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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by quarterwit on September 4, 2004, at 15:24:09
Need advice! Any MAOI to new wonder drug switchers? I'm in a decision-jam and need advice!
3 weeks ago, new pdoc gave me choice of new med Cymbalta or carrying out recommendation of OLD pdoc (!); I had to switch doctors since I moved cities. Decided on Parnate since I felt horrible, absolute dead-as-lead, no motivation, the usual. Reasoning was that Nardil had helped somewhat in past (except for side effects), so a more activating MAOI was called for.
Also, former doctor said Parnate worked fast and was a reliable "last resort" for some of his other patients.I didn't know anything about Cymbalta but was desperate for something to work. And Effexor never did (I could never get beyond 225 mg, and never for very long). I'm also cynical; the next "new wonder AD" never is in my experience.
So should I be patient with Parnate, which hasn't done anything but put me to sleep after 2 weeks at 40 mg (I just woke up for a low blood pressure snooze, pathetically). Or maybe even go higher and wait it out?
Or should I taper now before more time goes by and try Cymbalta? I'm also on Lamictal. Thanks for any feedback
Posted by SLS on September 4, 2004, at 16:26:37
In reply to Parnate to Cymbalta?, posted by quarterwit on September 4, 2004, at 15:24:09
How much Lamictal are you taking? Too much Lamictal caused me to sleep too much when I combined it with high dosages of Parnate. I don't think I could tolerate any more than 150mg of Lamictal at the time without it producing somnolence. Without Parnate, I can handle 300mg.
You are already well into a trial of Parnate, and it would be a shame if you were to miss out on a remission at 60mg. I think it is logical to continue with it, perhaps increasing to 60mg and waiting 3 weeks. Cymbalta will always be there for you.
If you do decide to switch, the prudent recommendation is to wait 2 weeks after discontinuing Parnate to begin Cymbalta.
Good luck.
- Scott
Posted by quarterwit on September 5, 2004, at 9:22:44
In reply to Re: Parnate to Cymbalta?, posted by SLS on September 4, 2004, at 16:26:37
Thanks for reply. I'm on 175 mg of Lamictal -- once beyond 100 it became sedating, with or without Parnate. I'm leaning towards staying on Parnate for full trial. Up to 50 on Tuesday, then onwards up.
BTW, why did you go off the Parnate? Also, any suggestions on how to spread out dose once it gets to 60? How about 30 in morning, 30 early afternoon? A weird effect so far for me is that once I hit >20, taking 10 mg in singles made me drowsy, but if I took 20 at once I got some perkiness. In the past Dexedrine did same thing: low doses got me tired, and I needed higher doses spread through day to get any positive effects. Thanks, Scott
> How much Lamictal are you taking? Too much Lamictal caused me to sleep too much when I combined it with high dosages of Parnate. I don't think I could tolerate any more than 150mg of Lamictal at the time without it producing somnolence. Without Parnate, I can handle 300mg.
>
> You are already well into a trial of Parnate, and it would be a shame if you were to miss out on a remission at 60mg. I think it is logical to continue with it, perhaps increasing to 60mg and waiting 3 weeks. Cymbalta will always be there for you.
>
> If you do decide to switch, the prudent recommendation is to wait 2 weeks after discontinuing Parnate to begin Cymbalta.
>
> Good luck.
>
>
> - Scott
>
>
Posted by SLS on September 5, 2004, at 9:33:46
In reply to Re: Parnate to Cymbalta?, posted by quarterwit on September 5, 2004, at 9:22:44
> Thanks for reply. I'm on 175 mg of Lamictal -- once beyond 100 it became sedating, with or without Parnate. I'm leaning towards staying on Parnate for full trial. Up to 50 on Tuesday, then onwards up.
> BTW, why did you go off the Parnate?
It didn't produce an adequate antidepressant response - even at 150mg. I tried mixing it with Lamictal, desipramine, thyroxine, Dexedrine, and bromocriptine.
> Also, any suggestions on how to spread out dose once it gets to 60? How about 30 in morning, 30 early afternoon?
Perfect.
If low blood pressure becomes an issue, you can try spreading it more evenly, with the last dose to be given at 3:00pm. If insomnia does not develop, you can spread it over a longer period of time. I found that the low blood pressure became less pronounced over time.
- Scott
Posted by King Vultan on September 5, 2004, at 11:21:02
In reply to Re: Parnate to Cymbalta?, posted by quarterwit on September 5, 2004, at 9:22:44
>
> BTW, why did you go off the Parnate? Also, any suggestions on how to spread out dose once it gets to 60? How about 30 in morning, 30 early afternoon? A weird effect so far for me is that once I hit >20, taking 10 mg in singles made me drowsy, but if I took 20 at once I got some perkiness. In the past Dexedrine did same thing: low doses got me tired, and I needed higher doses spread through day to get any positive effects. Thanks, Scott
>
This makes me think of an issue that was being discussed recently about certain people who get sleepy upon administration of stimulant type drugs. The hypothesis proposed was that these people may have hypersensitive dopamine autoreceptors, that is, too many inhibitory receptors keeping dopamine transmission at a chronically low level, and which may also tend to slow or shut down the firing rate of the dopamine neuron if there is any extra dopamine around, as what happens when taking a stimulant. If this does happen to be the case with you, in theory, anyway, Parnate has a good chance of ultimately working, as the hope would be that the extra dopamine available from its inhibition of MAO-B added to that from its stimulant effect may be enough in total to downregulate, or reduce in number, the inhibitory autoreceptors. The end result would be that the neuron's firing rate would speed up to normal and relieve your symptoms.Unfortunately, I don't know how long this downregulation process, if it occurs, winds up taking. I have some of the same issues as you, as some drugs such as Provigil have made me paradoxically sleepy. Like you, I have also just started Parnate and am wondering what kind of time frame will be involved for the full therapeutic effects to be apparent. In my case, I seem to be tolerating it somewhat better, as I can't really say that it's made me sleepy; however, it does seem to be making me a bit more depressed at times. Again, this could perhaps involve some of the same autoreceptor hypersensitivity issues--it's really hard to say for sure what exactly is going on. I have noticed a big improvement in cognitive function, at least. This is my 5th day on 30 mg/day; I was on 20 mg/day for a week before that. I'll soon be making an appointment to see my pdoc about going up to 40 mg/day but am not really doing all that bad on 30--well, depending on the day, anyway.
Todd
Posted by quarterwit on September 6, 2004, at 9:43:44
In reply to Re: Parnate to Cymbalta? » quarterwit, posted by King Vultan on September 5, 2004, at 11:21:02
Well, this is encouraging. Pdoc never delves into specific biochemistry with me, just vaguely pointing out the top 3. I've always known there are complexities in there beyond just this.
I'm giving the Parnate a full run. 4-6 weeks at 60 or higher. You think that's enough? Even if there's slight improvement, I'm inclined to stay on it unless it makes things worse. I just have a bad feeling about the Cymbalta, although the immediate effect on norepenephrine has its appeal. Doesn't it hit dopamine at small levels too?
Staying on Parnate also forces us to be cautious about combos -- Wellbutrin maybe, although it never did much (up to 300 mg but maybe not long enough) on its own. Reboxetine might be good cautious choice, although I don't know if it differs from Straterra much. But being cautious means I stay off at least serious doses of Dexedrine which to be honest has been a problem. Taking between 30-60 for several years caused an addiction of sorts, and I had tough times trying to go off it, including the pre-Parnate period.
Keep me posted on your own Parnate progress. Thanks --
> >
>
> This makes me think of an issue that was being discussed recently about certain people who get sleepy upon administration of stimulant type drugs. The hypothesis proposed was that these people may have hypersensitive dopamine autoreceptors, that is, too many inhibitory receptors keeping dopamine transmission at a chronically low level, and which may also tend to slow or shut down the firing rate of the dopamine neuron if there is any extra dopamine around, as what happens when taking a stimulant. If this does happen to be the case with you, in theory, anyway, Parnate has a good chance of ultimately working, as the hope would be that the extra dopamine available from its inhibition of MAO-B added to that from its stimulant effect may be enough in total to downregulate, or reduce in number, the inhibitory autoreceptors. The end result would be that the neuron's firing rate would speed up to normal and relieve your symptoms.
>
> Unfortunately, I don't know how long this downregulation process, if it occurs, winds up taking. I have some of the same issues as you, as some drugs such as Provigil have made me paradoxically sleepy. Like you, I have also just started Parnate and am wondering what kind of time frame will be involved for the full therapeutic effects to be apparent. In my case, I seem to be tolerating it somewhat better, as I can't really say that it's made me sleepy; however, it does seem to be making me a bit more depressed at times. Again, this could perhaps involve some of the same autoreceptor hypersensitivity issues--it's really hard to say for sure what exactly is going on. I have noticed a big improvement in cognitive function, at least. This is my 5th day on 30 mg/day; I was on 20 mg/day for a week before that. I'll soon be making an appointment to see my pdoc about going up to 40 mg/day but am not really doing all that bad on 30--well, depending on the day, anyway.
>
> Todd
Posted by quarterwit on September 6, 2004, at 9:53:02
In reply to Re: Parnate to Cymbalta?, posted by SLS on September 5, 2004, at 9:33:46
Thanks Scott, and tracking your own Cymbalta progress, I'm sorry about the poor response. But despite the quick-response marketing hype, maybe a full trial of 4-6 weeks still makes sense? There have been so many times when I've wondered "would that 9th week at Effexor 225 mg (the highest I could handle) had made a difference?"; "would that 6th week at Wellbutrin 150-300 mg (highest I could take, but better SE profile than Effexor) had made a difference?"
These symptoms I think like total lack of motivation, feeling leaden and slow, resulting social and other problems are particularly tough to deal with. I have the same problems and feel as if I'm living a half-life. Tough to take and I'm fed up, as you must be.
With your Parnate expereince, did AD effects poop out or did you never have them to begin with?
Keep us posted --
> > Thanks for reply. I'm on 175 mg of Lamictal -- once beyond 100 it became sedating, with or without Parnate. I'm leaning towards staying on Parnate for full trial. Up to 50 on Tuesday, then onwards up.
>
> > BTW, why did you go off the Parnate?
>
> It didn't produce an adequate antidepressant response - even at 150mg. I tried mixing it with Lamictal, desipramine, thyroxine, Dexedrine, and bromocriptine.
>
> > Also, any suggestions on how to spread out dose once it gets to 60? How about 30 in morning, 30 early afternoon?
>
> Perfect.
>
> If low blood pressure becomes an issue, you can try spreading it more evenly, with the last dose to be given at 3:00pm. If insomnia does not develop, you can spread it over a longer period of time. I found that the low blood pressure became less pronounced over time.
>
>
> - Scott
Posted by SLS on September 6, 2004, at 11:18:48
In reply to Re: Parnate to Cymbalta?, posted by quarterwit on September 6, 2004, at 9:53:02
If I had half a brain, I'd still only be a quarterwit.
> Thanks Scott, and tracking your own Cymbalta progress, I'm sorry about the poor response. But despite the quick-response marketing hype, maybe a full trial of 4-6 weeks still makes sense? There have been so many times when I've wondered "would that 9th week at Effexor 225 mg (the highest I could handle) had made a difference?"; "would that 6th week at Wellbutrin 150-300 mg (highest I could take, but better SE profile than Effexor) had made a difference?"
I guess it's logical for me to continue testing each dosage for 3 weeks and then increase.
> With your Parnate expereince, did AD effects poop out or did you never have them to begin with?
The first time I took Parnate, I responded to it after about 2 weeks. The improvement only lasted for a few days, but the difference was dramatic.
The only thing that ever got me well was a combination of Parnate 60mg + desipramine 150mg. It was very safe. My doctor had me discontinue it when mania emerged, and I never responded to it again. If you don't respond to Parnate, and you are not willing to give up on it so soon, you can try adding 300-600mg of lithium.
- Scott
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