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Depression
21 min read
Written by Klarity Editorial Team
Published: Jan 13, 2023
Medically Reviewed by Dr. Zoe Russell
Living with depression can be exhausting, especially if you have yet to find relief from your symptoms. It can take time to find the right treatment for you, and with all of the available medication options available, it can be difficult to understand which one will work best for your depression.
This article looks deeper into two commonly prescribed antidepressant medications, Nortriptyline and Amoxapine. We will discuss what they are used for, their potential side effects, and warnings associated with each so that you can be better informed when discussing treatment options with your healthcare provider.
If you are experiencing depression symptoms, medications like Nortriptyline or Amoxapine may be able to help. To determine if these drugs or another form of antidepressant is right for you, find a provider on Klarity today for online depression treatment in as little as 48 hours.
Amoxapine | Nortriptyline | |
Drug Class | Tricyclic antidepressant | Tricyclic antidepressant |
Brand / Generic Status | Generic (Brand name: Asendin) | Generic (Brand name: Pamelor) |
Form(s) of the Drug | Immediate-release color-coded tablets | • Immediate-release capsules • Clear, cherry-flavored liquid suspension |
Standard Dosage | Immediate-release color-coded tablets: • 25mg: white • 50mg: orange • 100mg: blue • 150mg: light orange | Immediate-release capsules: • 10mg • 25mg • 50mg • 75mg Liquid suspension: • 10mg per dose |
Conditions Treated | FDA-approved: • Depression with psychotic features • Nerve pain Off-label: • Difficulty sleeping | FDA-approved uses: • Major depressive disorder Off-label uses: • Diabetic neuropathy • Migraines • Postherpetic neuralgia or post-shingles skin pain • Neurogenic cough • Chronic pain • Persistent myofascial pain •Trigeminal neuralgia or painful shock sensations on the face |
Cost | Generic (amoxapine): • $20 to $36 for a 30-day supply Brand name: • Brand name formula not available for Rx | Brand name (Pamelor): • $1250 for a 30-day supply (no insurance) • $10 for a 30-day supply (with insurance) Generic form (nortriptyline): • $13 for a 30-day supply |
Side-Effects | Common side effects: • Sedation or drowsiness • Dry mouth • Constipation, nausea • Fatigue or weakness • Blurred vision • Anxiety or restlessness • Insomnia or difficulty sleeping • Confusion or altered consciousness • Palpitations or changes in EKG patterns • Tremors • Increased appetite causing changes in weight over time Serious side effects • Signs of Neuroleptic • Malignant Syndrome (NMS) • Serotonin syndrome • Increased suicidal thoughts or self-harm behaviors | Common 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 Serious side effects: • Blurred or tunnel vision • Eye pain • Seeing halos around lights • Seizure • Chest pain • Jaundice • Difficulty urinating • Fever or sore throat • Bruising or bleeding • Numbness or slurred speech |
Warnings For Use | Drug interactions • Other anticholinergic medications • Blood pressure medication • Alcohol and barbiturates • MAOIs • SSRIs • Thyroid supplements | Drug interactions: • Arbutamine • Blood thinning medications like • Warfarin • Disulfiram • Thyroid Supplements • Anticholinergic drugs • Clonidine • Guanabenz • MAOIs |
Amoxapine and Nortriptyline are two commonly prescribed medications that belong to the same class of drugs called tricyclic antidepressants (TCAs). Although they share many characteristics, they are two different medications with unique properties, which we will discuss below.
Tricyclics were among the first antidepressant medications to be developed. While they are no longer considered to be first-line agents for the treatment of depression, they are still used in certain cases, such as those who cannot tolerate other antidepressants or for those who have treatment-resistant depression and cannot find relief from their symptoms with other methods.
Tricyclics act by increasing two important neurotransmitters, norepinephrine and serotonin. These chemical messengers are important in many bodily functions, such as mood regulation, sleep, appetite, and sex drive. Decreased levels of these neurotransmitters are responsible for the symptoms of depression, and tricyclic antidepressants work to correct this imbalance.
Tricyclics are not selective in the neurotransmitters that they target unlike SSRIs and SNRIs. For this reason, TCAs can affect other parts of the brain unrelated to mood, which can cause an increased risk of negative side effects.
Major depressive disorder is one of the most common psychiatric disorders, characterized by a loss of interest in pleasurable activities and feelings of sadness. Depression presents differently from person to person, but some shared symptoms include:
Amoxapine is a unique tricyclic medication because it affects dopamine, serotonin, and norepinephrine. Dopamine plays a role in hallucinations and delusional thought processes, which makes this medication useful in treating depression with psychotic features.
In addition to treating anxiety and depression, Amoxapine is commonly prescribed to treat nerve pain. Because of its sedating effects, it may be a better choice for patients who have agitation associated with their depression.
Like most TCAs, Amoxapine has sedative effects and, therefore, can be potentially useful in treating insomnia.
Nortriptyline is only FDA-approved to treat depression. However, it has several off-label uses, which is a term used to describe any indication that has not been approved by the FDA. This does not mean that the medication is not effective for the given condition but that the drug manufacturer has not gone through the extensive FDA research process.
The most common off-label uses for Nortriptyline include:
Nortriptyline, also known by its brand name, Pamelor, is a tricyclic antidepressant that is used to treat depression. It is used off-label to treat a number of other conditions as well, including headaches, anxiety, and various forms of nerve pain.
Nortriptyline is also known by its brand name, Pamelor, and is available in capsules as well as an oral solution. The capsules come in the following dosages: 10 mg, 25 mg, 50 mg, and 75 mg, while the oral solution is one concentration of 10 mg/5mL and is typically reserved for those who have difficulty swallowing pills.
As with most psychotropic medications, the initial starting dose is low, around 25 mg, and is taken multiple times throughout the day. The dose can then be titrated up every week until the desired dose is reached, but it should not exceed 150 mg per day.
As with most TCA medications, there are a number of side effects that are associated with Nortriptyline. This unfavorable side effect profile is one of the main reasons TCA medications are no longer considered first-line agents for depression treatment.
Some common side effects associated with Nortriptyline include:
Due to extensive drug interactions associated with TCA medication, disclose all medications and supplements you are currently taking with your healthcare provider before starting a new medication.
Some common drug interactions with Nortriptyline include:
Pamelor is the brand name of the generic drug Nortriptyline. The cost of your monthly supply of medication will dramatically vary based on your insurance coverage, which dose you are on, and what pharmacy you use.
Most insurance plans cover Nortriptyline, and coupon codes can significantly lower the cost of your prescription if you are underinsured or uninsured. The retail price of name brand Nortriptyline is typically over $1200 for a 30-day supply, but using a generic formulary and coupons, you can reduce the cost to under $15 per month.
Amoxapine, or Asendin, is a tricyclic antidepressant with unique effects on dopamine in the brain. Amoxapine’s properties result in mild antipsychotic effects, making it useful in treating more severe forms of depression with psychotic features or agitation. It can also be helpful in treating insomnia and chronic nerve pain.
Amoxapine is also known by its brand name Asendin, and is available in tablets with the following dosages: 25 mg, 50 mg, 100 mg, and 150 mg. Similar to Nortriptyline, the initial dose is typically started low, around 25 mg, and it can be increased weekly to the targeted dose.
The maximum daily dose of Amoxapine is 400 mg per day and 600 mg per day in patients who are in a hospitalized setting and are being closely monitored by healthcare professionals.
Nortriptyline and Amoxapine share many side effects because they belong to the same class of medication and work in a similar way in the body.
Some common side effects of Amoxapine include:
Similar to side effects, Amoxapine and Nortriptyline share many drug interactions as well. When starting a new medication, it is important to disclose all medication you are currently taking with your healthcare provider, including all over-the-counter medications and supplements.
Some common drug interactions seen with Amoxapine include:
The cost of your Amoxapine or Asendin prescription varies based on your insurance coverage, dosage, and pharmacy. For those who are uninsured, there are coupon codes available at most commercial pharmacies that can significantly lower the cost of your prescription from its retail price of $42 to around $20 for a 30-day supply.
Yes, you need a prescription from a state-licensed healthcare provider for all tricyclic antidepressant drugs, including Amoxapine and Nortriptyline. As discussed, there are a number of serious side effects and drug interactions associated with TCAs, making this class of medication not the best choice for certain groups of people.
Your healthcare provider will determine if you may benefit from starting a TCA medication.
The unfavorable side effect profile of TCA medications is one of the main reasons why they are no longer considered first-line agents in the treatment of depression. There are a few rare but serious side effects associated with TCAs as a class that will be discussed below.
Serotonin syndrome is an uncommon but serious and potentially life-threatening condition that occurs when there are dangerously high levels of serotonin built up within the body. This most commonly occurs when someone is taking more than one medication that increases the level of serotonin in the body.
It is important to closely monitor yourself when starting a TCA medication for the following signs and symptoms and seek out urgent medical attention if you begin to experience:
Tricyclic antidepressants should be avoided during pregnancy because of the potential complications during gestation:
If you are taking a TCA medication when you get pregnant, your healthcare provider can provide alternative medication options that are safe during pregnancy. If you restart your TCA medication immediately after birth, it is generally considered safe to breastfeed while taking your medication because there are low levels of the drug found within breast milk.
The majority of antidepressant medications are associated with a black box warning for worsening depression and suicidal ideation once starting a new medication. While this is rare and most commonly seen in those under the age of 24, it is important to monitor yourself for negative changes in mood or thought process when starting a new antidepressant.
You should always follow your healthcare provider’s instructions on how to take your medication, but this is particularly important with tricyclic medications. We have previously discussed how TCAs are no longer considered first-line treatment because of their side effects, but they are also considered to be dangerous if not taken as prescribed.
When TCAs are taken in high doses, there is a serious risk of heart arrhythmias or irregular heartbeats that can be deadly if not treated immediately. For this reason, TCAs should be avoided in those with a history of suicide attempts or who are actively suicidal.
In addition, TCAs should be avoided or used with great caution in the elderly population for several reasons. Firstly, the risk of developing serious side effects is much higher in those over 65, particularly fatal cardiac events. In addition, cognitive decline is inevitable with age, and elderly patients are more likely to struggle with remembering if or when they took their medications, resulting in a risk of accidental overdose.
With so many antidepressant options available, each with its own benefits and side effect profiles, it can be difficult to find the right one for you without the help of an experienced healthcare provider. For this reason, you should never attempt to self-medicate your symptoms and should always consult with a psychiatric expert to receive a safe and effective prescription.
Klarity has connected thousands of patients nationwide with healthcare providers for affordable and straightforward online mental health treatment. Find a provider today and discuss your symptoms in a private telehealth appointment to determine if Nortriptyline, Amoxapine, or another antidepressant is right for you.
We understand that comparing two medications from the same class of drugs can get confusing, so we have answered some of the most frequently asked questions about Nortriptyline and Amoxapine below.
Although they belong to the same class of medications and have many similarities, Nortriptyline and Amoxapine are two unique drugs.
Nortriptyline is not a first-line treatment for anxiety because there are newer, safer, and more effective medications used to treat anxiety. Pamelor can still be effective in some patients who cannot tolerate first-line drugs.
Although neither medication is FDA-approved nor considered a first-line treatment for anxiety, Nortriptyline is a better choice for treating anxiety when compared to Amoxapine.
While both medications are used to treat depression, Asendin may be a better treatment option for severe depression with psychotic features or with agitation. Pamelor would likely be a better option for mild depression, as it has a better side effect profile.
Due to the sedating effects of TCAs, you should not drive or operate heavy machinery after taking Nortriptyline or Amoxapine.
Drinking alcohol should be avoided when taking a TCA medication for several reasons, including the increased risk of adverse effects. There is also a greater potential for dangerous CNS depression and sedative effects when combining the two drugs.
Because of their sedative effects, TCA medications are typically taken at night before bed. Your healthcare provider will instruct you on how to take your medication as they see fit.
Sources:
“Amoxapine” GoodRx. https://www.goodrx.com/amoxapine
“Amoxapine: Drug Information” UpToDate. https://www.uptodate.com/contents/search?search=amoxapine&sp=0&searchType=PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOWN&searchOffset=1&autoComplete=false&language=&max=0&index=&autoCompleteTerm=&rawSentence=
“Amoxapine Prices, Coupons, and Patient Assistance Programs” Drugs.com. https://www.drugs.com/price-guide/amoxapine#:~:text=The%20cost%20for%20amoxapine%20oral,accepted%20at%20most%20U.S.%20pharmacies.
“Compare amaxapine vs Pamelor” Iodine. https://www.iodine.com/compare/amoxapine-vs-pamelor
“Generic Pamelor” GoodRx. https://www.goodrx.com/pamelor
“Nortriptyline: Drug Information” UpToDate. https://www.uptodate.com/contents/nortriptyline-drug-information?source=auto_suggest&selectedTitle=1~1—1~4—nortri&search=nortriptyline
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