Nortriptyline for ADHD

Nortriptyline is a tricyclic antidepressant.
Trade names are Nortrilen (EU, CH), Aventyl (USA, CDN), Pamelor (USA)

Nortrilen was withdrawn from the German market in 2017 and since then has only been available (at a higher price) from other European countries. According to reports from individual patients, the Nortrilen re-imported from Holland does not work as well as the one previously available in Germany.

Nortriptyline has a predominantly noradrenergic effect as a noradrenaline reuptake inhibitor.¹
It also has a weaker serotonergic effect as a serotonin reuptake inhibitor (to a much lesser extent than imipramine).

Nortriptyline is sometimes used as an augmenting agent for ADHD. It can support the effect of stimulants.

When used to treat ADHD, a much lower dosage is required than would otherwise be usual when used as an antidepressant.
Dosage as an antidepressant: 20 - 225 mg / day
Dosage for ADHD: 1 x 10 mg to 2 x 20 mg/day
(Dosage instructions of the attending physician alone are decisive!)

Compared to imipramine, nortriptyline has a more activating / drive-enhancing effect. Nortriptyline is therefore indicated for ADHD-I (without hyperactivity). The administration of nortriptyline to ADHD-HI sufferers (with hyperactivity) can trigger aggression or jitteriness.

In very rare cases, nortriptyline can trigger depression as a side effect. This can be triggered in particular by an overdose or rapid starting and stopping.

Many ADHD sufferers report that nortriptyline works very well in the first few days of taking it. As with imipramine, the effect is that the “green zone” between overload and underload becomes wider. However, this effect diminishes after 2 to 4 weeks.
This could indicate a down- or upregulation of receptors.
One patient reported that taking the drug for 2 days at a time followed by a 2-day break counteracted the decrease in effect. This could possibly indicate that in ADHD there could be a problem of phasic rather than tonic noradrenaline availability.
More on this at ⇒ Interaction cortisol - locus coeruleus And further sections in the article ⇒ Noradrenaline.
As is known from the use of SSRIs, prolonged use of serotonin reuptake inhibitors is regularly associated with receptor adaptation (up- or downregulation), as the antidepressant effect usually only sets in after a few weeks. This is different with a low dose of SSRIs to reduce impulsivity problems, which have an immediate effect.
It is possible that the reported adaptation reactions are also the result of excessive dosing.

Nortryptiline is said to be associated with weight gain as a side effect²
This opens up the theoretical option of using a combination medication to counteract excessive weight loss with stimulants.