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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 klein on April 23, 2014, at 12:30:37
Hi everyone - I'm new here.
I've been on a small dose of Zoloft for a couple of years now for MDD. My mood is okay but I still feel lethargic. After trying Provigil and assorted amphetamines, my doc decided to add an SNRI.
First came Effexor at different dosages over the course of several months (dosage range from 37.5 to 300+, tried both XR and IR and a combination of the two). It was activating at times but not consistent.
Then we tried Savella (dosage range from 12.5mg to 200mg) to see if it worked better. Knowing about the NE hit, I had high hopes but it turned out to be ineffective for my needs, it made me feel incredibly drowsy and even more lethargic. The drowsiness got worse every time the dose was increased.
So now he wants to try Cymbalta. I'm a bit leery as (I think) duloxetine seems to be more similar to Savella than to Effexor.
I know it's all about trial + error but, given that I did relatively well on Effexor, I'm wondering if Pristiq might be a better choice to try next.
Any thoughts? Thanks!
Posted by jono_in_adelaide on April 23, 2014, at 18:24:11
In reply to Cymbalta vs Pristiq, posted by klein on April 23, 2014, at 12:30:37
I'd suggest combining Zoloft at whatever dose worked for you with Welbutrin XL 300mg in hte morning.
Try this for a month and see how you feel after 4 weeks.
Posted by klein on April 23, 2014, at 19:31:46
In reply to Re: Cymbalta vs Pristiq, posted by jono_in_adelaide on April 23, 2014, at 18:24:11
Thanks for replying, Jono.
I tried Wellbutrin XL at 300 with the Zoloft some time ago; the combination worked nicely for a while with no additional side effects, but after a few months it lost effectiveness (started to make me very sleepy, just like Savella and Provigil).
Wellbutrin SR might be an option though, I tried it alone ages ago and it was definitely very activating.
I wouldn't mind losing the Zoloft altogether. My doc won't prescribe my optimal sertraline dose because it's higher than the usual recommended max dose. Even though there are several studies in Pubmed which demonstrate the safety of long-term treatments well in excess of 200mg, my pdoc won't have it.
I don't protest too much because the higher doses of Z. don't bring about remission, but just a bit of extra relief. While it lasted, 50mg Zoloft + 225 Effexor was better than 300+mg Zoloft alone.
> I'd suggest combining Zoloft at whatever dose worked for you with Welbutrin XL 300mg in hte morning.
>
> Try this for a month and see how you feel after 4 weeks.
Posted by LouisianaSportsman on April 23, 2014, at 21:01:03
In reply to Cymbalta vs Pristiq, posted by klein on April 23, 2014, at 12:30:37
I doubt desvenlafaxine is significant enough to be different from venlafaxine as it is just a synthetic form of its major active metabolite. If you failed venlafaxine, it is likely you'll fail desvenlafaxine as well. I wouldn't trial Pristiq.
If you failed on milnacipran, it hints that you'll fail duloxetine and recently approved SNRI that is is an active enantiomer of milnacipran, levomilnacipran (Fetzima). It is similar to the Pristiq situation.
I do not think SNRIs are the right option for you. An MAOI would probably be the right option, but you could consider a TCA.
I would look into desipramine. There are other medications within the TCA class, and other classes which could boost NE as well, desipramine (Norpramin): I would compare it more to Savella. Within the TCA class, you can also strongly consider nortriptyline (Pamelor): I would compare it more to Effexor.
If you preferred venlafaxine, consider nortriptyline; if you preferred milnacipran, consider desipramine-- it hits NE harder than nortriptyline. The strongest NE boost would come from protriptyline, but many patients complain about side effects; however, it is a valid consideration you and your doctor could discuss.
The best thing, honestly, would be a MAOI. The EMSAM patch is very safe but selegiline (Deprenyl) comes in a pill form as well.
Phenelzine (Nardil) and tranylcypromine (Parnate) would likely be the best options for you in termrs of MAOIs.
Good luck with your treatment!
Posted by klein on April 24, 2014, at 4:40:57
In reply to Re: Cymbalta vs Pristiq, posted by LouisianaSportsman on April 23, 2014, at 21:01:03
Hey LP, thanks for answering!
If you can believe it, where I live most TCAs have been gradually withdrawn from the market due to poor sales :( I've tried the available ones - all 3 of them! Amitriptyline (ok), imipramine (iffy) and clomipramine (ugh!). Not combined with sertraline though.
I talked to my doc earlier and we've tentatively settled on Pristiq (given that Effexor was pretty good) and either Remeron or Tolvon/Lerivon/ mianserin.
Although I tried it indirectly as a metabolite, I wish I could try nortiptyline, it sounds very good on paper..
-thanks, I appreciate your reply.
> I doubt desvenlafaxine is significant enough to be different from venlafaxine as it is just a synthetic form of its major active metabolite. If you failed venlafaxine, it is likely you'll fail desvenlafaxine as well. I wouldn't trial Pristiq.
>
> If you failed on milnacipran, it hints that you'll fail duloxetine and recently approved SNRI that is is an active enantiomer of milnacipran, levomilnacipran (Fetzima). It is similar to the Pristiq situation.
>
> I do not think SNRIs are the right option for you. An MAOI would probably be the right option, but you could consider a TCA.
>
> I would look into desipramine. There are other medications within the TCA class, and other classes which could boost NE as well, desipramine (Norpramin): I would compare it more to Savella. Within the TCA class, you can also strongly consider nortriptyline (Pamelor): I would compare it more to Effexor.
>
> If you preferred venlafaxine, consider nortriptyline; if you preferred milnacipran, consider desipramine-- it hits NE harder than nortriptyline. The strongest NE boost would come from protriptyline, but many patients complain about side effects; however, it is a valid consideration you and your doctor could discuss.
>
> The best thing, honestly, would be a MAOI. The EMSAM patch is very safe but selegiline (Deprenyl) comes in a pill form as well.
>
> Phenelzine (Nardil) and tranylcypromine (Parnate) would likely be the best options for you in termrs of MAOIs.
>
> Good luck with your treatment!
>
>
Posted by LouisianaSportsman on April 24, 2014, at 9:58:18
In reply to Re: Cymbalta vs Pristiq » LouisianaSportsman, posted by klein on April 24, 2014, at 4:40:57
> I talked to my doc earlier and we've tentatively settled on Pristiq (given that Effexor was pretty good) and either Remeron or Tolvon/Lerivon/ mianserin.
>Not a bad choice, but I think that if Effexor was pretty good, and you're looking for something better -- without the side effects and histamine antagonism of those yet effective, and not a bad choice, tetracyclic antidepressants -- then Pristiq isn't so bad, considering you did good on Effexor.
I did Effexor XR 75mg. when I was titrating off of Pristiq so I could use the beads, and I notice that it was significantly inferior and I had sexual side effects I didn't have on Pristiq.
Posted by phidippus on April 24, 2014, at 18:40:55
In reply to Cymbalta vs Pristiq, posted by klein on April 23, 2014, at 12:30:37
I doubt Cymbalta or Pristiq is going to provie you with the uplift you seek.
I would try Wellbutrin before I tried any other SNRI.
Also, have you tried Xyrem?
Eric
Posted by klein on April 24, 2014, at 23:04:23
In reply to Re: Cymbalta vs Pristiq, posted by LouisianaSportsman on April 24, 2014, at 9:58:18
> Not a bad choice, but I think that if Effexor was pretty good, and you're looking for something better -- without the side effects and histamine antagonism of those yet effective, and not a bad choice, tetracyclic antidepressants -- then Pristiq isn't so bad, considering you did good on Effexor.
>
> I did Effexor XR 75mg. when I was titrating off of Pristiq so I could use the beads, and I notice that it was significantly inferior and I had sexual side effects I didn't have on Pristiq.Remeron is my safety net. Like that other website says (I dunno if it's ok to quote it), Remeron pulls you out of the darkest, deepest depression like no other med will - at least this is true for me. I wasn't surprised when the Lancet found mirtazapine to be one of the most effective ADs available. The problem is, I can only use it sparingly, as it quits working very quickly. This time around my doc told me to load up on fish oil and foliate because they may prevent poop out.
So you used the bead method to taper off Pristiq / Effexor? You must be very patient, lol. When I quit Effexor after ... 6 months?... I loaded up on Prozac and suffered from mild withdrawal for a few days - okay, the third day was atrocious but it was all over soon enough.
Why do you think FX was inferior? Didn't it buffer the withdrawal? According to my doc, the problem with Effexor is that it's a CYPD6 substrate. Just about anything can inhibit CYPD6 so the levels of venlafaxine and desvenlafaxine in your systen can vary very quickly. So Pristiq should be smoother... or so he claims. We'll see.
Re: sexual side effect. I don't know about you, but I resigned myself to chemical castration long ago. It's either that or suicidal depression. There's an advantage to imho, if you're single and looking for a partner you're not ruled by your.. genitalia lol.. and can actually get to know the person on another level first. It's been interesting. TMI info maybe but sildenafil is a complete bust for me.
I'm rambling as usual. Thanks LSman :)
Posted by klein on April 24, 2014, at 23:19:55
In reply to Re: Cymbalta vs Pristiq » klein, posted by phidippus on April 24, 2014, at 18:40:55
> I doubt Cymbalta or Pristiq is going to provie you with the uplift you seek.
>
> I would try Wellbutrin before I tried any other SNRI.
>
> Also, have you tried Xyrem?
>
> EricHey Eric,
Xyrem is completely unavailable where I live. Have you tried it?
Wellbutrin didn't do much for me. I squeezed out the best results by using the old IR pills three times a day, but overall it was the same as drinking a strong cup of coffee.
I seem to need very high doses of any given med to get an an effect, and Wellbutrin has a definite limit.
Posted by klein on April 28, 2014, at 11:06:34
In reply to Cymbalta vs Pristiq, posted by klein on April 23, 2014, at 12:30:37
My doc added Pristiq 100mg and upped the Zoloft to 300, and so far it has been a very good choice. More energy, less anxious and I've had unexpected small bouts of happiness/feeling at ease/wellbeing (!); they are very short-lived (just a few seconds) but they're definitely there. I'd forgotten how that feels! I don't know if it's the increased Zoloft or the addition of Pristiq or both but, really, who cares as long as it's working. So far so good.
Note: I made a typo in my original post, I've never tried amphetamines, what I've tried is "assorted NON-amphetamines" (putative stimulants such as sulbutamine, Provigil, amisulpride / sulpiride / levosulpride, amantadine etc).
Posted by klein on April 28, 2014, at 11:07:55
In reply to Re: Cymbalta vs Pristiq, posted by klein on April 28, 2014, at 11:06:34
Posted by Beckett on April 28, 2014, at 14:24:52
In reply to Cymbalta vs Pristiq, posted by klein on April 23, 2014, at 12:30:37
Did you come to a decision yet? Having been on both effexor and Pristiq, it is true that there are far less side effects with Pristiq. It was mildly activating, although for me, it destabilized my mood. But if I recall correctly, that is not an issue for you. Cymbalta was good in many ways except I had a side effect which required me to discontinue (GI pain). Fwiw, heavy NE hitters make me drowsy and even worsen my pain condition (strattera) though I think that is an atypical response. Cymbalta was the exception, and I wished I could tolerate it. Welcome, btw.
Posted by klein on April 29, 2014, at 9:58:13
In reply to Re: Cymbalta vs Pristiq » klein, posted by Beckett on April 28, 2014, at 14:24:52
> Did you come to a decision yet? Having been on both effexor and Pristiq, it is true that there are far less side effects with Pristiq. It was mildly activating, although for me, it destabilized my mood. But if I recall correctly, that is not an issue for you. Cymbalta was good in many ways except I had a side effect which required me to discontinue (GI pain). Fwiw, heavy NE hitters make me drowsy and even worsen my pain condition (strattera) though I think that is an atypical response. Cymbalta was the exception, and I wished I could tolerate it. Welcome, btw.
Hi B,
Yeah, we decided to try Pristiq 100mg and upped the Zoloft to 300. We chose Pristiq because I have the same reaction to NE hitters as you, they send me right off to sleep! So Pristiq seemed like the best option (high dose Zoloft is also helping).We've discussed Savella and Fetzima in your thread, they're big on NE but I still think you should consider giving them try.
I'm becoming increasingly convinced that I have some sort of ADHD disorder (or whatever it's called) and could benefit from taking stimulants. So today I contacted my health insurance and asked to see another pdoc to get a second opinion, as my current one flat out refuses to prescribe amphetamines (for no good reason, I've never abused any of the meds he's given me)
I'm 100% unipolar.
Thanks for the welcome =)
Warm regards,
k
oh ps. about your GI problems with Cymbalta. I used to have GI *distress* on Zoloft (won't go into the gory details) so after a few weeks, I switched to another SSRI for a while. Then I switched back to Zoloft and the GI problems were much more manageable and they're gone now. It's like the previous med "prepared" me or desensitized me more gently for Zoloft's harsh GI side effects. If Cymbalta worked so well for you, maybe you can come up with a similar strategy.
Posted by Beckett on May 7, 2014, at 2:04:28
In reply to Re: Cymbalta vs Pristiq » Beckett, posted by klein on April 29, 2014, at 9:58:13
Hey, how is it going? Do you think the Pristiq is helpful? Wellbutrin helped with ADD (in attentive). I've tried different stimulants, so feel free to ask my opinion. Lots here with some form of ADHD.
Posted by klein on May 7, 2014, at 19:27:29
In reply to Re: Cymbalta vs Pristiq » klein, posted by Beckett on May 7, 2014, at 2:04:28
> Hey, how is it going? Do you think the Pristiq is helpful? Wellbutrin helped with ADD (in attentive). I've tried different stimulants, so feel free to ask my opinion. Lots here with some form of ADHD.
Hey Beckett, thanks for asking!
Pristiq at 250mg is nothing short of a miracle! I haven't felt this well in years =) Motivated, sleeping soundly, energized yet calm... today I actually *laughed* at something, jeez, I hadn't laughed in years. It was so weird to find something amusing and to feel it!
So the anxiety and depression lifted pretty quickly. I was amazed, I didn't expect much from Pristiq as I'd tried Effexor and it was iffy at best.
My doc chose Pristiq over Cymbalta because too much NE action sends me off to sleep. To me, Savella is practically a sleeping pill. I'd heard so many disappointing Pristiq experiences (I completely ignore horror stories) but Pristiq definitely has the right balance for my own biochemistry.
I'm cleaning my flat, it is a *pigsty* I can't believe I lived in these conditions for so long. So I'm slowly making progress.
Apparently we're adding Lamictal and Wellbutrin next cos I'm not just quite *there* yet. I've taken Wellby in the past and it works okay for me (til it poops out), but I have to to take either the old IR formulation or SR, Wellbutrin XL is too smooth.
I don't know what to expect from the Lamictal. An old pdoc put me on it several years ago but I don't remember anything, I was too depressed to notice any subtle differences.
The next step is to boost my motivation even more to see if I feel like socializing. I don't think I have any friends left =/ I neglected them for years. I used to be very outgoing. So we'll see..
I start CBT on Friday!
Thanks for asking Becks, warm regards!
Posted by Beckett on May 8, 2014, at 13:52:40
In reply to Re: Cymbalta vs Pristiq » Beckett, posted by klein on May 7, 2014, at 19:27:29
Klein, that's great :-D !!!!!! That's a lot of pristiq. I'm glad your doctor is willing to do what will work. I have wondered what role lamictal plays in unipolar treatment. I suppose it performs a similar action as on bipolarity--shore up the floor.
Best of luck on Friday. May your actions yield tons of positive change!
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