Pamelor vs Amitriptyline

If you have treatment-resistant depression and have already spent months trying SSRIs and SNRIs without finding relief from your depression symptoms, you may be ready to throw in the towel.

Don’t give up yet. 

There are antidepressants called tricyclic antidepressants that are usually prescribed after first-line depression treatments fail. 

If you are considering tricyclic antidepressants because other medications haven’t worked for you, two names you’ll want to know are Pamelor (Nortriptyline HCL) and Elavil (now only available in the US as generic Amitriptyline).

In this article, Klarity will explore both of these tricyclic medications so that you can decide which, if either, is suitable for you.

We’ll discuss—

• What tricyclic antidepressants are and how they work
• Potential side effects, drug interactions, and warnings
• How much each antidepressant cost
• The forms and doses of each
• Plus, we’ll answer some frequently asked questions the providers on Klarity often get asked

Speak to a board-certified mental health professional about your treatment-resistant depression in days—not weeks! Book an appointment on Klarity, and you’ll meet your new provider in 48 hours or less.

This article discusses suicide, suicidal ideation, and self-harm. If you or someone you know is experiencing suicidal thoughts or is in crisis, contact the Suicide Prevention Lifeline immediately at 800-273-8255.

Amitriptyline and Pamelor Are the Same Class of Drugs (Tricyclics)

Medical providers usually turn to tricyclic antidepressants after more modern antidepressants fail to relieve depression symptoms. Like other antidepressants, such as SSRIs and SNRIs, tricyclics elevate the amount of serotonin and norepinephrine available in the brain’s synapses. 

Low levels of serotonin and norepinephrine are associated with depression symptoms. Though tricyclics, SSRIs, and SNRIs elevate neurotransmitter levels, the physical mechanism each drug uses to accomplish this is different—

• SSRIs and SNRIs are more targeted (selective) and affect serotonin and norepinephrine receptors (dopamine, too) in the brain and central nervous system. 
• Tricyclics are less targeted (nonselective) and affect receptors all over the brain and body. This means Tricyclics will have more side effects than modern antidepressants because more receptors all over the body are affected. 

What Are Tricyclics?

Tricyclic antidepressants are a class of medications that were among the first developed to treat depression and other mood disorders. They have been in use since the 1950s and are named after their chemical structure, which contains three rings of atoms.

Tricyclic antidepressants work by increasing the levels of certain neurotransmitters, primarily serotonin and norepinephrine, in the brain. These neurotransmitters play a crucial role in regulating mood, and their increased availability is thought to help alleviate depressive symptoms.

Amitriptyline and Pamelor Are Both Used To Treat Major Depressive Disorder

Serotonin and norepinephrine are responsible for various aspects of cognition, emotion, and behavior. Both Pamelor and Amitriptyline prevent the “reuptake” of these neurotransmitters so that more are available for your brain to use. But why does your brain need more of these neurotransmitters in circulation?

• Low serotonin levels are linked to a higher risk of mood disorders, including depression and anxiety. Additionally, serotonin has a hand in regulating sleep, sexual functions, and wound healing. 
• Norepinephrine helps regulate emotions, concentration, and memory. It also helps regulate physical systems in the body, such as blood pressure, energy use, and blood sugar levels. Poor concentration, motivation, and energy are symptoms of depression. 

What Makes Amitriptyline and Pamelor Different From One Another?

The chemical structures of Amitriptyline and Pamelor are very similar. Both are compounds called amines—single nitrogen atoms bonded to a lone pair. Amitriptyline is a tertiary amine with three carbon atoms bonded to the nitrogen atom, and Pamelor is a secondary amine with only two carbon atoms attached to the nitrogen atom.

The chemical distinction between the two tricyclics is removed when the body digests Amitriptyline, effectively converting it to Pamelor (Nortriptyline HCL). This is why both medications are so similar—when the body goes to use either, each is effectively the same chemical compound. 

When treating depression, the only advantage of taking Pamelor is that it’s already in the final form that affects the targeted neurotransmitters. However, this is a very slight advantage, if at all.

There are greater differences between the two when treating other conditions and illnesses, though even here, there is overlap. 

What Else Does Amitriptyline Treat?

There are many off-label uses for Amitriptyline. A medical provider may prescribe it to treat any of the following conditions.

Off-label Uses for Amitriptyline

• Anxiety
• Irritable bowel syndrome (IBS)
• Insomnia
• Diabetic neuropathy
• Fibromyalgia
• Migraines
• Postherpetic neuralgia or post-shingles skin pain
• Post-traumatic stress disorder (PTSD)
• Sialorrhea or excessive saliva flow
• Interstitial cystitis or bladder pain syndrome

What Else Does Pamelor Treat?

Though Pamelor treats many of the same conditions as Amitriptyline, there are a few conditions Pamelor treats that Amitriptyline does not and vice versa. 

Off-label Uses for Pamelor that Amitriptyline Also Treats

• Diabetic neuropathy
• Migraines
• Postherpetic neuralgia or post-shingles skin pain

Off-label Uses for Pamelor that Amitriptyline Doesn’t Treat

• Neurogenic cough
• Chronic pain
• Persistent myofascial pain
• Trigeminal neuralgia or painful shock sensations on the face

Doses, Dosage Form, and Side Effects of Pamelor

Common Pamelor Doses and Forms

Pamelor is available in 10 mg, 25 mg, 50 mg, and 75 mg capsules. Additionally, it is available as a 5 mL oral solution.

For depression, patients often are directed to take 25 mg every six to eight hours and must not exceed 150 mg daily.

Common Pamelor Side Effects

Both Pamelor and Amitriptyline share many side effects because they are chemically very similar. Here is a list of Pamelor’s side effects:

• Blurred vision
• Impaired coordination
• Physical weakness
• Constipation
• Nausea and vomiting
• Sensitivity to sunlight
• Xerostomia or dry mouth
• Dizziness
• Excessive sweating
• Breast gland tissue growth 
• Insomnia
• Drowsiness
• Increased need to urinate
• Abnormal sensations
• Agitation
• Urinary retention
• Tremoring
• Disorientation
• Anxiety
• Changes in blood sugar levels
• Confusion
• Galactorrhea or nipple discharge
• Skin rash
• Itchy skin
• Restlessness

Common Pamelor Drug Interactions

This list of drug interactions is not exhaustive. Always share all medications, supplements, and dietary restrictions with your doctor before starting medication.

Avoid the following while taking Pamelor:

• Arbutamine
• Blood-thinning medications like Warfarin
• Disulfiram
• Thyroid Supplements
• Anticholinergic drugs
• Clonidine
• Guanabenz

Avoid taking MAO Inhibitors, which can cause a potentially fatal drug interaction. MAO inhibitors should be avoided two weeks before and after taking Pamelor.

Common MAO inhibitors include:

• Isocarboxazid
• Linezolid
• Metaxalone
• Methylene Blue
• Moclobemide
• Phenelzine
• Procarbazine
• Rasagiline
• Safinamide
• Selegiline
• Tranylcypromine 

Patients must be cautious when taking other medications that elevate serotonin levels to avoid developing serotonin syndrome.

Additionally, patients should monitor drugs that cause drowsiness when taking Pamelor, such as opioids, other painkillers, or allergy medications that induce drowsiness.

Here is an exhaustive list of drug interactions.

How Much Does Pamelor Cost?

Pamelor costs about $1250 for a 30-day supply of 10 mg capsules. Though with insurance, the price can be below $10 for a monthly supply. Generic Pamelor (Nortriptyline HCL) costs around $13 without insurance.

Doses, Dosage Form, and Side Effects of Amitriptyline

Common Amitriptyline Doses and Forms

Amitriptyline is available in tablet form at 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, and 150 mg.

To treat depression, medical providers often start patients with 25 – 50 mg/day tablets and increase the dose every 5 – 7 days up to 100 – 200 mg/day. Doctors recommend the medication be taken once a day at bedtime. 

Common Amitriptyline Side Effects

Though Amitriptyline is very similar to Pamelor, Amitriptyline has a few side effects that Pamelor doesn’t have. Here is a list of Amitriptyline’s most common side effects:

• Nausea
• Headaches
• Vomiting
• Dry mouth
• Drowsiness
• Physical weakness
• Confusion
• Nightmares
• Unsteadiness
• Excessive sweating
• Confusion
• Blurred vision
• Changes in weight
• Changes in appetite 
• Constipation
• Urinary retention 

Common Amitriptyline Drug Interactions

Being chemically comparable to Pamelor, many of the drug warnings for Amitriptyline will be similar.

Patients should avoid medications that thin the blood, MAO inhibitors, other serotonin-elevating drugs, and medications that induce drowsiness.

Common medications that thin the blood include

• Heparin
• Warfarin
• Aspirin
• Clopidogrel

Common MAO inhibitors include

• Marplan (Isocarboxazid)
• Nardil (Phenelzine)
• Emsam (Selegiline)
• Parnate (Tranylcypromine)

Here is an exhaustive list of drug interactions.

How Much Does Amitriptyline Cost?

Amitriptyline costs about $13 for a 28-day supply without insurance as a generic drug. With insurance, the price can be below $5.  

Do I Need A Prescription for Amitriptyline or Pamelor?

Yes, to take both Amitriptyline and Pamelor, a patient needs a prescription from a qualified medical provider. These medications are prescribed after modern antidepressants—like SNRIs and SSRIs—fail to relieve depression symptoms. 

Other Tricyclic Side Effects

Patients must be aware of other side effects that tricyclic medications (and other medications that affect a person’s neurotransmitter levels) can have on the mind and body.

Black Box Warning

All antidepressants come with a black box warning. In short-term studies, antidepressants, including amitriptyline and Pamelor, caused an increase in suicidal thoughts in children, teens, and young adults.

Mental health professionals and the children’s parents need to weigh the benefits of antidepressants against the risks and monitor for adverse changes in behavior and suicidal thoughts. This risk was not observed in patients between the ages of 25 and 65.    

What is Serotonin Syndrome?

When too much serotonin builds up in the brain due to medication, it can lead to a drug reaction called serotonin syndrome, which can be fatal. Mild serotonin syndrome can cause shivering and diarrhea, while severe serotonin syndrome can cause muscle rigidity, seizures, and fever. 

Serotonin syndrome most often occurs when starting a new drug or increasing the dose of a current drug. Patients need to monitor for serotonin syndrome symptoms, usually within a few hours of taking a new drug or drug dose. 

Symptoms of serotonin syndrome include

• Agitation
• Insomnia
• Restlessness
• Confusion
• Rapid heart rate
• Dilated pupils
• Loss of muscle control
• Seizures
• High blood pressure
• Shivering
• Diarrhea

Pregnancy and Breastfeeding on Tricyclics

It is generally considered safe for mothers taking nortriptyline to breastfeed with no risk to the child. Though nortriptyline does pass through breast milk, the amount is minimal. A few studies reported no side effects from nortriptyline exposure.

Increased Bleeding Risk With Tricyclics

When taken in combination with blood thinners, tricyclics can increase the risk of bleeding by exacerbating the effects of the blood thinners. However, no evidence suggests tricyclics increase bleeding risk when used alone. 

Pamelor and Amitriptyline Frequently Asked Questions

We’ve compiled common questions we receive from patients below:

What is Pamelor?

Pamelor (nortriptyline) is a tricyclic antidepressant medication that helps treat depression symptoms and other conditions off-label.

What is Amitriptyline?

Amitriptyline is another tricyclic antidepressant medication used to treat depression and other conditions.

Are Pamelor, Amitriptyline, and other Tricyclics the same drug?

Tricyclics as a drug category are relatively diverse. However, Pamelor and Amitriptyline are nearly identical chemically. When the body digests Amitriptyline, it converts into nortriptyline (Pamelor). Though there are slight differences, they are effectively the same drug. 

Why is Pamelor an off-label treatment for anxiety?

Serotonin and norepinephrine are vital neurotransmitters that help regulate thoughts, mood, and behavior. Medications such as Pamelor that elevate serotonin and norepinephrine can help regulate mood disorders like anxiety, reducing anxiety symptoms. 

What’s better for anxiety? Pamelor or Amitriptyline?

Both Pamelor and Amitriptyline can help relieve anxiety symptoms. However, they aren’t more effective than other medications explicitly used to address anxiety. Because both drugs are similar, one doesn’t have the edge over the other.

What’s better for depression? Pamelor or Amitriptyline?

Both Pamelor and Amitriptyline are clinically proven to be effective at treating symptoms of depression. These two medications are nearly identical and have very similar side effects. In general, one isn’t remarkably better at treating depression than the other. However, you might tolerate one medication better than the other. 

Can I drive on antidepressants like Pamelor or Amitriptyline?

Both medications can cause drowsiness. Before operating heavy machinery, driving, or doing other attention-oriented tasks, it’s essential to fully understand how the medication impacts you.

However, you can drive on Pamelor or Amitriptyline if you do not experience drowsiness as a side effect or if that side effect goes away after a few weeks. 

Can I drink alcohol on Pamelor or Amitriptyline?

It is not recommended that people taking tricyclics consume alcohol. Drinking alcohol while on tricyclics can make the medication’s side effects worse.  

Does it matter what time of day I take Pamelor or Amitriptyline?

Due to potential drowsiness as a side effect, most mental health professionals recommend taking these medications at night before bed. 

Klarity Can Connect You With A Depression Specialist In Under 48 Hours

Do you have treatment-resistant depression but can’t afford to wait weeks to see an in-person provider and get the treatment you need? Klarity makes finding online depression treatment easy.

Book an appointment on Klarity, and we’ll connect you with a medical provider in under 48 hours.

No more lengthy waiting periods and weeks in between follow-ups. You get the care you need fast.

Sources

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Cait O’Sullivan, PharmD; Courtenay, BC; Cristi Froyman, RPh; Kelowna, BC. “Nortriptyline safer than amitriptyline?” National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6135127/

“Compare Elavil vs. Pamelor.” Iodine. https://www.iodine.com/compare/elavil-vs-pamelor

Editorial Staff at Hims. “Nortriptyline vs Amitriptyline: What’s The Difference?” Hims. https://www.forhims.com/blog/nortriptyline-vs-amitriptyline

Mayo Clinic Staff. “Monoamine oxidase inhibitors (MAOIs).” Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/maois/art-20043992

Annamarya Scaccia. “Everything You Need to Know About Serotonin.” Healthline.  https://www.healthline.com/health/mental-health/serotonin#functions