Nortriptyline

INTRODUCTION

Indications

Various forms of depression. Unlabeled Use: Management of chronic neurogenic pain.

Action

Potentiates the effect of serotonin and norepinephrine. Has significant anticholinergic properties. Therapeutic Effects: Antidepressant action that develops slowly over several weeks.

Adverse Reactions/Side Effects

CNS: drowsiness, fatigue, lethargy, agitation, confusion, extrapyramidal reactions, hallucinations, headache, insomnia. EENT: blurred vision, dry eyes, dry mouth. CV: ARRHYTHMIAS, hypotension, ECG changes. GI: constipation, nausea, paralytic ileus, unpleasant taste, weight gain. GU: urinary retention. Derm: photosensitivity. Endo: gynecomastia. Hemat: blood dyscrasias.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report any rhythm disturbances or symptoms of increased arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Be alert for increased depression and suicidal thoughts and ideology, especially when initiating drug treatment or in children and teenagers. Notify physician or mental health professional immediately if patient exhibits worsening depression or other changes in mood and behavior.

• Assess blood pressure (BP) periodically and compare to normal values (See Appendix F). Report low BP (hypotension), especially if patient experiences dizziness or syncope.

• Watch for signs of leukopenia (fever, sore throat, signs of infection), thrombocytopenia (bruising, nose bleeds, bleeding gums), or unusual weakness and fatigue that might be due to anemia or other blood dyscrasias. Report these signs to the physician.

• Be alert for sedation, confusion, agitation, lethargy, hallucinations, or other alterations in mental status. Notify physician if these symptoms become problematic.

• Assess motor function, and be alert for extrapyramidal reactions including Parkinson-like symptoms, dyskinesias, dystonias, or other motor abnormalities. Report any motor problems that might affect gait, balance, and other functional activities.

• If used to treat chronic pain, assess pain levels periodically to help document drug efficacy.

• Periodically assess body weight and other anthropometric measures (body mass index, body composition). Report a rapid or unexplained weight gain or increased body fat.

Interventions

• Guard against falls and trauma (hip fractures, head injury, and so forth), and implement fall-prevention strategies (See Appendix E).

• Because of cardiac arrhythmias and abnormal BP responses, use caution during aerobic exercise and endurance conditioning. Assess exercise tolerance frequently (BP, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

• To minimize orthostatic hypotension, patient should move slowly when assuming a more upright position.

• Help patient explore nonpharmacologic methods to reduce depression (exercise, counseling, support groups, and so forth).

• If treating neuropathic pain or other pain syndromes, implement appropriate interventions (physical agents, manual techniques, therapeutic exercise) to manage pain and reduce the need ...