Ativan vs. Nortriptyline

• Ativan (lorazepam) is used to treat anxiety associated with depression, while nortriptyline is used to treat depression.
• Ativan is also used for the management of anxiety disorders, insomnia, and panic attacks, and it is used in combination with other medications to prevent nausea and vomiting resulting from chemotherapy. Ativan also is administered before anesthesia for sedation and used for prevention and treatment of alcohol withdrawal. It is also used for treating seizures (status epilepticus).
• Nortriptyline is also used off-label (non-FDA approved) to treat attention deficit hyperactivity disorder (ADHD) in adults, children, and adolescents, and as adjunctive therapy for chronic pain conditions.
• A brand name for nortriptyline is Pamelor.
• Both Ativan and nortriptyline are available in generic form.
• Side effects of Ativan and nortriptyline are different. Side effects of Ativan include sedation, dizziness, weakness, unsteadiness, depression, amnesia, loss of orientation, headache, and sleep disturbance.
• Side effects of nortriptyline include fast heart rate, blurred vision, urinary retention, dry mouth, constipation, weight gain or loss, and low blood pressure on standing (orthostatic hypotension).
• Both Ativan and nortriptyline can be habit-forming. Abruptly stopping either Ativan or nortriptyline may cause withdrawal symptoms.

Nortriptyline is in the tricyclic antidepressants (TCAs) drug class and is used for treating depression. Other tricyclic antidepressants include amitriptyline (Endep, Elavil), clomipramine (Anafranil), doxepin (Sinequan), imipramine (Tofranil), trimipramine (Surmontil), amoxapine (Amoxapine), desipramine (Norpramin), and protriptyline (Vivactil).

Ativan

The most common side effects associated with Ativan are:

• Sedation
• Dizziness
• Weakness
• Unsteadiness

Other side effects include:

• A feeling of depression
• Amnesia
• Loss of orientation
• Headache
• Sleep disturbance

Possible serious side effects include:

• Extrapyramidal symptoms
• Respiratory depression
• Suicidal ideation/attempt
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• Depression

WARNING:

Like all benzodiazepines, Ativan can cause physical dependence. Suddenly stopping therapy after a few months of daily therapy may be associated with a feeling of loss of self-worth, agitation, and insomnia. If Ativan is taken continuously for longer than a few months, stopping therapy suddenly may produce seizures, tremors, muscle cramping, vomiting, and sweating.

Nortriptyline

The most commonly encountered side effects associated with nortriptyline include:

• Fast heart rate
• Blurred vision
• Urinary retention
• Dry mouth
• Constipation
• Weight gain or loss
• Low blood pressure on standing (orthostatic hypotension)

Rare side effects include:

• Rash
• Hives
• Seizures
• Hepatitis

Nortriptyline also can cause elevated pressure in the eyes of some patients with glaucoma.

Overdoses of nortriptyline can cause life-threatening abnormal heart rhythms or seizures.

If nortriptyline is discontinued abruptly, headache, nausea, and general discomfort may occur. Therefore, it is recommended that the dose of antidepressant be reduced gradually when therapy is discontinued.

Antidepressants increased the risk of suicidal thinking and behavior in short-term studies in children and adolescents with depression and other psychiatric disorders. Anyone considering the use of nortriptyline or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be closely observed for clinical worsening, suicidal thinking or behavior, and unusual changes in behavior.

Ativan

• The dose of Ativan is tailored to the patient's needs.
• The usual dose for treating anxiety is 2-6 mg orally every 8 to 12 hours as needed.
• Insomnia is treated with 2-4 mg given at bedtime.

Nortriptyline

The usual adult dose for nortriptyline, the dose is 25 mg three or four times daily; dosage should begin at a low level and be increased as required. As an alternative regimen, the total daily dosage may be given once a day. When doses above 100 mg daily are administered, plasma levels of nortriptyline should be monitored and maintained in the optimum range of 50 to 150 ng/mL. Doses above 150 mg/day are not recommended.

Ativan

Ativan and all benzodiazepines accentuate the effects of other drugs that slow the brain's processes such as alcohol, barbiturates, narcotics, and tranquilizers, and the combination of Ativan and these drugs may lead to excessive sedation. There have been cases of marked sedation when Ativan was given to patients taking the tranquilizer loxapine (Loxitane); it is unclear if there is a drug interaction, but caution should be used if Ativan and loxapine are used together.

Nortriptyline

TCAs, including nortriptyline, should not be used concurrently with a monoamine oxidase inhibitors such as tranylcypromine (Parnate), isocarboxazid (Marplan), phenelzine (Nardil), and procarbazine (Matulane) because of the possibility of hyperpyretic crises (high fever), convulsions, and even death.

Cimetidine (Tagamet) can increase blood levels of nortriptyline in the blood by interfering with the metabolism (breakdown) of nortriptyline by the liver. Increased levels of nortriptyline may possibly lead to side effects. Other drugs which share this effect on nortriptyline include propafenone (Rythmol), flecainide (Tonocard), quinidine (Quinidex, Quinaglute), and fluoxetine (Prozac).

Nortriptyline exaggerates the effects of other medications and drugs that slow the activity of the brain, such as alcohol, barbiturates, benzodiazepines, for example lorazepam (Ativan), clonazepam (Klonopin), and diazepam (Valium), as well as narcotics. Reserpine (Harmonyl), stimulates the brain when given to patients taking nortriptyline.

Combining nortriptyline or other TCAs with drugs that block acetylcholine (anticholinergic drugs) can cause constipation and even paralyze the intestine (paralytic ileus). Dangerous elevations in blood pressure may occur if TCA's are combined with clonidine (Catapres, Catapres-TTS).

Ativan

Ativan and other benzodiazepines have been associated with fetal damage, including congenital malformations, when taken by pregnant women in their first trimester. Ativan is best avoided if at all possible in the first trimester and probably throughout pregnancy.

Ativan is excreted in human milk and should be avoided during pregnancy.

Nortriptyline

Safe use of nortriptyline during pregnancy has not been established. Doctors may use nortriptyline in pregnant women if its benefits are deemed to outweigh its potential but unknown risks.

Safe use of nortriptyline during lactation has not been established. It is not known if nortriptyline is secreted in breast milk.