Drug interactions
Nortriptyline + Physostigmine
Severity: Major
Nortriptyline and Physostigmine: major interaction.
Last updated
For healthcare professionals — reference only. This page is a brief summary, not medical advice and not a substitute for official labeling or clinical judgement. Always verify before prescribing or dispensing.
Summary
Physostigmine inhibits acetylcholinesterase and is used to reverse anticholinergic toxicity, whereas nortriptyline has anticholinergic activity, so the two have opposing effects. In tricyclic overdose physostigmine can precipitate seizures, bradycardia and asystole, so it is generally avoided. In therapeutic use the effects are partly antagonistic and unpredictable.
What this interaction means in plain words
Nortriptyline and Physostigmine can interact in a way that may be serious. Using them together is sometimes necessary, but it needs a deliberate decision by the prescriber, a plan for monitoring, and clear advice on the warning signs to watch for.
Why it happens
Pharmacodynamic antagonism of cholinergic effects; physostigmine may also provoke seizures and conduction disturbances in the presence of tricyclic toxicity.
What to do
Avoid physostigmine for treating tricyclic antidepressant overdose, and use supportive care with sodium bicarbonate and benzodiazepines as indicated. If it is used in other settings, give it with continuous ECG monitoring.
What to ask your pharmacist
- Does the benefit of taking both outweigh the risk in my case?
- Do I need any blood test, ECG or other check while on both?
- What early warning signs should I watch for, and what should I do if they appear?
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Other interactions of Nortriptyline
- Disopyramide + Nortriptyline Contraindicated
- Dofetilide + Nortriptyline Contraindicated
- Dronedarone + Nortriptyline Contraindicated
- Ibutilide + Nortriptyline Contraindicated
- Isocarboxazid + Nortriptyline Contraindicated
- Methylene blue + Nortriptyline Contraindicated
Frequently asked questions
Can I take Nortriptyline with Physostigmine?
MediHelp rates the interaction as major. Nortriptyline and Physostigmine can interact in a way that may be serious. Using them together is sometimes necessary, but it needs a deliberate decision by the prescriber, a plan for monitoring, and clear advice on the warning signs to watch for. Physostigmine inhibits acetylcholinesterase and is used to reverse anticholinergic toxicity, whereas nortriptyline has anticholinergic activity, so the two have opposing effects. In tricyclic overdose physostigmine can precipitate seizures, bradycardia and asystole, so it is generally avoided. In therapeutic use the effects are partly antagonistic and unpredictable.
How serious is the interaction between Nortriptyline and Physostigmine?
MediHelp rates it major, on a four-level scale (minor, moderate, major, contraindicated) based on published labels and references. What to do, in brief: Avoid physostigmine for treating tricyclic antidepressant overdose, and use supportive care with sodium bicarbonate and benzodiazepines as indicated. If it is used in other settings, give it with continuous ECG monitoring.
What other medicines interact with Nortriptyline?
MediHelp also lists interactions of Nortriptyline with, for example, Disopyramide, Dofetilide, Dronedarone. The full list is on the Nortriptyline page.
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