Posted by ed_uk on December 29, 2004, at 17:31:12
In reply to Re: What to combine with a mood stabilizer? » tensor, posted by Ritch on December 29, 2004, at 17:03:42
> Some people don't get them checked if they show no signs of toxicity and they are responding to the nortriptyline (as Ed mentioned). I just thought it might be a good idea should you combine the Zoloft with it--- because the Zoloft (and other SSRI's) will inhibit liver enzymes that break down the nortriptyline, which may cause very high levels of the nortriptyline at a "standard" dosage and possible toxicity. Some people are "poor metabolizers" of TCA's like nortiptyline as well (without taking an SSRi). Combining SSRI and TCA can raise blood levels of the TCA ten-fold in some cases. Just being cautious. When I took Zoloft+Nortiptyline I was only taking 20-30mg of NT, didn't get blood level done, the only side effects I got from nortrip. besides some dry mouth was a little shakiness with "pins and needles" skin sensations(like from watching a scary movie) and an elevated heart rate. Oh, you might get a decent mood boost when you stop the Remeron.. I definitely did! Good luck!
Hi Mattias,
Ritch is right, getting a plasma level is more important if you were going to combine nort with sertraline. In my last post I was assuming that you'd be taking the nort on its own.
Although sertraline certainly can raise nort plasma levels, it is considerably less problematic than some of the other SSRIs in this respect. Here is a summary of a little study...........
'A study in 14 elderly patients on nortriptyline found that when additionally given 50 mg sertraline daily, the median increase in plasma nortriptyline levels was only 2% (with a range of –26 to 117%), but two of them showed increases of 51% and 117% respectively, changes the authors considered clinically meaningful. For those taking higher doses of sertraline (100 to 150 mg daily) the median increase in nortriptyline plasma levels was 40% (with a range of −12% to +239%).'
Because some people are very sensitive to nortriptyline (eg. poor metabolizers) it is important to start with a very low dose and to increase gradually if necessary. Careful dose titration based on efficacy and tolerability is in many ways as useful as plasma concentration monitoring. People who suffer 'strong' side effects at very low doses are likely to be poor metabolizers.
A suitable starting dose for nortriptyline is 10mg. In the absense of other medication, most people need 50-100mg/day of nort to get a good antidepressant effect. As ever, YMMV, some people will need more (it is unusual to exceed 150mg/day) and others will do well on less. As Ritch said, lower doses of nort may be sufficient for a person taking sertraline.
If severe side effects are present at very low doses it would be useful to get a plasma level- a high plasma conc would suggest that the person may be a poor metabolizer.
If a person fails to improve on nort, a plasma level can tell you whether you should increase or decrease the dose in order to maximize effectiveness. With nort, too high a dose may make the treatment less effective ie. it has a 'therapeutic window'.
Ed.
poster:ed_uk
thread:434951
URL: http://www.dr-bob.org/babble/20041228/msgs/435426.html