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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by ben on July 16, 2009, at 12:52:30
I was on 3x240mg Noveril (TCA Dibenzepin) along with lithium and 400mg Trazodone at night. This combo wasnt working altough Noveril along with lithium did it during 3 years before I reduced the Noveril dose and it pooped out.
After adding Trazodone first without success Effexor was added - each (second) day 37.5mg more. after 4 days I felt euthymic up to mild hypomanic (I am bipolar II). Noveril was reduced to half during this time. after 10 days they gave me Remeron due to sleep problems. 30mg along with 200mg trazodone at night. Furthermore the Noveril dose was reduced to 2 x 120 mg. The other day i was sad again and 2 days after that I was crying mostly the hole day (sadness and depression came back).
My question is why this improvement? Was it the TCA which was successfully augmented to work again (after the poop out)with Effexor? Did this effect faded away because the TCA Noveril was gradualy reduced to an none working level? And what about the change to Remeron? Now I am on 300mg effexor along with lithium 30mg Remeron and 200mg Trazodone. The Goal should be Effexor alone with lithium and Remeron. How long should I stick to this combo? What about to combine the effexor again wit Noveril?
Posted by Phillipa on July 16, 2009, at 13:05:05
In reply to complex med situation after poop out, posted by ben on July 16, 2009, at 12:52:30
Ben I've not heard of noveril sounds like a combo of TCA and other meds. Not sure as google didn't turn up any real definitions. Phillipa
Posted by ben on July 16, 2009, at 13:40:41
In reply to Re: complex med situation after poop out » ben, posted by Phillipa on July 16, 2009, at 13:05:05
Noveril = Dibenzepin = a tricyclic TCA
Posted by Zana on July 16, 2009, at 14:35:04
In reply to complex med situation after poop out, posted by ben on July 16, 2009, at 12:52:30
It sounds like you lost the AD effect when trazadone was added. Maybe you need to drop the trazadone out to recapture the effects of the lithium and dibenzabine.
Zana
Posted by Zana on July 16, 2009, at 14:38:18
In reply to complex med situation after poop out, posted by ben on July 16, 2009, at 12:52:30
PS Is the remeron alone enough to give you a good night's sleep? I don't know about the combination of a TCA and an SSRI/SNRI. Maybe you could post that as a specific question. There are certainly posters who could address that better than I can. There are also other good options for sleep. Remeron did it for me but other people swear by seroquel for sleep.
Posted by bleauberry on July 16, 2009, at 18:58:40
In reply to complex med situation after poop out, posted by ben on July 16, 2009, at 12:52:30
Holy cow, I can't even count how many mistakes were made in all this.
Sorry. It is just such a confusing mess and such poor management I can't even begin to sort it out. Nobody can. That's the problem with that kind of poor med management.
It sure looks like you were on the right path adding low dose effexor to existing TCA dose, but then everything went bizarre and I don't understand that kind of chaotic management. Sometimes I wonder if some doctors aren't more mentally ill than we are.
From what I gather from the little bit of history you shared, the TCA was the bedrock of your success. It just needed a small amount of a partner to renew the honeymoon. Low dose effexor was probably the one to do that, as it appears from your description of the sequence of events.
I have very low faith in trazodone. Experienced pharmacologists stopped using it years ago. It is worthless for depression. It is a common sleep aid, but makes some of us feel a lot worse. I also have very low faith in Remeron. Its claimed actions on serotonin and norepinephrine have been disproved. It is basically one of the world's most potent antihistamines. Its affinity for the histamine receptors far exceeds anything else it might do. A 7.5mg dose is very good for sleep. Low dose lithium with a TCA is something I do have faith in. Whether you personally need it or not I have no clue.
In your title to this thread you used the word "complex". It really wasn't complex at all. The doctors made it that way. It did not have to be that way. It would have actually been fairly simple and straight forward if done in a methodical management manner with reliable med choices.
Geez. Look, I'm really sorry they did this to you. It is not too late. This can be unravelled. I do believe you can get back to where you were. I guess if you want to stick it out with the new cocktail you can. I personally have very little faith in it.
Posted by ben on July 18, 2009, at 4:46:44
In reply to Re: complex med situation after poop out, posted by bleauberry on July 16, 2009, at 18:58:40
Should we increase the TCA again ?
Posted by SLS on July 18, 2009, at 6:38:35
In reply to Re: complex med situation after poop out, posted by ben on July 18, 2009, at 4:46:44
> Should we increase the TCA again ?
I would bring the TCA dosage back up to at least that which helped you the last time. I agree that low-dosage lithium should remain as part of your core treatment. You can try the Effexor low-dosage strategy as Bleauberry suggested. However, if you don't respond, you might want to continue increasing the dosage instead of moving to another drug. When I combined nortriptyline with Effexor, I needed 300mg of Effexor to do the job.
I know a few people who have had good results mixing therapeutic dosages of Effexor and Wellbutrin.
Adding Remeron at dosages above 45mg to a full therapeutic dosage of Effexor has been claimed to be particularly effective, being dubbed "California Rocket Fuel" by some doctors. This might be influencing your doctor to use it. I don't know. I would ask your doctor about his success rate with this combination.
- Scott
Posted by ben on July 18, 2009, at 9:27:36
In reply to Re: complex med situation after poop out, posted by SLS on July 18, 2009, at 6:38:35
Hi Scott
Why low dose Effexor to the TCA?
regards
ben
Posted by Zana on July 18, 2009, at 10:25:58
In reply to Re: complex med situation after poop out SLS, posted by ben on July 18, 2009, at 9:27:36
Hi Scott,
I'm taking 100mgs of pristiq, the "new" effexor and 45mgs of remeron. You think the dose of remeron should be higher?
Thanks
Zana
Posted by SLS on July 18, 2009, at 10:56:10
In reply to Re: complex med situation after poop out SLS, posted by ben on July 18, 2009, at 9:27:36
> Hi Scott
>
> Why low dose Effexor to the TCA?
>
> regards
>
> ben
The only reason I mentioned it is because it was one of Bleauberry's suggestions. It seems his doctor uses this sort of strategy. I really don't see how it would work, but you never know. If you have never tried Effexor before, you will, of course, want to start at a low dosage and move up slowly.From what I can gather, the minimum dosage of Effexor that people respond to when used alone is 150mg. I don't consider giving Effexor a full trial until one goes up to 300mg. If I ever return to Effexor, it will be at 300mg in combination with 150mg of nortriptyline.
- Scott
Posted by SLS on July 18, 2009, at 11:24:30
In reply to Re: complex med situation after poop out SLS, posted by Zana on July 18, 2009, at 10:25:58
> Hi Scott,
> I'm taking 100mgs of pristiq, the "new" effexor and 45mgs of remeron. You think the dose of remeron should be higher?
> Thanks
> Zana
All I can say is that in real life, the more aggressive doctors will use 60mg or 75mg. I've even heard of higher dosages being used in difficult cases. If it were me, I would go up to 45mg as soon as I could tolerate and titrate upwards from there.
- Scott
Posted by bleauberry on July 18, 2009, at 12:26:16
In reply to Re: complex med situation after poop out SLS » ben, posted by SLS on July 18, 2009, at 10:56:10
> > Hi Scott
> >
> > Why low dose Effexor to the TCA?
> >
> > regards
> >
> > ben
>
>
> The only reason I mentioned it is because it was one of Bleauberry's suggestions. It seems his doctor uses this sort of strategy. I really don't see how it would work, but you never know. If you have never tried Effexor before, you will, of course, want to start at a low dosage and move up slowly.
>
> From what I can gather, the minimum dosage of Effexor that people respond to when used alone is 150mg. I don't consider giving Effexor a full trial until one goes up to 300mg. If I ever return to Effexor, it will be at 300mg in combination with 150mg of nortriptyline.
>
>
> - ScottScott is generally correct. I must clarify for perspective that my doctor's patient population is a little more defined than the average psychiatrist or doctor patient population. These people are ill with known diseases such as Lyme, Lyme-like, or yeast overgrowth, they have histories of psychiatric meds, and they are more prone to negative reactions and side effects than most people. That's why the low doses work for them. They are sensitive to the negatives, but also sensitive to the postives, so the whole dosing spectrum is lower.
I agree with SLS completely. Get the TCA back up where it was. Get effexor to where it feels good, where ever that is. SLS is generally correct in shooting for a high dose, but as can be seen at askapatient.com, there are plenty of people who find that just 37.5mg or 75mg is an excellent therapeutic dose for them. Everyone is different and everyone needs to be treated different. My opinion.
It's the other meds you are taking that I have a problem with. I agree with SLS the lithium should stay at some low dose probably forever. Outside of TCA + Effexor, I think the removal of other variable meds is a good thing unless you know for sure they are doing you significant goodness.
Posted by Zana on July 18, 2009, at 16:01:36
In reply to Re: complex med situation after poop out SLS » Zana, posted by SLS on July 18, 2009, at 11:24:30
Thanks Scott. I'm really surprised you are in favor of upping the remeron since I have read so much in recent posts about it's lack of efficacy. Something I will definitely talk over with my pdoc.
Zana
Posted by ben on July 19, 2009, at 2:00:46
In reply to Re: complex med situation after poop out )) SLS, posted by Zana on July 18, 2009, at 16:01:36
> Thanks Scott. I'm really surprised you are in favor of upping the remeron since I have read so much in recent posts about it's lack of efficacy. Something I will definitely talk over with my pdoc.
> ZanaI have headaches from Remeron in the morning so I dondt know if I can go higher.
Posted by ben on August 15, 2009, at 9:45:17
In reply to Re: complex med situation after poop out, posted by ben on July 19, 2009, at 2:00:46
now I am on 60mg Remeron, 375mg Efexor, Lithium, 200mg Lyrica and 240mg Noveril (dibenzepine = TCA). I had realy good days up topne week or maybe 10 days then I fail back in depression for some days. this pattern is repeating. Remeron plasma level is 117nmol/l (reference range 150 -300nmol/l). Lithium is at 0.8mmol/l and Efexor is in the upper range. Noveril is in the lower range. I have several options now:
1) increasing the Remeron
2) increasing the TCA
3) adding Thyroxin
4) adding a third mood stabilizer (quetiapine /valproic acid) or replace the Lyrica with another. Lamictal probably doesnt work for me because I had to get off it due headaches.I am bipolar II and was stable over the last 3 years on Lithium and Noveril but this spring Noveril pooped out and I am in depression again. what should I do?
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