Low dose nortriptyline

[Librella]

My doctor wants to start me on the lowest dose (10 mg) of nortriptyline for chronic pain and stomach problems, insomnia, and anxiety. I’m scared to try it because of side effects. I don’t want to be too tired to work. I heard you can get bad withdrawal if you stop it suddenly too. Has anyone taken it? Is it worth trying?

[panic_down_under]

My doctor wants to start me on the lowest dose (10 mg) of nortriptyline for chronic pain and stomach problems, insomnia, and anxiety. I’m scared to try it because of side effects. I don’t want to be too tired to work. I heard you can get bad withdrawal if you stop it suddenly too. Has anyone taken it? Is it worth trying?

You should have few, if any issues taking 10mg. This is a very low dose. The usual starting dose for anxiety, or depression is 75mg. The tricyclic antidepressants generally produce fewer and less severe withdrawal symptoms than SSRIs and SNRIs and that would be even more the case from 10mg.

While low doses of nortriptyline are often prescribed for pain, 10mg is unlikely to do much for anxiety. The usual therapeutic dose range for anxiety/depression is 75-150mg (25-50mg for the elderly) with most needing to take at least 100mg for optimum results.

[WiseMonkey]

My doctor wants to start me on the lowest dose (10 mg) of nortriptyline for chronic pain and stomach problems, insomnia, and anxiety. I’m scared to try it because of side effects. I don’t want to be too tired to work. I heard you can get bad withdrawal if you stop it suddenly too. Has anyone taken it? Is it worth trying?

Hi, I would have thought that Amitriptyline would be better for chronic pain plus it is better for sleep. I used to take Doxepin 10 mgs which was great for me but it's not available anymore so switched to Ami. At this low dose it does not cause any withdrawl issues. I've been on low dose TA for over 25+ years for CFS and I've had no problems. I've taken breaks at various times too.

[Librella]

Thanks, that reassures me. I think she wanted to start at the lowest dose and increase as needed. I don’t know why nori over amitryptline. I’m taking it primarily for pain from IBS, so maybe that’s better for those issues.

[WiseMonkey]

Thanks, that reassures me. I think she wanted to start at the lowest dose and increase as needed. I don’t know why nori over amitryptline. I’m taking it primarily for pain from IBS, so maybe that’s better for those issues.

Yes, I originally had mine for IBS as well at the lowest dose and it's really helped, it cut down the flares I'd get.

[panic_down_under]

Hi, I would have thought that Amitriptyline would be better for chronic pain plus it is better for sleep.

Nortriptyline is the active metabolite of amitriptyline and I guess Librella's GP is just cutting out the 'middle man'. She might be right as nortriptyline is a more potent inhibitor of noradrenaline/norepinephrine (NA) than serotonin (5-HT) and NA reuptake inhibition seems to be (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5713449/) more critical to easing pain than blocking 5-HT reuptake is.

The other issue is serotonergic ADs tend to upset the enteric nervous system, the mini brain which controls the gut less than NA ADs do. The gut is by far the most serotonergic organ of the body. [Correction: The other issue is serotonergic ADs tend to upset the enteric nervous system, the mini brain which controls the gut MORE than NA ADs do.] Sigh! :doh:


ADs that are biased to inhibit NA tend to produce fewer withdrawal effects too although, as with everything about ADs, this isn't guaranteed. I doubt it matters much at these low doses anyway, but it may have psychological benefits.

[Librella]

Thank you panic down under for the detailed explanation of how this works!

[Librella]

Just an update as I’ve been taking this for 10 days now. I didn’t have any bad side effects, a little sleepy the first 3 days but then it faded. (Unfortunately, it hasn’t helped my middle of the night awakenings!) if anything I’ve noticed an increase in anxiety the past few days, but I don’t know if that’s related. Digestive symptoms still there but as I understand it that might take a few more weeks.

[panic_down_under]

Unfortunately, it hasn’t helped my middle of the night awakenings!

Nortriptyline is only mildly sedating. Its parent amitriptyline is much more potent in that regard.


if anything I’ve noticed an increase in anxiety the past few days

Unfortunately, this is the biggest drawback of most antidepressants, they often make anxiety worse in the beginning. It usually diminishes after a week, or two, but may return for a while following dose increases.

[Dasani95]

I just started 10mg every evening for headaches. I’m almost at a week. So far no side effects.

I haven’t had headaches as bad the last few days... but I don’t think the medication kicks in for a few weeks (maybe I’m wrong). Either way, coincidence or not — I’m glad I haven’t had headaches the last few days!

[WiseMonkey]

Nortriptyline is only mildly sedating. Its parent amitriptyline is much more potent in that regard. Unfortunately, this is the biggest drawback of most antidepressants, they often make anxiety worse in the beginning. It usually diminishes after a week, or two, but may return for a while following dose increases.

If you're looking for a sedating effect then Ami is the one to try and I'd try a low dose if the Nortripyline doesn't suit you. I don't know what dose you're taking but I didn't get any anxiety symptoms on either Doxepin (unavailable now) or Ami. The only noticeable symptoms I had was dry mouth and that wears off after a while.

TCA's suit some people's systems whereas the SSRI's and SNRI's just don't due to bad anxiety. It's good they're still available.

[Librella]

Just an update on this. Been taking it for 6 or 7 weeks now. The nortriptyline is going well. All the side effects disappeared after the first few weeks. However right now I feel like the chronic pain and IBS treatment benefits are also starting to wear off. I’m thinking I might ask for a higher dose. I’m only on 10mg. I have my follow up appointment next week to assess things with my doctor.

[panic_down_under]

However right now I feel like the chronic pain and IBS treatment benefits are also starting to wear off. I’m thinking I might ask for a higher dose. I’m only on 10mg.

The usual nortriptyline dose range for pain and IBS is 10-50mg with most taking 25-50mg.

[Librella]

I increased to 25mg. It's been a week and I don't feel any different, still like the efficacy has worn off which is disappointing. Will it take another few weeks for the benefits of the increased dose to be seen?

[panic_down_under]

I increased to 25mg. It's been a week and I don't feel any different, still like the efficacy has worn off which is disappointing. Will it take another few weeks for the benefits of the increased dose to be seen?

It (and other ADs) typically takes 4-6 weeks to reach peak effectiveness for general pain and migraines so don't give up on it yet.

[Librella]

I’m having some unpleasant side effects now. Dry mouth and constipation. I’m taking this for ibs so it’s just made me swing the other way! I messaged my doctor, but does anyone know if these side effects will fade after a few weeks or will it be something I deal with long term? I noticed the change when I went from taking 2 of the 10mg pills together to just one 25mg pill 2 weeks ago but I wouldn’t think there was so much difference in 5mg.

[panic_down_under]

I’m having some unpleasant side effects now. Dry mouth and constipation. I’m taking this for ibs so it’s just made me swing the other way! I messaged my doctor, but does anyone know if these side effects will fade after a few weeks or will it be something I deal with long term? I noticed the change when I went from taking 2 of the 10mg pills together to just one 25mg pill 2 weeks ago but I wouldn’t think there was so much difference in 5mg.

It seems the extra 5mg has taken the dose above the tripping point. Dry mouth and constipation are frequent ongoing side-effects of some TCAs due to their effect on acetylcholine receptors. I can't say whether they will be transient, or permanent. At typical antidepressive doses they would probably be permanent, but at low doses they may diminish after a few weeks. If they are still an issue after 4-6 weeks they will likely continue to some extent as long as you're taking nortriptyline. Sipping water and stool softeners should help.

[Librella]

Update:
It's been about a year since I started nortriptyline and I'm still on the 25 mg.
It's been helpful for pain but it took about 6 months to finally see all the benefits. Now, I've been having some pain creep up again. For IBS, it definitely helped my chronic daily problems but as you can probably see from my post history I still have quite a lot of inconsitency there. Also, the constipation caused by nor is sometimes rough. It hasn't helped with appetite/weight gain at all either even though tcas can cause weight gain supposedly. I'm not taking anything specifically for anxiety right now and have been debating talking to a psych about switching things up but I'm scared of possible withdrawal/relapse if I go off the nortriptyline. GI, GP, and therapist don't communicate with each other about meds of course. Just wondering if anyone else has experience with this.

It doesn't seem like TCAs are very popular at all considering the lack of activity in this forum.

[panic_down_under]

Also, the constipation caused by nor is sometimes rough.

Constipation and dry-mouth are usually the main ongoing TCA side-effects. A high fibre diet and drinking lots of water helps. Fortunately, consitpation hasn't been a problem on the TCA I'm on now despite on paper it being the TCA most prone to it, but it was on high doses of imipramine. I found adding about a tablespoon of crushed linseed, aka flax seed sprinkled on the morning cornflakes helped.


It hasn't helped with appetite/weight gain at all either even though tcas can cause weight gain supposedly.

This is true of most ADs, not just TCAs. The only ones that usually don't are bupropion (Wellbutrin) and trazodone, though even with these a few gain weight. Bupropion is a very stimulating ADs which can have those with anxiety disorders almost literally climbing the walls, however, small doses, <=75mg/day, taken with other ADs can ease weight gains.


I'm not taking anything specifically for anxiety right now and have been debating talking to a psych about switching things up but I'm scared of possible withdrawal/relapse if I go off the nortriptyline.

You don't necessarily need to quit nortriptyline if taking a SSRI. Before SNRIs it was common for psychiatrists to prescribe it in addition to a SSRI to create a bespoke SNRI for treatment-resistance anxiety, and/or depression. The combo is still arguably a better option than taking a SNRI.


GI, GP, and therapist don't communicate with each other about meds of course.

Sigh!!! :weep:


It doesn't seem like TCAs are very popular at all considering the lack of activity in this forum.

Put that down to ignorance. Most doctors these days have little experience of anything other than SSRIs/SNRIs and mirtazapine. TCAs are often more effective than SSRIs with fewer initial side-effects and withdrawal symptoms are are less likely to poop-out. The only advantages SSRIs have is safety in overdose, and even this isn't true of all of them, and they are less likely to cause constipation, though it can be a problem for some.