Tapering Nortriptyline: Guidelines for Discontinuation

Introduction to Tapering

• The American Geriatrics Society recommends that nortriptyline at 20mg daily should not be stopped abruptly and requires a gradual taper to minimize withdrawal symptoms and ensure patient safety 1

Withdrawal Risk with Tricyclic Antidepressants

• Tricyclic antidepressants (TCAs) like nortriptyline can cause a discontinuation syndrome when stopped abruptly, primarily manifested as adrenergic hyperactivity 1, 2
• Even at relatively low doses used for pain management (which includes 20mg daily), tapering is advisable to reduce the risk of withdrawal symptoms 1

Recommended Tapering Approach

• A reasonable starting point for tapering is to reduce the dose by approximately 10% of the original dose per week 3
• For patients who have been on nortriptyline long-term, consider slower tapers (10% per month or less) 3
• For 20mg daily dosing, a practical approach would be to reduce to 10mg daily for the first two weeks, then to 10mg every other day for the next two weeks, and finally discontinue completely by the fifth week 1, 3

Monitoring During Taper

• Watch for withdrawal symptoms which typically appear within days of dose reduction and may last 1-3 days per step 3
• Common withdrawal symptoms include adrenergic hyperactivity (increased heart rate, blood pressure) 1, 2
• Sleep disturbances are also a common withdrawal symptom 3

Special Considerations

• If withdrawal symptoms become severe, pause the taper and restart when the patient is ready 3
• Do not mistake withdrawal symptoms for recurrence of the original condition (pain or depression) 3

When Immediate Discontinuation Might Be Considered

• In cases of confirmed medication diversion, immediate discontinuation might be considered 4, 5, 6
• When the current treatment involves significant immediate danger to the patient, immediate discontinuation might be considered 4, 5, 6
• Even in these scenarios, clinical supervision is strongly recommended 4, 6

Managing Withdrawal Symptoms

• Consider supportive medications for specific symptoms if they occur 3
• Use sleep hygiene measures for sleep disturbances 3

Pitfalls to Avoid

• Tapering too quickly, which increases withdrawal risk 3
• Assuming that a low dose (20mg) doesn't require tapering - even low doses of TCAs should be tapered 1, 2