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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 18 of 18. This is the beginning of the thread.
Posted by MuseMemento on April 26, 2014, at 20:19:01
I've just finished, unsuccessfully, a trial of methylphenidate 20 mg in addition to 300 mg bupropion xl, 20 mg escitalopram and 2 mg abilify. Tuesday is the next appointment with the pdoc and TCAs will be the next step. So, question, I know we'll be either discontinuing or tapering off the escitalopram to make way for clomipramine but should I also discontinue the bupropion, which had previously been my only successfuly AD, and abilify or change only the one agent at a time? I'm not sure the abiilify ever helped or that the bupropion is adding anything currently. I also know that there's an enzymatic interaction between clomipramine and bupropion which increases the plasma levels of clomipramine but I also smoke currently and it seems that may even the effect out. Treatment is for MDD, OCD, GAD, possibly PTSD. Thanks for any replies.
Posted by Christ_empowered on April 26, 2014, at 20:45:46
In reply to Start over with clomipramine or combination?, posted by MuseMemento on April 26, 2014, at 20:19:01
I'm on Tofranil. I kinda sorta wanted to add bupropion, but there are case studies of that particular combo killing older people. Bummer.
Talk to your doc. Maybe drop the wellbutrin and go for Provigil, another trial of Ritalin, or an amphetamine w/ your tca?
Posted by Phillipa on April 26, 2014, at 21:20:35
In reply to Re: Start over with clomipramine or combination?, posted by Christ_empowered on April 26, 2014, at 20:45:46
Luvox?
Posted by MuseMemento on April 26, 2014, at 21:25:33
In reply to Re: Start over with clomipramine or combination?, posted by Christ_empowered on April 26, 2014, at 20:45:46
Mhmm. I liked provigil and might consider even adding it to what I'm currently taking if the pdoc is amenable. It's supposed to decrease clomipramine by the same enzyme that bupropion increases it, so maybe it'll also even out?
Posted by MuseMemento on April 26, 2014, at 21:27:19
In reply to Re: Start over with clomipramine or combination? » Christ_empowered, posted by Phillipa on April 26, 2014, at 21:20:35
I like the suggestion but my pdoc hasn't used it and I've failed all of the other SSRIs and a couple SNRIs so we're looking at the more robust antidepressant action of the TCAs, and clomipramine is supposed to be the gold standard for OCD.
Posted by Phillipa on April 26, 2014, at 22:17:28
In reply to Re: Start over with clomipramine or combination? » Phillipa, posted by MuseMemento on April 26, 2014, at 21:27:19
True, very strong from what I've read here in the past. Phillipa
Posted by MuseMemento on April 26, 2014, at 22:36:07
In reply to Re: Start over with clomipramine or combination? » MuseMemento, posted by Phillipa on April 26, 2014, at 22:17:28
I just hope that's my personal experience of them. Nortriptyline didn't work at all for me but it was in conjunction with sertraline which also didn't work, so who knows what the culprit was at the time?
Posted by LouisianaSportsman on April 27, 2014, at 0:53:36
In reply to Start over with clomipramine or combination?, posted by MuseMemento on April 26, 2014, at 20:19:01
> I've just finished, unsuccessfully, a trial of methylphenidate 20 mg in addition to 300 mg bupropion xl, 20 mg escitalopram and 2 mg abilify. Tuesday is the next appointment with the pdoc and TCAs will be the next step. So, question, I know we'll be either discontinuing or tapering off the escitalopram to make way for clomipramine but should I also discontinue the bupropion, which had previously been my only successfuly AD, and abilify or change only the one agent at a time? I'm not sure the abiilify ever helped or that the bupropion is adding anything currently. I also know that there's an enzymatic interaction between clomipramine and bupropion which increases the plasma levels of clomipramine but I also smoke currently and it seems that may even the effect out. Treatment is for MDD, OCD, GAD, possibly PTSD. Thanks for any replies.
Hey, Muse! I appreciate anyone on here who comes and contributes to my hobby of thinking like a PDOC and what I'd do if I was one.I've been on this combination at one time briefly. What a coincidence! :O (but in different forms of the medicament (it was Zoloft, actually, but still it was an SSRI with Abilify with Concerta with Wellbutrin but I'm a completely different combo now).
Straight-forward, you can also discontinue the bupropion. I quit cold turkey 522 mg. bupropion hbr later when I switched to Dexedrine IR because it actually attentuates the effects of amps but not methylphenidates.
I had no side effects except that I got way, way bigger buzzes off my dipping tobacco that I vomited twice. Trust me, I'm not an amateur when it comes to that stuff, and my stimulant (d-amp) was stronger-- but you probably won't have that effect. Basically, it will escape from your nicotinic receptors. Very good idea to continue it considering the enzyme response.
I didn't notice aripriprazole nor bupropion do anything, but I still took them, and I'm not really sure why, just because maybe.
Abilify, I've quit cold turkey one time and it was really easy one time when I directly switched to an another AAP (Latuda) that likely dissuaded side effects. But, with ariprazole, you need to look in to reports about dopamine agonist withdrawal syndrome due to unique mechanism of action.
Good luck finding the right medication! Trust me, I've been right where you are, but I kept going. I'm currently on a rather good combo of Brintellix (2014's SRI), Desoxyn (m-amp), Gralise (special gabapentin xr), Lamictal XR, Latuda, Nuvigil (armodafinil), Trokendi XR (Topamax) and Xanax XR [many, as you can see, are just fancy brand-names for typical medicament]
Keep us in the loop.
Posted by klein on April 27, 2014, at 7:41:01
In reply to Start over with clomipramine or combination?, posted by MuseMemento on April 26, 2014, at 20:19:01
> I've just finished, unsuccessfully, a trial of methylphenidate 20 mg in addition to 300 mg bupropion xl, 20 mg escitalopram and 2 mg abilify. Tuesday is the next appointment with the pdoc and TCAs will be the next step. So, question, I know we'll be either discontinuing or tapering off the escitalopram to make way for clomipramine but should I also discontinue the bupropion, which had previously been my only successfuly AD, and abilify or change only the one agent at a time? I'm not sure the abiilify ever helped or that the bupropion is adding anything currently. I also know that there's an enzymatic interaction between clomipramine and bupropion which increases the plasma levels of clomipramine but I also smoke currently and it seems that may even the effect out. Treatment is for MDD, OCD, GAD, possibly PTSD. Thanks for any replies.
As bupropion works for you and clomipramine + metabolites blood levels can be measured very reliably, maybe you could cut down your dose of Wellbutrin and keep close tabs on any interactions. Maybe even quit the Wellby for a while, then cautiously and slowly reintroduce it, measuring your clomipramine blood levels to avoid toxicity.Anafranil didn't do much for me when I tried it last year, but I was on a lowish dose because my doctor has an unfounded fear of QT prolongation (I'm in my late 30s and my EKG always come out fine). Imipramine and amitriptyline were much better.
However, if your main concern is OCD, clomipramine a good med to try. If you don't respond to it, your doctor could carefully add Luvox, which is apparently the best combination available for treatment-resistant OCD (I don't know if this is due to fluvoxamine adding anything specific to the mix, or if it simply inhibits a bunch of enzymes, thus raising clomipramine levels).
As for the Abilify.. what are you taking it for? 1-5mg usually works well for MDD, but you can go up to 15mg (max dose for MDD is 15mg and 30mg for bipolar etc). Its long half like makes it a pain to deal with, as it can take a full 2 weeks to notice the effects of a dosage modification. And the dosage needs to be tweaked really often. If you need an AAP onboard, maybe you could switch to something else? Cautiously though, some of the newer AAPs are also reuptake inhibitors (eg ziprasidone)
Good luck!
Posted by MuseMemento on April 27, 2014, at 13:53:20
In reply to Re: Start over with clomipramine or combination? » MuseMemento, posted by klein on April 27, 2014, at 7:41:01
Thanks for all of the posts!
I'm curious to see what the pdoc says about interactions. I'm now curious about adding modafinil, possibly up to 400 mg daily, because I previously had a positive response to 200 mg when I wasn't taking an SSRI. I've considered giving the wellbutrin a break and then re-introducing it to re-initiate the antidepressant effect but I'm concerned about having too many interactions that lower the level of the clomipramine (smoking, modafinil). Maybe the enhanced levels via wellbutrin will be a positive effect.
MDD is the more debilitating of the two conditions right now, although it's difficult for me to discern between OCD-type obsessions and depressive ruminations, but I know I'll need a medication that treats OCD as well, which is why I'm intent on clomipramine instead of simply adding something like desipramine.
The abilify was intended for MDD but if it also turns out to help OCD, all the better. I haven't noticed anything from it yet, so I would like to try increasing it before dismissing the possibility that it will do something for me. Perhaps latuda or saphris would be a better addition, though? I hope I haven't missed anything. The more I discuss it, the more optimistic I feel about this switch, so thanks, everyone!
Posted by MuseMemento on April 27, 2014, at 14:04:41
In reply to Re: Start over with clomipramine or combination?, posted by LouisianaSportsman on April 27, 2014, at 0:53:36
Is the latuda treating you better than the abilify did? How are the effects of the brintellix compared to other SSRIs that you've tried? I've been curious to try brintellix or vilazodone in combination with desipramine, amongst others, simply because it seems to offer something unique. I'd also like to try lamictal but I don't want to make too many changes too quickly lest I have no sense of what's working. Any other thoughts on the merits of your current combo?
Posted by Louisiana Sportsman on April 27, 2014, at 20:30:27
In reply to Re: Start over with clomipramine or combination? » LouisianaSportsman, posted by MuseMemento on April 27, 2014, at 14:04:41
>I'm now curious about adding modafinil, possibly up to 400 mg daily.
>I'm currently on Nuvigil #60 150mg. (300mg.) which is equal ~ to 600mg. of modafinil.
>Perhaps latuda or saphris would be a better addition, though?
>My "favorite" AAPs are Abilify, Latuda and Saphris because they seem effective without excessive H1 antagonism (sedation). Asenapine isn't one of the AAPs indicated for depression (like olanzapine, quetiapine, and aforementioned aripiprazole and lurasidone), but I tend to suggest it over Seroquel and especially Zyprexa unless there is a sleep problem at hand.
> Is the latuda treating you better than the abilify did?
>Physiologically, yes. Lurasidone is more metabolically sound and I am losing weight that I gained with the aripiprazole. In terms of symptom relief, I'd say that it is about equal, perhaps. One of the reasons I was reluctant to switch from Abilify was because I thought maybe due to partial agonism, it wouldn't attenuate my stimulants as much as some AAPs, but I actually noticed more out of my stimulants once I switched to Latuda, a full D2 antagonist.
> How are the effects of the brintellix compared to other SSRIs that you've tried?
>Here's a post where I answer this exact question:
http://www.dr-bob.org/babble/20140419/msgs/1064505.html
>I've been curious to try brintellix or vilazodone in combination with desipramine, amongst others, simply because it seems to offer something unique.
>Great idea for a combo! I made a post about the merits of a vortioxetine augmentation combo here:
http://www.dr-bob.org/babble/20140328/msgs/1064234.html
> I'd also like to try lamictal but I don't want to make too many changes too quickly lest I have no sense of what's working.
>Not really sure what lamotrigine does for me to be quite honest, but of course my PDOC says it would be ill-advised to take me off of my long-term mood stabilizer in regards to Lamictal due to its unique titration requirements. It's a good medicine for a lot of people and I think it's a good idea for you.
My pick? eslicarbazepine acetate, a prodrug which is activated into eslicarbazepine which an active metabolite of oxcarbamazepine which is a structural derivative of carbamazepine. (Tegretol -> Trileptal -> and now, Aptiom) Aptiom, from the manufacturer of Latuda, actually, came out earlier this month, in fact. The suggested maintenance dosage is one 800mg. tablet QD.
> Any other thoughts on the merits of your current combo?
>YES! Have you considered gabapentin or pregabalin? Hands down the best anxiolytic (better than alprazolam) for me that also acts a mood stabilizer and and antidepressant. My favorite medicament.
I urge you to check into it.
I find that modafinils + stimulants = happy campers.
Posted by klein on April 28, 2014, at 10:43:45
In reply to Re: Start over with clomipramine or combination? » MuseMemento, posted by Louisiana Sportsman on April 27, 2014, at 20:30:27
> YES! Have you considered gabapentin or pregabalin? Hands down the best anxiolytic (better than alprazolam) for me that also acts a mood stabilizer and and antidepressant. My favorite medicament.
>Hey L.,
I so agree with you. I haven't tried traditional stimulants but Modafinil + Gabapentin/Pregabalin = amazing.
My main issue with this combo is that both Lyrica and Neurontin poop out very soon, and I find that withdrawing from them is excruciating. Most people quit taking them with minimal side effects... I plummet into deep depression that lasts for weeks (no anxiety symptoms though). I've quit high dose Effexor and benzos doing very rapid tapers almost without a hitch, but I find that withdrawing from Lyrica//gabapentin is not just "debilitating", but downright disabling.
Any ideas?
BTW, I do taper off slowly but it makes no difference. The last time I quit Lyrica (swearing I'd never touch that drug again) my doc prescribed Namenda/memantine, which helped considerably, but it was still quite a bad experience.
Posted by phidippus on April 28, 2014, at 16:57:09
In reply to Start over with clomipramine or combination?, posted by MuseMemento on April 26, 2014, at 20:19:01
Raised levels of dopamine in the nucleus accumbens is an issue with OCD, so the Bupropion may be working against you by raising overall dopamine levels. I would discontinue the Bupropion.
The Abilify, on the other hand, may be helping with both your depression and the OCD.
I would change one agent at a time.
BTW, dextoamphetamine has been shown to be useful in the treatment of OCD-I would favor it over the ritalin.
Eric
Posted by MuseMemento on April 28, 2014, at 17:47:01
In reply to Re: Start over with clomipramine or combination? » MuseMemento, posted by phidippus on April 28, 2014, at 16:57:09
I really hadn't thought about the bupropion proving more harmful than helpful. It's the only agent that ever really worked for depression but perhaps that's NE related and not dopamine.
I'll consider the amphetamine suggestion but I think the focus for tomorrow will be the clomipramine and, possibly, the bupropion. Thank you.
Posted by LouisianaSportsman on April 28, 2014, at 22:47:11
In reply to Re: Start over with clomipramine or combination? » Louisiana Sportsman, posted by klein on April 28, 2014, at 10:43:45
>
> > YES! Have you considered gabapentin or pregabalin? Hands down the best anxiolytic (better than alprazolam) for me that also acts a mood stabilizer and and antidepressant. My favorite medicament.
> >
>
> Hey L.,
>
> I so agree with you. I haven't tried traditional stimulants but Modafinil + Gabapentin/Pregabalin = amazing.
>
> My main issue with this combo is that both Lyrica and Neurontin poop out very soon, and I find that withdrawing from them is excruciating. Most people quit taking them with minimal side effects... I plummet into deep depression that lasts for weeks (no anxiety symptoms though). I've quit high dose Effexor and benzos doing very rapid tapers almost without a hitch, but I find that withdrawing from Lyrica//gabapentin is not just "debilitating", but downright disabling.
>
> Any ideas?
>
> BTW, I do taper off slowly but it makes no difference. The last time I quit Lyrica (swearing I'd never touch that drug again) my doc prescribed Namenda/memantine, which helped considerably, but it was still quite a bad experience.
>
>
>Well, I was getting prescriptions for 600mg./daily from my PDOC as well a sample packs from a GP; I also paid some people I knew to go and get Lyrica prescribed so I could get their scripts.
I was going 1,200mg. - 3,000mg./day of pregabalin for a while.
I told my PDOC about my addiction and she helped prescribe gabapentin, titrate the dosage of pregabalin, and use #90 diazepam 10mg augmentation with Baclofen for a month until I was completely clean with no hassles.
With my primary anxiolyic off board, my PDOC knew that I needed something to help so I was about to get Xanax 1.5mg. afterwards. Recently, I mentioned that I wanted to responsibly use gabapentin so I'm now on Gralise 1,800mg. which is a time released gabapentin and we decided to it would be best to continue with the Xanax XR.
My PDOC discussed Memantine was a possible option in the near future. You like it, I'm assuming? I want it to manage my amphetamine tolerance, receive cognitive benefits, and possible depression relief. I feel it needs to be added since we recently switched my Dexedrine to Desoxyn (m-amp).
I'm prescribed Nuvigil 300mg./month which is equal to Provigil 600mg. and I find it works synergicitally with the methamphetamine. While I no longer receive the AMAZING results-- daily gabapentin has been effective with the Xanax XR to keep my anxiety under control. And the double punch of modafinil + m-amp has kept me focused and reduced ADHD symptoms.
The next time you're trying to get off pregabalin/gabapentin, your PDOC should taper your gabapentinoid intake and write a Baclofen/Valium taper.
But yes. Lyrica + Nuvigil is one of the most underutilized remedies.
Posted by klein on April 29, 2014, at 6:15:18
In reply to Re: Start over with clomipramine or combination?, posted by LouisianaSportsman on April 28, 2014, at 22:47:11
>
> Well, I was getting prescriptions for 600mg./daily from my PDOC as well a sample packs from a GP; I also paid some people I knew to go and get Lyrica prescribed so I could get their scripts.
>
> I was going 1,200mg. - 3,000mg./day of pregabalin for a while.
>
> I told my PDOC about my addiction and she helped prescribe gabapentin, titrate the dosage of pregabalin, and use #90 diazepam 10mg augmentation with Baclofen for a month until I was completely clean with no hassles.
>
> With my primary anxiolyic off board, my PDOC knew that I needed something to help so I was about to get Xanax 1.5mg. afterwards. Recently, I mentioned that I wanted to responsibly use gabapentin so I'm now on Gralise 1,800mg. which is a time released gabapentin and we decided to it would be best to continue with the Xanax XR.
>
> My PDOC discussed Memantine was a possible option in the near future. You like it, I'm assuming? I want it to manage my amphetamine tolerance, receive cognitive benefits, and possible depression relief. I feel it needs to be added since we recently switched my Dexedrine to Desoxyn (m-amp).
>
> I'm prescribed Nuvigil 300mg./month which is equal to Provigil 600mg. and I find it works synergicitally with the methamphetamine. While I no longer receive the AMAZING results-- daily gabapentin has been effective with the Xanax XR to keep my anxiety under control. And the double punch of modafinil + m-amp has kept me focused and reduced ADHD symptoms.
>
> The next time you're trying to get off pregabalin/gabapentin, your PDOC should taper your gabapentinoid intake and write a Baclofen/Valium taper.
>
> But yes. Lyrica + Nuvigil is one of the most underutilized remedies.
>Yeah, I can see how that could happen. The first time I tried Lyrica (my pdoc at the time gave me samples) I felt like I was at the top of the world. You know that I take my benzos responsibly, never abused them, and I never get a rush on them. But Lyrica is totally different. It doesn't help that I can get both Lyrica and Neurontin easily and legally without a script here (they both cost a fortune though).
When I stopped taking Lyrica for the last time (900mg/day) my withdrawal was so severe that I was paralyzed. Benzos did not help. My doctor put me on Namenda to aid the withdrawal and it helped somewhat, but the withdrawal was still hellish. It lasted two weeks. I don't take the Namenda anymore.
Memantine is very benign, I don't seem to glean much benefit from it alone (plain old magnesium citrate is basically the same thing and works much better). I do hear memantine buffers stimulant tolerance, maybe it's worth a try?
Also, memantine's cousin amantadine is great, energizing and pro-sexual with no addictive issues, but it does cause bad insomnia and can be fatally toxic at relatively low doses. I'm not sure if it helps with apm tolerance.
Warm regards.
Posted by MuseMemento on April 30, 2014, at 13:59:51
In reply to Re: Start over with clomipramine or combination? » LouisianaSportsman, posted by klein on April 29, 2014, at 6:15:18
So, the verdict is to raise abilify to 5 mg, lower dose of cipralex to 10 for four days, stop then initiate clomipramine at 50 mg. If the clomipramine is effective, I ultimately hope to raise the dose and discontinue the wellbutrin. I'm fairly sure it's causing neck and head twitches that I'm experiencing frequently. I've considered that it could be tardive dyskinesia but my abilify dose is low and there are no facial movements, just head and neck. Or it could be anxiety but that could also be from wellbutrin and caffeine intake. We shall see. Thanks for everyone's input!
This is the end of the thread.
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