Nortriptyline for ADHD

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

Nortrilen was withdrawn from the market in Germany in 2017 and since then has only been available (more expensively) from other European countries. According to reports from individual sufferers, the Nortrilen re-imported from Holland is said not to work as well as the one previously available in Germany.

Nortriptyline acts predominantly noradrenergically as a norepinephrine reuptake inhibitor.¹
In addition, 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 in ADHD. It can support the effect of stimulants.

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

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

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

Quite a few 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. After 2 to 4 weeks, however, this effect wears off.
This could indicate down- or upregulation of receptors.
One affected person reported that taking the medication for 2 days at a time with a subsequent break of 2 days counteracted the diminishing effect. This could possibly indicate that in ADHD there may be a problem of phasic rather than tonic norepinephrine availability.
See more at ⇒ Interaction cortisol - locus coeruleus And further sections in the article ⇒ Norepinephrine.
As is known from the use of SSRIs, prolonged use of serotonin reuptake inhibitors is regularly associated with receptor adaptation (upregulation or downregulation), since the effect as an antidepressant there quite usually only sets in after a few weeks. This is different with a small SSRI administration to reduce impulsivity problems, which mediates an immediate effect.
It is also possible that the reported adaptation reactions are a consequence of too high a dosage.

Nortryptiline is reported to be associated with weight gain as a side effect²
This opens the theoretical option of counteracting excessive weight loss with stimulants through combination medication.