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Psychotropic Use during Pregnancy
Published in “Bert” Bertis Britt Little, Drugs and Pregnancy, 2022
The usual starting dosages for imipramine, amitriptyline, and desipramine are 25–50 mg daily at bedtime. The dose can be increased to 25–50 mg daily every week, if warranted, to a maximum dose of 300 mg daily. The initial dosage for nortriptyline is 10–25 mg PO q d and can be increased by 10 mg each week if necessary to a maximum dose of 150 mg daily (Bryant and Brown, 1986). However, if the pregnant patient’s depression is not improved on these older drugs, it is recommended to use one of the SSRIs. In fact, it may be beneficial to begin therapy with a well-studied SSRI such as fluoxetine (Yonkers, 2003).
Mood Disorders
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Madeleine A. Becker, Tal E. Weinberger, Leigh J. Ocker
When the use of antidepressant medication is indicated in a nursing woman, the drugs that should be preferred as first-line choice in a treatment-naive patient are paroxetine and sertraline, because of their good safety profiles as reported in exposed infants. However, if a woman has been stable on an antidepressant throughout her pregnancy, preference is usually to remain on that same medication postpartum, as evidence suggests that most infant SSRI levels are compatible with breastfeeding. The postpartum period, a period of significant vulnerability for women with mood disorders, is generally an inappropriate time to stop an effective medication and try another that has not been previously used or demonstrated to be helpful in a particular patient. These findings are in line with the recommendations of most authoritative guidelines [46, 200, 201, 203]. For the tricyclic antidepressants, nortriptyline is the preferred choice [201, 206]. Although most antidepressant drugs do not pose a risk to the nursing infant; consideration to the individual risk/benefit is necessary in each individual patient. Medications with longer half-lives are less preferred options as first-line treatment as they may accumulate in the infants, especially those that are premature or those with underlying medical conditions [199, 207]. Overall, positive benefits of breastfeeding outweigh possible adverse side effects of antidepressant drugs [206]. Long-term effects of infant exposure to SSRIs through nursing have been less well studied [206].
Clinical Pharmacogenomics Of Human Cyp2d6
Published in Shufeng Zhou, Cytochrome P450 2D6, 2018
A number of cases have been reported where marked CNS toxicities (e.g., dizziness and sedation) with increased nortrip-tyline plasma concentrations in PMs and individuals receiving CYP2D6 inhibitors such as terbinafine are documented (van der Kuy and Hooymans 1998). Cases of therapeutic failures in UMs on nortriptyline have also been documented (Bertilsson et al. 1985). However, the anticholinergic effects including inhibition of salivation and accommodation disturbances, sedation, blood pressure, and pulse rate did not differ between genotypes in healthy subjects receiving a single dose of nortriptyline (25 to 50 mg) (Dalen et al. 1998).
Rationale and design of a multicenter randomized clinical trial of vestibulodynia: understanding pathophysiology and determining appropriate treatments (vestibulodynia: UPDATe)
Published in Annals of Medicine, 2022
Erin T. Carey, Elizabeth J. Geller, Andrea Rapkin, Debbie Farb, Haley Cutting, Jasmyn Akaninwor, Christopher Stirling, Andrey Bortsov, Steven McNulty, Peter Merrill, Pearl Zakroysky, Jesse DeLaRosa, Sheng Luo, Andrea G. Nackley
Tricyclic antidepressants (TCAs) are the most commonly prescribed centrally-targeted treatment for the management of vulvar pain [10] and have been shown to improve sexual function [19]. An open trial of nortriptyline for 2 months found that 6/7 women had a complete or partial reduction in chronic pelvic pain [20]. In a case study, nortriptyline completely alleviated vaginal pain in a woman for whom topical lidocaine, oestrogen, and other peripheral treatments failed [21]. While the TCA Amitriptyline has been prescribed for vulvar pain, clinical studies demonstrating its efficacy are limited and upwards of 30% of women may discontinue its use due to sedation and other side effects [22]. The anti-epileptic Gabapentin has also been commonly prescribed for vaginal pain, however recent results from a randomized controlled trial found that gabapentin was ineffective in reducing pain among women with VBD [23]. Nortriptyline has been well studied for the treatment of other neuropathic pain disorders and evidence-based guidelines support its use as a first-line medication [24]. Nortriptyline produces analgesia via multiple molecular mechanisms in the CNS, including (1) inhibiting reuptake of norepinephrine to promote descending inhibition [25], (2) blocking sodium channels to inhibit the activity of nociceptive neurons [26], and (3) inhibiting the release of pro-inflammatory cytokines from glia so as to reduce neuroinflammation [27].
Successful treatment of acute worsening complex regional pain syndrome in affected dominant right-hand from secondary pathology of new onset third and fourth digit trigger finger
Published in Case Reports in Plastic Surgery and Hand Surgery, 2022
Multimodal treatments included occupational therapy for improved range of motion, hand and finger bracing, desensitization techniques; two sessions of scrambler therapy about 1 year apart; and neuropathic and opioid pain medications. Over the subsequent years, patient’s symptoms improved to a tolerable level of right-hand pain and improved finger range of motion. However, he suffered from continued allodynia and discoloration of the right wrist and palm, sudden shooting pains in the hand, and frequent dropping objects from the hand. He continued to take nortriptyline 60 mg daily, oxycodone/acetaminophen 5/325 mg twice a day as needed, and duloxetine 60 mg daily. Sympathetic block or spinal cord stimulation interventions were not pursued due to life-long anticoagulation and previous extensive cervical to lumbar spine fusion surgeries.
A systematic review and meta‐analysis of maintenance treatment for psychotic depression
Published in Nordic Journal of Psychiatry, 2022
Ahmed Al-Wandi, Christoffer Holmberg, Mikael Landén, Axel Nordenskjöld
In a randomized study by Navarro et al. 38 elderly patients aged 60 and older with psychotic unipolar depression received acute treatment with ECT and nortriptyline [18]. In patients who remitted, 16 received nortriptyline and ECT as a maintenance treatment. The ECT was administered weekly for the first month, and then every 2 weeks for another month, and then monthly until the end of the follow-up after 2 years. This group was compared with a group of 17 patients remitting from acute treatment who received nortriptyline monotherapy as maintenance treatment. The patients treated with nortriptyline monotherapy also received risperidone for 6 weeks after cessation of acute treatment; the dose of risperidone was gradually tapered-off for another 4 weeks. The study was conducted under single-blind conditions during the maintenance phase.