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Bupropion + modafinil alternatives

Posted by Tony P on April 4, 2024, at 5:24:23

I have been taking bupropion and modafinil for about two years, for MDD and severe daytime sleepiness. Now, for a couple of reasons, I am having to drop the bupropion, and revisit my use of modafinil.

Last year, I went on tamoxifen (breast cancer followup) and the oncologist was very insistent I drop bupropion, as it strongly interacts with tamoxifen (inhibits via CYP enzymes). I negotiated a compromise to reduce my dose by 1/2. Ironically, I was just about to ask my GP about _increasing_ my dose, as I had developed tolerance to the low dose I was on (100 mg/day) and wasn't getting the same benefit as originally. So now I'm looking for a substitute that doesn't interact with tamoxifen, an NDRI or similar. I've done fairly well on Cymbalta in the past (it's only a moderate inhibitor of tamoxifen), but it's not covered by my insurance and I only tolerated it in combination with clonazepam; having spent over a year withdrawing from benzos, I'd be very reluctant to go back on them, even if I could persuade a Dr to prescribe one in the present disfavoring climate. In any case, Cymbalta is only an SNRI, and I really need the dopamine, not so much for pleasure, but for decisiveness and coping skills.

I've also developed tolerance to the modafinil, in retrospect I probably shouldn't have been on it for so long. AFAIK there's no substitute for its unique "wakefulness" effect, so I may have to go off it for a while -- I've been tapering a bit in anticipation. I am continuing to have problems with compulsive daytime sleepiness, verging on narcolepsy, often falling asleep at my desk and (nearly) falling -- a few times I _have_ fallen, luckily no serious injury, but at my age (77) falls are a real concern. We haven't completely diagnosed the cause of my dropping off, it's partly just irregular sleep habits and DSPD, but we haven't ruled out sleep apnea. I'm seriously overweight, which is a risk factor for that, so an NDRI might help with losing weight too.

I've tried occasional doses of Ritalin, but I don't want to make my stimulant tolerance even worse! I came across a reference to an NDRI rejoicing in the name of Atomoxetine (Strattera), which sounds like a nuclear fission moderator, but my GP (who's uncomfortable prescribing anything that says "stimulant" in the monograph) declined the suggestion. I do take kava-kava regularly, quite a large dose (4-8g per day of standardized 30%), and it helps my mood considerably (it's a mild MAOI as well its better-known sedative properties), but it's more of a pleasant intoxicant than an activator. I've been on low-dose selegeline in the past with some success, and I've considered stronger MAOI's, but I'd have trouble with the dietary restrictions. First generation TCAs are a possibility, but besides their unpleasant S/E, I came across a disturbing comment on trimipramine: that it (and possibly other TCAs) have been implicated in causing breast cancer after 11-15 years -- an aha! moment, I was taking it exactly 11 years before I developed breast cancer myself, which is the main reason I'm looking for a new A/D!

BTW, I was also getting considerable benefit from testosterone injections -- I was diagnosed years ago with serious hypogonadism -- but the oncologist vetoed that too! So I've been off that, as well, for 6 months. I really miss it; besides the expected mood benefits, I was somewhat surprised to find it helped my age-related stiffness.

In my own consultations with the oncologist, he has said it's my choice to decide how to balance the expected five-year survival benefit of tamoxifen, dropping any meds which interact (& the testosterone), against the benefits of the latter. However my GP says he can't go against the advice of the oncologist, which sounds like it was much more peremptory and categorical as communicated to him. Professional ethics, I guess.

My GP has referred me to a geriatric psychiatrist, whom I saw a couple of times two years ago -- he prescribed the modafinil. I have an appointment in about 3 weeks, but I always like to come to a session prepared. So I'm looking for suggestions, especially to replace the bupropion.

I think I am a verb
Bupropion (low dose)
Tamoxifen, Rosuvastatin, Tamsulosin
Kava-kava & other supplements




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