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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by schleprock on August 17, 2012, at 17:15:54
Anybody think that some amount of Effexor added to 150mg of pooped-out Nortriptyline would work well for anxiety and depression? The interactions may not be as risky as compared with other types of ADs. Anyone ever try this (with a tricyclic?) Any thoughts on dosage, or the effectiveness of other SNRIs?
Posted by softheprairie on August 18, 2012, at 2:45:08
In reply to Nortriptyline + Effexor: A good combo?, posted by schleprock on August 17, 2012, at 17:15:54
Yes, I think it is a good try for depression. On the anxiety, I'm not sure -- I'm thinking there is a fair chance it could worsen anxiety. But, it could be worth a try.
At one time, probably around 1999, I was on smallish doses of Effexor, nortriptyline, and Wellbutrin (all three together). I don't recall if it helped or not, but I do think it was an excellent try by my psychiatrist. I had previously not gotten noticeable help by Prozac, then Zoloft, then my memory gets fuzzy, but I'm guessing I built up to the three combo. Also, my depression manifested with a lot of tiredness/lack of energy, and I was obese, so I appreciate that she was willing to prescribe beyond just stuff that acted on serotonin.
Posted by SLS on August 18, 2012, at 5:41:37
In reply to Nortriptyline + Effexor: A good combo?, posted by schleprock on August 17, 2012, at 17:15:54
> Anybody think that some amount of Effexor added to 150mg of pooped-out Nortriptyline would work well for anxiety and depression? The interactions may not be as risky as compared with other types of ADs. Anyone ever try this (with a tricyclic?) Any thoughts on dosage, or the effectiveness of other SNRIs?
Great combination!
I got relief from nortriptyline 150 mg/day + Effexor 300 mg/day. I think you need to use the full therapeutic dosages of both drugs to glean a maximum response.
A friend of mine is doing very well with Pristiq 100 mg/day + Wellbutrin 300 mg/day. For her, she reports that Pristiq works better than Effexor. For you, the Wellbutrin might make anxiety worse. This combination works for people who are anergic and anhedonic.
- Scott
Posted by bleauberry on August 18, 2012, at 8:51:34
In reply to Nortriptyline + Effexor: A good combo?, posted by schleprock on August 17, 2012, at 17:15:54
That looks to me like it should have a higher than average chance of efficacy.
That said, I might favor zoloft first choice, and savella second choice, over effexor. For a couple reasons. Equal chance of effectiveness, maybe even more so with savella.....also, drug and liver interactions lowest....and finally, if it doesn't work out, the withdrawal syndrome getting off the chosen med would be much tamer on zoloft or savella compared to effexor. Effexor is almost always extra nasty when trying to get off it, compared to most other meds.
So I think adding effexor looks attractive, it's just that I think two other choices look more attractive than that.
Posted by schleprock on August 18, 2012, at 12:33:02
In reply to Re: Nortriptyline + Effexor: A good combo? » schleprock, posted by SLS on August 18, 2012, at 5:41:37
> > Anybody think that some amount of Effexor added to 150mg of pooped-out Nortriptyline would work well for anxiety and depression? The interactions may not be as risky as compared with other types of ADs. Anyone ever try this (with a tricyclic?) Any thoughts on dosage, or the effectiveness of other SNRIs?
>
> Great combination!
>
> I got relief from nortriptyline 150 mg/day + Effexor 300 mg/day. I think you need to use the full therapeutic dosages of both drugs to glean a maximum response.
>
> A friend of mine is doing very well with Pristiq 100 mg/day + Wellbutrin 300 mg/day. For her, she reports that Pristiq works better than Effexor. For you, the Wellbutrin might make anxiety worse. This combination works for people who are anergic and anhedonic.
>
>
> - ScottSLS, if I may ask, and it's not too convoluted, how did you arrive at that combination. Also, did you take both dosages at the same time, and were there any noticable side effects?
The main reason that I'm looking at Effexor is that there was apparently a small study done with that drug combined with different TCAs (clomipramine and imipramine) where "82% responded, with 64% achieving full remission".
With Zoloft, I'd be a little worried about raising my Nortriptyline serum levels (which are already a bit high.)
Posted by schleprock on August 18, 2012, at 13:06:10
In reply to Re: Nortriptyline + Effexor: A good combo? » SLS, posted by schleprock on August 18, 2012, at 12:33:02
Also, were you using the XR version, and would that be somehow safer when combined with nortriptyline?
Posted by phidippus on August 19, 2012, at 0:49:53
In reply to Nortriptyline + Effexor: A good combo?, posted by schleprock on August 17, 2012, at 17:15:54
I thought you were looking for something that promoted sleep.
Also, why bother taking the Nortriptyline if you perceive it to have pooped out? (note: poop out is somewhat of a myth-it is more likely your symptoms have worsened and the nortripyline just isn't enough anymore.)
Effexor is a strong antidepressant, but sometimes it can cause anxiety with its norepinephrinee reuptake inhibition. Mix it up with the nortryptaline and you might get an unnpleasant buzz.
I would recommend Mirtazapine. It will help with both the depression and the anxiety and it also promotes better sleep. Its a Tetracyclic Antidepressant and is quite potent. I took it tto treat my OCD and it worked very well. It also got me out of a deep funk.
Eric
Posted by schleprock on August 19, 2012, at 10:22:56
In reply to Re: Nortriptyline + Effexor: A good combo? » schleprock, posted by phidippus on August 19, 2012, at 0:49:53
> I thought you were looking for something that promoted sleep.
>
> Also, why bother taking the Nortriptyline if you perceive it to have pooped out? (note: poop out is somewhat of a myth-it is more likely your symptoms have worsened and the nortripyline just isn't enough anymore.)
>
> Effexor is a strong antidepressant, but sometimes it can cause anxiety with its norepinephrinee reuptake inhibition. Mix it up with the nortryptaline and you might get an unnpleasant buzz.
>
> I would recommend Mirtazapine. It will help with both the depression and the anxiety and it also promotes better sleep. Its a Tetracyclic Antidepressant and is quite potent. I took it tto treat my OCD and it worked very well. It also got me out of a deep funk.
>
> Eric
>
>
>I've heard that Mirtazapine is known for quickly losing its effect. I'm looking for something long term.
Posted by schleprock on August 19, 2012, at 11:19:37
In reply to Re: Nortriptyline + Effexor: A good combo? » phidippus, posted by schleprock on August 19, 2012, at 10:22:56
I think, and please correct me if I'm wrong, I'm looking for a way to raise my Nortriptyline dose from 150mg to 200mg, but without actually increasing the Nortriptyline dosage (which would be unsafe), while retaining the effect that that dosage would have.
Or am I getting this all wrong, and would the real solution be to hit all the neurotransmitters that the Nortriptyline isn't hitting, rather than merely just strengthening the effect on a certain set of neurotransmitters?
Posted by schleprock on August 19, 2012, at 12:47:20
In reply to Re: Nortriptyline + Effexor: A good combo?, posted by schleprock on August 19, 2012, at 11:19:37
Any thoughts? Would it be reasonable to mix the two for a little boost? Would this increase the cardiac side effects?
Posted by phidippus on August 19, 2012, at 17:34:21
In reply to Re: Nortriptyline + Effexor: A good combo?, posted by schleprock on August 19, 2012, at 11:19:37
Why would raising the Nortryptaline be unsafe?
It would be nice to add an antidepressant with a complimentary mode of action.
Eric
Posted by schleprock on August 19, 2012, at 18:08:15
In reply to Re: Nortriptyline + Effexor: A good combo? » schleprock, posted by phidippus on August 19, 2012, at 17:34:21
> Why would raising the Nortryptaline be unsafe?
>
> It would be nice to add an antidepressant with a complimentary mode of action.
>
> Eric150 mgs is Nortriptylines is conventional maximum dosage, I don't think my pdoc would raise it, and my plasma levels are already slightly above the reference range.
I've heard that clomipramine is perhaps the best AD for depression, but I don't know enough about pharmaceuticals to determine whether adding another tricyclic would increase nortriptyline toxicity.
Effexor seems like it might be the best augment going beyond the tricyclic class, but I'm just thinking it's easier to deal with augments from a class I'm already familiar with. Is there a more logical tricyclic than clomipramine that would compliment the regular action of Nortriptyline.
I'm not sure how relevent it is, but there was a study that determend Nort. + Clomi. was more effective for OCD than one of them alone (too bad I don't have OCD). Presumably that would indicate at least that they're safe to take together.
Posted by SLS on August 19, 2012, at 18:20:53
In reply to Re: Nortriptyline + Effexor: A good combo? » phidippus, posted by schleprock on August 19, 2012, at 18:08:15
Perhaps you should take a blood test to establish your nortriptyline levels. If you take too much, you can overshoot the "zone". People who respond well to 75 mg/day can lose the response if they go up to 150 mg/day. There is a therapeutic window for nortriptyline.
- Scott
Posted by schleprock on August 19, 2012, at 18:45:47
In reply to Re: Nortriptyline + Effexor: A good combo? » schleprock, posted by SLS on August 19, 2012, at 18:20:53
> Perhaps you should take a blood test to establish your nortriptyline levels. If you take too much, you can overshoot the "zone". People who respond well to 75 mg/day can lose the response if they go up to 150 mg/day. There is a therapeutic window for nortriptyline.
>
>
> - ScottYes, I just had them tested a month ago.. 145 (ug/L?) within reference range of 50 - 140. If I had stuck to my 100mg/150mg staggered dosage which I had been on many years previously, the levels probably would have been a bit lower; my pdoc thought a steady dosage would be better.
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