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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by AnneL on March 13, 2002, at 23:40:06
Went to pdoc today. I was trying to get my point across that Effexor just dosen't seem to be doing much anymore. All of a sudden it just seemed to poop out. I am taking 225 mg. and 1 mg. at night of Klonopin. Can Effexor just poop out suddenly?
I learned something though. . . You never know how well you were really doing until you start feeling really crappy again. I guess I got used to feeling OK. Now I am depressed, agitated and ruminate about suicide, although I think I just think about it for "mind torture" and have no intention. I think the Effexor is making me feel worse along with the Klonopin and I want off!!
Problem is just tapering to 187.5 made me so depressed! Pdoc wants to add Luvox for "ruminating" thoughts. I just want to feel better and I don't think another SSRI is safe.
What do you all think?
Posted by TSA West on March 13, 2002, at 23:57:32
In reply to My intuition says no to Effexor + Luvox. . ., posted by AnneL on March 13, 2002, at 23:40:06
Luvox is safe along with Effexor--there is only a tiny chance of serotonin syndrome, hepatoxicity, or ExtraPyramidal Symptoms. The convenient part of Luvox is that 50 mg (the starting dose) _is_ a therapeutic dose that stands a chance at relieving agitation immediately.
Your other option is to add an augmentation agent such as Lithium to Effexor. But Lithium is not as tolerable as an SSRI (although millions of people do well with Lithium anyway, mostly for bipolar disorder).
Posted by Janelle on March 14, 2002, at 0:11:11
In reply to My intuition says no to Effexor + Luvox. . ., posted by AnneL on March 13, 2002, at 23:40:06
Oh, can I relate to much of what you are saying. I too am on EffexorXR (150 mg - tried higher but could not tolerate it - way to activating and agitating for me) -- I am also feeling as though it is not doing a whole heckuva lot for me - keeps my head above water but that's it. Feel like I've plateau'ed on it. Pdoc has just added Lamictal to the mix. Hopefully it might boost the Effexor.
I also take 1mg of Klonopin, sometimes in the am, sometimes in the pm.
To answer your question, based on everything I've read and heard, yes, Effexor (and any other SSRI for that matter) can just poop out all of a sudden.
And oh, how I know what you mean when you said that you never know how well you were really doing until you start feeling really crappy again. I just about get used to feeling OK when I crash. It's like a roller coaster ride. I'm feeling similarly to how you are (depressed, agitated and ruminate).
I took LUVOX for OCD type behaviors and "ruminating" thoughts - it was of minimal help. It basically got me sedated at night and kinda foggy during the day. Also, because I had so much anxiety with the OCD stuff and racing thoughts my pdoc had me titrate up very rapidly on the Luvox - not good. Then I DID develop Serotonin Syndrome from being on both EffexorXR (I think could be one of the more powerful SSRI's) and Luvox. I tapered OFF the Luvox and the Serotonin Syndrome went away - thank goodness.
Don't want to scare you away from Luvox, it CAN be taken *safely* with another SSRI - the key is the dosages of each of them.
Good luck - let me know what you decide!
Posted by TSA West on March 14, 2002, at 1:22:25
In reply to Re: My intuition says no to Effexor + Luvox. . . » AnneL, posted by Janelle on March 14, 2002, at 0:11:11
I believe Lamictal could benefit you greatly, and here's an article I'd like you to see:
"To the Editor: Lamotrigine, which at present has been indicated only for the treatment of epilepsy, has been reported to be possibly useful as an adjunctive treatment for bipolar disorder. This letter presents two cases of its successful use as an adjunctive treatment for refractory major depression.
Ms. A was a 45-year-old woman who had been diagnosed with recurrent major depressive disorder; her therapeutic trials of bupropion, phenelzine, venlafaxine, imipramine, and nortriptyline had failed, and she had only been partially responsive to ECT. To her regimen of tranylcypromine, 70 mg/day, lithium carbonate, 1200 mg/day, and clonazepam (0.5 mg/day b.i.d. as needed, used sparingly for anxiety) treatment was added lamotrigine, 25 mg/day, and titrated to 75 mg/day within 3 weeks. Within 8 weeks, Ms. A reported a dramatic improvement in her mood and shortly thereafter returned to work. She continued to do well on this treatment regimen when assessed 6 months later.
Ms. B was a 43-year-old woman with recurrent major depressive disorder whose therapeutic trials of venlafaxine, fluoxetine, and paroxetine had failed. In addition, she could not tolerate a trial of nefazodone treatment. To her regimen of fluoxetine, 50 mg/day, and bupropion, 150 mg/day (sustained-release preparation), was added lamotrigine, 25 mg/day. Within 4 weeks, she, too, reported a dramatic improvement. "I can't remember the last time I felt this good," she commented. She continued to do well when assessed 2 months later.
In both cases, the addition of lamotrigine to the current psychotropic regimen resulted in a significant improvement in mood. The agent was well tolerated, with no additional side effects reported by either patient. In addition, neither had developed a rash of any kind. It appears that lamotrigine may be effective as an augmentation strategy in treating major depressive disorder."
--THOMAS M. MALTESE, M.D. The American Journal of Psychiatry, November 1999.
-----TSA West: Practicing Self-Denial Daily------
Posted by Janelle on March 14, 2002, at 14:35:35
In reply to Effexor + Lamictal in your case » Janelle, posted by TSA West on March 14, 2002, at 1:22:25
Posted by AnneL on March 14, 2002, at 23:39:44
In reply to Re: My intuition says no to Effexor + Luvox. . . » AnneL, posted by TSA West on March 13, 2002, at 23:57:32
Called my old pdoc today. I had to stop seeing him because of insurance problems and it was too much out of pocket:( When I last saw him, he said he wanted me to see a psychopharmacologist because he was "not convinced" Effexor was the appropriate drug for me and wanted me to see one of his esteemed colleagues to help him tease out the diagnosis. He said something like a "mood problem". Well this was back in October and I had to go to a pdoc that my insurance would cover and I just don't trust him. The incredible news is that this psychopharmacologist is now covered by my insurance!!! So I called my favorite pdoc and told him I was having a bad time and he called the psychopharmacologist and he got me in 2 weeks earlier! In the meantime, he upped my Effexor to 262.5 mg. from 225 mg. today and said just "hang on" until Tuesday! I feel so wierd though. . . It's that start-up, drugged out, spacey feeling. In just a few hours, I stopped obsessing about death, and I'am not crying. Really puts a halt on the emotions (not sure if this is good or bad, but it's ok). Anyway, I just feel bodily "strange" and just need some support during this time until I see the new doctor. Will this sleepy, lethargic, a little agitated feeling dissipate? It's a little unsettling. . . Thanks AnneL
Posted by SLS on March 15, 2002, at 10:47:58
In reply to Re: My intuition says no to Effexor + Luvox. . . ?AnneL, posted by Janelle on March 14, 2002, at 0:11:11
Hi Janelle.
I'm glad you were able to elude a severe serotonin-syndrome reaction. I have developed a healthy respect for this thing. I once tried taking a very small dose of Effexor - less than 20mg - while I was taking Parnate (an MAOI). Within 30 minutes, I ended up in a dilerious stupor, confused and babbling nonsense. I was lucky. I chose Effexor because of its short half-life. I almost managed to have a half-life of my own.
What sorts of things did you experience that brought you to the conclusion that it was serotonin-syndrome?
> To answer your question, based on everything I've read and heard, yes, Effexor (and any other SSRI for that matter) can just poop out all of a sudden.
Effexor does not seem to "poop-out" nearly as often the SSRIs do. However, it might not be so unusual that someone fails to respond to its reintroduction once they have relapsed as a result of its discontinuation. Effexor is not an SSRI, even though it is a potent serotonin reuptake inhibitor. It also inhibits the reuptake of norepinephrine, and to a lesser degree, dopamine. It is sometimes referred to as serotonin/norepinephrine reuptake inhibitor (SNRI) The order of potency in which Effexor inhibits the reuptake of the monoamine neurotransmitters is as:
serotonin (5-HT) > greater than norepinephrine (NE) >> much greater than dopamine (DA)
Effexor is perhaps 4 or 5 times more potent at 5-HT than it is at NE.
A new drug, duloxetine, might be released within the next year. Like Effexor, it also inhibits the reuptake of both 5-HT and NE. However, it does so nearly equally. Because of this, one might dare to hope that this antidepressant would get a whole bunch of people well that had not responded adequately to the others. Duloxetine has been developed by Eli Lilly, the makers of Prozac. Lilly is also pushing to get approved a single preparation containing a combination of Prozac and Zyprexa. They are looking to market it as being particularly useful for treatment-resistent depression. What a silly idea. I should think that anyone would want the flexibility to titrate each drug individually to optimize efficacy versus side effects. Like Serafem, it is an attempt to reincarnate Prozac (fluoxetine) and sell it as a brand new drug with a brand new patent. Silly.
Be Well.
- Scott
Posted by Janelle on March 15, 2002, at 17:13:40
In reply to Re: My intuition says no to Effexor + Luvox. . . » Janelle, posted by SLS on March 15, 2002, at 10:47:58
Hi,
First, the reason that you had such a bad reaction when you took a very small dose of Effexor - less than 20mg - while you were taking Parnate (an MAOI) is because there are warnings all over the place NOT to mix SSRI's with MAOI's. I imagine the dilirious stupor you wound up in where you were confused and babbling nonsense was because apparently SSRI's and MAOI's do not mix! I have read all over the place not to take them together and also if you're going to switch from one to the other you should wait 14 days before making the change.
As for the sorts of things I experienced that brought me to the conclusion that I had gotten serotonin-syndrome from the high dose of Luvox plus a moderate dose of EffexorXR well it's a blur now (my memory is shot thanks to the depression condition and I think the meds too), but I recall that I had the shakes and tremors big time, headaches, my head also *jiggled* inside. It was mostly the shakiness and feeling over stimulated, an overly caffeinated type feeling. I almost felt like I was on a high. It was my sister who first thought it could be too much serotonin and then when I had a visit with the pdoc she immediately said it was probably SS after I described my symptoms. That was what made her decide to titrate me down on the Luvox and lo and behold the symptoms went away. That this happened also led us to conclude it had to be SS.
I'm encouraged to that you mentioned that Effexor does not seem to "poop-out" nearly as often the SSRIs do because I am still very bummed out that Paxil which had worked wonders for me suddenly pooped out and I've not been able to stabilize since then yet.
take care
-Janelle
Posted by SLS on March 15, 2002, at 19:26:14
In reply to SLS: re Serotonin syndrome, more: » SLS, posted by Janelle on March 15, 2002, at 17:13:40
Hi Janelle.
Thanks for your concern.
> First, the reason that you had such a bad reaction when you took a very small dose of Effexor - less than 20mg - while you were taking Parnate (an MAOI) is because there are warnings all over the place NOT to mix SSRI's with MAOI's.
There exist similar warnings all over the place not to mix MAOIs with any other antidepressant or stimulant. You can - quite safely. You will find recommendations regarding these combinations in Dr. Bob's Tips. I have taken Nardil with amitriptyline and desipramine. I have also taken Parnate (150mg) with imipramine and desipramine. To the latter, my doctor added on top of that amphetamine (Dexedrine) and bromocriptine (Parlodel).
> I imagine the dilirious stupor you wound up in where you were confused and babbling nonsense was because apparently SSRI's and MAOI's do not mix! I have read all over the place not to take them together and also if you're going to switch from one to the other you should wait 14 days before making the change.
All I can say is that desperation can greatly influence one's decision-making process.
> As for the sorts of things I experienced that brought me to the conclusion that I had gotten serotonin-syndrome from the high dose of Luvox plus a moderate dose of EffexorXR well it's a blur now (my memory is shot thanks to the depression condition and I think the meds too),
I know the feeling.
> but I recall that I had the shakes and tremors big time, headaches, my head also *jiggled* inside. It was mostly the shakiness and feeling over stimulated, an overly caffeinated type feeling. I almost felt like I was on a high. It was my sister who first thought it could be too much serotonin and then when I had a visit with the pdoc she immediately said it was probably SS after I described my symptoms. That was what made her decide to titrate me down on the Luvox and lo and behold the symptoms went away. That this happened also led us to conclude it had to be SS.
Thanks for responding. SS seems to look different from individual to individual. I was curious as to how it was expressed in your case in order to get a better idea of what to look out for.
> I'm encouraged to that you mentioned that Effexor does not seem to "poop-out" nearly as often the SSRIs do because I am still very bummed out that Paxil which had worked wonders for me suddenly pooped out and I've not been able to stabilize since then yet.
I'll probably have to discontinue Effexor for lack of efficacy, but the results of a recent multi-center study of over 2000 cases compared Effexor to various SSRIs. The results demonstrated that Effexor got more people well and got each person weller than the SSRIs.
Other studies have yielded similar results.
> take care
> -JanelleYou too.
- Scott
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