits must be weighed against the possible hazards. Animal reproduction studies have yielded inconclusive results.

Has anyone used nortriptyline tablets to ease vulvoldynia/ vestibulities pain?, Extreme vulval pain with discharge for eight months, have tried Endep,
pregablin, and efexor with no help. Pandine fort makes little difference. Please, if anyone has any information.

I haven't but have talked to a few women in the past who have had good results with nortiptyline (Pamelor). If you are interested in joining a group to discuss treatment options available for vulvodynia please feel free to e-mail or IM me off site any time and I will give you the link.

What are the side effects of nortriptyline trazidine gabapentin taken in combination?, I have itching all over my body

Strange skin fungal infections and minor rashes can occur with that combo of drugs.

Those three drugs also should have a huge sedative effect in combination...

can i take chantix while I am on nortriptyline?, my regular md prescribed chantix and my neurologist prescribed chantix. I have been taking nortriptyline for 2 months with no side effects. I have had the chantix laying around for 3 months and I am ready to quit smoking.

Naomi,

Ok so I am in medical school and just started taking Chantix this past week. I would advise you to ask you doctor if he thinks it would be ok, but having looked this up myself it should not have any interactions with one another. However some of the common side effects are similar which may increase your chance of experiencing them. Right now the side effects I am experiencing with Chantix are fatigue, distaste, very minimal nausea and dizziness (rarely), weird dreams, and decreased attention span. However it is hard to explain how good it feels being on this medication. The feeling of relief you get while smoking that much needed cigarette occurs all day long! This is due to the activation of the nicotine receptors in your brain. Anyway I would consult your doctor before taking it, unless he is already aware of your nortriptyline, which he already took interactions between the two into consideration. Also another side note is that when you start Chantix the dosages are on a gradual scale meaning a gradual increase throughout a week. This gives you a chance to assess for any major interactions or side effects that may occur with you. Good luck, and congrats on your decision to quit!

Was given Nortriptyline by my pain clinic for multiple reasons?, 1) Sleep aid
2) Depression
3) To get boost of energy
4) To help with my pain (was told only little bit of help though)

I was told it can be used for my sleep problem with the first night I be out without problems is this true?

I take it as part of a pain management program to help nerve pain. Here are a few links you may enjoy.
http://health.discovery.com/centers/pain...
http://www.webmd.com/pain-management/def...
http://www.mayoclinic.com/health/pain-me...

How to remain off nortriptyline?, its been 3 weeks off after 25 years! any suggestions?
if i am functioning fine is there reason to go back on it?

well, i'm sure you've discussed this with your doctor...25 years' worth of drugs may take a long time to get out of your system, so i'd definitely keep in touch with your doctor either way.