Nortriptyline Dosing Guidelines for Depression

Standard Adult Dosing

The American Academy of Family Physicians recommends a maintenance dose range of 75-150 mg/day for nortriptyline, with the total daily dose administered once daily at bedtime offering administrative advantages and not being inferior to divided dosing 1, 2
The American Academy of Family Physicians suggests that the maximum dose for elderly patients is 40 mg/day, given twice daily 1, 2

The American Academy of Family Physicians and Dialogues in Clinical Neuroscience recommend plasma level monitoring, with a target plasma concentration of 50-150 ng/mL 1, 2, 3, 4, 5, 6
Concentrations above 150 ng/mL are associated with decreased efficacy and increased adverse effects, according to Dialogues in Clinical Neuroscience 3, 4

The American Academy of Family Physicians recommends increasing the dosage using increments of the initial dose every 5-7 days until therapeutic benefits appear or significant side effects develop 1, 2
A full therapeutic trial requires at least 4-8 weeks, as suggested by the American Academy of Family Physicians 1, 2
Clinical monitoring should assess therapeutic response, adverse effects, and suicidal ideation within 1-2 weeks of starting therapy, according to Praxis Medical Insights 7

Nortriptyline tends to be more sedating than desipramine, making it particularly useful in patients with agitated depression and insomnia, as noted by the American Academy of Family Physicians 1, 2
The side effect profile of nortriptyline is similar to desipramine, with a lower risk for cardiotoxic, hypotensive, and anticholinergic effects compared to tertiary amine tricyclics, according to the American Academy of Family Physicians 1, 2

The American Academy of Family Physicians recommends continuing treatment for 4-9 months after a satisfactory response for patients with a first episode of depression 8
Patients with recurrent depression may require years to lifetime treatment, as suggested by Praxis Medical Insights 7