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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by linkadge on July 12, 2009, at 10:50:27
I may be starting nortriptyline. I have a few questions.
1) How commonly do doctors use nortriptyline blood levels to guide treatment these days?
2) Approximately what doses of the drug correspond to theraputic blood levels?
3) Does anyone have any links to pharmokinetic activitys of the drug (ie how long it takes to achieve a certain plasma level).
I have a feeling I won't be able to get up that high on the dosage due to cardiac effects (they always get me).
Linkadge
Posted by linkadge on July 12, 2009, at 10:55:35
In reply to Nortriptyline questions -SLS?, posted by linkadge on July 12, 2009, at 10:50:27
Also,
Is it common to go to 75mg then see what happens or do most doctors consider 150mg a target?
Linkadge
Posted by SLS on July 12, 2009, at 12:23:51
In reply to Re: Nortriptyline questions -SLS?, posted by linkadge on July 12, 2009, at 10:55:35
Hi Linkadge.
I don't think most doctors using nortriptyline use blood levels in their clinical titration, although they can be extremely valuable. Nortriptyline is the most well-studied antidepressant with regard to blood levels and clinical response. If one takes 75mg for a month and nothing is happening, it can be ascertained whether or not that dosage was within the therapeutic range. Actually, you can get a blood level after a week or so subsequent to a dosage adjustment. So you can see how getting blood levels can expedite a titration process.
For most people, 75mg is the target dosage for nortriptyline. If one is a rapid metabolizer, he may need as much as 150mg. Assaying a blood concentration represents a good guideline to determine if such a high dosage is warranted. The therapeutic range for blood levels is 50-150ng/ml. This is to be used as a guideline, but empirical observation is still important. Just because you are at 60ng/ml does not mean that this is your ideal dosage. You might need to be at the higher end of the scale to reap any benefits.
Your heart rate is bound to increase with nortriptyline. Perhaps you can titrate the drug gradually enough so that your body can ease into it. If you are determined not to go through life with an elevated heart rate, at least you can perform this TCA experiment as a brief trial to gain information as to what you are responsive to. If you do respond well to nortriptyline, I would suggest to you to research the consequences of having an elevated heart rate. Remember, though, that nortriptyline is a NE alpha-1 agonist, and will decrease vascular tone peripherally. The places less of a load on the heart. My guess is that after awhile, your heart rate should return to 80 bpm or so. I'll be curious to see how nortriptyline affects you.
Good luck.
- Scott
Posted by bulldog2 on July 12, 2009, at 14:31:11
In reply to Nortriptyline questions -SLS?, posted by linkadge on July 12, 2009, at 10:50:27
> I may be starting nortriptyline. I have a few questions.
>
> 1) How commonly do doctors use nortriptyline blood levels to guide treatment these days?
>
> 2) Approximately what doses of the drug correspond to theraputic blood levels?
>
> 3) Does anyone have any links to pharmokinetic activitys of the drug (ie how long it takes to achieve a certain plasma level).
>
> I have a feeling I won't be able to get up that high on the dosage due to cardiac effects (they always get me).
>
> LinkadgeI took nortriptyline a few times. I'm very sensitive to drug side effects. Anyhow the first time I took it I was in my 40's and got a robust ad response at only 50 mg and stayed there. Realy got used to all the sides. Had to use a laxative because for me constipation was bad.
Posted by linkadge on July 12, 2009, at 14:55:10
In reply to Re: Nortriptyline questions -SLS?, posted by bulldog2 on July 12, 2009, at 14:31:11
Thanks for the feedback.
So, if a person was to respond to 75mg you don't think a doctor would bother doing a blood test?
Linkadge
Posted by linkadge on July 12, 2009, at 14:57:45
In reply to Re: Nortriptyline questions -SLS?, posted by bulldog2 on July 12, 2009, at 14:31:11
When I took clomipramine I noticed that I started to feel best about 20 hours after taking the drug - much more energy and improved mood. The matabolite, desmethylclomipramine is much more like nortriptyline in its affinity ratios for uptake pumps.
I am hoping that this is an indication of how I will respond.
Linkadge
Posted by SLS on July 12, 2009, at 15:30:11
In reply to Re: Nortriptyline questions -SLS?, posted by linkadge on July 12, 2009, at 14:55:10
> Thanks for the feedback.
>
> So, if a person was to respond to 75mg you don't think a doctor would bother doing a blood test?
>
> LinkadgeProbably not, but if you would feel more comfortable getting a blood level, you might as well do it. Perhaps you'll find that you can get away with a reduced dosage. Some people do respond to 50mg. Think of nortriptyline as being twice as potent as imipramine or amitriptyline milligram per milligram. Most people respond to imipramine around 150mg or so.
NOR IMI
50mg = 100mg
75mg = 150mg
150mg = 300mgIt is really up to you. Because you are so cautious with the use of TCAs, you might as well start out at 10mg and move up slowly from there. In this way, you might reduce the magnitude of the side effects. If you never took nortriptyline before, it might be soporific in the beginning, but this wears off quickly.
If you deem your depression to resemble the classic melancholic endogenous depression, the TCAs might be your best choice at this point.
I wish you luck and really hope that the startup side effects are tolerable.
- Scott
Posted by bulldog2 on July 12, 2009, at 16:20:35
In reply to Re: Nortriptyline questions -SLS?, posted by linkadge on July 12, 2009, at 14:57:45
> When I took clomipramine I noticed that I started to feel best about 20 hours after taking the drug - much more energy and improved mood. The matabolite, desmethylclomipramine is much more like nortriptyline in its affinity ratios for uptake pumps.
>
> I am hoping that this is an indication of how I will respond.
>
> LinkadgeAdd a dash of lexapro or zoloft? small dash..maybe 5 mg selegiline? make a nice cocktail..
Posted by viper1431 on July 12, 2009, at 16:23:36
In reply to Re: Nortriptyline questions -SLS?, posted by SLS on July 12, 2009, at 15:30:11
Nortriptyline didn't actually end up increasing my heart rate, i was on a high dose. Imipramine though sent it souring.
On the other hand nortriptyline made me really agitated where as imipramine did the opposite :S
Posted by linkadge on July 12, 2009, at 16:39:35
In reply to Re: Nortriptyline questions -SLS?, posted by viper1431 on July 12, 2009, at 16:23:36
How much nortriptyline were you taking?
Linkadge
Posted by viper1431 on July 12, 2009, at 23:15:44
In reply to Re: Nortriptyline questions -SLS? » viper1431, posted by linkadge on July 12, 2009, at 16:39:35
150mg
> How much nortriptyline were you taking?
>
> Linkadge
Posted by bleauberry on July 13, 2009, at 17:41:36
In reply to Nortriptyline questions -SLS?, posted by linkadge on July 12, 2009, at 10:50:27
I have to give two thumbs up to nortriptyline, no matter what the dose, ranging from a mere 5mg all the way up to 150mg. Details another day.
I noticed a trend at pubmed where nortriptyline is better tolerated and more effective than ssris in specific populations of either male, elderly, or both, and in the melancholic depression types.
This is the end of the thread.
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