Nortriptyline with St John's Wort Interaction Details
Brand Names Associated with Nortriptyline
- Aventyl®
- Nortriptyline
- Pamelor®
Medical Content Editor Dr. Brian Staiger, PharmD
Last updated
Dec 03, 2023
Interaction Effect
Decreased effectiveness of nortriptyline and possible increased risk of serotonin syndrome (hypertension, hyperthermia, myoclonus, mental status changes)
Interaction Summary
Coadministration of amitriptyline and St. John's Wort decreased the area under the concentration-time curve of amitriptyline and its metabolite nortriptyline. Theoretically, since St. John's Wort is thought to inhibit serotonin reuptake and may have mild monoamine oxidase inhibitory activity , serotonin syndrome could result when St. John's Wort is taken along with a tricyclic antidepressant such as nortriptyline. This theoretical risk of serotonin syndrome is also based on case reports of serotonin syndrome resulting from concomitant use of selective serotonin reuptake inhibitors with tricyclic antidepressants , as well as concomitant use of monoamine oxidase inhibitors with tricyclic antidepressants . The risk of serotonin syndrome is decreased if nortriptyline levels are reduced by St. John's Wort. To maintain maximal effectiveness of nortriptyline as well as to avoid any potential risk of serotonin syndrome, avoid concomitant use of St. John's Wort and nortriptyline.
Severity
Moderate
Onset
Delayed
Evidence
Theoretical
How To Manage Interaction
Avoid concomitant use of St. John's Wort with nortriptyline.
Mechanism Of Interaction
Induction of metabolizing enzymes; additive serotonergic effect
Literature Reports
A) In an open-label study involving twelve depressed patients, the effect of St. John's Wort on the steady-state pharmacokinetics of amitriptyline, a tricyclic antidepressant, was investigated. St. John's Wort (900 mg/day) was administered concomitantly with amitriptyline (75 mg twice daily) for a minimum of fourteen days. A 21.7% decrease (p equal to 0.034) in area under the concentration-time curve (AUC) of amitriptyline and a 41.6% decrease (p equal to 0.002) in the AUC of nortriptyline, the metabolite of amitriptyline occurred. The cause of the interaction may be attributed to the induction of drug metabolizing enzymes or drug transporters by St. John's Wort .
Nortriptyline Overview
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Nortriptyline is used to treat depression. Nortriptyline is in a group of medications called tricyclic antidepressants. It works by increasing the amounts of certain natural substances in the brain that are needed to maintain mental balance.
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Definitions
Severity Categories
Contraindicated
These drugs, generally, should not be used together simultaneously due to the high risk of severe adverse effects. Combining these medications can lead to dangerous health outcomes and should be strictly avoided unless otherwise instructed by your provider.
Major
This interaction could result in very serious and potentially life-threatening consequences. If you are taking this drug combination, it is very important to be under close medical supervision to minimize severe side effects and ensure your safety. It may be necessary to change a medication or dosage to prevent harm.
Moderate
This interaction has the potential to worsen your medical condition or alter the effectiveness of your treatment. It's important that you are monitored closely and you potentially may need to make adjustments in your treatment plan or drug dosage to maintain optimal health.
Minor
While this interaction is unlikely to cause significant problems, it could intensify side effects or reduce the effectiveness of one or both medications. Monitoring for changes in symptoms and your condition is recommended, and adjustments may be made if needed to manage any increased or more pronounced side effects.
Onset
Rapid: Onset of drug interaction typically occurs within 24 hours of co-administration.
Delayed: Onset of drug interaction typically occurs more than 24 hours after co-administration.
Evidence
Level of documentation of the interaction.
Established: The interaction is documented and substantiated in peer-reviewed medical literature.
Theoretical: This interaction is not fully supported by current medical evidence or well-documented sources, but it is based on known drug mechanisms, drug effects, and other relevant information.
How To Manage The Interaction
Provides a detailed discussion on how patients and clinicians can approach the identified drug interaction as well as offers guidance on what to expect and strategies to potentially mitigate the effects of the interaction. This may include recommendations on adjusting medication dosages, altering the timing of drug administration, or closely monitoring for specific symptoms.
It's important to note that all medical situations are unique, and management approaches should be tailored to individual circumstances. Patients should always consult their healthcare provider for personalized advice and guidance on managing drug interactions effectively.
Mechanism Of Interaction
The theorized or clinically determined reason (i.e., mechanism) why the drug-drug interaction occurs.
Disclaimer: The information provided on this page is for informational purposes only and should not be considered medical advice. Always consult with a qualified healthcare professional regarding your specific circumstances and medical conditions.
Where Does Our Information Come From?
Information for our drug interactions is compiled from several drug compendia, including:
The prescribing information for each drug, as published on DailyMED, is also used.
Individual drug-drug interaction detail pages contain references specific to that interaction. You can click on the reference number within brackets '[]' to see what reference was utilized.
The information posted is fact-checked by HelloPharmacist clinicians and reviewed quarterly.