![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 21 to 45 of 62. Go back in thread:
Posted by Chloe on June 11, 2002, at 18:13:24
In reply to Re: Trimipramine= no sleep! (Ami vs. Dox vs. Trim) » Chloe, posted by fachad on June 11, 2002, at 16:42:16
> I've taken all three, and also have researched the pharmacological differences between these three. Each one has unique properties.
>
> The three parameters that accout for the way the drugs effect you are:
>
> Histamine blockade (sedation, increased appetite)
>
> Cholenergic blockade (dry mouth, consitpation, etc.)
>
> Re-uptake of NE and 5HT.
>
> Ami is the most potent at cholenergic blockade. At the same doses, it causes much more dry mouth and constipation than Dox or Trimip. Also, there is a withdrawl symptom from "cholenergic rebound" that could explain why you felt bad subing trimip for ami.
>
> Doxepin is the most potent at Histamine blockade. At the same doses it is the most potent sedative. Trimip is very close to doxepin, slighty less H1 blockade than dox, but much more than ami.
>
> Trimp is nearly as potent as dox at H1 blockade, and should be much more sedating than ami. It is slightly more potent than dox at cholenergic blockade. The other unique things about trimp are lack of re-uptake of NE and 5HT, and very slight DA blockade
>
> Here are the numbers for the three on H1 and Ach blockade from one study I read:
>
> Drug------H1------Ach
>
> Ami-------91------5.1
> Dox------410------1.3
> Trim-----370------1.7
>
>
> So for me dox and trimp seem much stronger, but much cleaner for sleep. I would not underestimate the severity of the cholenergic rebound if switching from ami to one of the other two.
>Fachad,
that information is so helpful. But I am not sure why trimip's sedative effect did not allow me to sleep some...I had to resort to benzo's to sleep. But I do think I had the cholinergic rebound. I was sweating and peeing, etc like crazy. It was very uncomfortable. Really a withdrawal syndrome. I guess, or maybe I am just oversensitive???, that I should have stayed on the ami and added the trimip? Then gradually decrease the ami?However, Trimip is out for me. I have bad eps in my mouth, clenching, tongue wagging, it exacerbated some old td symptoms. :(
But I am really curious about doxepin. If it wouldn't be so drying. I have sores in my mouth that just won't go away. My mouth gets so dry when I sleep (so soundly!) that my gums, lips never heal up. But maybe the H1 in doxepin would also cause drying? You said the H1 causes weight gain. Did you experience this? And if you know, how strong is the NE reuptake compared to ami? I think that is the component in ami that makes me incredibly grouchy and short fused. I get nasty really fast, no warning. It's awful. That's why I had high hopes for trimip. And for those two day+ on trimip, my mood was exceptionally even with an long fuse.
Hope you don't mind all the questions. I just want to have as much info as possible before I ask my pdoc about doxepin. I only have such a short time to talk to her, I have to be totally prepared.
Thanks again, your researched info is so appreciated. Have you found the "right" dose of trimip for you yet? I know 25 is too much still, right?
Chloe
Posted by fachad on June 12, 2002, at 0:58:28
In reply to Re: Trimipramine= no sleep! (Ami vs. Dox vs. Trim) » fachad, posted by Chloe on June 11, 2002, at 18:13:24
Chloe: I am not sure why trimip's sedative effect did not allow me to sleep some...I do think I had the cholinergic rebound. I was sweating and peeing, etc like crazy.
fachad: I really think it was the cholinergic rebound. Ami is far more potent at Ach blockade than trimip.
REM sleep suppression, urinary retention, and temperature regulation are all caused by cholinergic blockade. If you have been taking ami for awhile, your body has equilibrated to that, and if you take something the does not suppress Ach as much, those are the symptoms you would expect.
Chloe: However, Trimip is out for me. I have bad eps in my mouth, clenching, tongue wagging, it exacerbated some old td symptoms. :(
fachad: I don't know if you know this or not, but cholinergic blockade actually reduces TD symptoms.
I don't know the exact mechanism, but anti-cholinergics are used to alleviate TD and EPS symptoms. If your recurrence of EPS was due to the sudden absence of anti-cholinergic effects, you would do worse on doxepin than trimp, even though doxepin has no effect on DA.
In fact, if the EPS was being suppressed by ami, you would have worse EPS on nothing at all than on trimip. A question for your pdoc.
Chloe: But I am really curious about doxepin. If it wouldn't be so drying. I have sores in my mouth that just won't go away. My mouth gets so dry when I sleep (so soundly!) that my gums, lips never heal up.
fachad: It is the anti-cholinergic effect that causes that awful drying. H1 blockade does not cause drying at all. Remeron (mirtazapine) is far more potent at H1 blockade than even doxepin, almost 10 times more than ami, without any anti-cholinergic effects, and it is not drying at all.
So it's safe to say that you would be less dried out on dox than you are on ami, but I'd bet you'd have constant peeing, and maybe EPS too if you didn’t taper slowly off ami or substitute another Ach blocker (which would dry you out).
Chloe: You said the H1 causes weight gain. Did you experience this?
fachad: Well, that's really a difficult question, one that research has not been able to answer with certainty. Some meds (esp. non-psych antihistamines) block H1 very potently without causing weight gain. Many psych meds cause weight gain without blocking H1 (MAOIs, lithium, many others). But there does seem to be some general correlation between weight gain and H1 blockade.
My personal experience is that ami and dox caused some mild weight gain, while trimip does not. Literature reports show weight gain from all three. Avoiding weight gain is my main reason for trying to find the lowest effective dose.
Chloe: how strong is the NE reuptake compared to ami? I think that is the component in ami that makes me incredibly grouchy and short fused
fachad: I've seen other people become short fused on ami. I don't know if anyone has tried to tie it to NE reuptake or anything else.
As far as the NE potency, here are a few numbers:
Drug-------NE reuptake
ami----------4-------
nortrip-----25-------
imimp--------8-------
desip------110-------
trimp------0.2-------
dox----------5-------Note that when you take ami, it is metabolized into nortrip, so you get NE uptake from both drugs, same for imipramine and desipramine. So even though dox is more potent, than ami, it is far less potent than nortrip.
Chloe: Hope you don't mind all the questions. I just want to have as much info as possible before I ask my pdoc about doxepin.
fachad: I don't mind at all - I like to be able to share some of this stuff I've picked up. Another cool thing about doxepin, it comes in a liquid form. I just like that idea both on general principal, and because it allows for very minute dosage adjustments. Doxepin is also a dirt cheap generic.
Chloe: I only have such a short time to talk to her, I have to be totally prepared.
fachad: I hear you there. I have never achieved my "holy grail" of getting the entire 15 minutes of an already too short 15 minute med check appt. with my pdoc. The evils of managed care.
Chloe: Have you found the "right" dose of trimip for you yet? I know 25 is too much still, right?
fachad: I know I would love the sleep from 25mg, but I'm afraid I'd have more side effects. When I get the RX for the 2.5 mg capsules, I'll be able to know exactly how little I can take and still get good sleep. For now, I'm just taking less than 25mg, but I can't accurately tell you how much it is.
Hope doxepin works for you.
Posted by johnj on June 12, 2002, at 9:04:58
In reply to Trimip= cholenergic rebound, EPS, etc (long expl.) » Chloe, posted by fachad on June 12, 2002, at 0:58:28
Fachad:
That is great info you posted. I was hoping you could post the same type of info (ACh, H1) for nortry as compared to the others?
I might have told you, but here is my problem: I get severe rebound of side effects and mood disturbance when I excercise. It takes days to recover and usually it doesn't hit until a day or so after working out. I get dizzy, sleep disturbance and then mood decline.
I have heard from two other people one on amit.(nortry mother drug) and one on notryp that had the same or similar problem. One person told me they didn't get this effect on imipramine, but I had some terrible jitterness and night sweats when I added just a few 10 mgs of impramine to my norty. Is that an Ach effect?
Maybe it is the NE reuptake? As you said amit metabolizes to despramine so the combo has high NE reuptake. I am seriously looking at adding some trimp since I have had trouble sleeping, but I added some omega 3's last week and had to up my benzo a bit and have slept better. I thought the omega 3's were just crap, but I may have to re-evaluate that. Anyway, I would like to switch(with my docs help) and see if things stabilize and then try working out again. It is a mystery why excercise hoses things up, and the doc doesn't quite believe me. This has been going on for years so I know it is not in my head. I may find it is just TCA's that do it or I may find it is just nortry for some odd reason. Well, thanks for reading my rambling. Take care and keep us posted on your trimp dosing. Thank you
Johnj
Posted by Chloe on June 12, 2002, at 9:42:41
In reply to Trimip= cholenergic rebound, EPS, etc (long expl.) » Chloe, posted by fachad on June 12, 2002, at 0:58:28
>> fachad: I've seen other people become short fused on ami. I don't know if anyone has tried to tie it to NE reuptake or anything else.
Fachad,
This info is so invaluable. It is so wonderful to correspond with you. You have helped so much. Google, medline, etc search hasn't been as helpful as you have been to me. I am so appreciative!That is interesting you have heard of others getting short fused on Ami. Do you think this is simply related to Ami? Have you heard of Doxepin causing grouchiness too??? I wonder if all the ACh properties have something to do with this the grouchiness. Can you speculate?
>> As far as the NE potency, here are a few numbers:
>
> Drug-------NE reuptake
>
> ami----------4-------
> nortrip-----25-------
> imimp--------8-------
> desip------110-------
> trimp------0.2-------
> dox----------5-------
>Your charts are so helpful! I love the science part of meds.
Well, if it is the NE reuptake, Doxepin has slightly more! So I guess it wouldn't make a difference...But I am just really wanting to find out if I could be more civil on another TCA.BTW, Trimipramine really is out, because even though I have been back on the Ami for 3 days, I still have awful EPS. This happens when I take an AP. It takes weeks to stop the EPS that only a pill or two with dopamine can cause :(.
>>fachad: I don't mind at all - I like to be able to share some of this stuff I've picked up. Another cool thing about doxepin, it comes in a liquid form. I just like that idea both on general principal, and because it allows for very minute dosage adjustments. Doxepin is also a dirt cheap generic.Thanks again for sharing your insights and experiences. Look forward to hearing more, if you have the energy!
>> Hope doxepin works for you.
Me too! But I am kinda scared to try...Med changes are always such an adjustment! And a gamble.
Chloe
Posted by fachad on June 12, 2002, at 23:00:15
In reply to Re: Norty compared to trimp (fachad), posted by johnj on June 12, 2002, at 9:04:58
Here is the earlier table with nortrip and benedryl added for comparison:
Drug------H1------Ach
Ami---------91------5.1
Dox--------410------1.3
Trim-------370------1.7
Nortrip-----10------0.7
Benadryl-----7---------
Atropine-------------42I have no idea what the underlying mechanism of the exercize problem could be. The only thing you could do is to try other meds.
> Fachad:
>
> That is great info you posted. I was hoping you could post the same type of info (ACh, H1) for nortry as compared to the others?
>
> I might have told you, but here is my problem: I get severe rebound of side effects and mood disturbance when I excercise. It takes days to recover and usually it doesn't hit until a day or so after working out. I get dizzy, sleep disturbance and then mood decline.
>
> I have heard from two other people one on amit.(nortry mother drug) and one on notryp that had the same or similar problem. One person told me they didn't get this effect on imipramine, but I had some terrible jitterness and night sweats when I added just a few 10 mgs of impramine to my norty. Is that an Ach effect?
>
> Maybe it is the NE reuptake? As you said amit metabolizes to despramine so the combo has high NE reuptake. I am seriously looking at adding some trimp since I have had trouble sleeping, but I added some omega 3's last week and had to up my benzo a bit and have slept better. I thought the omega 3's were just crap, but I may have to re-evaluate that. Anyway, I would like to switch(with my docs help) and see if things stabilize and then try working out again. It is a mystery why excercise hoses things up, and the doc doesn't quite believe me. This has been going on for years so I know it is not in my head. I may find it is just TCA's that do it or I may find it is just nortry for some odd reason. Well, thanks for reading my rambling. Take care and keep us posted on your trimp dosing. Thank you
> Johnj
Posted by fachad on June 12, 2002, at 23:07:53
In reply to Re: Trimip= cholenergic rebound, EPS, etc (long expl.) » fachad, posted by Chloe on June 12, 2002, at 9:42:41
Chloe,
I think the information about receptor affinities is very interesting and it does provide some basis of comparison between different TCAs.
However, as my pdoc put it, this data is derived from rat brain tissue that had been blenderized, centrifuged, and then put into a test tube.
How closely that data is going to predict the way the meds are going to act a living human body is very difficult to predict.
Hence the origin of the PSB saying, "Your Mileage May Vary" (YMMV).
> >> fachad: I've seen other people become short fused on ami. I don't know if anyone has tried to tie it to NE reuptake or anything else.
>
>
> Fachad,
> This info is so invaluable. It is so wonderful to correspond with you. You have helped so much. Google, medline, etc search hasn't been as helpful as you have been to me. I am so appreciative!
>
> That is interesting you have heard of others getting short fused on Ami. Do you think this is simply related to Ami? Have you heard of Doxepin causing grouchiness too??? I wonder if all the ACh properties have something to do with this the grouchiness. Can you speculate?
>
>
> >> As far as the NE potency, here are a few numbers:
> >
> > Drug-------NE reuptake
> >
> > ami----------4-------
> > nortrip-----25-------
> > imimp--------8-------
> > desip------110-------
> > trimp------0.2-------
> > dox----------5-------
> >
>
> Your charts are so helpful! I love the science part of meds.
> Well, if it is the NE reuptake, Doxepin has slightly more! So I guess it wouldn't make a difference...But I am just really wanting to find out if I could be more civil on another TCA.
>
> BTW, Trimipramine really is out, because even though I have been back on the Ami for 3 days, I still have awful EPS. This happens when I take an AP. It takes weeks to stop the EPS that only a pill or two with dopamine can cause :(.
>
>
> >>fachad: I don't mind at all - I like to be able to share some of this stuff I've picked up. Another cool thing about doxepin, it comes in a liquid form. I just like that idea both on general principal, and because it allows for very minute dosage adjustments. Doxepin is also a dirt cheap generic.
>
> Thanks again for sharing your insights and experiences. Look forward to hearing more, if you have the energy!
>
> >> Hope doxepin works for you.
> Me too! But I am kinda scared to try...Med changes are always such an adjustment! And a gamble.
> Chloe
Posted by Cece on June 13, 2002, at 0:54:44
In reply to Nortrip vs. other TCAs on H1 and Ach Blockade » johnj, posted by fachad on June 12, 2002, at 23:00:15
Hi Fachad-
I've posted earlier on this thread, but have some new developments/questions/feedback.
I've been taking 25 mg Trim for over 6 mos. having switched from Nortiptyline- my pdoc thought that it would give me less morning grogginess and better sleep. And it did.
But I've been weaning off benzos, and since my nighttime dose of xanax has gone from .75mg to .25mg I have been dreaming 'too much'. And I have not been falling asleep very fast, which is okay cuz I used to fall out like a log, and sleeping more restlessly which is not so okay. My body temp is fine and I don't wake up too early.
I used to have a problem with spending too much time in REM sleep and not enough in the deeper restorative level. I would wake up feeling like I had been working all night. My various combo of meds seemed to take care of that. (I was diagnosed a few years ago with "Upper Airway Obstructive Disorder"- a step below sleep apnea, and set up with a CPAP machine- but eventually decided that it was a crock (a long story)).
Anyway, I thought that you had said that Trim promotes deep level sleep- ? If that's so, am I just adjusting to less benzo? I really need that deep sleep.
My pdoc has just encouraged me to take a small dose of zyprexa (1/4 to 1/2 of a 2.5mg tab) regularly as I am becoming destabilized by summer's approach (I have reverse SAD). I have taken it very occassional PRN at that dose and it definitely makes me saner, but I dread the weight gain. I took half a tab yesterday and slept better last night.
So now I'm confused- again- and wondering what to do. Take the zyprexa and deal with the weight somehow? Take more Trim? Going back up on benzos is out- I need to clear my brain of their cobwebs, and you said earlier that benzos mess with "sleep architecture".
You seem to be pretty knowledgeable; do you have any feedback to offer?
Thanks, Cece
Posted by fachad on June 13, 2002, at 12:34:11
In reply to Trim and sleep » fachad, posted by Cece on June 13, 2002, at 0:54:44
Cece,
Suggestions:
increase trimip dose
try doxepin
try ambien
try sleep restriction
Funny that you say you have "reverse SAD". I've always told my docs that I have that, and they smiled at me like, "sure, whatever". But I really do much worse in the summer.Quality of sleep is a very slippery thing. People who take benzos will report that they believe that they had good sleep, but a polysomnigraph will say otherwise.
We tend to think of sleep like pain, where if you say, "I am in pain", your subjective experience of pain is truly the essence of pain. But in reality, sleep is a physical function that can be measured, and there is not always total correlation between subjective quality and objective quality of sleep.
One thing I discovered about why I seem to sleep better on benzos is the amnesia they cause. I dream a lot, I wake up, but I forget that I had dreamed and waked in the night.
If you have reduced your dose of benzo recently, that could cause rebound REM; if that is it, it will go away with some time.
As far as to what to do, ask your pdoc if you could take more trimip and see if that helps. Or you could try doxepin, which does suppress REM some which may be what you need.
Have you ever tried Ambien? It's very short acting, but it is quite powerful and does not disturb sleep like benzos.
Finally, I think the stuff about sleep hygiene is over hyped by benzo-phobic docs, but it is good to make sure you are not missing anything here.
And the most powerful thing to induce deep quality sleep is still sleep deprivation / sleep restriction. If you are not sleeping well in an 8 hour night, try a 7 hr. sleep period the next night, if poor sleep a 6 hr night etc. Get up earlier is far better than staying up later - it really does make a difference.
> Hi Fachad-
>
> I've posted earlier on this thread, but have some new developments/questions/feedback.
>
> I've been taking 25 mg Trim for over 6 mos. having switched from Nortiptyline- my pdoc thought that it would give me less morning grogginess and better sleep. And it did.
>
> But I've been weaning off benzos, and since my nighttime dose of xanax has gone from .75mg to .25mg I have been dreaming 'too much'. And I have not been falling asleep very fast, which is okay cuz I used to fall out like a log, and sleeping more restlessly which is not so okay. My body temp is fine and I don't wake up too early.
>
> I used to have a problem with spending too much time in REM sleep and not enough in the deeper restorative level. I would wake up feeling like I had been working all night. My various combo of meds seemed to take care of that. (I was diagnosed a few years ago with "Upper Airway Obstructive Disorder"- a step below sleep apnea, and set up with a CPAP machine- but eventually decided that it was a crock (a long story)).
>
> Anyway, I thought that you had said that Trim promotes deep level sleep- ? If that's so, am I just adjusting to less benzo? I really need that deep sleep.
>
> My pdoc has just encouraged me to take a small dose of zyprexa (1/4 to 1/2 of a 2.5mg tab) regularly as I am becoming destabilized by summer's approach (I have reverse SAD). I have taken it very occassional PRN at that dose and it definitely makes me saner, but I dread the weight gain. I took half a tab yesterday and slept better last night.
>
> So now I'm confused- again- and wondering what to do. Take the zyprexa and deal with the weight somehow? Take more Trim? Going back up on benzos is out- I need to clear my brain of their cobwebs, and you said earlier that benzos mess with "sleep architecture".
>
> You seem to be pretty knowledgeable; do you have any feedback to offer?
>
> Thanks, Cece
Posted by Cece on June 13, 2002, at 15:18:32
In reply to Re: Trim and sleep » Cece, posted by fachad on June 13, 2002, at 12:34:11
Thanks for your response Fachad.
I was interviewed recently by a reporter for the NY Times for a story on Reverse SAD. She found me through a post that I made last year on P-B (Dr. Bob did not give her my personal info- just forwarded her inquiry to me and left it to me whether to respond or not). It will be appearing soon in a special supplement on Women's Health although it is not a problem unique to women. It has been reasearched some but the cause is not known. I suffer from the bright light of summer, and although where I live is relatively cool (Northern CA), I become virtually non-functional in a heat spell. I've been thinking of starting a new thread on this since the season is here- feel free to start it yourself.
My pdoc is very interested in the effect of artificial light on BP disorders. He and others believe that living out of synch with the natural cycles of night and day stimulate cycling. There is an interesting article on this issue as a link off of:
http://www.psycheducation.org/.
This seems right to me intuitively, and as much as possible (not often enough) I take his suggestion of no electrical lighting after sunset, just candles and kerosene lanterns. It is very relaxing, and I do sleep better and wake up more easily. My neice who is BPI decided to try the idea out and has done it for 3 months! It's one of those things that it's hard to evaluate direct cause and effect, but she is feeling strong enough to take a very challenging graduate class that she had postponed for a long time.I may try raising my Trim a little- fine with my pdoc. Re the other med ideas, I am really trying to pare the meds that I take down to the bare bones- the reverse process of the layering that created a cumbersome cocktail that is a lot of work to maintain. I'm tired of running my own major pharmacy. I think that I'm going to try doing the Zyprexa, but consider it short-term, or maybe just a summer med. But thanks for the other suggestions, I'll keep them in mind.
I have been told, and experience, that sleep deprivation is a short-term fix. I'm really someone who does best with a solid 8 hours, but it does only really work if I keep 'sensible' hours which is hard for me- I tend to be a night owl. My previous pdoc told me that the quality of sleep between 10 and 6 is much better than say 2 and 10. I agree that some of the sleep hygiene stuff is 'bunky'- I'll use my bed for any activities that I choose thank you!
Cece
Posted by Chloe on June 13, 2002, at 17:29:04
In reply to Speculation on Blenderized Rat Brains » Chloe, posted by fachad on June 12, 2002, at 23:07:53
Yuck, the poor rats! but you are so right. One never knows how one is going to feel until one swallows the pill.
I am going to try doxepin and and have been tapering the amit. Boy, is that awful, I am not sleepoing great, depressed and kinda grumpy, instead of agitated and grumpy. Go figure!
I can't believe how much H1 blockage dox has! The dry mouth must be unbearable. And that was one thing I was try to lessen (thinking it was an ACh problem...) because I have such sores on my tongue and raw insides of my lips.But in your experience, Doxepin is a better sleep aid than ami? You did not mention amitrip. to Cece who had some Q's about sleep/dreaming etc. Have you tried ami, and if so, what was your response?
Thanks, Fachad. How true about YMMV!
Posted by fachad on June 13, 2002, at 19:10:41
In reply to Re: Speculation on Blenderized Rat Brains » fachad, posted by Chloe on June 13, 2002, at 17:29:04
> I am going to try doxepin and and have been tapering the amit.
How much ami are you taking? You could probably just switch from one day to the next unless your ami dose is really high.
My wife once switched from 150 mg ami every day to 150 mg dox the next day and it seemed ok, but her GI problem that the ami was treating came back on dox.
> I can't believe how much H1 blockage dox has! The dry mouth must be unbearable. And that was one thing I was try to lessen
The dry mouth is an Ach thing, not an H1 thing. Dox causes much much less dry mouth than ami. Remeron is much stronger at H1 blockade than even dox, with no ach blockade, and it does not cause any dryness.
I can't stand the dry mouth from ami, that's why I switched to dox years ago.
> But in your experience, Doxepin is a better sleep aid than ami? You did not mention amitrip. to Cece who had some Q's about sleep/dreaming etc. Have you tried ami, and if so, what was your response?
Yes, I tried ami, and, like I said, I absolutely hated the dry mouth. Since dox has more of what you want (H1) with less of what you don't want (Ach) I just can't see why someone who was aware of those facts would choose ami.
I think most likely it's because docs are very comfortable and familiar with ami. Your doc may have chosen it for the Ach blockade to control EPS, but more likely that was just a fortunate coincidence.
> Yuck, the poor rats! but you are so right. One never knows how one is going to feel until one swallows the pill.
>
> I am going to try doxepin and and have been tapering the amit. Boy, is that awful, I am not sleepoing great, depressed and kinda grumpy, instead of agitated and grumpy. Go figure!
> I can't believe how much H1 blockage dox has! The dry mouth must be unbearable. And that was one thing I was try to lessen (thinking it was an ACh problem...) because I have such sores on my tongue and raw insides of my lips.
>
> But in your experience, Doxepin is a better sleep aid than ami? You did not mention amitrip. to Cece who had some Q's about sleep/dreaming etc. Have you tried ami, and if so, what was your response?
>
> Thanks, Fachad. How true about YMMV!
Posted by Chloe on June 13, 2002, at 20:46:27
In reply to Re: Speculation on Blenderized Rat Brains » Chloe, posted by fachad on June 13, 2002, at 19:10:41
Your post was most helpful...
I was only on 20 of ami, and have been taking ten for the last 3 days. Today, I have the worst epigastric pain. I know it's a withdrawal thing from ami. My body wants it's ami. I just picked up 10 mg size of Doxepin. I am supposed to take one or two at night. So I guess I will just jump in and take 2 caps of doxepin...What was the stomach ailment of your wife, if you don't mind me asking. The constipation on ami for me is awful. Even with flaxseed oil, fiberous diet, lots of water. It's a loosing battle with ami! But for some problems I imagine this is a good thing. I assume dox would be binding with less ACh?
I am so glad the H1 doesn't necessarily mean terrible dry mouth. You should see the inside of my mouth. It's so raw. I try to use rinses for mouth sores, but they burn so...
Oh, I was given amitriptyline initially for neurogenic scalp pain induced from lithium, I think...I didn't really help the pain and burn, but it did help me sleep at night. It was hard sometimes to lie on my pillow without my hair hurting, and it would keep me up.
My hope is that dox will be less drying in general, because I think I am on so many drying meds, it makes the scalp pain worse. And Dox is supposed to be good for itching. I have ezcema, and when I get under stress, I can really get scatching. So lets hope this is a bit more targeted to my needs.
Oh, one last thing. I did read that dox has a much shorter half life than ami. Dox, about 6-8 hours, where ami is 10-50 hours. Do you ever find some rebound anxiety or edginess the next day from the dox? I tend to notice when meds run out...I wonder if this is an issue?I can't thank you enough for taking the time and energy to discuss these TCA's in such detail.
Chloe
Posted by fachad on June 13, 2002, at 22:12:02
In reply to Re:Doxepin » fachad, posted by Chloe on June 13, 2002, at 20:46:27
> I was only on 20 of ami, and have been taking ten for the last 3 days. Today, I have the worst epigastric pain. I know it's a withdrawal thing from ami.
That is a pretty small dose, but I bet the epigastric pain is ami withdrawal.
>I just picked up 10 mg size of Doxepin. I am supposed to take one or two at night. So I guess I will just jump in and take 2 caps of doxepin...
I would. When used for depression, ami, doxepin, trimip, typical doses are 150mg/day, and can be as high as 300mg/day. So even if you still had 20 mg of ami in your system, and you took the full 20 mg of doxepin, it would be a relatively tiny total TCA dose.
> What was the stomach ailment of your wife, if you don't mind me asking.
She has pain dominant Irritable Bowel Syndrome (IBS). Here's a link to the full story of how ami worked when nothing else did. (I referred to ami by it's brand name, "Elavil" in that post.)
http://www.dr-bob.org/babble/20020322/msgs/99806.html
Anyway, that whole ordeal was quite amazing, and left me with a renewed respect for TCAs.
>The constipation on ami for me is awful. Even with flaxseed oil, fiberous diet, lots of water. It's a loosing battle with ami!
Yes, the ami constipation is pretty bad.
>I assume dox would be binding with less ACh?
Yes. For blenderized rat brains it is almost 5 times less potent at blocking ACH, and ACH blockade is definitely the cause of dry mouth and constipation. ACH neurons mediate both salivation and intestinal motility. ACH blockade is the highest thing on my personal "yuck" scale.
> I am so glad the H1 doesn't necessarily mean terrible dry mouth. You should see the inside of my mouth. It's so raw. I try to use rinses for mouth sores, but they burn so...
No, H1 blockade does not mean dryness. Some people believe that because most conventional H1 blockers (antihistamines) cause dryness, that H1 blockade is the culprit. But those antihistamines also block ACH, and that's why they cause dry mouth. But it's the ACh, not the H1, that's drying them out.
Regarding the mouth sores, in the past few weeks I've had a few mouth ulcers spring up, and I found an OTC remedy that seems to help. It's called DGL, de glyceryzed licorice. It sooths the sores, and it contains some chemical which stimulates the flow of mucous to the membranes, helping them heal. You can get it in lozenge form at a health food store.
>And Dox is supposed to be good for itching. I have ezcema, and when I get under stress, I can really get scatching. So lets hope this is a bit more targeted to my needs.
Dox is stronger at H1 blockade, so it should be better for both blocking itching and inducing sleep. Regarding the itching, they acutally make a doxepin topical creme for severe itching. People say it works better than anything else, but it makes them too tired, just from being absorbed thru the skin!
> Oh, one last thing. I did read that dox has a much shorter half life than ami. Dox, about 6-8 hours, where ami is 10-50 hours. Do you ever find some rebound anxiety or edginess the next day from the dox?
For me that is a big plus because it means less next day grogginess. I was a little worried that because trimp has so much longer half life than dox that I would want to sleep thru the next morning, but it's been OK.
One final comment since we're talking about doxepin pharmacokenetics: doxepin has a very high "first pass" effect. This means that after it is absorbed from your GI, it passes thru the liver before it gets to your brain. All meds do this, but doxepin is broken down very extensively during this first pass, so much less of it gets to your brain than ami, even though you've taken the same dose. So you might need a higher dose of dox to do the same job as the ami because of this. Just a possibility to consider if it seems like it's not working.
Posted by Ritch on June 13, 2002, at 22:32:03
In reply to Re: Reverse SAD, sleep, light, meds » fachad, posted by Cece on June 13, 2002, at 15:18:32
> Thanks for your response Fachad.
>
> I was interviewed recently by a reporter for the NY Times for a story on Reverse SAD. She found me through a post that I made last year on P-B (Dr. Bob did not give her my personal info- just forwarded her inquiry to me and left it to me whether to respond or not). It will be appearing soon in a special supplement on Women's Health although it is not a problem unique to women. It has been reasearched some but the cause is not known. I suffer from the bright light of summer, and although where I live is relatively cool (Northern CA), I become virtually non-functional in a heat spell. I've been thinking of starting a new thread on this since the season is here- feel free to start it yourself.
>
> My pdoc is very interested in the effect of artificial light on BP disorders. He and others believe that living out of synch with the natural cycles of night and day stimulate cycling. There is an interesting article on this issue as a link off of:
> http://www.psycheducation.org/.
> This seems right to me intuitively, and as much as possible (not often enough) I take his suggestion of no electrical lighting after sunset, just candles and kerosene lanterns. It is very relaxing, and I do sleep better and wake up more easily. My neice who is BPI decided to try the idea out and has done it for 3 months! It's one of those things that it's hard to evaluate direct cause and effect, but she is feeling strong enough to take a very challenging graduate class that she had postponed for a long time.
>
> I may try raising my Trim a little- fine with my pdoc. Re the other med ideas, I am really trying to pare the meds that I take down to the bare bones- the reverse process of the layering that created a cumbersome cocktail that is a lot of work to maintain. I'm tired of running my own major pharmacy. I think that I'm going to try doing the Zyprexa, but consider it short-term, or maybe just a summer med. But thanks for the other suggestions, I'll keep them in mind.
>
> I have been told, and experience, that sleep deprivation is a short-term fix. I'm really someone who does best with a solid 8 hours, but it does only really work if I keep 'sensible' hours which is hard for me- I tend to be a night owl. My previous pdoc told me that the quality of sleep between 10 and 6 is much better than say 2 and 10. I agree that some of the sleep hygiene stuff is 'bunky'- I'll use my bed for any activities that I choose thank you!
>
> CeceCece,
That is very interesting reading. I have two SAD episodes a year-one in the winter and one in the summer. The summer one is already starting and it is marked by early morning awakenings (most of the last week or so). Imipramine is making this worse and I have stopped it (because of REM suppression?). I work evenings with artificial light and don't have the option of synching myself with nature. However, my take on the origin of the "reverse" SAD symptoms isn't the *bright* light-it is the *DURATION* of the available light. Let me start from scratch. I get depressed the worst in the winter centered around the winter solstice (lack of light). BUT, there are a lot of factors influencing the amount of light that you expose yourself to. One is the amount of natural vegetation in your environment and how much time you spend indoors versus outdoors. Anyhow, I notice that I feel *recovery* from the wintertime episode about mid-January. Snow makes things better. I have to get outside to shovel the snow away, walk to the store after a blizzard, etc. But, by the end of February I clearly notice the marked intensity of light coming through my windows (no trees yet). That is when I start developing hypomanic and mixed states. That worsens *until* the tree "canopy" is fully developed (which provides shade). So, though the temperature is increasing outside, the amount of light *INTENSITY* is drastically reduced, however the light *DURATION* is increasing. That is when I start to get my 2nd "reverse" SAD depression. It starts to significantly remit (and another hypomanic spell usally happens-however less intense) whenever the trees start dropping leaves and there is no storms or rain and the sky is cloudless and bright during the fall, while the light *DURATION* is decreasing and decreased, but the light *INTENSITY* is coming back up again-everything is very bright and "contrasty" outside.
Mitch
Posted by Cece on June 13, 2002, at 22:40:30
In reply to Re: Reverse SAD, sleep, light, meds » Cece, posted by Ritch on June 13, 2002, at 22:32:03
Hey Ritch-
Let's start a thread on Reverse SAD! I think that I'll copy some of my last post here and expand upon it. It would be great if you could repost your last message to me on the new thread. I know that there are more of us out there and it could make a good discussion. You and I have a number of similarities.
By the way, I'm a horticulturalist and landscaper and spend a lot of time outdoors.
Cece
Posted by Chloe on June 14, 2002, at 20:54:45
In reply to Re:Doxepin » Chloe, posted by fachad on June 13, 2002, at 22:12:02
Fachad,
I have to say, you really have done your research! I have a whole new respect for TCA's and your ability to understand and relay the information.I really don't want to jinx anything, because it was only one night. But the doxepin worked great! I was anxious that I would not fall asleep like with Trimip. But I fell into the black hole of sleep. God, that experience is priceless. In hind sight, I think I had a paradoxical reaction to trimip. It really caused a great deal of anxiety and angst, as well as profound insomnia and restlessness. Not to mention all the ACh rebound peeing, etc.
I did wake up very refreshed this morning and in a very pleasant mood. This is highly uncharacteristic of me on ami. I am usually nasty and short fused and fussy. I AM starting to notice some reemerging scalp pain. Perhaps related to less doxepin being available to the body at only 20 mgs? I will stay at 20 for a while and hope it gets better. But as you say, I may need to bump the dose to continue to get sleep and pain relief. (AND I didn't even think the ami was doing much for the scalp burn/pain! I guess it was..)
I am only taking the TCA for sleep and pain. I also take a tiny tiny (1.5 mgs) amount of Celexa. I am BP2 so I don't require alot of AD, and of course too much can make me hypomanic. But with ami, I was always in this dysphoric angry state, just with more energy to a pick fight with a good friend or family member or anyone for that matter.
So I hope the doxepin will ease some of the grouchy, short fuse stuff, and boost my mood a bit. I got enough mood stabilizers to support taking a bit more doxepin than I did with ami...I know this is highly individualized, but what is the usual dose for "sleep" or pain? I have only seen the AD dose recommendations...They couldn't be the same. Isn't 150 mgs of Dox pretty sedating? Or does one acclimate quickly?
Thanks for the link about elavil and your wife. I am so glad she found a med that has helped her control her disease, despite the miserable side effects. She must be a brave person.
Thanks Fachad for sharing
Chloe
Posted by fachad on June 14, 2002, at 23:10:00
In reply to Re:Doxepin » fachad, posted by Chloe on June 14, 2002, at 20:54:45
I think the usual TCA dose for sleep or pain is 25mg or 50mg.
Some people may get by with only 10mg but others may need the full AD dose of 150 - 300mg.
I think a dr. would usually titrate the dose up until you are sleeping fine and the pain is gone, or the side effects become intolerable, whichever comes first.
Regarding the sedation at 150mg, my wife slept around the clock at first, but over a few months she got back to normal. Almost 10 years later, it still knocks her out at night, and she sleeps really hard, but by the next morning she is fine.
I hope the dox works for you.
> Fachad,
> I have to say, you really have done your research! I have a whole new respect for TCA's and your ability to understand and relay the information.
>
> I really don't want to jinx anything, because it was only one night. But the doxepin worked great! I was anxious that I would not fall asleep like with Trimip. But I fell into the black hole of sleep. God, that experience is priceless. In hind sight, I think I had a paradoxical reaction to trimip. It really caused a great deal of anxiety and angst, as well as profound insomnia and restlessness. Not to mention all the ACh rebound peeing, etc.
>
> I did wake up very refreshed this morning and in a very pleasant mood. This is highly uncharacteristic of me on ami. I am usually nasty and short fused and fussy. I AM starting to notice some reemerging scalp pain. Perhaps related to less doxepin being available to the body at only 20 mgs? I will stay at 20 for a while and hope it gets better. But as you say, I may need to bump the dose to continue to get sleep and pain relief. (AND I didn't even think the ami was doing much for the scalp burn/pain! I guess it was..)
>
> I am only taking the TCA for sleep and pain. I also take a tiny tiny (1.5 mgs) amount of Celexa. I am BP2 so I don't require alot of AD, and of course too much can make me hypomanic. But with ami, I was always in this dysphoric angry state, just with more energy to a pick fight with a good friend or family member or anyone for that matter.
> So I hope the doxepin will ease some of the grouchy, short fuse stuff, and boost my mood a bit. I got enough mood stabilizers to support taking a bit more doxepin than I did with ami...
>
> I know this is highly individualized, but what is the usual dose for "sleep" or pain? I have only seen the AD dose recommendations...They couldn't be the same. Isn't 150 mgs of Dox pretty sedating? Or does one acclimate quickly?
>
> Thanks for the link about elavil and your wife. I am so glad she found a med that has helped her control her disease, despite the miserable side effects. She must be a brave person.
>
> Thanks Fachad for sharing
> Chloe
Posted by fachad on June 14, 2002, at 23:12:50
In reply to Re:Doxepin » fachad, posted by Chloe on June 14, 2002, at 20:54:45
Here's an abstract from an article on using doxepin or ami for scalp pain:
Arch Dermatol 1998 Mar;134(3):327-30 Related Articles, Books, LinkOutScalp dysesthesia.
Hoss D, Segal S.
Department of Dermatology, University of Connecticut Health Center, Farmington 06030, USA.
BACKGROUND: Cutaneous dysesthesia syndrome is a disorder characterized by chronic cutaneous symptoms without objective findings. Patients complain of burning, stinging, or itching, which is often triggered or exacerbated by psychological or physical stress. These symptoms may be manifestations of an underlying psychiatric disorder or may represent a type of chronic pain syndrome.
OBSERVATIONS: Eleven women presented with chronic severe pain and/or pruritus of the scalp only without objective physical findings, a condition we term "scalp dysesthesia." Five women described pain, stinging, or burning only; 4 women complained of pain and pruritus; and 2 women reported pruritus only. The patients ranged in age from 36 to 70 years. The duration of symptoms ranged from 9 months to 7 years. Five women had physician-diagnosed psychiatric disorders, including dysthymic disorder, generalized anxiety, and somatization. Seven women reported that stress triggers or exacerbates their symptoms.
Eight women experienced improvement or complete resolution of symptoms with treatment with low-dose doxepin hydrochloride or amitriptyline hydrochloride.
One patient responded completely to treatment with sertraline and hydroxyzine hydrochloride but then experienced a relapse.
CONCLUSIONS: We describe 11 patients with a new syndrome that we term scalp dysesthesia. Of 11 patients, 9 benefited from treatment with low doses of antidepressants.
PMID: 9521031 [PubMed - indexed for MEDLINE]
Posted by Chloe on June 15, 2002, at 11:25:32
In reply to Re: Abstract on Doxepin for Scalp Pain » Chloe, posted by fachad on June 14, 2002, at 23:12:50
Fachad,
Great abstract!!!
I had read something about "scalp dysesthesia", but only related to men who were or feared they were experiencing hairloss. This abstract describes me to a Tee, I guess. This must be why the dermatologist only spent 30 seconds with me. He knew right off that it is a "psychiatric disorder." Especially after he heard the list of psychtropic meds I was taking.But, the symptoms seemed to come on after being on therapeutic levels of Li with Neurontin for about 3 months. My hair and skin got so dry, but thyroid normal. Then the scalp pain emerged, but like the article said, no evidence like flakes or inflammation. Just a searing burn, so i couldn't brush my hair, etc.
Well, in terms of dose, I know 20 mgs is not enough to control the pain. So I think I will creep it up by 10 or 20, and call my pdoc next week.
Doxepin, IMO is much more tolerable than amitriptyline. (Let's just hope it will knock out the pain too, but at higher doses than ami.) I was grouchy ALL the time on ami. It just made me feel "yucky" physically and mentally. I had asked my pdoc for Dox months ago, but she dismissed my request saying that all TCA's are the same. HOW UNTRUE. Thanks for showing me the light!Be well.
Chloe> Here's an abstract from an article on using doxepin or ami for scalp pain:
>
>
> Arch Dermatol 1998 Mar;134(3):327-30 Related Articles, Books, LinkOut
>
> Scalp dysesthesia.
>
> Hoss D, Segal S.
>
> Department of Dermatology, University of Connecticut Health Center, Farmington 06030, USA.
>
> BACKGROUND: Cutaneous dysesthesia syndrome is a disorder characterized by chronic cutaneous symptoms without objective findings. Patients complain of burning, stinging, or itching, which is often triggered or exacerbated by psychological or physical stress. These symptoms may be manifestations of an underlying psychiatric disorder or may represent a type of chronic pain syndrome.
>
> OBSERVATIONS: Eleven women presented with chronic severe pain and/or pruritus of the scalp only without objective physical findings, a condition we term "scalp dysesthesia." Five women described pain, stinging, or burning only; 4 women complained of pain and pruritus; and 2 women reported pruritus only. The patients ranged in age from 36 to 70 years. The duration of symptoms ranged from 9 months to 7 years. Five women had physician-diagnosed psychiatric disorders, including dysthymic disorder, generalized anxiety, and somatization. Seven women reported that stress triggers or exacerbates their symptoms.
>
> Eight women experienced improvement or complete resolution of symptoms with treatment with low-dose doxepin hydrochloride or amitriptyline hydrochloride.
>
> One patient responded completely to treatment with sertraline and hydroxyzine hydrochloride but then experienced a relapse.
>
> CONCLUSIONS: We describe 11 patients with a new syndrome that we term scalp dysesthesia. Of 11 patients, 9 benefited from treatment with low doses of antidepressants.
>
> PMID: 9521031 [PubMed - indexed for MEDLINE]
Posted by Ritch on June 15, 2002, at 16:05:46
In reply to Re: Abstract on Doxepin for Scalp Pain » fachad, posted by Chloe on June 15, 2002, at 11:25:32
Hi Chloe,
So *that's* what that is! Got a question for you. You said it started when you were taking Neurontin+lithium. Had you ever been on lithium before without being combined with the Neurontin? I just wonder if the Neurontin might have precipitated it. It's a good thing you have nailed it. It helps when it has a *name*! You are also very lucky you don't mind heavy-hitting sedative meds. The first psych meds I was prescribed (all at once, too), was lithium 900mg/day + doxepin 75mg/bedtime + amitripytline 25mg/bedtime + chlordiazepoxide 10mg/bedtime. Needless to say my first night's sleep on that was rather, well.. heavy to say the least. Doxepin is weird in that you get whalloped pretty good when you start a given dose (say 25mg at bedtime). But, after a few weeks the daytime sedation does wear away quite a bit. I can't believe it was possible, but I was up to 150mg/day for a few weeks and actually worked around dangerous machinery! I don't think I could hack that now! I had to give up the imipramine trial. It just screwed up my sleep so badly. I was evidently not sleeping soundly, and it was triggering the early morning awakenings. Since I stopped it my sleep has improved steadily. But, I still feel the depression during the day. It looks like I am going to start a smidge of Effexor starting Monday (to be my sole AD-no more Celexa, etc.). Just 12.5mg first thing in the morning, and then let it wash out later on so it (hopefully) won't wreck my sleep. I got hypomanic and irritable on it before, but that was related to steroids I was taking. Also, I wasn't on Depakote at the time but subtherapeutic lithium instead. So, this will be the Effexor irritability challenge (to see if the Depakote will keep a lid on it).
good luck with the doxepin,
Mitch
> Fachad,
> Great abstract!!!
> I had read something about "scalp dysesthesia", but only related to men who were or feared they were experiencing hairloss. This abstract describes me to a Tee, I guess. This must be why the dermatologist only spent 30 seconds with me. He knew right off that it is a "psychiatric disorder." Especially after he heard the list of psychtropic meds I was taking.
>
> But, the symptoms seemed to come on after being on therapeutic levels of Li with Neurontin for about 3 months. My hair and skin got so dry, but thyroid normal. Then the scalp pain emerged, but like the article said, no evidence like flakes or inflammation. Just a searing burn, so i couldn't brush my hair, etc.
>
> Well, in terms of dose, I know 20 mgs is not enough to control the pain. So I think I will creep it up by 10 or 20, and call my pdoc next week.
> Doxepin, IMO is much more tolerable than amitriptyline. (Let's just hope it will knock out the pain too, but at higher doses than ami.) I was grouchy ALL the time on ami. It just made me feel "yucky" physically and mentally. I had asked my pdoc for Dox months ago, but she dismissed my request saying that all TCA's are the same. HOW UNTRUE. Thanks for showing me the light!
>
> Be well.
> Chloe
>
> > Here's an abstract from an article on using doxepin or ami for scalp pain:
> >
> >
> > Arch Dermatol 1998 Mar;134(3):327-30 Related Articles, Books, LinkOut
> >
> > Scalp dysesthesia.
> >
> > Hoss D, Segal S.
> >
> > Department of Dermatology, University of Connecticut Health Center, Farmington 06030, USA.
> >
> > BACKGROUND: Cutaneous dysesthesia syndrome is a disorder characterized by chronic cutaneous symptoms without objective findings. Patients complain of burning, stinging, or itching, which is often triggered or exacerbated by psychological or physical stress. These symptoms may be manifestations of an underlying psychiatric disorder or may represent a type of chronic pain syndrome.
> >
> > OBSERVATIONS: Eleven women presented with chronic severe pain and/or pruritus of the scalp only without objective physical findings, a condition we term "scalp dysesthesia." Five women described pain, stinging, or burning only; 4 women complained of pain and pruritus; and 2 women reported pruritus only. The patients ranged in age from 36 to 70 years. The duration of symptoms ranged from 9 months to 7 years. Five women had physician-diagnosed psychiatric disorders, including dysthymic disorder, generalized anxiety, and somatization. Seven women reported that stress triggers or exacerbates their symptoms.
> >
> > Eight women experienced improvement or complete resolution of symptoms with treatment with low-dose doxepin hydrochloride or amitriptyline hydrochloride.
> >
> > One patient responded completely to treatment with sertraline and hydroxyzine hydrochloride but then experienced a relapse.
> >
> > CONCLUSIONS: We describe 11 patients with a new syndrome that we term scalp dysesthesia. Of 11 patients, 9 benefited from treatment with low doses of antidepressants.
> >
> > PMID: 9521031 [PubMed - indexed for MEDLINE]
Posted by Chloe on June 15, 2002, at 22:12:30
In reply to Re: Abstract on Doxepin for Scalp Pain » Chloe, posted by Ritch on June 15, 2002, at 16:05:46
> Hi Chloe,
>
> So *that's* what that is! Got a question for you. You said it started when you were taking Neurontin+lithium. Had you ever been on lithium before without being combined with the Neurontin? I just wonder if the Neurontin might have precipitated it.No, I was on lithium for years in the '80's. Neurontin wasn't "born" yet! I never remember Li being drying back then...I had really thick long hair, and never had any problems with scalp or hair. I DO know that neurontin for me, is *extremely* drying. When I started it, I felt everything dry up. My mouth, my *female parts*, my skin. My body doesn't make ANY natural oils. Hence the 1 tbs FSO and 2000 mgs Evening primrose oil. That has helped some...
Whenever I increase the dose of N, I get increased burning of the skin and scalp for about a week. Then it seems to settle down. But then several weeks will go by, and I will run my hand thru my hair, and it will feel so brittle and dry. And I condition the hell out of it too...So I do think N was probably the culprit. But now my body is just so dried out and weary from daily meds. Because any new med or dosage change seems to start the scalp burn now...
>It's a good thing you have nailed it. It helps when it has a *name*!Yes, thanks to Fachad's diligent research. I wish the derm doc had just come out and said it was that. Rather than saying I don't have a rash, this something I need to bring up with my psychiatrist. GEEZ, I felt like a hypochondriac or I was faking the pain. It was rather uncomfortable, though brief!
>You are also very lucky you don't mind heavy-hitting sedative meds. The first psych meds I was prescribed (all at once, too), was lithium 900mg/day + doxepin 75mg/bedtime + amitripytline 25mg/bedtime + chlordiazepoxide 10mg/bedtime.
Just curious, why would you take amitrip and doxepin? Was there a reason for that one? That is alot of meds! You must have felt awful! Or at least not (hypo)manic!
>Needless to say my first night's sleep on that was rather, well.. heavy to say the least. Doxepin is weird in that you get whalloped pretty good when you start a given dose (say 25mg at bedtime). But, after a few weeks the daytime sedation does wear away quite a bit. I can't believe it was possible, but I was up to 150mg/day for a few weeks and actually worked around dangerous machinery! I don't think I could hack that now!
So far, I really like Doxepin, at my low dose of 20 mg. I will probably need to raise it, but I am going to try another night at 20 to give my scalp time to adjust, and let the blood level go up. Maybe 20 will be all I need, but I doubt it.
I have less orthostatic hypotension, less thump, thump, cardiac changes, less constipation, but oddly some heartburn. That ami is powerful in slowing down the gut! I am also glad to report, that *so far* I am not noticing a withdrawal or rebound of anxiety when I wake up on Doxepin. With ami, the alarm would go off, and perhaps startle me, and my heart would pound and race, though I am half asleep. And then I would be in a frantic nasty mood from the moment I was awakened, throughout the entire day.
With Dox, the last two mornings, I have awoken with dreams I can't remember, and I am glad and have some desire to get out of bed. My fear was that anxiety would creep in with dox's short 6-8 hour half-life. But today was so even, and I have been calm. Did this "calmness" wear off with the sedation in your experience with dox? Did you notice any rebound anxiety during the day?>I had to give up the imipramine trial. It just screwed up my sleep so badly. I was evidently not sleeping soundly, and it was triggering the early morning awakenings. Since I stopped it my sleep has improved steadily. But, I still feel the depression during the day.
Maybe imiprimine is just not a good TCA for you. I realized that Trimip. gave me a pradoxical effect. I had anxiety, insomnia, shakes, oh and EPS. It was very unpleasant. Didn't nortrip work well pretty for you?
>It looks like I am going to start a smidge of Effexor starting Monday (to be my sole AD-no more Celexa, etc.). Just 12.5mg first thing in the morning, and then let it wash out later on so it (hopefully) won't wreck my sleep. I got hypomanic and irritable on it before, but that was related to steroids I was taking. Also, I wasn't on Depakote at the time but subtherapeutic lithium instead. So, this will be the Effexor irritability challenge (to see if the Depakote will keep a lid on it).
Gee, I really hope you trial of effexor goes well. Perhaps with the protection from dep. it will be a more positive experience this time. Dep. is definitely better for the short fuse/irritability stuff. So you are no longer on a stimulant? I guess I have lost track a bit.
Shifting meds can really mess up my head. Usually I feel pretty on top of things. But I can't remember anything lately. I keep telling myself to write things down, but I forget everything looking for a damn piece of paper!Let us know how the Effexor goes. I hope it helps your sleep troubles, too...I'll keep my fingers crossed for you
Chloe
>
> good luck with the doxepin,
>
> Mitch
Posted by Chloe on June 15, 2002, at 22:29:30
In reply to Re:Doxepin - Usual Dose for Sleep or Pain » Chloe, posted by fachad on June 14, 2002, at 23:10:00
>I think the usual TCA dose for sleep or pain is 25mg or 50mg.
>Some people may get by with only 10mg but others may need the full AD dose of 150 - 300mg.>I think a dr. would usually titrate the dose up until you are sleeping fine and the pain is gone, or the side effects become intolerable, whichever comes first.
>Regarding the sedation at 150mg, my wife slept around the clock at first, but over a few months she got back to normal. Almost 10 years later, it still knocks her out at night, and she sleeps really hard, but by the next morning she is fine.
>I hope the dox works for you.Fachad
This is very helpful. 25-50 mgs sounds about right for me.
I am very grateful that your could share your copious experience/knowledge/research on TCA's (and pain).
So far Doxepin is quite an improvement with mood and side effects :)
Keep us posted on your trimipramine trials, if you wish...Chloe
Posted by Ritch on June 16, 2002, at 11:33:39
In reply to Re:Doxepin for Scalp Pain, etc » Ritch, posted by Chloe on June 15, 2002, at 22:12:30
> > Hi Chloe,
> >
> > So *that's* what that is! Got a question for you. You said it started when you were taking Neurontin+lithium. Had you ever been on lithium before without being combined with the Neurontin? I just wonder if the Neurontin might have precipitated it.
>
> No, I was on lithium for years in the '80's. Neurontin wasn't "born" yet! I never remember Li being drying back then...I had really thick long hair, and never had any problems with scalp or hair. I DO know that neurontin for me, is *extremely* drying. When I started it, I felt everything dry up. My mouth, my *female parts*, my skin. My body doesn't make ANY natural oils. Hence the 1 tbs FSO and 2000 mgs Evening primrose oil. That has helped some...
> Whenever I increase the dose of N, I get increased burning of the skin and scalp for about a week. Then it seems to settle down. But then several weeks will go by, and I will run my hand thru my hair, and it will feel so brittle and dry. And I condition the hell out of it too...So I do think N was probably the culprit. But now my body is just so dried out and weary from daily meds. Because any new med or dosage change seems to start the scalp burn now...That's interesting. I notice that in the wintertime I can't take more than 100mg of Neurontin at night or I wake up with extremely dry throat and I have to drink a lot of water for the dryness and soreness to fade away. I read somebody else post about that a few weeks ago. However, N. seemed to *add* oil to my facial skin-bizarre! I think it tinkers with collagens or something. Depakote works fine for hypomania and temper, BUT, if I try to stop the Neurontin (I am still just at 100mg tid), my depression worsens, and I feel "tweaky". It definitely helps social anxiety. I have kept everything the same and just reduced Neurontin and I clearly felt worse. I hope that if pregabalin gets out on the market it will work just as good or better, with fewer sfx. Maybe it won't have this dryness thing.
>
>
> >It's a good thing you have nailed it. It helps when it has a *name*!
>
> Yes, thanks to Fachad's diligent research. I wish the derm doc had just come out and said it was that. Rather than saying I don't have a rash, this something I need to bring up with my psychiatrist. GEEZ, I felt like a hypochondriac or I was faking the pain. It was rather uncomfortable, though brief!Yes, I hate polypharmacy because of those kinds of problems. You go and see a GP, or an internist about something and if they don't think you are a hypochrondriac, they don't want to get involved with trying to figure it out-because they are afraid it is just a sfx of all of the psych meds you are taking! That's why I would like to get rid of the N. and the Klonopin, but they both clearly help.
>
> >You are also very lucky you don't mind heavy-hitting sedative meds. The first psych meds I was prescribed (all at once, too), was lithium 900mg/day + doxepin 75mg/bedtime + amitripytline 25mg/bedtime + chlordiazepoxide 10mg/bedtime.
>
> Just curious, why would you take amitrip and doxepin? Was there a reason for that one? That is alot of meds! You must have felt awful! Or at least not (hypo)manic!When I first seen a shrink-it wasn't somebody hauling my ass in for an evaluation. I was in a nasty agitated mixed-state (not psychotic-but probably getting there), and sleeping about 2 hours every nite and getting paranoid while the depression was deepening along with very intense anxiety. I wanted relief NOW! The ami. and chlord. were just for two weeks until my sleep normalized and my anxiety level dropped off. Then I was just on 75mg doxepin and 900mg/LI. Amazingly, I managed to go to work everyday.
>
> >Needless to say my first night's sleep on that was rather, well.. heavy to say the least. Doxepin is weird in that you get whalloped pretty good when you start a given dose (say 25mg at bedtime). But, after a few weeks the daytime sedation does wear away quite a bit. I can't believe it was possible, but I was up to 150mg/day for a few weeks and actually worked around dangerous machinery! I don't think I could hack that now!
>
> So far, I really like Doxepin, at my low dose of 20 mg. I will probably need to raise it, but I am going to try another night at 20 to give my scalp time to adjust, and let the blood level go up. Maybe 20 will be all I need, but I doubt it.
> I have less orthostatic hypotension, less thump, thump, cardiac changes, less constipation, but oddly some heartburn. That ami is powerful in slowing down the gut! I am also glad to report, that *so far* I am not noticing a withdrawal or rebound of anxiety when I wake up on Doxepin. With ami, the alarm would go off, and perhaps startle me, and my heart would pound and race, though I am half asleep. And then I would be in a frantic nasty mood from the moment I was awakened, throughout the entire day.
> With Dox, the last two mornings, I have awoken with dreams I can't remember, and I am glad and have some desire to get out of bed. My fear was that anxiety would creep in with dox's short 6-8 hour half-life. But today was so even, and I have been calm. Did this "calmness" wear off with the sedation in your experience with dox? Did you notice any rebound anxiety during the day?I wouldn't worry too much about increasing it. TCA's have very long half-lives (I wish its half-life would have been 6-8hrs!). Your blood levels are continuing to increase just by taking the same dose every nite. I would wait until you had been on 20mg for two full weeks before bumping it further. As far as the racing heartbeat when waking-I had that on doxepin, but only at the higher doses. It was really bad at 150mg/day. It was there at 75mg/day, too. However, at 25mg/day it went away. So, I stayed at that dose for a few years. The daytime sedation-you will adjust to that.
>
> >I had to give up the imipramine trial. It just screwed up my sleep so badly. I was evidently not sleeping soundly, and it was triggering the early morning awakenings. Since I stopped it my sleep has improved steadily. But, I still feel the depression during the day.
>
> Maybe imiprimine is just not a good TCA for you. I realized that Trimip. gave me a pradoxical effect. I had anxiety, insomnia, shakes, oh and EPS. It was very unpleasant. Didn't nortrip work well pretty for you?If, I ever take another TCA, nortriptyline would be the only one. It was easily the most tolerable one (at lower doses anyhow). It was good for anxiety and attention. It didn't disrupt my sleep as much as the imipramine. But, I don't like the cardio-toxicity potential, and I do a lot of work outside in the heat, and imipramine and to a lesser extent nortrip. aggravated chest pain if overexerting.
>
> >It looks like I am going to start a smidge of Effexor starting Monday (to be my sole AD-no more Celexa, etc.). Just 12.5mg first thing in the morning, and then let it wash out later on so it (hopefully) won't wreck my sleep. I got hypomanic and irritable on it before, but that was related to steroids I was taking. Also, I wasn't on Depakote at the time but subtherapeutic lithium instead. So, this will be the Effexor irritability challenge (to see if the Depakote will keep a lid on it).
>
> Gee, I really hope you trial of effexor goes well. Perhaps with the protection from dep. it will be a more positive experience this time. Dep. is definitely better for the short fuse/irritability stuff. So you are no longer on a stimulant? I guess I have lost track a bit.
> Shifting meds can really mess up my head. Usually I feel pretty on top of things. But I can't remember anything lately. I keep telling myself to write things down, but I forget everything looking for a damn piece of paper!Well, the problem with stimulants is the too short half-life (of most of them anyhow), and they don't have the capacity to really reduce any type of anxiety I have (except some elements of social anxiety with dexedrine), other than that I could tolerate them fairly well without cycling, which I found odd.
>
> Let us know how the Effexor goes. I hope it helps your sleep troubles, too...I'll keep my fingers crossed for you
> ChloeWe'll see. Without any AD my sleeping is better but is starting to lengthen. I am starting to sleep more than 8 hrs (bad sign), and I am still yawning during the day and fairly listless, but my mood isn't that bad.
take care,
Mitch
Posted by fachad on June 16, 2002, at 20:22:35
In reply to Re: Abstract on Doxepin for Scalp Pain » fachad, posted by Chloe on June 15, 2002, at 11:25:32
> Great abstract!!!
> I had read something about "scalp dysesthesia", but only related to men who were or feared they were experiencing hairloss.It really does provide some validation to have a name for your suffering; it also makes you feel less alone if others have the same diagnosis.
> But, the symptoms seemed to come on after being on therapeutic levels of Li with Neurontin for about 3 months.
Do you tell your pdoc about all the misery from side effects? It just seems like your side effect burden is too severe - does the benefit really offset all that suffering? Are there any other meds that might work and not be so intolerable?
> Doxepin, IMO is much more tolerable than amitriptyline.
Yes, I really think so. Hope it works for you.
> Fachad,
> Great abstract!!!
> I had read something about "scalp dysesthesia", but only related to men who were or feared they were experiencing hairloss. This abstract describes me to a Tee, I guess. This must be why the dermatologist only spent 30 seconds with me. He knew right off that it is a "psychiatric disorder." Especially after he heard the list of psychtropic meds I was taking.
>
> But, the symptoms seemed to come on after being on therapeutic levels of Li with Neurontin for about 3 months. My hair and skin got so dry, but thyroid normal. Then the scalp pain emerged, but like the article said, no evidence like flakes or inflammation. Just a searing burn, so i couldn't brush my hair, etc.
>
> Well, in terms of dose, I know 20 mgs is not enough to control the pain. So I think I will creep it up by 10 or 20, and call my pdoc next week.
> Doxepin, IMO is much more tolerable than amitriptyline. (Let's just hope it will knock out the pain too, but at higher doses than ami.) I was grouchy ALL the time on ami. It just made me feel "yucky" physically and mentally. I had asked my pdoc for Dox months ago, but she dismissed my request saying that all TCA's are the same. HOW UNTRUE. Thanks for showing me the light!
>
> Be well.
> Chloe
>
> > Here's an abstract from an article on using doxepin or ami for scalp pain:
> >
> >
> > Arch Dermatol 1998 Mar;134(3):327-30 Related Articles, Books, LinkOut
> >
> > Scalp dysesthesia.
> >
> > Hoss D, Segal S.
> >
> > Department of Dermatology, University of Connecticut Health Center, Farmington 06030, USA.
> >
> > BACKGROUND: Cutaneous dysesthesia syndrome is a disorder characterized by chronic cutaneous symptoms without objective findings. Patients complain of burning, stinging, or itching, which is often triggered or exacerbated by psychological or physical stress. These symptoms may be manifestations of an underlying psychiatric disorder or may represent a type of chronic pain syndrome.
> >
> > OBSERVATIONS: Eleven women presented with chronic severe pain and/or pruritus of the scalp only without objective physical findings, a condition we term "scalp dysesthesia." Five women described pain, stinging, or burning only; 4 women complained of pain and pruritus; and 2 women reported pruritus only. The patients ranged in age from 36 to 70 years. The duration of symptoms ranged from 9 months to 7 years. Five women had physician-diagnosed psychiatric disorders, including dysthymic disorder, generalized anxiety, and somatization. Seven women reported that stress triggers or exacerbates their symptoms.
> >
> > Eight women experienced improvement or complete resolution of symptoms with treatment with low-dose doxepin hydrochloride or amitriptyline hydrochloride.
> >
> > One patient responded completely to treatment with sertraline and hydroxyzine hydrochloride but then experienced a relapse.
> >
> > CONCLUSIONS: We describe 11 patients with a new syndrome that we term scalp dysesthesia. Of 11 patients, 9 benefited from treatment with low doses of antidepressants.
> >
> > PMID: 9521031 [PubMed - indexed for MEDLINE]
Posted by fachad on June 16, 2002, at 20:26:49
In reply to Re: Abstract on Doxepin for Scalp Pain » Chloe, posted by Ritch on June 15, 2002, at 16:05:46
>The first psych meds I was prescribed (all at once, too), was lithium 900mg/day + doxepin 75mg/bedtime + amitripytline 25mg/bedtime + chlordiazepoxide 10mg/bedtime.
Whoa, that's enough to take down a charging Rhino! What were they thinking? Lithium + Doxepin + Elavil + Librium!
It's a wonder you were even conscious enough to swallow the pills.
> Hi Chloe,
>
> So *that's* what that is! Got a question for you. You said it started when you were taking Neurontin+lithium. Had you ever been on lithium before without being combined with the Neurontin? I just wonder if the Neurontin might have precipitated it. It's a good thing you have nailed it. It helps when it has a *name*! You are also very lucky you don't mind heavy-hitting sedative meds. The first psych meds I was prescribed (all at once, too), was lithium 900mg/day + doxepin 75mg/bedtime + amitripytline 25mg/bedtime + chlordiazepoxide 10mg/bedtime. Needless to say my first night's sleep on that was rather, well.. heavy to say the least. Doxepin is weird in that you get whalloped pretty good when you start a given dose (say 25mg at bedtime). But, after a few weeks the daytime sedation does wear away quite a bit. I can't believe it was possible, but I was up to 150mg/day for a few weeks and actually worked around dangerous machinery! I don't think I could hack that now! I had to give up the imipramine trial. It just screwed up my sleep so badly. I was evidently not sleeping soundly, and it was triggering the early morning awakenings. Since I stopped it my sleep has improved steadily. But, I still feel the depression during the day. It looks like I am going to start a smidge of Effexor starting Monday (to be my sole AD-no more Celexa, etc.). Just 12.5mg first thing in the morning, and then let it wash out later on so it (hopefully) won't wreck my sleep. I got hypomanic and irritable on it before, but that was related to steroids I was taking. Also, I wasn't on Depakote at the time but subtherapeutic lithium instead. So, this will be the Effexor irritability challenge (to see if the Depakote will keep a lid on it).
>
> good luck with the doxepin,
>
> Mitch
>
> > Fachad,
> > Great abstract!!!
> > I had read something about "scalp dysesthesia", but only related to men who were or feared they were experiencing hairloss. This abstract describes me to a Tee, I guess. This must be why the dermatologist only spent 30 seconds with me. He knew right off that it is a "psychiatric disorder." Especially after he heard the list of psychtropic meds I was taking.
> >
> > But, the symptoms seemed to come on after being on therapeutic levels of Li with Neurontin for about 3 months. My hair and skin got so dry, but thyroid normal. Then the scalp pain emerged, but like the article said, no evidence like flakes or inflammation. Just a searing burn, so i couldn't brush my hair, etc.
> >
> > Well, in terms of dose, I know 20 mgs is not enough to control the pain. So I think I will creep it up by 10 or 20, and call my pdoc next week.
> > Doxepin, IMO is much more tolerable than amitriptyline. (Let's just hope it will knock out the pain too, but at higher doses than ami.) I was grouchy ALL the time on ami. It just made me feel "yucky" physically and mentally. I had asked my pdoc for Dox months ago, but she dismissed my request saying that all TCA's are the same. HOW UNTRUE. Thanks for showing me the light!
> >
> > Be well.
> > Chloe
> >
> > > Here's an abstract from an article on using doxepin or ami for scalp pain:
> > >
> > >
> > > Arch Dermatol 1998 Mar;134(3):327-30 Related Articles, Books, LinkOut
> > >
> > > Scalp dysesthesia.
> > >
> > > Hoss D, Segal S.
> > >
> > > Department of Dermatology, University of Connecticut Health Center, Farmington 06030, USA.
> > >
> > > BACKGROUND: Cutaneous dysesthesia syndrome is a disorder characterized by chronic cutaneous symptoms without objective findings. Patients complain of burning, stinging, or itching, which is often triggered or exacerbated by psychological or physical stress. These symptoms may be manifestations of an underlying psychiatric disorder or may represent a type of chronic pain syndrome.
> > >
> > > OBSERVATIONS: Eleven women presented with chronic severe pain and/or pruritus of the scalp only without objective physical findings, a condition we term "scalp dysesthesia." Five women described pain, stinging, or burning only; 4 women complained of pain and pruritus; and 2 women reported pruritus only. The patients ranged in age from 36 to 70 years. The duration of symptoms ranged from 9 months to 7 years. Five women had physician-diagnosed psychiatric disorders, including dysthymic disorder, generalized anxiety, and somatization. Seven women reported that stress triggers or exacerbates their symptoms.
> > >
> > > Eight women experienced improvement or complete resolution of symptoms with treatment with low-dose doxepin hydrochloride or amitriptyline hydrochloride.
> > >
> > > One patient responded completely to treatment with sertraline and hydroxyzine hydrochloride but then experienced a relapse.
> > >
> > > CONCLUSIONS: We describe 11 patients with a new syndrome that we term scalp dysesthesia. Of 11 patients, 9 benefited from treatment with low doses of antidepressants.
> > >
> > > PMID: 9521031 [PubMed - indexed for MEDLINE]
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