![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 23 to 47 of 47. Go back in thread:
Posted by notfred on June 14, 2006, at 10:33:34
In reply to Re: EMSAM doses too low to effect depression ?, posted by cecilia on June 14, 2006, at 0:13:37
> That's interesting, Endof90, that you actually felt LESS insomnia and anxiety at the higher doses.
EMSAM has totally different actions at higher doses.
Posted by Pops_1 on June 14, 2006, at 13:22:24
In reply to Re: EMSAM doses too low to effect depression ?, posted by notfred on June 14, 2006, at 10:33:34
Your original speculation - that EMSAM doesn't require dietary restrictions b/c it is essentially equivalent to sub-therapeutic oral selegline dose levels - is interesting but incorrect on two points.
(See http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=400 for excellent overview of MAO Inhibitors and EMSAM's pharmokinetics).
1. Transdermal delivery has very different pharmokinetics than oral delivery. Since it enters the bloodstream directly, it has much stronger effect than oral dose, which much of which is metabolized before it can reach brain to inhibit MAO A & B.
"The bioavailability of selegiline is ~75% following STS compared with 4.4% after oral administration due to first-pass metabolism. Therefore, STS produces higher and more sustained steady-state levels compared with oral selegiline."
"STS also was 10–20 times more potent than oral selegiline in producing its antidepressant-like effect and inhibiting cortical MAO-A."
2. Dietary restrictions aren't require despite the higher potency of transdermal selegiline because transdermal delivery doesn't inhibit the MAO-A in the gut to the extent oral selegline dose. If your gut MAO-A are OK, you can still eat tyramine-rich foods.
"Doses of [Selegiline Transdermal System] that inhibit brain MAO-A and MAO-B by 60% and 90%, respectively, do not alter [gastro intestinal] MAO-A activity."
Hope that explanation is clear...
Posted by notfred on June 14, 2006, at 14:11:55
In reply to EMSAM stronger than oral selegline, posted by Pops_1 on June 14, 2006, at 13:22:24
> Your original speculation - that EMSAM doesn't require dietary restrictions b/c it is essentially equivalent to sub-therapeutic oral selegline dose levels - is interesting but incorrect on two points.
>Reread a bit and you will see that is not what I was saying.
(See http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=400 for excellent overview of MAO Inhibitors and EMSAM's pharmokinetics).
The manufacture says there is "limited clinical experience" with this.
Posted by SFY on June 14, 2006, at 15:53:13
In reply to Re: EMSAM doses too low to effect depression ? » cecilia, posted by endof90 on June 14, 2006, at 6:02:39
> Hi, I have fortunately not experienced any eye pain but have had frequent headches that are sometimes unrelenting no matter what I try, ever since I started this med. Sorry to hear you are experiencing this, I can just imagine how uncomfortable it must be. Have you had an eye exam recently? They routinely do a glaucoma test to see if there might be increased intraoccular pressure. Might be a good idea to be checked just to be sure. What we have to go thru w/some of these medications is really terrible. Besides the headaches, I have had the worst constipation I have ever had on a med, and sometimes experience alot of epigastric discomfort which feels like my stomach is being twisted into a knot. Might be from taking so many damn analgesics for the headaches. Zantac usually helps though, and this particular side effect has become less frequent. It was really bad when I first started the Emsam. I really don't understand the sudden tiredness either, having felt not sleeping so much was one of the positive aspects of this med. initially. My sleeping usually increases when a med. starts losing it's effect. Anxiety is still there but not as bad. I only have to take an Ativan when going out in the world b/c of the social anxiety. The only med that really ever helped w/this was Nardil,(until it stopped working again) The Emsam hasn't really helped in this area. Seem to feel uncomfortable in my own skin and less @ ease around people than I had been. Only difference is I don't need to take it when I'm home and feel safe I guess. The first weeks I needed to take it all the time. I was really hoping for better results w/this med.
Have you checked your blood pressure? Headaches from Emsam could be a sign of a potentially dangerous hypertensive crisis.
Posted by Pops_1 on June 14, 2006, at 17:22:25
In reply to Re: EMSAM stronger than oral selegline, posted by notfred on June 14, 2006, at 14:11:55
> > Your original speculation - that EMSAM doesn't require dietary restrictions b/c it is essentially equivalent to sub-therapeutic oral selegline dose levels - is interesting but incorrect on two points.
> >
>
> Reread a bit and you will see that is not what I was saying.
>
> (See http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=400 for excellent overview of MAO Inhibitors and EMSAM's pharmokinetics).
>
> The manufacture says there is "limited clinical experience" with this.Um, sorry if I interpolated your posts incorrectly, but I took from your following two statements...
"Deprenyl and EMSAM contain the same active ingredient. The doses for depression are far higher that those mentioned on this board."
"Yes, that is fundamental and well known as to why there are no dietary restrictions at lower doses. EMSAM does not inhibit MAO-A at lower doses. This alone and not its transdermal delivery system accounts for the lack of dietary restrictions."...that you assumed:
a. EMSAM & deprenyl dosing were equivalent (e.g., if you needed 40mg-60mg oral dose for AD, you would need 40-60mg EMSAM dose for AD)
b. MAO-A inhibition is what produces antidepressant efficacy
c. MAO-A inhibition is what creates dietary restrictions
d. Since EMSAM 20mg doesn't have dietary restrictions, it must not inibit MAO-A
What did you actually mean to suggest?
As indicated in the article I linked, EMSAM 20mg achieves cortical MAO-A inhibition equivalent to 60mg-120mg of oral deprenyl (way beyond doses required for AD efficacy) without impacting GI MAO-A levels sufficiently to warrant dietary restrictions. "STS allows inhibition of brain MAO-A and MAO-B enzymes with reduced effects on GI MAO-A, thereby reducing the risk of possible interactions with tyramine-rich foods at therapeutic doses."
If you read the full article, you'll see that even the 30mg & 40mg patches are likely to not cause dietary problems, but that data from the test trials indicated that the most tyramine-sensitive patient could in theory have a hypertensive crisis at these doses if they ate a really, really tyramine rich meal, which is probably why Somerset was OK with the dietary restrictions on labelling for the higher doses.
Posted by notfred on June 14, 2006, at 17:50:40
In reply to Re: EMSAM stronger than oral selegline, posted by Pops_1 on June 14, 2006, at 17:22:25
>
> b. MAO-A inhibition is what produces antidepressant efficacyI have already posted studies to bear out this.
>
> c. MAO-A inhibition is what creates dietary restrictions
>see http://www.biopsychiatry.com/pressor.htm
Monoamine oxidase inhibitors
and pressor response to dietary amines
by
Tipton KF
Department of Biochemistry,
Trinity College Dublin, Ireland.
ktipton@tcd.ie
Vopr Med Khim 1997 Nov-Dec;43(6):494-503"Because gastro-intestinal monoamine oxidase (MAO) effectively prevents dietary pressor amines, typically tyramine, from entering the tissues, a marked hypertensive response (the "cheese reaction") can occur when subjects treated with antidepressant MAO inhibitors ingest foods or beverages rich in such amines. Although tyramine is a substrate for both MAO-A and -B, it is only inhibitors of the former enzyme"
Posted by endof90 on June 14, 2006, at 18:07:05
In reply to Re: EMSAM doses too low to effect depression ?, posted by SFY on June 14, 2006, at 15:53:13
You are right, it was one of the first things I thought of as I have unfortunately been thru 2 incidents of hypertensive crisis in the past while on Nardil. The circumstances of one of them I had posted on this thread earlier today in response to a question from Declan. Today is the first time I've had the nerve to post anything so I really don't even know if I am using this board correctly. The first hypertensive crisis I experienced was while I was taking Dexedrine as an augmentor to the Nardil in 1999. I had been on the Dexedrine for @ least 2 mos. w/out any problem before it happened. Beleive me when it happens it is a headache you will never, ever, forget. I usually run a low B/P, 90/60, and since starting the Emsam it has not really changed, even w/the headaches. It went up to 200/90 during the hypertensive crises. The 2 incidents I experienced really knocked me for a loop because I was always very vigilant w/the MAO diet. As much as I loved cheese it was worth giving up,( as well as other some other foods )not to be depressed. The first time I was put on it was in 1992 and @ the time I had been not too long out of eating disorder treatment for bulemia ( which started @ age 16). So I was pretty much used to being on somewhat of a restricted diet as it was. Unfortunately I've struggled w/bulemia again in recent years when falling back into depression, usually when whatever med. that has helped suddenly stops working. Despite this, I have always continued to avoid the forbidden foods during these times. Sadly, it is probably b/c of such an ingrained fear of potentially dying in such a humiliating way. Thank you for your concern regarding the headaches though.
Posted by Jakeman on June 15, 2006, at 1:22:28
In reply to Re: EMSAM stronger than oral selegline, posted by notfred on June 14, 2006, at 17:50:40
>
> >
> > b. MAO-A inhibition is what produces antidepressant efficacy
>Other studies have shown that antidepressant efficacy for transdermal selelinge is provided at lower doses(6 mg) See below. Which may indicate that transdermal delivery has a stronger effect. Maybe its hitting both A and B. I don't know.
http://www.rxlist.com/cgi/generic4/emsam_cp.htm
Clinical Efficacy TrialsThe efficacy of EMSAM as a treatment for major depressive disorder was established in two placebo-controlled studies of six and eight weeks duration in adult outpatients (ages 18 to 70 years) meeting DSM-IV criteria for major depressive disorder. In both studies, patients were randomized to double-blind treatment with EMSAM or placebo. The 6-week trial (N=176) showed that EMSAM 6mg/24hours was significantly more effective than placebo on the 17-item Hamilton Depression Rating Scale (HAM-D). In an 8-week dose titration trial, depressed patients (N=265), who received EMSAM or placebo at a starting dose of 6mg/24hours, with possible increases to 9mg/24hours or 12mg/24hours based on clinical response, showed significant improvement compared with placebo on the primary outcome measure, the 28-item HAM-D total score.
In another trial, 322 patients meeting DSM-IV criteria for major depressive disorder who had responded during an initial 10-week open-label treatment phase for about 25 days, on average, to EMSAM 6mg/24hours, were randomized either to continuation of EMSAM at the same dose (N=159) or to placebo (N=163) under double-blind conditions for observation of relapse. About 52% of the EMSAM-treated patients, as well as about 52% of the placebo-treated patients, had discontinued treatment by week 12 of the double-blind phase. Response during the open-label phase was defined as 17-item HAM-D score <10 at either week 8 or 9 and at week 10 of the open-label phase. Relapse during the double-blind phase was defined as follows : (1) a 17-item HAM-D score ³ 14, (2) a CGI-S score of ³ 3 (with at least a 2-point increase from double-blind baseline), and (3) meeting DSM-IV criteria for major depressive disorder on two consecutive visits ³ 11 days apart. In the double-blind phase, patients receiving continued EMSAM experienced a significantly longer time to relapse
Posted by Pops_1 on June 15, 2006, at 12:44:48
In reply to Re: EMSAM stronger than oral selegline, posted by notfred on June 14, 2006, at 17:50:40
>
> >
> > b. MAO-A inhibition is what produces antidepressant efficacy
>
> I have already posted studies to bear out this.> >
> > c. MAO-A inhibition is what creates dietary restrictions
> >
>
> see http://www.biopsychiatry.com/pressor.htmBoth of these statements are correct and are confirmed in the monograph I cited. I was trying to clarify that your OTHER two apparent assumptions were incorrect, and hence dispel any suggestion that EMSAM 20mg doesn't require dietary restrictions because it doesn't inhibit cortical MAO-A.
- "a. EMSAM & deprenyl dosing were equivalent (e.g., if you needed 40mg-60mg oral dose for AD, you would need 40-60mg EMSAM dose for AD)"
- "d. Since EMSAM 20mg doesn't have dietary restrictions, it must not inibit MAO-A"
Is this what you were suggesting? If not, what is your point about EMSAM 20mg?
I provided the quotes from the monograph to demonstrate that EMSAM 20mg achieves its status as "MAOI without dietary restrictions" by producing therapeutic inhibition of brain MAO-A without impacting GI MAO-A, not because it only inhibits MAO-B.
I think this is important to clarify, since someone currently on a traditional MAOI might infer from your post that they would have to go to the dietary-restricted EMSAM doses to get the same benefits, which is probably not the case.
Posted by Pops_1 on June 15, 2006, at 12:47:57
In reply to Re: EMSAM stronger than oral selegline » notfred, posted by Jakeman on June 15, 2006, at 1:22:28
> >
> > >
> > > b. MAO-A inhibition is what produces antidepressant efficacy
> >
>
> Other studies have shown that antidepressant efficacy for transdermal selelinge is provided at lower doses(6 mg) See below. Which may indicate that transdermal delivery has a stronger effect. Maybe its hitting both A and B. I don't know.You're right, it effective because it hits both A & B in the brain, but not the gut.
Transdermal Selegiline: The New Generation of Monoamine Oxidase Inhibitors
http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=400"STS allows inhibition of brain MAO-A and MAO-B enzymes with reduced effects on GI MAO-A, thereby reducing the risk of possible interactions with tyramine-rich foods at therapeutic doses."
Posted by mworkman on June 15, 2006, at 22:36:13
In reply to Re: EMSAM doses too low to effect depression ?, posted by notfred on June 11, 2006, at 21:08:36
Well, rxlist says that "EMSAM systems are transdermal patches that contain 1 mg of selegiline per cm2 and deliver approximately 0.3 mg of selegiline per cm2 over 24 hours."
That is how they get the 20mg/20cm2 = 6mg/24 hours dosing. 20 * .3 = 6 mg. So 6 mg of the drug goes into your system over 24 hours.
It then says that "Following dermal application of EMSAM to humans, 25% - 30% of the selegiline content on average is delivered systemically over 24 hours, (range ~10% - 40%). Consequently, the degree of drug absorption may be 1/3 higher than the average amounts of 6 to 12mg per 24 hours."
What I get from this is that you could get up to 9 mg over 24 hours from the patch. 6 mg is just the average.
That is just the drug going into your system, though. The big difference is the blood concentrations of emsam vs. oral selegiline. If you look at the 6mg emsam vs. 10 mg oral, the blood concentrations of emsam are 7 or 8 times higher, and the metabolites are much lower. So, to me, it seems that you are getting about 7 or 8 times as much of the drug. So, emsam seems to make the blood concentration much higher than the oral dosing, which is what really matters.
You can't really say that since you only get so much more of the drug from emsam that it isn't as strong. What happens in the body is what really matters, and emsam puts much more selegiline into the blood at lower doses than oral does.
As for a it being a dirty drug, ssri's may only directly effect serotonin, but the brain and the rest of the body is so interconnected that they indirectly affect many other parts of the brain and body. It is like dominos, you can only push one, but the rest will fall down with it.
Posted by Jakeman on June 15, 2006, at 22:44:06
In reply to Re: EMSAM stronger than oral selegline, posted by Pops_1 on June 15, 2006, at 12:47:57
Hi Pops notfred and others,
Very good article, thanks for posting:
http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=400One sentence concerns me:
Mechanism of Antidepressant Action of Selegiline Transdermal System
"Interestingly, the acute increases in brain 5-HT and NE with MAOIs subside with continued treatment and the levels gradually return to the pre-treatment state due to end-product inhibition of biosynthesis and adaptive changes in the neurotransmitter receptor sensitivity.1 " (I'd like to find this article).They seem to imply that poop-out will occur just like so many other AD's.
But other studes say a minimum 1 year efficacy is predicted:
"It seems that improvement seen in short-term trials is maintained for at least 1 year with continued STS treatment. The data from the three trials as well as an unpublished trial (data submitted to the FDA) are summarized in Table 5."
Another part of the article comments on the oral vs transdermal potency which has discussed on this board:
"STS also was 10–20 times more potent than oral selegiline in producing its antidepressant-like effect and inhibiting cortical MAO-A.10"
I tried to reseach the studies they cited but couldn't find much detail, just the abstracts. I've read that other people complain about MAOI poop-out. I wonder if that's also the case with Emsam. As they always say, more research may be needed.
~Jake
Posted by Weather on June 16, 2006, at 0:23:18
In reply to Re: EMSAM doses too low to effect depression ? » SFY, posted by endof90 on June 14, 2006, at 18:07:05
> You are right, it was one of the first things I thought of as I have unfortunately been thru 2 incidents of hypertensive crisis in the past while on Nardil. The circumstances of one of them I had posted on this thread earlier today in response to a question from Declan. Today is the first time I've had the nerve to post anything so I really don't even know if I am using this board correctly. The first hypertensive crisis I experienced was while I was taking Dexedrine as an augmentor to the Nardil in 1999. I had been on the Dexedrine for @ least 2 mos. w/out any problem before it happened. Beleive me when it happens it is a headache you will never, ever, forget. I usually run a low B/P, 90/60, and since starting the Emsam it has not really changed, even w/the headaches. It went up to 200/90 during the hypertensive crises. The 2 incidents I experienced really knocked me for a loop because I was always very vigilant w/the MAO diet. As much as I loved cheese it was worth giving up,( as well as other some other foods )not to be depressed. The first time I was put on it was in 1992 and @ the time I had been not too long out of eating disorder treatment for bulemia ( which started @ age 16). So I was pretty much used to being on somewhat of a restricted diet as it was. Unfortunately I've struggled w/bulemia again in recent years when falling back into depression, usually when whatever med. that has helped suddenly stops working. Despite this, I have always continued to avoid the forbidden foods during these times. Sadly, it is probably b/c of such an ingrained fear of potentially dying in such a humiliating way. Thank you for your concern regarding the headaches though.
SFY, what dose of Dexedrine were you taking when you had the hypertensive crisis ?
Posted by SFY on June 16, 2006, at 12:43:59
In reply to Re: EMSAM doses too low to effect depression ? » endof90, posted by Weather on June 16, 2006, at 0:23:18
> > You are right, it was one of the first things I thought of as I have unfortunately been thru 2 incidents of hypertensive crisis in the past while on Nardil. The circumstances of one of them I had posted on this thread earlier today in response to a question from Declan. Today is the first time I've had the nerve to post anything so I really don't even know if I am using this board correctly. The first hypertensive crisis I experienced was while I was taking Dexedrine as an augmentor to the Nardil in 1999. I had been on the Dexedrine for @ least 2 mos. w/out any problem before it happened. Beleive me when it happens it is a headache you will never, ever, forget. I usually run a low B/P, 90/60, and since starting the Emsam it has not really changed, even w/the headaches. It went up to 200/90 during the hypertensive crises. The 2 incidents I experienced really knocked me for a loop because I was always very vigilant w/the MAO diet. As much as I loved cheese it was worth giving up,( as well as other some other foods )not to be depressed. The first time I was put on it was in 1992 and @ the time I had been not too long out of eating disorder treatment for bulemia ( which started @ age 16). So I was pretty much used to being on somewhat of a restricted diet as it was. Unfortunately I've struggled w/bulemia again in recent years when falling back into depression, usually when whatever med. that has helped suddenly stops working. Despite this, I have always continued to avoid the forbidden foods during these times. Sadly, it is probably b/c of such an ingrained fear of potentially dying in such a humiliating way. Thank you for your concern regarding the headaches though.
>
> SFY, what dose of Dexedrine were you taking when you had the hypertensive crisis ?I think you mean to direct this question to endof90.
Posted by endof90 on June 17, 2006, at 11:31:53
In reply to Re: EMSAM doses too low to effect depression ? » endof90, posted by Weather on June 16, 2006, at 0:23:18
Didn't respond right away b/c I just could not remember. Finally found an old Rx bottle that says 10mg daily. I think I used to take it in the AM, but on that particular day took it in the afternoon as I had to get a refill. The Hypertensive Crisis occured around 8PM that evening.
Posted by Donna Louise on June 18, 2006, at 6:16:34
In reply to Re: EMSAM doses too low to effect depression ? » notfred, posted by endof90 on June 13, 2006, at 23:21:36
> Hi, I started Emsam on April 13, after coming off of Nardil 2wks. prior. As many others on this board I have been on multiple AD's w/various augmentors over the past 16yrs., due to refractory depression and social phobia. The ones that have helped eventually lose their effect, while others (mainly SSRI's) do not help @ all. Nardil was always my lifesaver, and I have been on and off of it for various periods since 1992. This past year it only really helped me for about 4 mos. but stayed on it anyway trying the addition of Lithium (didn't help)and then Lamictal which I really don't feel made much of a difference, though I continue to take 200mg daily. My first week on Emsam 6mg was intolerable due to excessive anxiety and insomnia. I would of welcomed the extra energy if I weren't so damned depressed and unmotivated,as my depression can usually have me sleeping @ least 15hrs/day @ times. I was increased to the 9mg patch after 7 days as my psydoc. stated the excessive anxiety was due to the MAO-B inhibition, whereas I respond best to the inhibition of MAO-A which only occurs @ the higher doses. Ativan and Ambien also helped me get thru this time. After 4wks. on 9mg I was better than I had been before starting this med. but in noway did it come close to the releif I felt w/Nardil when it was working for me. So I was increased to the 12mg patch on May 24. I have not noticed any significant improvement since, and am very worried that I am going down to where I've been too many times. I'm able to function still but it takes a tremendous effort to motivate myself. Stayed in bed from Wed. to Sun. this past week. Suddenly I'm tired again, w/absolutely no problem sleeping. Have been seeing my therapist twice a week so I can try to keep myself from completely isolating from the world again. If I don't try to fight it I'd never leave the house. Life is not supposed to be so hard. Just trying to hold on and not give up yet. Maybe something can be added. I'm also in the process of finding a new psydoc. b/c I'm not really happy w/the one I have for various reasons. Live in NJ, trying to find someone w/more experience in treatment resistant depression. Tried ECT in 2001, think it made me worse. I am truly happy for everyone that Emsam has helped so far and I wish you all continued success. Wish I could have a better response, but we're all different. I'm not ready to give up trying just as yet.
I am so sorry to hear that you are not responding as expected. I know what a huge disappointment that is. I was wondering. Have you tried adding provigil? I take it with EMSAM anywhere from 100-300mg divided during the day. I can still sleep if I wanted during the day, I am a good sleeper like you, but it gives me a choice. It also lifts my mood helps me be more social. I have been taking it with everything for about 4 years and is the only drug I have hung on to. Maybe that would help.donna
Posted by Donna Louise on June 18, 2006, at 6:28:57
In reply to Re: EMSAM doses too low to effect depression ? » cecilia, posted by endof90 on June 14, 2006, at 6:02:39
> Hi, I have fortunately not experienced any eye pain but have had frequent headches that are sometimes unrelenting no matter what I try, ever since I started this med. Sorry to hear you are experiencing this, I can just imagine how uncomfortable it must be. Have you had an eye exam recently? They routinely do a glaucoma test to see if there might be increased intraoccular pressure. Might be a good idea to be checked just to be sure. What we have to go thru w/some of these medications is really terrible. Besides the headaches, I have had the worst constipation I have ever had on a med, and sometimes experience alot of epigastric discomfort which feels like my stomach is being twisted into a knot. Might be from taking so many damn analgesics for the headaches. Zantac usually helps though, and this particular side effect has become less frequent. It was really bad when I first started the Emsam. I really don't understand the sudden tiredness either, having felt not sleeping so much was one of the positive aspects of this med. initially. My sleeping usually increases when a med. starts losing it's effect. Anxiety is still there but not as bad. I only have to take an Ativan when going out in the world b/c of the social anxiety. The only med that really ever helped w/this was Nardil,(until it stopped working again) The Emsam hasn't really helped in this area. Seem to feel uncomfortable in my own skin and less @ ease around people than I had been. Only difference is I don't need to take it when I'm home and feel safe I guess. The first weeks I needed to take it all the time. I was really hoping for better results w/this med.
I did not think I could use any of the triptans with and MAOI but ED UK told me about AXERT. Which is what I use with EMSAM without a problem. I can't take a migraine or any headache for that matter. However, you do seem sensitive to drug interactions. It comes in two doses, a 6.25 and a 12. something. I take the lower dose and don't have a problem.donna
Posted by Donna Louise on June 18, 2006, at 6:34:46
In reply to Re: EMSAM doses too low to effect depression ? » notfred, posted by endof90 on June 13, 2006, at 23:21:36
> Hi, I started Emsam on April 13, after coming off of Nardil 2wks. prior. As many others on this board I have been on multiple AD's w/various augmentors over the past 16yrs., due to refractory depression and social phobia. The ones that have helped eventually lose their effect, while others (mainly SSRI's) do not help @ all. Nardil was always my lifesaver, and I have been on and off of it for various periods since 1992. This past year it only really helped me for about 4 mos. but stayed on it anyway trying the addition of Lithium (didn't help)and then Lamictal which I really don't feel made much of a difference, though I continue to take 200mg daily. My first week on Emsam 6mg was intolerable due to excessive anxiety and insomnia. I would of welcomed the extra energy if I weren't so damned depressed and unmotivated,as my depression can usually have me sleeping @ least 15hrs/day @ times. I was increased to the 9mg patch after 7 days as my psydoc. stated the excessive anxiety was due to the MAO-B inhibition, whereas I respond best to the inhibition of MAO-A which only occurs @ the higher doses. Ativan and Ambien also helped me get thru this time. After 4wks. on 9mg I was better than I had been before starting this med. but in noway did it come close to the releif I felt w/Nardil when it was working for me. So I was increased to the 12mg patch on May 24. I have not noticed any significant improvement since, and am very worried that I am going down to where I've been too many times. I'm able to function still but it takes a tremendous effort to motivate myself. Stayed in bed from Wed. to Sun. this past week. Suddenly I'm tired again, w/absolutely no problem sleeping. Have been seeing my therapist twice a week so I can try to keep myself from completely isolating from the world again. If I don't try to fight it I'd never leave the house. Life is not supposed to be so hard. Just trying to hold on and not give up yet. Maybe something can be added. I'm also in the process of finding a new psydoc. b/c I'm not really happy w/the one I have for various reasons. Live in NJ, trying to find someone w/more experience in treatment resistant depression. Tried ECT in 2001, think it made me worse. I am truly happy for everyone that Emsam has helped so far and I wish you all continued success. Wish I could have a better response, but we're all different. I'm not ready to give up trying just as yet.
I just wrote a long letter to you and I dont know where it went.. sigh. I think what I said was that I asked if you have tried provigil. I am good sleeper like you and take 100-300mg daily in divided doses. I can still sleep but I have a choice. Also it lifts my mood and makes me feel more like being with people. I have taken it for about 4 years with all the combos and is the only drug I have kept in the arsenal through all the changes. It is well worth a try and maybe just the boost the 4omg needs. Also, the 40mg may need a little longer to work. I know you are really tired of waiting for that to happen!
Hang in there.Donna
Posted by Donna Louise on June 18, 2006, at 6:40:24
In reply to Re: EMSAM doses too low to effect depression ? » Declan, posted by endof90 on June 14, 2006, at 7:30:26
> > How old are you? (you sleep so well)
> > No problems sleeping on the 12mg patch? Would it make sense to try a higher dose?
> > 2mg sublingual deprenyl/d disturbed my already bad sleep.
> > But then you've come off Nardil 2 months ago, which might....?
> > Declan
> I am 47. My problems started w/panic attacks @ 16. Completely ruined me @ 30, but is a long story. Have you heard of anyone going higher than the 12mg patch? My last months on the Nardil were really bad, and my somnolence increased as well as the isolation. I was put on Lamictal about the 4th month on the Nardil, when it seemed to be losing it's effect. A few weeks into taking Lamictal, I began having heart palpitations and pressure in my chest soon after taking my usual Nardil dose. I had to take sublingual Procardia whenever this occurred because my B/P would shoot up. Anyway the Nardil had to be lowered to 45mg from 90mg/day. My psydoc. insisted the Lamictal had nothing to do w/this. I had never experienced this w/Nardil before nor had any history of any cardiac problems. I had been on it for 6 mos. in 2003 where it was working well, but in Dec. of that year I had a hypertensive crisis that seemed to hit me out of nowhere. It occurred after eating a peice of chocolate, which I had never had a problem with previously. It had come as a gift and was from a place that made their own confections, so that might have been the reason. It was a terrible, frightening experience. This happened during the time Pfizer was apparently in the process of changing the formula, and @ the time it was very difficult getting Nardil anywhere. I remember having to write to the company to get a emergency supply b/c all pharmacies were out of it, and having a difficult time obtaining it. I now wonder if this had something to do w/it, as I now see alot of people have had problems w/Nardil since then. Problem is, after having such a good response to a med. and then having it lose it's effect is so discouraging. When it worked I felt as if I had experienced a miracle. Had been hoping for this w/Emsam, but just don't know now. Terrible thing also is when something does finally help, I feel like I am always looking over my shoulder for it's eventual failure. Guess I should just be grateful for the respites I have had in my life dealing w/this ugly disease. My Dr. wanted me to add a small dose of Lexapro while on the Nardil, but I was too scared to try. Maybe if he had offered to supervise the experiment in his office, I would have tried it. Then Emsam became available and he decided to go w/that. Did you ever hear of combining a MAO w/Lexapro? I haven't been able to find any info on such a combination. Would have been willing to try it if there had been some evidence of it being used w/out dying of a hypertensive crisis.That is a really bad idea. To mix an ssri with an MAOI. I don't care how small the dose. That is one of the main things sure to cause a hypertensive crisis. Even if you could get away with a tiny dose, that would have to be so tiny it would do no good anyway. Gads, hasn't he read the monograph or whatever you call the long winded tiny writing thing that comes with the rx?? This is how MAOI's get a bad rap. And since you sound especially sensitive to such things, it is not out of the realm of possibility that lamictal gave you a problem even if it isn't supposed to you. Anything can be possible with an individual chemistry. I am glad you listened to you and not him.
Donna
Posted by Donna Louise on June 18, 2006, at 6:42:38
In reply to Re: EMSAM doses too low to effect depression ? » SFY, posted by endof90 on June 14, 2006, at 18:07:05
> You are right, it was one of the first things I thought of as I have unfortunately been thru 2 incidents of hypertensive crisis in the past while on Nardil. The circumstances of one of them I had posted on this thread earlier today in response to a question from Declan. Today is the first time I've had the nerve to post anything so I really don't even know if I am using this board correctly. The first hypertensive crisis I experienced was while I was taking Dexedrine as an augmentor to the Nardil in 1999. I had been on the Dexedrine for @ least 2 mos. w/out any problem before it happened. Beleive me when it happens it is a headache you will never, ever, forget. I usually run a low B/P, 90/60, and since starting the Emsam it has not really changed, even w/the headaches. It went up to 200/90 during the hypertensive crises. The 2 incidents I experienced really knocked me for a loop because I was always very vigilant w/the MAO diet. As much as I loved cheese it was worth giving up,( as well as other some other foods )not to be depressed. The first time I was put on it was in 1992 and @ the time I had been not too long out of eating disorder treatment for bulemia ( which started @ age 16). So I was pretty much used to being on somewhat of a restricted diet as it was. Unfortunately I've struggled w/bulemia again in recent years when falling back into depression, usually when whatever med. that has helped suddenly stops working. Despite this, I have always continued to avoid the forbidden foods during these times. Sadly, it is probably b/c of such an ingrained fear of potentially dying in such a humiliating way. Thank you for your concern regarding the headaches though.
Jeez, dexedrine is another drug likely to cause a hypertensive crisis. I don't understand this dr. I am glad you have been able survive him.donna
Posted by endof90 on June 18, 2006, at 13:51:24
In reply to Re: EMSAM doses too low to effect depression ? » endof90, posted by Donna Louise on June 18, 2006, at 6:34:46
Hi, Just wrote you a long response as well and have no idea where it went either! So I guess I'll just have to start over. Sorry for the redundancy if it should reappear. Thank you for the Provigil suggestion. I really feel I would possibly benefit from something that would help combat this strange onset of tiredness w/Emsam. My only concern is that 3yrs. ago I was put on Provigil while on a combo of Effexor XR 375mg OD, Wellbutrin SR 150mg TID, and Lamictal 100mg BID. It worked great initially but seemed to lose it's effect after a month or so. I think I was taking 400mg in the AM. Eventually it was changed to Ritalin, then Adderall XR 30mg which I beleive helped me the most @ the time. Haven't been on any med like this since the end of 2003, so I really think it might be worth a try. I will definitely suggest it to my Dr. @ my next appt.-(that is if I haven't found a new one by then) I've been in the process of finding a new psychiatrist w/the help of my therapist. I have never been really comfortable with, or had much faith in this guy, but kept seeing him b/c I just didn't have the energy to look for anyone else. I guess the Emsam is helping me somewhat in this respect, as I feel very determined to find someone more experienced in my problem w/treatment resistance. I had a psychiatrist while living in Florida who helped me the most, and always gave me hope. Always made me feel like he was never willing to give up on me. Sadly, I had been seeing him for about 5yrs, and then he suddenly became sick and 6mos. later was dead from Malignant Lymphoma. Just don't know if I'll ever find someone that I really trust has my best interests @ heart again.
Posted by endof90 on June 18, 2006, at 14:07:36
In reply to Re: EMSAM doses too low to effect depression ? » endof90, posted by Donna Louise on June 18, 2006, at 6:42:38
> > You are right, it was one of the first things I thought of as I have unfortunately been thru 2 incidents of hypertensive crisis in the past while on Nardil. The circumstances of one of them I had posted on this thread earlier today in response to a question from Declan. Today is the first time I've had the nerve to post anything so I really don't even know if I am using this board correctly. The first hypertensive crisis I experienced was while I was taking Dexedrine as an augmentor to the Nardil in 1999. I had been on the Dexedrine for @ least 2 mos. w/out any problem before it happened. Beleive me when it happens it is a headache you will never, ever, forget. I usually run a low B/P, 90/60, and since starting the Emsam it has not really changed, even w/the headaches. It went up to 200/90 during the hypertensive crises. The 2 incidents I experienced really knocked me for a loop because I was always very vigilant w/the MAO diet. As much as I loved cheese it was worth giving up,( as well as other some other foods )not to be depressed. The first time I was put on it was in 1992 and @ the time I had been not too long out of eating disorder treatment for bulemia ( which started @ age 16). So I was pretty much used to being on somewhat of a restricted diet as it was. Unfortunately I've struggled w/bulemia again in recent years when falling back into depression, usually when whatever med. that has helped suddenly stops working. Despite this, I have always continued to avoid the forbidden foods during these times. Sadly, it is probably b/c of such an ingrained fear of potentially dying in such a humiliating way. Thank you for your concern regarding the headaches though.
>
>
> Jeez, dexedrine is another drug likely to cause a hypertensive crisis. I don't understand this dr. I am glad you have been able survive him.
>
> donna
>
You gave me a good laugh. Fortunately it wasn't the same Dr. who prescribed both of these. I got rid of the Dexedrine prescriber shortly after the hypertensive crisis. When I told him what had happened, his first response was, "Well @ least you know now that you don't have any congenital cerebral aneurysms, since you survived it." I was like, "Uh,Thanks"(I think!)
Posted by helpme on June 30, 2006, at 17:27:22
In reply to Re: EMSAM doses too low to effect depression ? » notfred, posted by Jakeman on June 11, 2006, at 22:11:09
You believe the marketeers at the pharmaceutical companies? You think they are out to do favors for humanity or make money with novel products and clever spins? Ever notice they like to specialize in drugs for CHRONIC conditions?> What you are saying is in opposition to the studies conducted my Somerset and others which indicate that transdermal delivery by-passes first-pass metabolism resulting in higher exposure to selegline and less dietary restrictions as well as less exposure to metabolites. How are they wrong?
>
> Warm regards, Jake
>
> MSAM does not inhibit MAO-A at lower doses. This alone and not its transdermal delivery system accounts for the lack of dietary restrictions.
> >
Posted by helpme on June 30, 2006, at 17:36:37
In reply to Re: EMSAM stronger than oral selegline, posted by Pops_1 on June 15, 2006, at 12:47:57
Just feel a bit suspicious of some of the unquestioning touting and quoting of company literature. Who pays for that research? You know they are not required to publish all (ie unfavorable) studies, right?
Posted by Jakeman on June 30, 2006, at 19:35:52
In reply to Re: EMSAM doses too low to effect depression ?, posted by helpme on June 30, 2006, at 17:27:22
> You believe the marketeers at the pharmaceutical companies? You think they are out to do favors for humanity or make money with novel products and clever spins? Ever notice they like to specialize in drugs for CHRONIC conditions?
>The profit motive is always the bottom line of the pharmaceutical industry. The perfect antidepressant would be extremely profitable. The FDA examines the studies, many are peer reviewed in professional journals. Do I trust drug company studies? No, not completely, but they can't be totally discounted either IMO. I think anecdotal reports are equally important to look at. In the case of selegiline, it's been widely studied for years for treatment of other ailments that has produced a lot a data.. which gives me some measure of comfort.
BTW, I am not a drug rep.
warm regards, Jake
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