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Re: advice on adusting

Posted by SLS on November 30, 2022, at 19:35:12

In reply to advice on adusting, posted by gman22 on November 30, 2022, at 15:49:18

> I had another good response to nortriptyline and sertaline, 50mg each. (2nd time this worked for me). But I'm starting to have some breakthrough symptoms, and I'm wondering which med I should increase first...50 mg is basically a starting dose for both. Or should i scrap this strategy all together and try something else?
> Thanks

I think that before you make any choices, you get a blood test to assay your nortriptyline level. Nortriptyline is a bit of an odd-ball tricyclic. It's the only one that has a therapeutic window.


50 mg/day = Failure to respond
100 mg/day = Full remission
150 mg/day = Relapse

Nortriptyline is the best studied of the tricyclics with respect to blood levels and response curves. Originally, the recommended range of effective blood concentrations of nortriptyline were 50-150 ng/mL. More recently, I have seen a range of 70-170 ng/mL. At 150 mg/day, my blood level was 153 ng/mL. This concentration turned out to be too high for me. A dosage of 100 mg/day brought me to remission. I have yet to have a follow-up blood test. Of course, it would be for instructive purposes only. Either of the two recommended reference ranges should be used as a guideline rather than an inflexible prescription.

I have come to see most people respond to either 25-75 mg/day or 100-150 mg/day. The numbers may not be precise, but the important concept is that there are probably two therapeutic windows for nortriptyline. People are either low-dosage responders or high-dosage responders. I have not gone digging for corroborative data. If you are too high, you might find yourself losing your balance or feeling like the ground is moving. You might find yourself biting or sucking ridges in the sides of your tongue. A mild amount of dizziness can actually be an indicator of an ultimately successful treatment. It might have to do with a transient dysautonomia that occurs as things are changing in in a healthy direction for brain. Too much is too much, though. If these side effects do not wane at a steady dosage, this is an indicator that you are taking too much. A noticeable increase in short-term memory impairment and a persistent brain-fog yield "dumb mistakes". Generally, the emergence and persistence of ataxia can be viewed as an indicator that you are taking too much nortriptyline.

Too many words, perhaps.

The bottom line is that you should first determine whether or not your blood levels of nortriptyline fall within a therapeutic range / dosage window. Adjust the dosages of nortriptyline up or down as necessary. I would then recommend giving enough time to establish the right dosage of nortriptylinhe and add on another 4-6 weeks afterwards to perform a legitimate trial. Hopefully, you will see an improvement during the 3rd week. If you feel only slightly better at first is what you should expect. It took somewhere between 2 and 3 months for me to beginning to respond robustly to Nardil. A few others described the same pattern with Nardil. From what I can see, a slow and bumpy improvement is a better prognosticator of remission than is a rapid or paroxysmal improvement.

If you feel absolutely nothing at all by the end of week 4, studies show that it is unlikely that giving 2 more weeks will help.

If, after adjusting the dosage of nortriptyline and titrating the dosage of sertraline clinically (going up to 200 mg/day if necessary), you might then consider leaving both drugs in place and adding Wellbutrin 300 mg/day.

I think this makes clinical sense. The brain might not be a black box anymore, but it is still a very dark gray. My remission is the product of clinical observation and recording treatment results. I did not succeed by trying to mix-and-match drugs according to their (presumed) pharmacologies. I didn't categorize neurotransmitters and receptors, nor did I assign them exclusivity when trying to understand a particular brain function. The brain is a Gestalt. Neuroscientists have untold amounts of data that they have collected over the course of decades using the scientific method. However, there is no picture on the box of the jigsaw puzzle to act as a guide.

1. Nortriptyline blood test.
2. Adjust dosage of nortriptyline using the blood test as a guide.
3. Allow enough time for a well-adjusted dosage of nortriptyline to produce a response.
4. Titrate sertraline up to 200 mg/day
5. Add Wellbutrin 300-450 mg/day
6. Keep your fingers crossed.

- Scott

Some see things as they are and ask why.
I dream of things that never were and ask why not.

The only thing necessary for the triumph of evil is that good men do nothing.




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