[bptoo]

Cam,

I've been being treated with Nortriptyline for the pain I've been having in my upper back and neck for about 6 mos now. My current dose is 100 mgs at bedtime. Sometimes I think I'm seeing some help from it, but most of the time I don't notice a difference. The only thing that really brings me any relief is the Norco.

Have you heard of the Nortrip being used for nerve pain, and if so, do you know if I'm at an maximum effective dose right now?

Your help as always is appreciated bud!

My love to you and the family!

bp

"The brain is a wonderful organ; it starts working the moment you get up in the morning and does not stop until you get to work."

[CamW]

Sorry beep - I have seen nortriptyline (Aventyl™ - CDN) used for nerve pain (esp. in the last 2 years), but other TCAs are more commonly; the most commonly used is amitriptyline (Elavil™). When used for depression nortriptyline is one of those TCAs (like maprotiline [Ludiomil™], and desipramine [Norpramin™]) that blocks norepinephrine-reuptake more so than they block serotonin-reuptake. This might lead one to think that the mechanism of action for pain relief might be due the blocking of norepinephrine-reuptake. This is probably not the case, as desipramine, which has no serotonin-reuptake activity, has little efficacy in neuropathic pain.

It is believed that the TCAs blunt the pain response in the dorsal horn of the spinal column. Another theory on how TCAs work to relieve neuropathic pains is by blocking Adenosin-A2A receptors to regulate the transmission of pain impulses. Amitriptyline has been shown to block this receptor, but I have not seen any literature on the potential mechanism of action of nortriptyline, but it may too block the A2A-receptor. I dunno, the above sounds impressive, but I am not certain that this is what really is happening.

When using TCAs (or any other AD - [more to follow]) the dose of the AD is much, much lower than the dose used for antidepressant activity. For nortriptyline the normal dose for pain relief is 10mg to 50mg at bedtime. I have only seen a couple of people using the 50mg dose. The most commonly prescribed dose (in my personal experience) is 25mg at bedtime.

Taking doses of nortriptyline greater than 25mg to 50mg does not seem to increase the drug's analgesic response. It is as if the lower doses saturate whatever receptor nortriptyline is blocking (? or, maybe stimulating??). Doses of more than 50mg for neuropathic pain relief results in a flattening of the dose/response curve (similar to the SSRIs, which incidently have no activity against neuropathic pain).

The one common characteristic shared by all (or at least most) ADs that have efficacy in treating neuropathic pain is the blockade of both norepinephrine re-uptake and serotonin re-uptake. From this observation, venlafaxine (Effexor™) was tested for analgesic properties. Surprising to me was that the Effexor (at doses of 37.5mg to 75mg of the XR/day), in several small, unblinded studies seemed to work as well as amitriptyline, with far fewer irritating side effects.

Doses of 100mg to 150mg are usually used for depressives symptoms. I have seen one guy taking 250mg/day, but doses that high one does run the risk of having their blood pressure drop too much due to alpha-1 blockade. Blocking this receptor, as well as blocking the muscarinic-M1 and histamine-H1 receptors, can lead to excessive drowsiness and dizziness (as well as a pronouced "hangover" effect in the morning) as well as weight gain. The weight gain from nortriptyline is usually negligible, when compared to mirtazapine (Remeron™), olanzapine (Zyprexa™), or even amitriptyline. Anyway, daily nortriptyline doses of greater than 150mg/day are not recommended.

I hope that this helps a bit.
Love ya dude, and give M and the kids a hug and kiss from me. - Cam