BNF for Children (BNFC) 2018-2019

(singke) #1

Nortriptyline


lINDICATIONS AND DOSE
Depressive illness
▶BY MOUTH
▶Child 12–17 years:To be initiated at a low dose, then
increased if necessary to 30 – 50 mg daily in divided
doses, alternatively increased if necessary to 30 – 50 mg
once daily; maximum 150 mg per day

lCONTRA-INDICATIONSArrhythmias.during the manic
phase of bipolar disorder.heart block


lCAUTIONSCardiovascular disease.chronic constipation.
diabetes.epilepsy.history of bipolar disorder.history of
psychosis.hyperthyroidism (risk of arrhythmias).patients
with a significant risk of suicide.phaeochromocytoma
(risk of arrhythmias).susceptibility to angle-closure
glaucoma.urinary retention
CAUTIONS, FURTHER INFORMATIONTreatment should be
stopped if the patient enters a manic phase.


lINTERACTIONS→Appendix 1 : tricyclic antidepressants


lSIDE-EFFECTSAgranulocytosis.alopecia.anxiety.
appetite decreased.arrhythmias.asthenia.
atrioventricular block.bone marrow disorders.breast
enlargement.confusion.constipation.delusions.
diarrhoea.dizziness.drowsiness.drug cross-reactivity.
drug fever.dry mouth.eosinophilia.fever.flushing.
galactorrhoea.gastrointestinal discomfort.
gynaecomastia.hallucination.headache.hepatic
disorders.hyperhidrosis.hypertension.hypomania.
hypotension.increased risk of fracture.increased risk of
infection.malaise.movement disorders.mydriasis.
myocardial infarction.nausea.oedema.oral disorders.
palpitations.paralytic ileus.peripheral neuropathy.
photosensitivity reaction.psychosis exacerbated.seizure.
sensation abnormal.sexual dysfunction.SIADH.skin
reactions.sleep disorders.stroke.suicidal tendencies.
taste altered.testicular swelling.thrombocytopenia.
tinnitus.tremor.urinary disorders.urinary tract dilation.
vision disorders.vomiting.weight changes
Overdose Tricyclic and related antidepressants cause dry
mouth, coma of varying degree, hypotension,
hypothermia, hyperreflexia, extensor plantar responses,
convulsions, respiratory failure, cardiac conduction
defects, and arrhythmias. Dilated pupils and urinary
retention also occur. For details on the management of
poisoning see Tricyclic and related antidepressants under
Emergency treatment of poisoning p. 832.


lPREGNANCYUse only if potential benefit outweighs risk.


lBREAST FEEDINGThe amount secreted into breast milk is
too small to be harmful.


lHEPATIC IMPAIRMENTSedative effects are increased in
hepatic impairment. Avoid in severe liver disease.
lMONITORING REQUIREMENTS
▶Manufacturer advises plasma-nortriptyline concentration
monitoring if dose above 100 mg daily, but evidence of
practical value uncertain.


lTREATMENT CESSATIONWithdrawal effects may occur
within 5 days of stopping treatment with antidepressant
drugs; they are usually mild and self-limiting, but in some
cases may be severe. The risk of withdrawal symptoms is
increased if the antidepressant is stopped suddenly after
regular administration for 8 weeks or more. The dose
should preferably be reduced gradually over about 4 weeks,
or longer if withdrawal symptoms emerge ( 6 months in
patients who have been on long-term maintenance
treatment). If possible tricyclic and related antidepressants
should be withdrawn slowly.
lPRESCRIBING AND DISPENSING INFORMATIONLimited
quantities of tricyclic antidepressants should be prescribed


at any one time because their cardiovascular and
epileptogenic effects are dangerous in overdosage.
lPATIENT AND CARER ADVICEDrowsiness may affect the
performance of skilled tasks (e.g. driving). Effects of
alcohol enhanced.

lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug. Forms available from special-order
manufacturers include: oral suspension, oral solution
Tablet
CAUTIONARY AND ADVISORY LABELS 2
▶Nortriptyline (Non-proprietary)
Nortriptyline (as Nortriptyline hydrochloride) 10 mgNortriptyline
10 mg tablets| 30 tabletP£ 6. 87 – £ 11. 79 | 100 tabletP
£ 68. 41 DT = £ 9. 57
Nortriptyline (as Nortriptyline hydrochloride) 25 mgNortriptyline
25 mg tablets| 30 tabletP£ 6. 81 – £ 12. 43 | 100 tabletP
£ 111. 06 DT = £ 11. 57
Nortriptyline (as Nortriptyline hydrochloride) 50 mgNortriptyline
50 mg tablets| 30 tabletP£ 24. 86 DT = £ 24. 86

2.4 Psychoses and schizophrenia


Psychoses and related disorders
06-Mar-2017

Advice on doses of antipsychotic drugs above BNF
for Childrenupper limit

.Consider alternative approaches including adjuvant
therapy.
.Bear in mind risk factors, including obesity. Consider
potential for drug interactions—see interactions:
Appendix 1 (antipsychotics).
.Carry out ECG to exclude untoward abnormalities such as
prolonged QT interval; repeat ECG periodicallyandreduce
dose if prolonged QT interval or other adverse abnormality
develops.
.Increase dose slowly and not more often than once weekly.
.Carry out regular pulse, blood pressure, and temperature
checks; ensure that patient maintains adequatefluid
intake.
.Consider high-dose therapy to be for limited period and
review regularly; abandon if no improvement after
3 months (return to standard dosage).
Important: When prescribing an antipsychotic for
administration on an emergency basis, the intramuscular
dose should belowerthan the corresponding oral dose
(owing to absence offirst-pass effect), particularly if the
child is very active (increased bloodflow to muscle
considerably increases the rate of absorption). The
prescription should specify the dose foreach routeand
should not imply that the same dose can be given by mouth
or by intramuscular injection. The dose of antipsychotic for
emergency use should be reviewed at leastdaily.

Antipsychotic drugs
There is little information on the efficacy and safety of
antipsychotic drugs in children and adolescents and much of
the information available has been extrapolated from adult
data; in particular, little is known about the long-term
effects of antipsychotic drugs on the developing nervous
system. Antipsychotic drugs should be initiated and
managed under the close supervision of an appropriate
specialist.
Antipsychotic drugs are also known as‘neuroleptics’and
(misleadingly) as‘major tranquillisers’.
In the short term they are used to calm disturbed children
whatever the underlying psychopathology, which may be
schizophrenia, brain damage, mania, toxic delirium, or

BNFC 2018 – 2019 Psychoses and schizophrenia 241


Nervous system

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