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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by blueberry on June 9, 2006, at 7:33:03
For my endogenous melancholic severe depression I am thinking about nortriptyline. None of the ssri's or snri's do any good, actually make things much worse.
I would like details about nortriptyline. I know it is a NE/5HT reuptake inhibitor, and I know about the anticholinergic and antihistimine and side effects and stuff.
I am curious about more details such as...does it function as a 5th2 receptor antagonist? Does it have any effect on 5ht1, such as agonist or antagonist? Any other receptors that it affects? Does it directly or indirectly influence dopamine and if so, how? Any and all details appreciated.
I have slight nervousness and hand jitters from zyprexa, usually between doses but not after a dose. I remember years ago zoloft gave me hand jitters and a tiny bit of nortriptyline made them go away, so I am thinking maybe nortriptyline might be good for anxiety and jitters as well as depression?
Posted by SLS on June 9, 2006, at 9:15:03
In reply to Nortriptyline Details Please, posted by blueberry on June 9, 2006, at 7:33:03
> For my endogenous melancholic severe depression I am thinking about nortriptyline. None of the ssri's or snri's do any good, actually make things much worse.
Do you feel worst in the morning?
Will this be the first time that you take a TCA?
Nortriptyline demonstrates a significant degree of antagonism at 5-HT2a/c receptors. It does bind weakly to 5-HT1a receptors, but I don't know whether it acts as an antagonist or agonist (probably antagonist). It also binds with moderate affinity to 5-HT1c receptors. Nortriptyline is more potent at the NE transporter than at the 5-HT transporter by a factor of 5-10. Chronic treatment can desensitize 5-HT1a receptors. However, the stimulation of 5-HT1a receptors can produce an increase in the release of dopamine in the prefrontal cortex. Personally, I think that the downregulation of 5-HT1a is a compensatory adjustment that prevents the chronic depolarization of postsynaptic neurons that results from 5-HT reuptake inhibition, and that this renders them more functional. I guess it is the location of these stimulated 5-HT1a receptors that is important and determines whether they will be inhibitory or facilitatory upon 5-HT neurotransmission. Ratios. Chronic antidepressant treatment is known to increase the release of dopamine in the nucleus accumbens, the reward center, perhaps via 5-HT2c antagonism.
I find nortriptyline to be more calming that desipramine. Be aware, though, that nortriptyline has a therapeutic window. If you increase the dosage too high, the antidepressant response disappears. Most people respond to 75-100mg. Monitoring blood levels is helpful with this drug. The therapeutic range is 50-150 ng/ml. This is really a just guideline to approximate dosing. A clinical titration is still necessary. I would set as a target 75mg and allow 3 weeks before raising the dosage. You will probably want to start at a lower dosage and increase gradaully. For some people, even 25mg can be soporific. You might want to start at 10mg.
Good luck. Nortriptyline is a good drug that I believe is less apt to poop-out than the SSRIs.
- Scott
Posted by blueberry on June 9, 2006, at 15:50:28
In reply to Re: Nortriptyline Details Please » blueberry, posted by SLS on June 9, 2006, at 9:15:03
Thanks Scott for all the info.
I tried nortriptyline at low dose (25mg?) years ago along with zoloft. It was mainly for sleep and as an augmentor. I discovered it immediately stopped the hand tremors that zoloft caused. It made me pretty foggy all morning and most of the afternoon, with only a couple hours of clearheadedness before the next evening dose. The dry mouth was bothersome. Other than that I don't remember much about it. I only stayed with it for a week or two. At the time I wasn't much depressed but looking for some anti-anhedonia pro-motivational stuff, and the lethargy of nortriptyline side effects just wasn't what I had in mind. Things are different now though, with major depression and anxiety center stage.
Posted by Phillipa on June 9, 2006, at 21:58:10
In reply to Re: Nortriptyline Details Please » SLS, posted by blueberry on June 9, 2006, at 15:50:28
Pamelor at l0mg knocked me out. I felt like I was molded to my bed until 2pm. I don't think your hands would twitch on this you can't even move Love Phillipa
Posted by corafree on June 9, 2006, at 23:53:49
In reply to Re: Nortriptyline Details Please, posted by Phillipa on June 9, 2006, at 21:58:10
Just a thought to share re: TCAs. Since taking desipramine, my hand tremors seems to have vanished. Although, am on Valium simultaneously; usually take 5mg twice a day. Maybe the TCA, maybe not. Whichever, I had them horribly and now they've vanished.
(This past week, P and I thinking back to Effexor-XR again?! I'm so confused and he pretty much looks to me for ideas. Maybe should stay on TCA and increase dosage; seems I'm really sensitive to them tho'; can't believe you all can go so high re: dosage.)
How's Zoloft going Scott?
cf
Posted by SLS on June 10, 2006, at 7:25:50
In reply to Re: Nortriptyline Details Please » Phillipa, posted by corafree on June 9, 2006, at 23:53:49
> (This past week, P and I thinking back to Effexor-XR again?! I'm so confused and he pretty much looks to me for ideas. Maybe should stay on TCA and increase dosage; seems I'm really sensitive to them tho'; can't believe you all can go so high re: dosage.)
>
> How's Zoloft going Scott?
Thanks for asking!:-)
Unfortunately, the Zoloft 200mg shows no sign of working. I raised the dosage of Wellbutrin to 450mg. It is the logical thing to do. It will optimize my chances of responding and save time. I am early in my third week of Zoloft therapy, so it is "officially" too early to pass judgment. I am not optimistic though.
:-(
You might consider just adding the Effexor to the desipramine. It was my experience that nortiptyline and Effexor acted synergistically.
What dosage of desipramine are you taking?
- Scott
Posted by corafree on June 10, 2006, at 14:08:44
In reply to Re: Nortriptyline Details Please » corafree, posted by SLS on June 10, 2006, at 7:25:50
I'm sorry. I know what you felt re: Zoloft. It happened to me too ... and only, ever, w/ that one particular drug. It was 'an unbelievable lift' and then it was gone.
Maybe raising the Wellbutrin will help. My P had a lot of good things to say about it. I tried it once. I got out of bed; my body felt very heavy w/ my feet heavy on the floor, moving slow, thinking slow. He said this reaction to it is very unusual.
Maybe I'm wrong Scott, but it sounds more like you are not so much 'more clinically depressed' as you are 'understandably discouraged' at the lack of response to the increase in Zoloft.
We discussed co*ktails. He focused on The Ca*ifornia Co*ktail which is Eff-XR and Remeron. I've never taken Remeron. Those are the scrips I've filled but not yet picked up. I'm having 'second and third thoughts' and luckily have an appt next week. (This past week was an emerg. appt. I was supposed to cancel this coming week's appt, but forgot. For once forgetting pays off!)
He mentioned one combo could cause 'heart probs'; can't recall and will ask. (Better print my own post and tape it to my face!)
Will discuss desipramine & Eff-XR.
I have to stay away from 'hunger triggering' drugs as have a small stomach and suffer w/ ailments in this area. I'm thinking he said Remeron had this property. It's been brought to my attn this is also true of desipramine.
Only 15mins to discuss a serious issue until the 15mins 30 days later; county system :[! Makes me yearn for the info-sucking memory of my youth as it's almost mandatory you be somewhat pro-actively correct!
bestwishes, cf
Posted by SLS on June 10, 2006, at 14:21:28
In reply to Re: Nortriptyline Details Please » SLS, posted by corafree on June 10, 2006, at 14:08:44
Hi CF.
> Maybe I'm wrong Scott, but it sounds more like you are not so much 'more clinically depressed' as you are 'understandably discouraged' at the lack of response to the increase in Zoloft.
I was emotionally devastated when Wellbutrin stopped working for me. I still haven't recovered. I have become partially disengaged from life. I am despondent and demoralized. To me, it seems like the Wellbutrin was my last best chance at getting well. Now that it has failed, I don't feel that anything will ever work.
- Scott
Posted by Phillipa on June 10, 2006, at 20:30:25
In reply to Re: Nortriptyline Details Please » Phillipa, posted by corafree on June 9, 2006, at 23:53:49
Corafree thought you were on l0mg of valium three times a day? Love Phillipa
Posted by corafree on June 10, 2006, at 21:05:19
In reply to Re: Nortriptyline Details Please » corafree, posted by SLS on June 10, 2006, at 14:21:28
I am unhappy and very frustrated as well. Are we simply becoming too quickly 'de-sensitized' to medication? Let's not give up!
I struggle with what's situational and what's clinical of my depression because of the past two years' of subtle turmoil in my life. I believe no matter the reason, the debilitation feels the same. I believe symptoms should be treated.
I am wasting my time wondering. Maybe I'm afraid that too much medication may damage me when it is something as simple as 'love' or a 'change of my surroundings' that I need.
Because of the subtle (The important people in my life say that I 'should be happy' with who/what/where I am in my life.) unhappiness of the last two years, I shy away from going up in dosages and cocktails. I shy away from more aggressive medicinal treatment!
Maybe I'm telling myself to be patient or playing a waiting game ... hoping 'time' will help heal my pain. There's always the possibility what may happen tomorrow could change my life for the better. It's been a long time, but it's happened to me before. But then, was I 'participating in life' instead of 'watching it from the stadium' at that time. I'm too depressed to make that distinction!
I must say this last couple weeks, some eye-openers have popped up and forced me to see I need more serious help.
I forgot to answer your ? re: dosage of desipramine 'maybe purposely(?)' as it is only 10mg! It's embarrassingly low!
So, at this point, I can only think about 'my P's part in the matter of my severe depression', because I believe I am unable to be pro-active and aggressive for these reasons. I refuse to create a suicidal scenario to get attention.
I said, straight out, to him, "You do know that I'm much more depressed than I appear, don't you?"
He acknowledged by nodding yes and mentioned something re: the borderline factor.(?) Did he believe me? It never occurred to me until right now that maybe he didn't take that as seriously as it was meant. Do you suppose that he thought to himself, if she is borderline, she may be 'toying w/ me'? I hope not, because I certainly wasn't.
If I'm not being treated aggressively enough due to my reservations and the absence of an outwardly appearance of severe depression (I have tried to push him to see this.), shouldn't he take the reigns and forge ahead more aggressively on my behalf? I think maybe so. Maybe I need to challenge him. But I cannot let him 'write it off' as a symptom of borderline behavior. I must get his attention!
sincerely, cf
Posted by corafree on June 10, 2006, at 21:11:44
In reply to Re: Nortriptyline Details Please » corafree, posted by SLS on June 10, 2006, at 14:21:28
Yes, I also have the Valium 10mg x3 a day for anxiety, but I only take about 5mg twice a day, and the rest for bedtime. The small dosage of desipramine was not giving me enough sleep. We just tried Ambien, but it was causing me very bad stomachache (and more), so d.c.'d it.
love, cf
Posted by pulse on June 12, 2006, at 7:36:31
In reply to Nortriptyline Details Please, posted by blueberry on June 9, 2006, at 7:33:03
for many folks, even me, nortrip is known to be both calming and slightly stimulating, at the same time. a very nice effect that seems to be unique. very good for sleep. i can't remember now, if i was using it to try to get rid of the renowned prozac insomnia - OR - if i was using it as monotherapy. may have been on one trial of each.
scott is right - nortrip DOES have a narror therapeutic window, so watch that.
unfortunately, it is also very well known to be the worst GERD/ reflux promoter, during the night. i was so disappointed, when i finally had to cry 'uncle!!!' and give it up, only because of this side-effect. it was intractable, even with prevacid. i'll spare you the gory details.
pulse
Posted by corafree on June 12, 2006, at 21:30:18
In reply to Re: Nortriptyline Details Please, posted by pulse on June 12, 2006, at 7:36:31
By narrow therapeutic window, you mean if go too low or too high, can miss the relief; there's a narrow point or small area where it is effective .. correct?
Re: GERD. Do the gory details have something to do w/ digestion and elimination.
I'm going to d.c. desipramine as it's creating an insatiable appetite. I'm distended, so uncomfortable all the time, and literally 'full of it'! (Yep, in more ways than one; I know.) I'm on a very low dose too, but guessing it's prob' built up in my bloodstream. Believe I've been on 2-3mos.
I guess all TCAs have high probability of this sort of side effect.
Too bad there isn't a counter-acting agent.
I've been drinking 'at least' three bottles of drinking water a day and taking 600 mg magnesium w/ silica at h.s., and it had been very helpful for quite a while. Seems to have stopped working. I've wondered if taking 1200mg mag w/ silica a day would be harmful.
Do you still feel that nortriptyline is/was your best bet though, as far as the TCAs go, and if so, why?
thankyou, cf
Posted by pulse on June 13, 2006, at 18:19:07
In reply to Re: Nortriptyline Details Please » pulse, posted by corafree on June 12, 2006, at 21:30:18
> By narrow therapeutic window, you mean if go too low or too high, can miss the relief; there's a narrow point or small area where it is effective .. correct?
correct.
>
> Re: GERD. Do the gory details have something to do w/ digestion and elimination.gory details - ok, you asked for it: waking up several times at night with vomit in my mouth! (WHILE taking prevacid.)
>
> I'm going to d.c. desipramine as it's creating an insatiable appetite. I'm distended, so uncomfortable all the time, and literally 'full of it'! (Yep, in more ways than one; I know.) I'm on a very low dose too, but guessing it's prob' built up in my bloodstream. Believe I've been on 2-3mos.desipramine - no thanx- nausea + VERY full of it.
>
> I guess all TCAs have high probability of this sort of side effect.yes, unfortunately, but lots of folks here recommend nortrip. - and, even moreso - desip. as the least constipating. desip. was one of the very worst tcas for me in that way...just like the infamous effexor pellets effect. fun fun.
>
> Too bad there isn't a counter-acting agent.there is, but i don't know name. someone here talked about it recently. believe it's ultra expensive, but i might be confusing this with an anti-nausiate (sp?) for chemo (?)
>
> I've been drinking 'at least' three bottles of drinking water a day and taking 600 mg magnesium w/ silica at h.s., and it had been very helpful for quite a while. Seems to have stopped working. I've wondered if taking 1200mg mag w/ silica a day would be harmful.
milk of magnesia, my therapist with 2 nursing degrees , warns NEVER to take WITH any AD. not so sure if regular magnium supps. are ok, but they gave me horrid cramps. even the drinkable ones said to be no problem. ha...oh yeah, right!
>
> Do you still feel that nortriptyline is/was your best bet though, as far as the TCAs go, and if so, why?yes, for the combo of calming + stimulating + good sleep...IF you get no gerd vomit.
>
> thankyou, cfyou're most welcome,
pulse
Posted by corafree on June 16, 2006, at 15:21:15
In reply to Re: Nortriptyline Details Please » corafree, posted by pulse on June 13, 2006, at 18:19:07
You sound 'just like me' as regards meds and physical reactions.
I am SOOOOOOOOOOO S I C K of playing this game! I'm not EVEN taking Effexor-XR today.
I'm not taking one damn anti-depressant. Today, I've had it!
I'm feeling completely miserable. I feel like giving up.
Again, need get offline in case hear from P as called him as soon as awakened ... 'at nearly noon' .. which is ridiculous!
love, cf
Posted by pulse on June 17, 2006, at 7:44:38
In reply to Re: Nortriptyline Details Please *Trigger* » pulse, posted by corafree on June 16, 2006, at 15:21:15
nah, no triggers for me, but thanks for concern, regardless.
although, come to think of it, 10 years ago, a friend did say, 'pulse, for you, life is a trigger.' funny gal. just loved her.
i think now that i've been through even more, nothing much fazes me - that's a plus AND a minus, i'm afraid.
i was off here alot yesterdy, so i'm catching up, and i answered another of your posts with some repetitive comments.
well, i sure can't blame you for quitting the useless and/ or sickening effexor.
the med game gets old! again, i hope you somehow feel better soon. please do try not to lose all hope.
best,
pulse
Posted by corafree on June 17, 2006, at 18:12:52
In reply to Re: Nortriptyline Details Please *Trigger* » corafree, posted by pulse on June 17, 2006, at 7:44:38
<the useless and/ or sickening effexor>
LOL!!!!!
I feel better now.
ThanksPulse,cf
This is the end of the thread.
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