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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 119. This is the beginning of the thread.
Posted by SLS on December 1, 2011, at 12:20:25
Has anyone tried Effexor at dosages of 450 mg or higher?
I might be headed in that direction. Pristiq at a dosage of 100 mg is not producing the partial improvement that I was expecting.
- Scott
Posted by Christ_empowered on December 1, 2011, at 13:07:30
In reply to Effexor 450 mg?, posted by SLS on December 1, 2011, at 12:20:25
I'm obviously no expert, but wouldn't it be easier to add a low dose of Ritalin or something?
Posted by SLS on December 1, 2011, at 13:27:35
In reply to Re: Effexor 450 mg?, posted by Christ_empowered on December 1, 2011, at 13:07:30
> I'm obviously no expert, but wouldn't it be easier to add a low dose of Ritalin or something?
I am not even sure what mechanisms I'm looking for in a drug. Maybe dopamine reuptake inhibition is more prominent at higher dosages, but who is to say that it is at all important?. Ritalin makes me irritable and "on edge" without helping with depression or mental energy. I wish triple reuptake inhibitors were still in the pipeline. They have disappeared from the http://www.neurotransmitter.net/newdrugs.html list.
I truly appreciate the input.
Thanks.
- Scott
Posted by Phillipa on December 1, 2011, at 15:41:46
In reply to Re: Effexor 450 mg? » Christ_empowered, posted by SLS on December 1, 2011, at 13:27:35
So sorry the pristiq isn't working. I may have found an article for you which could explain why some are treatment resistant? Will try to find. Phillipa
Posted by Zyprexa on December 1, 2011, at 15:51:49
In reply to Effexor 450 mg?, posted by SLS on December 1, 2011, at 12:20:25
Have you tried effexor at lower doses? Or just pristiq? I just started effexor, and not sure what to think of it yet. Wonder what its like compaired to pristiq.
Posted by jono_in_adelaide on December 1, 2011, at 16:04:31
In reply to Effexor 450 mg?, posted by SLS on December 1, 2011, at 12:20:25
Can I suggest that you instead try an SSRI (say Zoloft 100mg/day) combined with either Bupropion 300mg/day or Nortriptyline 75-100mg/day, before going down the single dug mega dose path.
Posted by europerep on December 1, 2011, at 18:08:39
In reply to Effexor 450 mg?, posted by SLS on December 1, 2011, at 12:20:25
Hello... I have been on 600mg/d of venlafaxine. I was on that dose for about 8 months. In total, i.e. including the time I was taking less than 600mg/d, I was on venlafaxine for approx. 18 months.
What questions do you have? Side effects were virtually none for me. Sexual side effects from venlafaxine vanished a month after I started it, thus long before I went on those high doses. I didn't have any trouble with sleeping either.
As for effectiveness: there was a huge difference between 375mg/d (which is now usually cited as the standard maximum dosage) and 600mg/d. Difficult to describe, but definitely a difference.
It did far from enough for me though, so after trying to augment it with other drugs (mirtazapine, aripiprazole, lithium... and buprenorphine... of course only venlafaxine plus one drug at at time) without success, I eventually tapered off and looked for solutions elsewhere...
Let me know if you have any specific questions that I might be able to answer...
ER
Posted by zonked on December 1, 2011, at 19:56:54
In reply to Effexor 450 mg?, posted by SLS on December 1, 2011, at 12:20:25
> Has anyone tried Effexor at dosages of 450 mg or higher?
>
> I might be headed in that direction. Pristiq at a dosage of 100 mg is not producing the partial improvement that I was expecting.
>
>
> - ScottScott,
Have you tried tramadol? It does 5-HT and NE reuptake blocking in addition to being a weak opiod. Some docs use it for resistant depression; it might be easier to convince your doctor to try this than buprenorphine.
-z
Posted by Christ_empowered on December 1, 2011, at 20:14:01
In reply to Re: Effexor 450 mg? » SLS, posted by zonked on December 1, 2011, at 19:56:54
Ritalin made me kinda nervous, too. Adderall (for me, 30xr AM and 10 tablet around lunch) was perfect. If you're on a high dose AD, I imagine your dose(s) could be lower. Some people can take 1 xr in the AM and they're good to go all day. And there's that newfangled Dexedrine...Vyvanse...lots of people are being given that stuff.
Posted by Phillipa on December 1, 2011, at 22:19:55
In reply to Re: Effexor 450 mg?, posted by Christ_empowered on December 1, 2011, at 20:14:01
CE I know a former poster who takes and loves vyannase. Now out of treatment resistant depression, takes with requip, some dose of a Tca, and back at his law practice. Phillipa
Posted by Christ_empowered on December 1, 2011, at 22:55:19
In reply to Re: Effexor 450 mg? » Christ_empowered, posted by Phillipa on December 1, 2011, at 22:19:55
wow, Phillipa, that's good to hear. Stimulants really do it for some people.
Posted by Phillipa on December 4, 2011, at 10:49:00
In reply to Re: Effexor 450 mg?, posted by Christ_empowered on December 1, 2011, at 22:55:19
Hope all are okay babble is up and running again thanks to Dr Bob. Phillipa
Posted by SLS on December 4, 2011, at 12:03:24
In reply to Re: Effexor 450 mg?, posted by jono_in_adelaide on December 1, 2011, at 16:04:31
> Can I suggest that you instead try an SSRI (say Zoloft 100mg/day) combined with either Bupropion 300mg/day or Nortriptyline 75-100mg/day, before going down the single dug mega dose path.
Those are great treatment recommendations.
Zoloft helped for about a day during week 2 of treatment at a dosage of 100 mg. I worked up to 200 mg without feeling at all better. I don't recall what other drugs I was taking at the time. Bupropion worsens my depression significantly. I have tried it at least 4 times.
This is where I'm at right now:Effexor 300 mg
nortriptyline 150 mg
Lamictal 200mg
Abilify 10 mg
lithium 300 mg
The last time I tried combining Effexor with nortriptyline, I was taking only 75 mg of nortriptyline. I subsequently discovered that I need 150 mg to feel better and achieve therapeutic blood levels.I'm pretty much out of ideas.
- Scott
Posted by Phillipa on December 4, 2011, at 18:29:01
In reply to Re: Effexor 450 mg? » jono_in_adelaide, posted by SLS on December 4, 2011, at 12:03:24
Any improvement since last time posted? Phillipa
Posted by Phidippus on December 4, 2011, at 21:11:56
In reply to Re: Effexor 450 mg? » jono_in_adelaide, posted by SLS on December 4, 2011, at 12:03:24
Its hard to believe you still suffer from depression with all the meds you are taking, all of which in some way or another have AD effects. Maybe you need to try a new cocktail.
Eric
Posted by jono_in_adelaide on December 4, 2011, at 22:41:46
In reply to Re: Effexor 450 mg? » jono_in_adelaide, posted by SLS on December 4, 2011, at 12:03:24
Have you considered (or tried) nortriptyline plus Parnate or Nardil?
> > Can I suggest that you instead try an SSRI (say Zoloft 100mg/day) combined with either Bupropion 300mg/day or Nortriptyline 75-100mg/day, before going down the single dug mega dose path.
>
> Those are great treatment recommendations.
>
> Zoloft helped for about a day during week 2 of treatment at a dosage of 100 mg. I worked up to 200 mg without feeling at all better. I don't recall what other drugs I was taking at the time. Bupropion worsens my depression significantly. I have tried it at least 4 times.
>
>
> This is where I'm at right now:
>
> Effexor 300 mg
> nortriptyline 150 mg
> Lamictal 200mg
> Abilify 10 mg
> lithium 300 mg
>
>
> The last time I tried combining Effexor with nortriptyline, I was taking only 75 mg of nortriptyline. I subsequently discovered that I need 150 mg to feel better and achieve therapeutic blood levels.
>
> I'm pretty much out of ideas.
>
>
> - Scott
Posted by sigismund on December 5, 2011, at 1:16:15
In reply to Re: Effexor 450 mg?, posted by jono_in_adelaide on December 4, 2011, at 22:41:46
Scott
I never expected anything to come of Effexor for you (although I do recall you saying that you had a partial response once) because the whole focus of your attempts has been (in the time I have known you) away from SSRIs.
I have always been puzzled by the fact (correct me if I am wrong) that amphetamine produced no effect at all in you.
Whereas methylphenidate did, inasmuch as it made you uneasy (same as me, kind of).Then there's bupe.
You have pretty much been through the pharmacopoeia. There may be some combinations yet to try, but.......
My Rx (for everyone?) would be coca leaf and very long walks in the Andes (perhaps in solitude). Quite impossible.
Wreck your teeth as well. But otherwise it would be hard to imagine it being less successful.Do you regret stopping Nardil now?
Just curious.
Posted by SLS on December 5, 2011, at 6:51:11
In reply to Re: Effexor 450 mg? » SLS, posted by europerep on December 1, 2011, at 18:08:39
> Let me know if you have any specific questions that I might be able to answer...
Thanks. I think you answered all of the questions that I would have had.
- Scott
Posted by SLS on December 5, 2011, at 6:59:26
In reply to Re: Effexor 450 mg? » SLS, posted by zonked on December 1, 2011, at 19:56:54
> Have you tried tramadol?
No. I'll keep it in mind.
Does a partial response to tramadol indicate a better response to buprenorphine?
Thanks.
- Scott
Posted by SLS on December 5, 2011, at 7:05:45
In reply to Re: Effexor 450 mg?, posted by jono_in_adelaide on December 4, 2011, at 22:41:46
> Have you considered (or tried) nortriptyline plus Parnate or Nardil?
I have tried both MAOIs in combination with nortriptyline. I get some relief, but not enough to make a major difference in my quality of life.
I once responded to a combination of Parnate and desipramine. It doesn't work anymore.
- Scott
Posted by SLS on December 5, 2011, at 7:24:13
In reply to Re: Effexor 450 mg?, posted by sigismund on December 5, 2011, at 1:16:15
> I never expected anything to come of Effexor for you (although I do recall you saying that you had a partial response once) because the whole focus of your attempts has been (in the time I have known you) away from SSRIs.
Aside from the opioids, I don't know what is left to try.
> I have always been puzzled by the fact (correct me if I am wrong) that amphetamine produced no effect at all in you.
I know. Scary.
> Whereas methylphenidate did, inasmuch as it made you uneasy (same as me, kind of).
This is true.
> Then there's bupe.
I may need to bring up the subject with my doctor again.
> You have pretty much been through the pharmacopoeia. There may be some combinations yet to try, but.......
I'm tapped out.
> Do you regret stopping Nardil now?
Not really. I knew it was a gamble, but I was not ready to settle for the small improvement that Nardil gives me just yet. At the very least, I was hoping to arrive at a treatment that was no less effective than Nardil. It would be nice to shed the excess weight and eat Mexican food again. I guess it makes sense to pursue dosages of Effexor higher than 300 mg. After that...
You have a great memory.
- Scott
Posted by SLS on December 5, 2011, at 7:33:09
In reply to Re: Effexor 450 mg? » SLS, posted by Phidippus on December 4, 2011, at 21:11:56
> Its hard to believe you still suffer from depression with all the meds you are taking, all of which in some way or another have AD effects.
Unfortunately, seeing is believing.
> Maybe you need to try a new cocktail.
I had been responsive to MAOI + TCA for awhile. My guess is that I have become less responsive over time as my brain has been continuously exposed to a wide variety of drugs. What choice do I have? DBS?
- Scott
Posted by Bob on December 5, 2011, at 14:18:58
In reply to Re: Effexor 450 mg? » jono_in_adelaide, posted by SLS on December 4, 2011, at 12:03:24
> > Can I suggest that you instead try an SSRI (say Zoloft 100mg/day) combined with either Bupropion 300mg/day or Nortriptyline 75-100mg/day, before going down the single dug mega dose path.
>
> Those are great treatment recommendations.
>
> Zoloft helped for about a day during week 2 of treatment at a dosage of 100 mg. I worked up to 200 mg without feeling at all better. I don't recall what other drugs I was taking at the time. Bupropion worsens my depression significantly. I have tried it at least 4 times.
>
>
> This is where I'm at right now:
>
> Effexor 300 mg
> nortriptyline 150 mg
> Lamictal 200mg
> Abilify 10 mg
> lithium 300 mg
>
>
> The last time I tried combining Effexor with nortriptyline, I was taking only 75 mg of nortriptyline. I subsequently discovered that I need 150 mg to feel better and achieve therapeutic blood levels.
>
> I'm pretty much out of ideas.
>
>
> - Scott
Scott,How exactly does bupropion intensify your depression? Can you give any details?
Bob
Posted by ed_uk2010 on December 5, 2011, at 16:01:41
In reply to Re: Effexor 450 mg? » Phidippus, posted by SLS on December 5, 2011, at 7:33:09
>My guess is that I have become less responsive over time as my brain has been continuously exposed to a wide variety of drugs. What choice do I have?
Perhaps to taper off all or most of your medication over a period of a few months?? It really could be the best option at this stage. Any rebound worsening of depression could be avoided by gradual tapering. You may be resensitised to the effects of ADs after a medication-free interval, or you may discover that you actually feel better without certain meds. At present, you appear to be tolerant to almost all medications. Although tapering off could be difficult in the short-term, if it could help you in the long-term it could be very worthwhile. You may also feel better on less medication in some ways. As an example, you might lose a lot of weight and your physical fitness may improve as a result.
Posted by ed_uk2010 on December 5, 2011, at 16:16:27
In reply to Re: Effexor 450 mg? » jono_in_adelaide, posted by SLS on December 5, 2011, at 7:05:45
I'm not sure how useful very high doses of venlafaxine actually are. Fatigue seems to be a major problem. Sometimes, less is more.... or if a drug is not helping, it is best to stop taking it.
I think there is very often a tendency for people to keep taking medication because of the fear that things may be even worse without it. Although things may be temporarily worse due to withdrawal or rebound, some symptoms may improve once an ineffective med has been stopped. ADs are not free of adverse effects by any means.
Tolerability of high-dose venlafaxine in depressed patients.
Harrison CL, Ferrier N, Young AH.
SourceSchool of Neurology, Neurobiology and Psychiatry, Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
AbstractHigh doses of antidepressants are often used for treatment-resistant depression. Venlafaxine, a dual serotonin and noradrenaline reuptake inhibitor, has been shown to have a tolerable side-effect profile in previous studies using doses of up to 375 mg/day. We investigated the tolerability of higher than currently recommended doses of venlafaxine using the UKU side-effect rating scale. Seventy outpatients fulfilling DSM-IV criteria for major depressive disorder were recruited into two demographically matched groups according to their daily dosage of venlafaxine: high dose n = 35 (> or = 375 mg/day, range 375-600 mg, average 437 mg/day) or standard dose n = 35 (< 375 mg/day, range 75-300 mg, average 195 mg/day. Clinical characteristics were noted and the UKU side-effect rating scale was administered to a subsample of patients. The most frequently reported complaints in both groups were increased fatigue (48%), concentration difficulties (48%), sleepiness/sedation (37%), failing memory (44.4%) and weight gain (29.6%). Apart from weight gain, the complaints were found to be experienced significantly more severely by the high-dose group. Six patients discontinued venlafaxine due to intolerable side-effects but only two of these patients were on a high dose. There was a tendency for mildly raised blood pressure in 10% of patients on an average dose of 342 mg/day. However, no difference between the two groups was found. This preliminary open study demonstrates that venlafaxine is tolerated at higher than British National Formulary recommended doses (i.e. up to 600 mg daily). However, increased frequency and severity of reported side-effects in the high-dose group are not associated with increased rates of discontinuation.
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