Correlation of Subjective Side Effects with Plasma Concentrations of Nortriptyline

Plasma levels of tricyclic antidepressant drugs vary considerably between individuals receiving the same amount of drug. The bearing of this variation on the occurrence of subjective side effects was investigated in 40 psychiatric inpatients with depressive disorders. Plasma levels were determined before and during four weeks of treatment with nortriptyline 50 mg. three times a day and patients were rated for subjective side effects, the assessors being unaware of the plasma levels of the drug.Plasma levels varied widely between individual patients, but in any given patient the plasma level tended to be constant over a period of time. The side effects of nortriptyline diminished significantly with time and were in most cases absent during the fourth week of treatment. There was a significant positive correlation between plasma level of nortriptyline and subjective side effects.The steady-state plasma level of a drug which is metabolized is usually a more important determinant for its effect than dosage, since it reflects the amount of drug available for biological action. Very high plasma levels of nortriptyline should presumably be avoided, since there is no evidence that they are needed for therapeutic effect and they are potentially harmful.     

Steady-state plasma levels of nortriptyline in twins: Influence of genetic factors and drug therapy

Nineteen identical (monozygotic) and 20 fraternal (dizygotic) sets of twins between 45 and 51 years of age were given nortriptyline orally in doses of 0·2 mg./kg. body weight three times daily for eight days. The steady-state plasma concentrations of nortriptyline were calculated from the mean of the determinations for days 6, 7, and 8. Identical twins, not treated with other drugs, achieved similar steady-state plasma concentrations of nortriptyline in contrast to fraternal twins who were not given other drugs. The intrapair similarity in steady-state plasma concentrations was not found in identical twins simultaneously treated with various drugs during the experiment. Identical and fraternal twins treated with drugs containing barbiturates had considerably lower steady-state plasma concentrations of nortriptyline compared with untreated twins.It is concluded that most of the variability in nor-triptyline steady-state plasma concentration between persons who have not received drugs is genetically determined. Exposure to other drugs also influences the steady-state plasma concentration of nortriptyline, which in a given patient may therefore be determined by a resultant of genetic and environmental factors.     

Simplified method for monitoring tricyclic antidepressant therapy using gas—liquid chromatography with nitrogen detection

A simplified gas chromatographic method for the rapid measurement of tricyclic anti-depressant drugs in plasma using a nitrogen-sensitive detector is described. All drugs are extracted and chromatographed under identical conditions. Tertiary amines are separated from their secondary amine metabolites, which are determined simultaneously without the need for derivatisation. The lower limit of accurate determination for most drugs is 10 μg/1.

The method has been applied to the routine measurement of amitriptyline and nortriptyline in plasma from patients receiving antidepressant treatment. Large and important interindividual differences in plasma concentrations in the patients investigated have been found, and the significance of these results is discussed.     

Relationship between Plasma Level and Therapeutic Effect of Nortriptyline

The relationship between plasma concentration of nortriptyline and therapeutic effect after two weeks'' treatment with the drug was investigated in 29 psychiatric inpatients. Endogenous depression was diagnosed in all patients. Amelioration of depressive symptoms was estimated as reduction in score on a rating scale, based on a psychiatric interview. Amelioration was not correlated to the patient''s sex or age. There was a curved relationship between plasma level of nortriptyline and therapeutic effect. Amelioration was most pronounced in the intermediate plasma level range (50-139 ng nortriptyline/ml plasma) and was slight both at lower and at higher plasma levels. This type of relationship may be due to the dual action of tricyclic antidepressants which has been found in animal experiments. On larger dosages a phenothiazine-like blockade of the monoaminergic receptor is added to the blockade of monoamine reuptake thought to be related to the antidepressant action of the drugs.This study thus suggests two possible reasons for a therapeutic failure with nortriptyline: a too low or a too high plasma level. The large individual variation in the pharmacokinetics of the tricyclic antidepressants makes prediction of plasma level from dosage in a given individual virtually impossible without knowledge of rate of elimination and apparent volume of distribution. Hence monitoring plasma levels may be a way to increase the efficacy of treatment with these drugs.     

Determination of amitriptyline-n-oxide,amitriptyline and nortriptyline in serum and plasma by high-performance liquid chromatography

A method for the determination of amitriptyline-N-oxide, amitriptyline and nortriptyline in serum and plasma has been developed. After extraction from serum or plasma the drugs were analysed by high-performance liquid chromatography.The detection limit was 10 ng/ml (2 ml serum or plasma actually used). The coefficient of variation for all three compounds was below 10%.Amitriptyline-N-oxide was found in rat plasma after an oral dose (10 mg/kg) of amitriptyline-N-oxide.     

Determination of amitriptyline and nortriptyline in human plasma by quantitative thin-layer chromatography

A thin-layer chromatographic method for simultaneous determination of amitriptyline (AT) and nortriptyline (NT) in human plasma is described. Both substances are extracted from biological material by means of a single extraction. The extract is evaporated until dry and the residue quantitatively applied to a silica gel thin-layer plate. AT and NT are separated from interfering plasma components by chromatography. The spots are visualized by nitration, reduction and coupling with N-(1-naphtyl)ethylenediamine on the plate. The intensity of the azo-dyes formed can be measured densitometrically. Using 1 ml of plasma, the sensitivity limit was 0.5 ng/ml for both substances. About 10–15 plasma samples can be analysed per day. The method is applicable to pharmacokinetic studies after a single oral dose of 25 mg AT as hydrochloride in man.     

Simultaneous determination of amitriptyline,nortriptyline and four hydroxylated metabolites in serum by capillary gas-liquid chromatography with nitrogen-phosphorus-selective detection

A method for the simultaneous quantification of the antidepressant drug amitriptyline, its demethylated metabolite nortriptyline and four hydroxy metabolites (E-10-hydroxyamitriptyline, Z-10-hydroxyamitriptyline, E-10-hydroxynortriptyline, Z-10-hydroxynortriptyline) in human serum or plasma has been developed. The method is based on a three-step liquid-liquid extraction followed by gas-liquid chromatography (split-splitless injection, HP-5, 25 m×0.2 mm I.D., 0.33 μm capillary) with nitrogen phosphorus-selective detection (GLC-NPD). The limits of detection are 1.5 ng/ml for amitriptyline, nortriptyline, E-10-hydroxyamitriptyline and Z-10-hydroxyamitriptyline and 3 ng/ml for E-10-hydroxynortriptyline and Z-10-hydroxynortriptyline. The within-day and between-day precision is between 6 and 15% at three concentrations (low, moderate and high) for amitriptyline, nortriptyline and E-10-hydroxy metabolites. At low concentrations of 10 ng/ml, the precision of the assay of the Z-10-hydroxy metabolites has been found to be up to 19%. Accuracy is between 91 and 115% for all analytes. The performance of the assay of the hydroxy metabolites is mainly determined by the cleanness and the deactivation of the quartz insert of the injector port. Therefore, every day a freshly cleaned and deactivated insert was used.     

Nortriptyline and antipyrine clearance in relation to debrisoquine hydroxylation in man

Eight healthy volunteers with a broad range in their ability to hydroxylate debrisoquine, a metabolic reaction which is under polymorphic genetic control, were given single oral doses of nortriptyline and antipyrine. There was a close correlation between an individual's ability to hydroxylate debrisoquine and nortriptyline (measured as plasma clerance of the drug) (Spearman r_s = 0.83; p = 0.01). This indicates that these two benzylic hydroxylations are controlled by similar if not identical genetic factors. In contrast to nortriptyline the clearance of antipyrine (assessed in saliva) was not positively related to the ability to hydroxylate debrisoquine.     

A simplified radioimmunoassay of plasma nortriptyline in depressed patients compared with high-pressure liquid chromatography and gas-liquid chromatography

Antiserum to nortriptyline was generated in male New Zealand rabbits innoculated with n-succinylnortriptyline-bovine serum albumin conjugates. The antiserum was used at a final dilution of 14000 and tritiated imipramine was used as the label antigen. An accurate, sensitive, and specific radioimmunoassay of depressed patients' plasma or serum nortriptyline is described. The accuracy was good with a recovery range of 90–100% with a mean of 94%. The method can be used to measure nortriptyline concentration in the range of 0.1 g/liter to 100 g/liter without prior extraction and purification of plasma or serum. Results of this method correlate well with those obtained by high-pressure liquid chromatography (r=0.979) and by gas-liquid chromatography (r=0.98). The specificity of the antiserum was examined by studying the cross-reactivity of 20 different psychopharmacological compounds, including nortriptyline's metabolites.     

7,7,8,8-Tetracyanoquinodimethane as a new derivatization reagent for high-performance liquid chromatography and thin-layer chromatography: rapid screening of plasma for some antidepressants

Using 7,7,8,8-tetracyanoquinodimethane (TCNQ) as a new derivatization reagent for HPLC and TLC, novel methods are described to detect secondary amine-bearing antidepressants (paroxetine, desipramine, fluoxetine, nortriptyline, maprotiline). The HPLC method is sensitive enough to detect these drugs in plasma at therapeutic levels whereas the latter has potential to detect them in overdose or forensic cases. The methods are based on purple chromogens formed by the displacement reaction of the drugs with TCNQ. The resulting chromogens are directly separated by either reversed-phase HPLC on a C(18) column or TLC on silicagel plates. For HPLC, acetonitrile-water (60:40) was used as mobile phase, with detection at 567 nm and separation in 40 min. For TLC, three developing solvent systems were used. By HPLC, 36 ng ml(-1) spiked plasma concentration of the drugs gave easily detectable signals whereas by TLC, detection limits varied mostly between 240 and 480 ng ml(-1). The HPLC method was applied to real plasma samples. The methods described are simple and very selective; some metabolites of these antidepressants and a vast number of drugs do not interfere with detection.     

Quantitative analysis of amitriptyline and nortriptyline in human plasma and liver microsomal preparations by high-performance liquid chromatography

A simple, rapid, highly selective and sensitive method for the analysis of amitriptyline and nortriptyline in plasma and human liver microsomes is described. It is suitable for the routine analysis of large numbers of samples using readily available instrumentation and low cost consumables. The detection limit was 2 ng/ml for both compounds and calibration curves were linear over a wide range of concentrations and passed through the origin. The within-batch and between-batch coefficients of variation for amitriptyline and nortriptyline were less than 7.4% and 12.8%, respectively. A series of compounds, including inhibitors used for probing cytochrome P450 activity in vitro, were tested for interference in the assay. Only ketoconazole caused interference and the assay was modified to allow samples containing ketoconazole to be analysed.     

High-performance liquid chromatographic determination of amitriptyline and its main metabolites using a silica column with reversed-phase eluent : Application in mice

A method was developed for the assay of amitriptyline, amitriptyline-N-oxide, nortriptyline, desmethylnortriptyline and E (trans) and Z (cis) isomers of 10-hydroxyamitriptyline and of 10-hydroxynortriptyline in plasma and brain of animals, using high-performance liquid chromatography with ultraviolet detection (254 nm). Single extraction was performed at pH 10.5 from 0.25 ml of plasma or 1 ml of brain mixture. Chromatographic separations were achieved with a silica column and an aqueous methanol mobile phase containing ammonia. This procedure offers high sensitivity (8–10 ng/ml), high linearity (r > 0.99) and acceptable precision (coefficient of variation ≤ 13.3%). The method was used to determine levels of amitriptyline and its major metabolites in mice 30 min after a single intraperitoneal administration of amitriptyline (20 mg/kg).     

Stir bar sorptive extraction and liquid chromatography with UV detection for determination of antidepressants in plasma samples

A sensitive and reproducible stir bar sorptive extraction and liquid chromatography (SBSE/LC-UV) method is described for the determination of sertraline, mirtazapine, fluoxetine, citalopram, paroxetine, imipramine, nortriptyline, amitriptyne, and desipramine in plasma samples. Important factors in the optimization of SBSE efficiency are discussed, such as extraction time, pH, ionic strength, influence of plasma proteins, and desorption conditions: solvents, modes (magnetic stir, ultrasonic), time, and number of desorption steps. The SBSE/LC-UV method showed to be linear in a concentration ranging from the limit of quantification (LOQ) to 1000.0 ng mL(-1). The LOQ values ranged from 10.0 ng mL(-1) to 40.0 ng mL(-1). The inter-day precision of the SBSE/LC-UV method presented coefficient of the variation lower than 15%. Based on figures of the merit results, the SBSE/LC-UV methodology showed to be adequate to the antidepressants analyses from therapeutic to toxic therapeutic levels. In order to evaluate the proposed method for clinical use, the SBSE/LC-UV method was applied to the analysis of plasma samples from elderly depressed patients.     

Quantitative analysis of tricyclic antidepressants in serum from psychiatric patients

A method for the quantitative analysis of tricyclic antidepressants in the serum of psychiatric patients is described. The method can be used for determining arnitriptyline, nortriptyline, imipramine, demethyllimipramine, clomipramine, demethylclomipramine, trimipramine and protriptyline. The method consists in a series of extraction steps followed by gas chromatography with a flame-ionization detector. The drugs are determined in their native state. The internal standard method is used for the quantitation.     

Kinetic Modelling for the Assay of Nortriptyline Hydrochloride Using Potassium Permanganate as Oxidant

Kinetic methods for accurate determination of nortriptyline hydrochloride have been described. The methods are based on the oxidation of nortriptyline hydrochloride with KMnO₄ in acidic and basic media. In acidic medium, the decrease in absorbance at 525.5 nm and in basic medium, the increase in absorbance at 608.5 nm were measured as a function of time. The variables affecting the reactions were carefully investigated and optimised. Kinetic models such as initial rate, rate constant, variable time and fixed time were employed to construct the calibration curves. The initial rate and fixed time methods were selected for quantification of nortriptyline hydrochloride. In acidic medium, the calibration curves showed a linear response over the concentration range 10–50 μg mL⁻¹ for initial rate and 10–60 μg mL⁻¹ for fixed time method (2 min). In basic medium, the calibration graphs were linear over the concentration range 10–100 μg mL⁻¹ for initial rate and fixed time methods (4 min). In acidic medium, the limits of detection for initial rate and fixed time methods (2 min) were 1.02 and 3.26 μg mL⁻¹, respectively. In basic medium, the limits of detection were found to be 1.67 and 1.55 μg mL⁻¹ for initial rate and fixed time methods (4 min), respectively. The initial rate and fixed time methods have been successfully applied to the determination of nortriptyline hydrochloride in commercial dosage form. Statistical comparison of the results of the proposed methods with those of reference method exhibited excellent agreement and there is no significant difference between the compared methods in terms of accuracy and precision.KEY WORDS: dosage forms, fixed time method, initial rate method, nortriptyline, potassium permanganate     

DFT and electrochemical studies on nortriptyline oxidation sites

A study on the possible sites of oxidation and epoxidation of nortriptyline was performed using electrochemical and quantum chemical methods; these sites are involved in the biological responses (for example, hepatotoxicity) of nortriptyline and other similar antidepressants. Quantum chemical studies and electrochemical experiments demonstrated that the oxidation and epoxidation sites are located on the apolar region of nortriptyline, which will useful for understanding the molecule’s activity. Also, for the determination of the compound in biological fluids or in pharmaceutical formulations, we propose a useful analytical methodology using a graphite-polyurethane composite electrode, which exhibited the best performance when compared with boron-doped diamond or glassy carbon surfaces.     

Stereoselective and simultaneous measurement of cis- and trans-isomers of doxepin and N-desmethyldoxepin in plasma or urine by high-performance liquid chromatography

Doxepin is a tricyclic antidepressant marketed as an irrational mixture of cis- and trans-geometric isomers in the ratio of 15:85. A convenient high-performance liquid chromatographic (HPLC) procedure for simultaneous quantitation of geometric isomers of doxepin and N-desmethyldoxepin in plasma and urine is described. The HPLC procedure employed a normal phase system with a silica column and a mobile phase consisting of hexane-methanol-nonylamine (95:5:0.3, v/v/v), a UV detector and nortriptyline as the internal standard. The liquid-liquid extraction solvent was a mixture of n-pentane-isopropanol (95:5, v/v). The limit of quantitation was 1 ng/ml for each isomer. The calibration curves were linear over the ranges 1–200 ng/ml (plasma) and 1–400 ng/ml (urine). In plasma, the accuracy (mean±S.D.) (97.53±1.67%) and precision (3.89±1.65%) data for trans-doxepin were similar to corresponding values for urine, i.e., 97.10±2.40 and 3.82±1.14%. Accuracy and precision data for trans-N-desmethyldoxepin in plasma were 97.57±2.06 and 4.38±3.24%, and in urine were 97.64±3.32 and 5.26±1.83%, respectively. Stability tests under three different conditions of storage indicated no evidence of degradation. The recovery of doxepin was 61–64% from plasma and 63–68% from urine. The method has been applied to analyses of plasma and urine samples from human volunteers and animals dosed with doxepin.     

Nortriptyline plus nicotine replacement versus placebo plus nicotine replacement for smoking cessation: pragmatic randomised controlled trial

Objective To test the efficacy of nortriptyline plus nicotine replacement therapy compared with placebo plus nicotine replacement therapy for smoking cessation.Design Pragmatic randomised controlled trial.Setting National Health Service stop smoking service clinics.Participants 901 people trying to stop smoking.Interventions Participants chose their nicotine replacement product, including combinations of nicotine replacement therapy, and received behavioural support. Nortriptyline was started one to two weeks before quit day, with the dose increased from 25 mg to 75 mg daily for eight weeks and reduced if not tolerated.Main outcome measures Primary outcome was prolonged confirmed abstinence at six months. Secondary outcomes were prolonged abstinence at 12 months, drug use, severity of side effects, nicotine withdrawal symptoms, and urges to smoke.Results 72 of 445 (16%) people using nortriptyline and 55 of 456 (12%) using placebo achieved prolonged abstinence at six months (relative risk 1.34, 95% confidence interval 0.97 to 1.86). At 12 months the corresponding values were 49 (11%) for nortriptyline and 40 (9%) for placebo (1.26, 0.84 to 1.87). 337 (79%) people in the nortriptyline arm and 325 (75%) in the placebo arm were taking combination treatment on quit day, median 75 mg per day in both groups. More people in the nortriptyline arm than in the placebo arm took lower doses. The nortriptyline arm had noticeably higher severity ratings for dry mouth and constipation than the placebo arm, with slightly higher ratings for sweating and feeling shaky. Both groups had similar urges to smoke, but nortriptyline reduced depression and anxiety. Overall, withdrawal symptom scores did not differ.Conclusions Nortriptyline and nicotine replacement therapy are both effective for smoking cessation but the effect of the combination is less than either alone and evidence is lacking that combination treatment is more effective than either alone.Trial registration Current Controlled Trials ISRCTN57852484.     

Quantification of nortriptyline in plasma by HPLC and fluorescence detection

A simple, sensitive and specific high-performance liquid chromatography method has been developed for the determination of nortriptyline (NT) in plasma samples. The assay involved derivatization with 9H-fluoren-9-ylmethyl chloroformate (Fmoc-Cl) and isocratic reversed-phase (C₁₈) chromatography with fluorescence detection. The developed method required only 100 μl of plasma sample, deproteinized and derivatized in one step. Calibration curves were lineal over the concentration range of 5–5000 ng/ml. The derivatization reaction was performed at room temperature in 20 min and the obtained NT derivative was stable for at least 48 h at room temperature. The within-day and between-day relative standard deviation was below 8%. The limit of detection (LOD) was 2 ng/ml, and the lower limit of quantification (LLOQ) was established at 10 ng/ml. The method was applied on plasma collected from rats, at different time intervals, after intravenous administration of 0.5 mg of NT.     

Effect of nortriptyline on intracellular Ca2+ handling and viability in canine renal tubular cells

In Madin-Darby canine kidney (MDCK) cells, the effect of nortriptyline, an antidepressant, on intracellular Ca2+ concentration ([Ca2+]i) was measured by using fura-2. Nortriptyline (> 10 microM) caused a rapid increase of [Ca2+]i in a concentration-dependent manner (EC50 = 75 microM). Nortriptyline-induced [Ca2+]i increase was prevented by 40% by removal of extracellular Ca2+ but was not altered by voltage-gated Ca2+ channel blockers. In Ca(2+)-free medium, thapsigargin, an inhibitor of the endoplasmic reticulum Ca(2+)-ATPase, caused a monophasic [Ca2+]i, increase, after which the increasing effect of nortriptyline on [Ca2+], was abolished; also, pretreatment with nortriptyline reduced a large portion of thapsigargin-induced [Ca2+]i increase. U73122, an inhibitor of phospholipase C, abolished ATP (but not nortriptyline)-induced [Ca2+]i increase. Overnight incubation with 10 microM nortriptyline decreased cell viability by 16%, and 50 microM nortriptyline killed all cells. Prechelation of cytosolic Ca2+ with BAPTA did not alter nortriptyline-induced cell death. These findings suggest that nortriptyline rapidly increased [Ca2+]i in renal tubular cells by stimulating both extracellular Ca2+ influx and intracellular Ca2+ release, and was cytotoxic at higher concentrations in a Ca(2+)-dissociated manner.