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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by Ant-Rock on October 16, 2001, at 20:21:08
Does anyone know if Ambien restores loss of REM sleep from taking Parnate(70mg)?
If not , is there something that does?
Thanks,
Anthony
Posted by Elizabeth on October 19, 2001, at 13:07:52
In reply to MAOI and REM sleep: Anyone?, posted by Ant-Rock on October 16, 2001, at 20:21:08
> Does anyone know if Ambien restores loss of REM sleep from taking Parnate(70mg)?
It doesn't.
> If not, is there something that does?
Aricept, maybe?
-elizabeth
Posted by Ant-Rock on October 20, 2001, at 16:11:25
In reply to Re: MAOI and REM sleep » Ant-Rock, posted by Elizabeth on October 19, 2001, at 13:07:52
> > Does anyone know if Ambien restores loss of REM sleep from taking Parnate(70mg)?
>
> It doesn't.
>
> > If not, is there something that does?
>
> Aricept, maybe?
>
> -elizabeth
Posted by Adam on October 21, 2001, at 18:34:16
In reply to MAOI and REM sleep: Anyone?, posted by Ant-Rock on October 16, 2001, at 20:21:08
Hey, Ant,
I did a bit of reading on the subject, since I had similar problems with loss of REM sleep (and loss of sleep in general) on selegiline.
One thing I think a lot of people ignore about the MAOIs is that they also inhibit the breakdown of histamine. As it turns out histaminergic signaling seems to be deeply involved in sleep mechanics, e.g. circadian rhythms and paradoxical sleep.
A pointer to a good, recent article of some relevance is here:
I made, myself, a couple of observations: Mirtazapine, which acts most potently as a histamine H1 antagonist, made me dream like crazy. Technicolour, super-hi-fi dreams from another planet. On selegiline, taking diphenhydramine would allow me to both sleep and dream. I figured, well, histaminergic neurons must be involved somehow, and the literature seems to bear that suspicion out.
I had an idea about what to do next, before I got off selegiline entirely: try a better antihistamine than diphenhydramine (better in that it would be more specific for the H1 receptor and not have all the side-effects) to help me sleep. One thing I thought of was low-dose mirtazapine. I think 7.5mg of mirtazapine before bedtime would be pretty safe on tranylcypromine, since it generally has very little activity at that dose on anything except the histamine H1 receptor. There may be other, better choices out there.
You could try an experiment with diphenhydramine just to see if it helps. One other possiblility might be addition of a trycyclic antidepressant, like desipramine, which also is a potent antihistamine, as well as a muscarinic-cholinergic receptor antagonist (those are also involved in sleep-wakefulness cycles).
Just a thought. Good luck!
Adam
> Does anyone know if Ambien restores loss of REM sleep from taking Parnate(70mg)?
>
> If not , is there something that does?
>
> Thanks,
>
> Anthony
Posted by Adam on October 21, 2001, at 19:05:52
In reply to Re: MAOI and REM sleep: Anyone?, posted by Adam on October 21, 2001, at 18:34:16
I should add that desipramine has all of the problems of diphenhydramine in spades, but has the added benefit of being an antidepressant, which is why I suggested it.
Posted by djmmm on October 22, 2001, at 10:41:13
In reply to MAOI and REM sleep: Anyone?, posted by Ant-Rock on October 16, 2001, at 20:21:08
> Does anyone know if Ambien restores loss of REM sleep from taking Parnate(70mg)?
>
> If not , is there something that does?
>
> Thanks,
>
> AnthonyTrazadone is typically used
Posted by Elizabeth on October 22, 2001, at 11:53:37
In reply to Re: MAOI and REM sleep: Anyone?, posted by Adam on October 21, 2001, at 19:05:52
> I should add that desipramine has all of the problems of diphenhydramine in spades, but has the added benefit of being an antidepressant, which is why I suggested it.
I respectfully disagree. :-) Desipramine seems to me to be quite tolerable, whereas Benadryl is something I generally try to avoid. Desipramine definitely is not much of an antihistamine or an anticholinergic, in any case. Benadryl is a pretty good anticholinergic as well as an antihistamine (it's often used in the treatment of extrapyramidal reactions to neuroleptics).
But now that you mention it, I have had some intense dreams when tricyclics (amoxapine, nortriptyline) or neuroleptics (Risperdal, Seroquel) were added to MAOIs (Nardil, Parnate, Marplan). I'm having vivid dreams on desipramine (no MAOI), but that could just be the return of my original sleep problems. (Interestingly, I haven't had problems with abnormal movements in REM sleep since I've been on desipramine, though I have been dreaming.)
One other thing I thought of...I did once have a surprise dream while on Parnate when I had taken Xanax (2 mg) the night before. I spoke to a professor about it, and he had a possible explanation but I can't remember what it was. (It might have been a non-REM dream, anyway, although it did have some of the features that are generally unique to REM dreams.) I'll see if I can find my notes.
Trazodone is known to cause nightmares for some people. It might restore dreams for some people on MAOIs, although I've used it for MAOI-associated insomnia and I didn't have any dreams.
HTH - HAND
-elizabeth
Posted by Adam on October 22, 2001, at 16:35:15
In reply to Re: MAOI and REM sleep: Anyone?, posted by Elizabeth on October 22, 2001, at 11:53:37
>
> I respectfully disagree. :-)Your right! I got them mixed up: I was mis-remembering something I read a while ago about imipramine...here is the reference:
http://www.preskorn.com/columns/0003.html
Note the Ki at H1 for mirtazapine!
Strangely, I myself found desipramine extrememly sedating, and I had all the bad anticholinergic symptoms that people complain about typically with tertiary-amine TCA's (I had clomipramine to compare it to... both bad!). I think this is part of the reason I got confused. It is interesting to note that imipramine is metabolized to desmethylimipramine (desipramine) very quickly...so much so that, in vivo, the serotonergic activity, for instance, of imipramine is quite a bit less than what one would predict from in vitro data. However, it is generally considered to be quite a bit less tolerable than its active metabolite, which dominates. Very strange, to me.
At any rate, because you can use diphenhydramine at like 25-50mg at bedtime as a sedative (quite a bit less than you would take for allergies), and therapeutic doses of DES are about 1/2 to one order of magnitude greater, differences in receptor affinity must be balanced with differences in "dose" at the receptor, when considering side-effects. This is a pretty complicated thing to sort out, as I'm sure you know. I would only consider the potential benefits of a tricyclic for sleep IF the need for an augmentation therapy for an MAOI was already compelling. If I'm correct, DES dosing as a mono- or augmentation therapy is similar, is it not?
P.S. I like my mirtazapine idea. Too risky for your average MD?
>Desipramine seems to me to be quite tolerable, whereas Benadryl is something I generally try to avoid. Desipramine definitely is not much of an antihistamine or an anticholinergic, in any case. Benadryl is a pretty good anticholinergic as well as an antihistamine (it's often used in the treatment of extrapyramidal reactions to neuroleptics).
>
> But now that you mention it, I have had some intense dreams when tricyclics (amoxapine, nortriptyline) or neuroleptics (Risperdal, Seroquel) were added to MAOIs (Nardil, Parnate, Marplan). I'm having vivid dreams on desipramine (no MAOI), but that could just be the return of my original sleep problems. (Interestingly, I haven't had problems with abnormal movements in REM sleep since I've been on desipramine, though I have been dreaming.)
>
> One other thing I thought of...I did once have a surprise dream while on Parnate when I had taken Xanax (2 mg) the night before. I spoke to a professor about it, and he had a possible explanation but I can't remember what it was. (It might have been a non-REM dream, anyway, although it did have some of the features that are generally unique to REM dreams.) I'll see if I can find my notes.
>
> Trazodone is known to cause nightmares for some people. It might restore dreams for some people on MAOIs, although I've used it for MAOI-associated insomnia and I didn't have any dreams.
>
> HTH - HAND
>
> -elizabeth
Posted by Lorraine on October 23, 2001, at 10:31:31
In reply to Re: MAOI and REM sleep: Anyone? » Elizabeth, posted by Adam on October 22, 2001, at 16:35:15
Thought I'd just throw in an article that suggests that suppression of REM sleep does not appear to be related to the antidepressant effect of MAOs:
BACKGROUND: The beneficial effect of antidepressant interventions has been proposed to depend on suppression of rapid eye movement (REM) sleep or inhibition of electroencephalographic (EEG) slow-wave activity (SWA) in non-REM sleep. Use of the monoamine oxidase inhibitor phenelzine sulfate can eliminate REM sleep. We studied the relation between REM sleep suppression and antidepressant response and the effect of phenelzine therapy on sleep EEG power spectra. METHODS: Open-labeled prescriptions of 30 to 90 mg of phenelzine were given to 11 patients with major depressive disorder (6 men and 5 women; mean age, 41.4 years); all were physically healthy. Mood, dream recall, sleep, sleep EEG, and ocular and muscular activity during sleep were studied before treatment and during the third and fifth weeks of pharmacotherapy. RESULTS: Six patients remitted from depression, 2 responded partially, and 3 showed no antidepressant response. Independent from clinical response, REM sleep was dramatically suppressed. On average, only 4.9 minutes of REM sleep was observed in treatment week 5, and it was completely absent in 6 patients. This effect was compensated for by increased stage 2 sleep. In non-REM sleep, EEG power was higher than at baseline between 16.25 and 25 Hz. Slow-wave activity (power within 0.75-4.5 Hz) and the exponential decline of SWA during sleep were not affected. CONCLUSIONS: Antidepressant response to phenelzine treatment does not depend on elimination of REM sleep or inhibition of SWA in non-REM sleep. In depressed patients, REM sleep is regulated independently from non-REM sleep and can be manipulated without altering the dynamics of SWA."
Posted by Elizabeth on October 25, 2001, at 13:12:10
In reply to Re: MAOI and REM sleep: Anyone? » Elizabeth, posted by Adam on October 22, 2001, at 16:35:15
> Note the Ki at H1 for mirtazapine!
Yup. I've used some of my leftover Remeron to counteract the itchies from buprenorphine. (I've also used trazodone for this purpose.)
> Strangely, I myself found desipramine extrememly sedating, and I had all the bad anticholinergic symptoms that people complain about typically with tertiary-amine TCA's (I had clomipramine to compare it to... both bad!).
Hmm...well, some noradrenergic drugs can cause anticholinergic symptoms (MAOIs, for example). Supposedly there is some kind of reciprocal interaction between NE and ACh, at least in relation to states of consciousness.
> It is interesting to note that imipramine is metabolized to desmethylimipramine (desipramine) very quickly...
Yes, this is something of a puzzle. I would look at steady-state plasma concentrations of imipramine and desipramine in vivo to determine what to expect.
> At any rate, because you can use diphenhydramine at like 25-50mg at bedtime as a sedative (quite a bit less than you would take for allergies),
I take 75 mg with buprenorphine (when I have to resort to Benadryl, that is -- my antihistamine of choice is promethazine).
> This is a pretty complicated thing to sort out, as I'm sure you know.
I think that you would also have to consider the relative volumes of distribution, ...!
> I would only consider the potential benefits of a tricyclic for sleep IF the need for an augmentation therapy for an MAOI was already compelling. If I'm correct, DES dosing as a mono- or augmentation therapy is similar, is it not?
Depends what you're augmenting. I think pdocs like to be cautious with the doses of both drugs when using MAOI/TCA combinations.
> P.S. I like my mirtazapine idea. Too risky for your average MD?
Too risky for me. And you know some of the things I'm willing to try. :-)
-elizabeth
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