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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by amigan on December 14, 2007, at 23:55:49
Hello.
I known that the combination of a MAOI with a potent serotonine reuptake inhibitor like all(?) SSRIs and certain TCAs like clomipramine can easily lead to a life-threatening, serotonine syndrome.
But, would it be relatively safe to combine a MAOI with a low dose of a WEAK SRI, like trazodone, nefazodone or nortriptyline?
Furthermore, some of these ADs are also blocking certain 5-HT receptors, which could be beneficial in preventing the development of a serotonine syndrome! (On the other hand, things might be more complicated with traz/nefazodone, as they are metabolized into mCPP which is a 5-HT agonist... but anyway, i refer them as an example)What do you think?
Posted by jedi on December 15, 2007, at 1:21:37
In reply to MAOIs and WEAK SRIs combination?, posted by amigan on December 14, 2007, at 23:55:49
Hi,
Trazodone in low dosage is often used as a sleep aid with Nardil. I have used it myself. I have also augmented Nardil with Nortriptyline, mostly as a sleep aid. There is some evidence that this type of TCA will help reduce the chance of a tyramine reaction with Nardil. I've taken nefazodone but don't know about any reaction with a MAOI.
Jedi
> Hello.
> I known that the combination of a MAOI with a potent serotonine reuptake inhibitor like all(?) SSRIs and certain TCAs like clomipramine can easily lead to a life-threatening, serotonine syndrome.
> But, would it be relatively safe to combine a MAOI with a low dose of a WEAK SRI, like trazodone, nefazodone or nortriptyline?
> Furthermore, some of these ADs are also blocking certain 5-HT receptors, which could be beneficial in preventing the development of a serotonine syndrome! (On the other hand, things might be more complicated with traz/nefazodone, as they are metabolized into mCPP which is a 5-HT agonist... but anyway, i refer them as an example)
>
> What do you think?
>
Posted by linkadge on December 15, 2007, at 1:40:35
In reply to Re: MAOIs and WEAK SRIs combination? » amigan, posted by jedi on December 15, 2007, at 1:21:37
Yes, I think the combination of Nardil + Nortryptaline is used somewhat often in severe TRD. An long time memeber SLS Scott, used these two in synergic combination.
The herbal product hypericum is to some extent both a MAOI and reuptake inhibitor.
Linkadge
Posted by ny2bk on December 15, 2007, at 5:05:43
In reply to Re: MAOIs and WEAK SRIs combination?, posted by linkadge on December 15, 2007, at 1:40:35
> Yes, I think the combination of Nardil + Nortryptaline is used somewhat often in severe TRD. An long time memeber SLS Scott, used these two in synergic combination.
>
> The herbal product hypericum is to some extent both a MAOI and reuptake inhibitor.
>
> LinkadgeSomw Can be used,some cant.The only thing that makes it a extreme risk is not the wide ratio of what WILL interact,but simply the result of if it happens to be the one that does.
I walked that thin maoi line so many times,and when i had a reaction all i could think about was cranial hemorage,also it took all my strentgh to push away the hands of nurses try to inject me with things until i spoke a actual MD and felt someone actual listened to my cy of IM ON A MAOI.
I felt i was ignored a great deal until then.After the actual doc heard me the next person i seen was one with the tag of TOXOLOGIST who knew of maois and i was in great relief to see that tag on him.
Posted by amigan on December 15, 2007, at 11:27:14
In reply to Re: MAOIs and WEAK SRIs combination?, posted by ny2bk on December 15, 2007, at 5:05:43
Ok then. It should be ok to take some trazodone to calm me down, as the moclobemide (aurorix) makes me agitated, insomniac and almost depressed. It feels like it reduces my serotonine levels instead of increase them.
Posted by Phillipa on December 15, 2007, at 12:01:05
In reply to Re: MAOIs and WEAK SRIs combination?, posted by linkadge on December 15, 2007, at 1:40:35
Yes Scott combines or combined the two with success. Phillipa
Posted by torachan on December 15, 2007, at 16:55:09
In reply to Re: MAOIs and WEAK SRIs combination? » linkadge, posted by Phillipa on December 15, 2007, at 12:01:05
I thought serotonin syndrome was only a danger when combining two serotinergic drugs like SSRI's. Do MAOI's affect serotonin?
Posted by jedi on December 15, 2007, at 22:07:44
In reply to Re: MAOIs and WEAK SRIs combination?, posted by torachan on December 15, 2007, at 16:55:09
> I thought serotonin syndrome was only a danger when combining two serotinergic drugs like SSRI's. Do MAOI's affect serotonin?
Yes, and the combination of say a MAOI and a SSRI is even more dangerous because they affect serotonin in different ways. The combination can result in serotonin toxicity which is indeed life threatening.
JediReference:
Br J Anaesth. 2005 Oct;95(4):434-41. Epub 2005 Jul 28.
Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. Gillman PK.
Pioneer Valley Private Hospital, Mackay, Queensland, Australia. kg@matilda.net.auToxicity resulting from excessive intra-synaptic serotonin, historically referred to as serotonin syndrome, is now understood to be an intra-synaptic serotonin concentration-related phenomenon. Recent research more clearly delineates serotonin toxicity as a discreet toxidrome characterized by clonus, hyper-reflexia, hyperthermia and agitation. Serotonergic side-effects occur with serotonergic drugs, and overdoses of serotonin re-uptake inhibitors (SRIs) frequently produce marked serotonergic side-effects, and in 15% of cases, moderate serotonergic toxicity, but not to a severe degree, which produces hyperthermia and risk of death. It is only combinations of serotonergic drugs acting by different mechanisms that are capable of raising intra-synaptic serotonin to a level that is life threatening. The combination that most commonly does this is a monoamine oxidase inhibitor (MAOI) drug combined with any SRI. There are a number of lesser-known drugs that are MAOIs, such as linezolid and moclobemide; and some opioid analgesics have serotonergic activity. These properties when combined can precipitate life threatening serotonin toxicity. Possibly preventable deaths are still occurring. Knowledge of the properties of these drugs will therefore help to ensure that problems can be avoided in most clinical situations, and treated appropriately (with 5-HT(2A) antagonists for severe cases) if they occur. The phenylpiperidine series opioids, pethidine (meperidine), tramadol, methadone and dextromethorphan and propoxyphene, appear to be weak serotonin re-uptake inhibitors and have all been involved in serotonin toxicity reactions with MAOIs (including some fatalities). Morphine, codeine, oxycodone and buprenorphine are known not to be SRIs, and do not precipitate serotonin toxicity with MAOIs.
PMID: 16051647 [PubMed - indexed for MEDLINE]
Posted by amigan on December 20, 2007, at 13:42:51
In reply to Re: MAOIs and WEAK SRIs combination?, posted by torachan on December 15, 2007, at 16:55:09
Speaking of Moclobemide.. Does anyone thinks that it's a good drug? If yes, for which conditions?
Multiple studies has established that it's inferior to most SRI/SSRI antidepressant in the treatment of major depression, but perhaps it performs better for other conditions like social phobia or other?
Posted by Phoenix1 on December 23, 2007, at 14:26:57
In reply to Re: Speaking of Moclobemide..., posted by amigan on December 20, 2007, at 13:42:51
Hi Amigan,
So far Moclobemide is the ONLY AD that worked for me, out of 12 different adequate dosage/length AD trials of various other drugs. It worked almost overnight. Unfortunately, it also pooped out 100% a few weeks later. But while it worked, it was a miracle. My issues are dysthymia alternating w/ unipolar major depression and mixed anxiety. It's worth a try, and the side effect profile is pretty benign even compared to an SSRI.
Phoenix1
> Speaking of Moclobemide.. Does anyone thinks that it's a good drug? If yes, for which conditions?
> Multiple studies has established that it's inferior to most SRI/SSRI antidepressant in the treatment of major depression, but perhaps it performs better for other conditions like social phobia or other?
>
Posted by amigan on December 23, 2007, at 18:17:53
In reply to Re: Speaking of Moclobemide... » amigan, posted by Phoenix1 on December 23, 2007, at 14:26:57
Thanks for sharing your experience.
Posted by zeugma on December 25, 2007, at 10:23:51
In reply to Re: MAOIs and WEAK SRIs combination? » torachan, posted by jedi on December 15, 2007, at 22:07:44
PK Gillman's site contains a lot of info on serotonin syndrome and MAOI combinations:
Posted by Sigismund on December 25, 2007, at 17:28:27
In reply to Re: Speaking of Moclobemide..., posted by amigan on December 20, 2007, at 13:42:51
It's no good for recovering alcoholics.
This gives you an idea of what it's like.
That is: no good for the agitated or the extremely edgy.
Pure speculation, of course.
This is the end of the thread.
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