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{{Short description|Antidepressant medication}}{{Use dmy dates|date=February 2024}}{{cs1 config |name-list-style=vanc |display-authors=6}}

factoids

| MedlinePlus = a682620| DailyMedID = Nortriptyline| pregnancy_AU = C DATE=22 JUNE 2020 ACCESS-DATE=10 OCTOBER 2020, Oral administration>By mouth| class = Tricyclic antidepressant (TCA)| ATC_prefix = N06| ATC_suffix = AA10| legal_AU = S4| legal_BR = C1DATE=31 MARCH 2023 TRANS-TITLE=COLLEGIATE BOARD RESOLUTION NO. 784 - LISTS OF NARCOTIC, PSYCHOTROPIC, PRECURSOR, AND OTHER SUBSTANCES UNDER SPECIAL CONTROLURL-STATUS=LIVE ARCHIVE-DATE=3 AUGUST 2023 PUBLISHER=DIáRIO OFICIAL DA UNIãO PUBLICATION-DATE=4 APRIL 2023, | legal_CA = Rx-only DATE=FEBRUARY 2024 ACCESS-DATE=24 MARCH 2024, | legal_US = Rx-onlyURL=HTTPS://BOOKS.GOOGLE.COM/BOOKS?ID=SD6OT9UL-BUC&PG=PA588PUBLISHER=LIPPINCOTT WILLIAMS & WILKINSPAGES=588–, | protein_bound = 92%| metabolism = Liver| metabolites = 10-E-Hydroxynortriptyline| elimination_half-life = 18–44 hours (mean 30 hours)| excretion = Urine: 40%Feces: minorcorrect|??}}| CAS_number = 72-69-5| CAS_number2 = 894-71-3| PubChem = 4543| IUPHAR_ligand = 2404correct|drugbank}}| DrugBank = DB00540correct|chemspider}}| ChemSpiderID = 4384correct|FDA}}| UNII = BL03SY4LXBcorrect|kegg}}| KEGG = D08288correct|EBI}}| ChEBI = 7640correct|EBI}}| ChEMBL = 445| synonyms = Desitriptyline; ELF-101; E.L.F. 101; N-7048| IUPAC_name = 3-(10,11-Dihydro-5H-dibenzo[a,d]cyclohepten-5-ylidene)-N-methyl-1-propanamine H=21 | N=1| SMILES = c3cc2c(/C(c1c(cccc1)CC2)=C/CCNC)cc3correct|chemspider}}| StdInChI = 1S/C19H21N/c1-20-14-6-11-19-17-9-4-2-7-15(17)12-13-16-8-3-5-10-18(16)19/h2-5,7-11,20H,6,12-14H2,1H3correct|chemspider}}| StdInChIKey = PHVGLTMQBUFIQQ-UHFFFAOYSA-N}}Nortriptyline, sold under the brand name Aventyl, among others, is a tricyclic antidepressant. This medicine is also sometimes used for neuropathic pain, attention deficit hyperactivity disorder (ADHD), smoking cessation and anxiety.BOOK, British national formulary : BNF 76, 2018, Pharmaceutical Press, 9780857113382, 374, 76, WEB, Nortriptyline Hydrochloride Monograph for Professionals,weblink Drugs.com, American Society of Health-System Pharmacists, 22 March 2019, en, As with many antidepressants, its use for young people with depression and other psychiatric disorders may be limited due to increased suicidality in the 18–24 population initiating treatment. Nortriptyline is a less preferred treatment for ADHD and stopping smoking. It is taken by mouth.Common side effects include dry mouth, constipation, blurry vision, sleepiness, low blood pressure with standing, and weakness. Serious side effects may include seizures, an increased risk of suicide in those less than 25 years of age, urinary retention, glaucoma, mania, and a number of heart issues. Nortriptyline may cause problems if taken during pregnancy. Use during breastfeeding appears to be relatively safe. It is a tricyclic antidepressant (TCA) and is believed to work by altering levels of serotonin and norepinephrine.{{efn| Nortriptyline actually belongs to a class of drugs called serotonin–norepinephrine reuptake inhibitors (SNRIs). They work at synapse level, and do not allow reuptake of both serotonin and norepinephrine by the neurons. This increases the amount of these neurotransmitters at synpase. In a way, that is not completely clear, this reduces the transmission of pain signals to the brain. It is for this reason, that SNRIs would work in neuropathic pain, but not in nociceptive pain.}}Nortriptyline was approved for medical use in the United States in 1964. It is available as a (generic medication]]. In 2021, it was the 139th most commonly prescribed medication in the United States, with more than 4{{nbsp}}million prescriptions.WEB, The Top 300 of 2021,weblink ClinCalc, 14 January 2024, 15 January 2024,weblink live, WEB, Nortriptyline - Drug Usage Statistics, ClinCalc,weblink 14 January 2024,

Medical uses

Nortriptyline is used to treat depression. This medication is in capsule or liquid and is taken by the mouth one to four times a day, with or without food.WEB, Nortriptyline,weblink MedlinePlus, National Library of Medicine, 6 May 2019, Usually people are started on a low dose and it is gradually increased. A level between 50 and 150 ng/mL of nortriptyline in the blood generally corresponds with an antidepressant effect.JOURNAL, Orsulak PJ, Therapeutic monitoring of antidepressant drugs: guidelines updated, Therapeutic Drug Monitoring, 11, 5, 497–507, September 1989, 2683251, 10.1097/00007691-198909000-00002, In the United Kingdom), it may also be used for treating nocturnal enuresis, with courses of treatment lasting no more than three months. It is also used off-label for the treatment of panic disorder, irritable bowel syndrome, migraine prophylaxis and chronic pain or neuralgia modification, particularly temporomandibular joint disorder.BOOK, Sweetman SC, Martindale. The complete drug reference, 33, 2002, Pharmaceutical Press, 0-85369-499-0, registration,weblink

Neuropathic pain

Although not approved by the FDA for neuropathic pain, many randomized controlled trials have demonstrated the effectiveness of TCAs for the treatment of this condition in both depressed and non-depressed individuals. In 2010, an evidence-based guideline sponsored by the International Association for the Study of Pain recommended nortriptyline as a first-line medication for neuropathic pain.JOURNAL, Dworkin RH, O'Connor AB, Audette J, Baron R, Gourlay GK, Haanpää ML, Kent JL, Krane EJ, Lebel AA, Levy RM, Mackey SC, Mayer J, Miaskowski C, Raja SN, Rice AS, Schmader KE, Stacey B, Stanos S, Treede RD, Turk DC, Walco GA, Wells CD, 6, Recommendations for the pharmacological management of neuropathic pain: an overview and literature update, Mayo Clinic Proceedings, 85, 3 Suppl, S3-14, March 2010, 20194146, 2844007, 10.4065/mcp.2009.0649, However, in a 2015 Cochrane systematic review the authors did not recommend nortriptyline as a first-line agent for neuropathic pain.JOURNAL, Derry S, Wiffen PJ, Aldington D, Moore RA, Nortriptyline for neuropathic pain in adults, The Cochrane Database of Systematic Reviews, 1, 1, CD011209, January 2015, 25569864, 10.1002/14651858.CD011605, 6485407, vanc,

Irritable bowel syndrome

Nortriptyline has also been used as an off-label treatment for irritable bowel syndrome (IBS).WEB, The Use of Antidepressants in the Treatment of Irritable Bowel Syndrome and Other Functional GI Disorders,weblink

Contraindications

Nortriptyline should not be used in the acute recovery phase after myocardial infarction (viz, heart attack).WEB,weblink Nortriptyline label, 2014, FDA, Use of tricyclic antidepressants along with a monoamine oxidase inhibitor (MAOI), linezolid, or IV methylene blue are contraindicated as it can cause an increased risk of developing serotonin syndrome.BOOK, Merwar G, Saadabadi A, Nortriptyline, 2018,weblink StatPearls, StatPearls Publishing, 29489270, 3 October 2018, Closer monitoring is required for those with a history of cardiovascular disease,JOURNAL, Bardai A, Amin AS, Blom MT, Bezzina CR, Berdowski J, Langendijk PN, Beekman L, Klemens CA, Souverein PC, Koster RW, de Boer A, Tan HL, 6, Sudden cardiac arrest associated with use of a non-cardiac drug that reduces cardiac excitability: evidence from bench, bedside, and community, European Heart Journal, 34, 20, 1506–16, May 2013, 23425522, 10.1093/eurheartj/eht054, free, stroke, glaucoma, or seizures, as well as in persons with hyperthyroidism or receiving thyroid hormones.

Side effects

The most common side effects include dry mouth, sedation, constipation, increased appetite, blurred vision and tinnitus.WEB, ALLEGRON, TGA eBusiness Services, Arrow Pharma Pty Ltd, 13 October 2016, 11 August 2017,weblink An occasional side effect is a rapid or irregular heartbeat. Alcohol may exacerbate some of its side effects.WEB, Nortriptyline Hydrochloride – Martindale: The Complete Drug Reference,weblink 9 January 2017, 11 August 2017, MedicinesComplete, Pharmaceutical Press, Brayfield A,

Overdose

The symptoms and the treatment of an overdose are generally the same as for the other TCAs, including anticholinergic effects, serotonin syndrome and adverse cardiac effects. TCAs, particularly nortriptyline, have a relatively narrow therapeutic index, which increase the chance of an overdose (both accidental and intentional). Symptoms of overdose include: irregular heartbeat, seizures, coma, confusion, hallucination, widened pupils, drowsiness, agitation, fever, low body temperature, stiff muscles and vomiting.

Interactions

Excessive consumption of alcohol in combination with nortriptyline therapy may have a potentiating effect, which may lead to the danger of increased suicidal attempts or overdosage, especially in patients with histories of emotional disturbances or suicidal ideation.It may interact with the following drugs:WEB,weblink nortriptyline, www.cardiosmart.org, 3 October 2018,

• heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute)
• cimetidine
• guanethidine
• reserpine

Pharmacology

Nortriptyline is a strong norepinephrine reuptake inhibitor and a moderate serotonin reuptake inhibitor. Its pharmacologic profile is as the table shows with (inhibition or antagonism of all sites).Brunton L, Chabner B, Knollman B. Goodman and Gilman's The Pharmacological Basis of Therapeutics, Twelfth Edition. McGraw Hill Professional; 2010.

Pharmacodynamics

{{See also|Pharmacology of antidepressants|Tricyclic antidepressant#Binding profiles}}{| class="wikitable floatright" style="font-size:small;"weblink ! Site !! Ki (nM) !! Species !! RefSERT JOURNAL = EUR. J. PHARMACOL. ISSUE = 2–3 YEAR = 1997 DOI = 10.1016/S0014-2999(97)01393-9, OWENS MJ, MORGAN WN, PLOTT SJ, NEMEROFF CB > TITLE = NEUROTRANSMITTER RECEPTOR AND TRANSPORTER BINDING PROFILE OF ANTIDEPRESSANTS AND THEIR METABOLITES VOLUME = 283 PAGES = 1305–22 PMID = 9400006, NET| DAT| 5-HT1A receptor>5-HT1A 294 Human CUSACK B, NELSON A, RICHELSON E >TITLE=BINDING OF ANTIDEPRESSANTS TO HUMAN BRAIN RECEPTORS: FOCUS ON NEWER GENERATION COMPOUNDS VOLUME=114 PAGES=559–65 PMID=7855217 S2CID=21236268, 5-HT2A receptor>5-HT2A 5.0–41 Human/rat PäLVIMäKI EP, ROTH BL, MAJASUO H, ET AL. >TITLE=INTERACTIONS OF SELECTIVE SEROTONIN REUPTAKE INHIBITORS WITH THE SEROTONIN 5-HT2C RECEPTOR VOLUME=126 PAGES=234–40 PMID=8876023 S2CID=24889381, 5-HT2C receptor>5-HT2C 8.5 Rat 5-HT3 receptor>5-HT3 1,400 Rat SCHMIDT AW, HURT SD, PEROUTKA SJ > TITLE = '[3H]QUIPAZINE' DEGRADATION PRODUCTS LABEL 5-HT UPTAKE SITES VOLUME = 171 PAGES = 141–3 PMID = 2533080, 10.1016/0014-2999(89)90439-1, 5-HT6 receptor>5-HT6 148 Rat MONSMA FJ, SHEN Y, WARD RP, HAMBLIN MW, SIBLEY DR >TITLE=CLONING AND EXPRESSION OF A NOVEL SEROTONIN RECEPTOR WITH HIGH AFFINITY FOR TRICYCLIC PSYCHOTROPIC DRUGS VOLUME=43 PAGES=320–7 PMID=7680751, Alpha-1 adrenergic receptor>α1 55 Human Alpha-2 adrenergic receptor>α2 2,030 Human Beta adrenergic receptor>β >10,000 Rat BYLUND DB, SNYDER SH >TITLE=BETA ADRENERGIC RECEPTOR BINDING IN MEMBRANE PREPARATIONS FROM MAMMALIAN BRAIN VOLUME=12 PAGES=568–80 PMID=8699, Dopamine receptor D2>D2 2,570 Human Histamine H1 receptor>H1 3.0–15 Human APPL H, HOLZAMMER T, DOVE S, HAEN E, STRASSER A, SEIFERT R > TITLE = INTERACTIONS OF RECOMBINANT HUMAN HISTAMINE H1R, H2R, H3R, AND H4R RECEPTORS WITH 34 ANTIDEPRESSANTS AND ANTIPSYCHOTICS VOLUME = 385 PAGES = 145–70 PMID = 22033803 S2CID = 14274150, GHONEIM OM, LEGERE JA, GOLBRAIKH A, TROPSHA A, BOOTH RG >TITLE=NOVEL LIGANDS FOR THE HUMAN HISTAMINE H1 RECEPTOR: SYNTHESIS, PHARMACOLOGY, AND COMPARATIVE MOLECULAR FIELD ANALYSIS STUDIES OF 2-DIMETHYLAMINO-5-(6)-PHENYL-1,2,3,4-TETRAHYDRONAPHTHALENES VOLUME=14 PAGES=6640–58 PMID=16782354, 10.1016/j.bmc.2006.05.077, Histamine H2 receptor>H2 646 Human Histamine H3 receptor>H3 45,700 Human Histamine H4 receptor>H4 6,920 Human mACh| Muscarinic acetylcholine receptor M1>M1 40 Human STANTON T, BOLDEN-WATSON C, CUSACK B, RICHELSON E >TITLE=ANTAGONISM OF THE FIVE CLONED HUMAN MUSCARINIC CHOLINERGIC RECEPTORS EXPRESSED IN CHO-K1 CELLS BY ANTIDEPRESSANTS AND ANTIHISTAMINICS VOLUME=45 PAGES=2352–4 PMID=8100134, 10.1016/0006-2952(93)90211-e, Muscarinic acetylcholine receptor M2>M2 110 Human Muscarinic acetylcholine receptor M3>M3 50 Human Muscarinic acetylcholine receptor M4>M4 84 Human Muscarinic acetylcholine receptor M5>M5 97 Human Sigma-1 receptor>σ1 2,000 Guinea pig WEBER E, SONDERS M, QUARUM M, MCLEAN S, POU S, KEANA JF >TITLE=1,3-DI(2-[5-3H]TOLYL)GUANIDINE: A SELECTIVE LIGAND THAT LABELS SIGMA-TYPE RECEPTORS FOR PSYCHOTOMIMETIC OPIATES AND ANTIPSYCHOTIC DRUGS VOLUME=83 PAGES=8784–8 PMID=2877462 DOI= 10.1073/PNAS.83.22.8784DOI-ACCESS=FREE, class="sortbottom" Values are Ki (nM). The smaller the value, the more strongly the drug binds to the site.Nortriptyline is an active metabolite of amitriptyline by demethylation in the liver. Chemically, it is a secondary amine dibenzocycloheptene and pharmacologically it is classed as a first-generation antidepressant.BOOK, O'Connor EA, Whitlock EP, Gaynes B, Beil TL, Screening for Depression in Adults and Older Adults in Primary Care: An Updated Systematic Review, 2009, Agency for Healthcare Research and Quality (US),weblink 20722174, Nortriptyline may also have a sleep-improving effect due to antagonism of the H1 and 5-HT2A receptors.JOURNAL, Thase ME, Depression and sleep: pathophysiology and treatment, Dialogues in Clinical Neuroscience, 8, 2, 217–26, 2006, 10.31887/DCNS.2006.8.2/mthase, 16889107, 3181772, In the short term, however, nortriptyline may disturb sleep due to its activating effect.In one study, nortriptyline had the highest affinity for the dopamine transporter among the TCAs (KD = 1,140 nM) besides amineptine (a norepinephrine–dopamine reuptake inhibitor), although its affinity for this transporter was still 261- and 63-fold lower than for the norepinephrine and serotonin transporters (KD = 4.37 and 18 nM, respectively).

Pharmacogenetics

Nortriptyline is metabolized in the liver by the hepatic enzyme CYP2D6, and genetic variations within the gene coding for this enzyme can affect its metabolism, leading to changes in the concentrations of the drug in the body.JOURNAL, Rudorfer MV, Potter WZ, Metabolism of tricyclic antidepressants, Cellular and Molecular Neurobiology, 19, 3, 373–409, Jun 1999, 10319193, 10.1023/A:1006949816036, 7940406, Increased concentrations of nortriptyline may increase the risk for side effects, including anticholinergic and nervous system adverse effects, while decreased concentrations may reduce the drug's efficacy.JOURNAL, Stingl JC, Brockmöller J, Viviani R, Genetic variability of drug-metabolizing enzymes: the dual impact on psychiatric therapy and regulation of brain function, Molecular Psychiatry, 18, 3, 273–87, Mar 2013, 22565785, 10.1038/mp.2012.42, 20888081, JOURNAL, Kirchheiner J, Seeringer A, Clinical implications of pharmacogenetics of cytochrome P450 drug metabolizing enzymes, Biochimica et Biophysica Acta (BBA) - General Subjects, 1770, 3, 489–94, Mar 2007, 17113714, 10.1016/j.bbagen.2006.09.019, JOURNAL, Hicks JK, Swen JJ, Thorn CF, Sangkuhl K, Kharasch ED, Ellingrod VL, Skaar TC, Müller DJ, Gaedigk A, Stingl JC, Clinical Pharmacogenetics Implementation Consortium guideline for CYP2D6 and CYP2C19 genotypes and dosing of tricyclic antidepressants, Clinical Pharmacology and Therapeutics, 93, 5, 402–8, May 2013, 23486447, 3689226, 10.1038/clpt.2013.2,weblink Individuals can be categorized into different types of CYP2D6 metabolizers depending on which genetic variations they carry. These metabolizer types include poor, intermediate, extensive, and ultrarapid metabolizers. Most individuals (about 77–92%) are extensive metabolizers, and have "normal" metabolism of nortriptyline. Poor and intermediate metabolizers have reduced metabolism of the drug as compared to extensive metabolizers; patients with these metabolizer types may have an increased probability of experiencing side effects. Ultrarapid metabolizers use nortriptyline much faster than extensive metabolizers; patients with this metabolizer type may have a greater chance of experiencing pharmacological failure.The Clinical Pharmacogenetics Implementation Consortium recommends avoiding nortriptyline in persons who are CYP2D6 ultrarapid or poor metabolizers, due to the risk of a lack of efficacy and side effects, respectively. A reduction in starting dose is recommended for patients who are CYP2D6 intermediate metabolizers. If use of nortriptyline is warranted, therapeutic drug monitoring is recommended to guide dose adjustments. The Dutch Pharmacogenetics Working Group recommends reducing the dose of nortriptyline in CYP2D6 poor or intermediate metabolizers, and selecting an alternative drug or increasing the dose in ultrarapid metabolizers.JOURNAL, Swen JJ, Nijenhuis M, de Boer A, Grandia L, Maitland-van der Zee AH, Mulder H, Rongen GA, van Schaik RH, Schalekamp T, Touw DJ, van der Weide J, Wilffert B, Deneer VH, Guchelaar HJ, Pharmacogenetics: from bench to byte—an update of guidelines, Clinical Pharmacology and Therapeutics, 89, 5, 662–73, May 2011, 21412232, 10.1038/clpt.2011.34, 2475005, free,

Chemistry

Nortriptyline is a tricyclic compound, specifically a dibenzocycloheptadiene, and possesses three rings fused together with a side chain attached in its chemical structure.BOOK, Ritsner MS, Polypharmacy in Psychiatry Practice, Volume I: Multiple Medication Use Strategies,weblink 15 February 2013, Springer Science & Business Media, 978-94-007-5805-6, 270–271, Other dibenzocycloheptadiene TCAs include amitriptyline (N-methylnortriptyline), protriptyline, and butriptyline.BOOK, Lemke TL, Williams DA, Foye's Principles of Medicinal Chemistry,weblink 2008, Lippincott Williams & Wilkins, 978-0-7817-6879-5, 580–, Nortriptyline is a secondary amine TCA, with its N-methylated parent amitriptyline being a tertiary amine.BOOK, Cutler NR, Sramek JJ, Narang PK, Pharmacodynamics and Drug Development: Perspectives in Clinical Pharmacology,weblink 20 September 1994, John Wiley & Sons, 978-0-471-95052-3, 160–, BOOK, Anzenbacher P, Zanger JM, Metabolism of Drugs and Other Xenobiotics,weblink 23 February 2012, John Wiley & Sons, 978-3-527-64632-6, 302–, Other secondary amine TCAs include desipramine and protriptyline.BOOK, Anthony PK, Pharmacology Secrets,weblink 2002, Elsevier Health Sciences, 1-56053-470-2, 39–, BOOK, Cowen P, Harrison P, Burns T, Shorter Oxford Textbook of Psychiatry,weblink 9 August 2012, OUP Oxford, 978-0-19-162675-3, 532–, The chemical name of nortriptyline is 3-(10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5-ylidene)-N-methyl-1-propanamine and its free base form has a chemical formula of C19H21N1 with a molecular weight of 263.384 g/mol. The drug is used commercially mostly as the hydrochloride salt; the free base form is used rarely. The CAS Registry Number of the free base is 72-69-5 and of the hydrochloride is 894-71-3.WEB,weblink ChemIDplus - 62265-06-9 - AMLRZIZSGSCSHZ-UHFFFAOYSA-N - Desipramine dibudinate - Similar structures search, synonyms, formulas, resource links, and other chemical information,

History

Nortriptyline was developed by Geigy.JOURNAL, Andersen J, Kristensen AS, Bang-Andersen B, Strømgaard K, Recent advances in the understanding of the interaction of antidepressant drugs with serotonin and norepinephrine transporters, Chem. Commun., 25, 3677–92, 2009, 19557250, 10.1039/b903035m, It first appeared in the literature in 1962 and was patented the same year. The drug was first introduced for the treatment of depression in 1963.BOOK, Dart RC, Medical Toxicology,weblink 2004, Lippincott Williams & Wilkins, 978-0-7817-2845-4, 836–,

Society and culture

File:Nortriptyline HCL capsules - 50mg and 25mg.JPG|thumb|50 mg (left) and 25 mg generic nortriptyline HCl capsules made by Teva Pharmaceutical IndustriesTeva Pharmaceutical Industries

Generic names

Nortriptyline is the generic name of the drug and its {{abbrlink|INN|International Nonproprietary Name}}, {{abbrlink|BAN|British Approved Name}}, and {{abbrlink|DCF|Dénomination Commune Française}}, while nortriptyline hydrochloride is its {{abbrlink|USAN|United States Adopted Name}}, {{abbrlink|USP|United States Pharmacopeia}}, {{abbrlink|BANM|British Approved Name}}, and {{abbrlink|JAN|Japanese Accepted Name}}.BOOK, Elks J, The Dictionary of Drugs: Chemical Data: Chemical Data, Structures and Bibliographies,weblink 14 November 2014, Springer, 978-1-4757-2085-3, 888–, BOOK, Index Nominum 2000: International Drug Directory,weblink 2000, Taylor & Francis, 978-3-88763-075-1, 752–, BOOK, Morton IK, Hall JM, Concise Dictionary of Pharmacological Agents: Properties and Synonyms,weblink 6 December 2012, Springer Science & Business Media, 978-94-011-4439-1, 202–, WEB,weblink Nortriptyline, Its generic name in Spanish and Italian and its {{abbrlink|DCIT|Denominazione Comune Italiana}} are nortriptilina, in German is nortriptylin, and in Latin is nortriptylinum.

Brand names

Brand names of nortriptyline include Allegron, Aventyl, Noritren, Norpress, Nortrilen, Norventyl, Norzepine, Pamelor, and Sensival, among many others.

Footnotes

{{notelist|1}}

References

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