![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by MuseMemento on June 15, 2014, at 15:09:34
For whatever reason, I'd been opposed to using more than two meds at a time to treat my condition until last fall. Even with additional meds I haven't had anywhere near the type of relief I believe I could. I wonder, though, if each med in one's cocktail has a clear and distinct purpose, and mode of action, how many meds is too many? In hindsight, I can determine that approximately 7 meds have helped to some degree. If there are minimal interactions between them all and side effects aren't overwhelming, would it be in my best interest to take them all simultaneously? Any opinions are welcome!
Posted by alexandra_k on June 15, 2014, at 15:57:20
In reply to Polypharmacy/How many is too many?, posted by MuseMemento on June 15, 2014, at 15:09:34
It isn't the case that each medication only does one thing. Each one does a bunch of different things, many of which we don't really know... They do different things for different people... People respond differently to the same med at different points in time... Meds interact with each other in various ways.
I guess the only issue is that you well and truly go beyond doing anything that we have any evidence of efficacy for.
That being said... Once one has exhausted the options that there is some evidence for... Then I guess it is time to search more broadly.
Posted by gadchik on June 15, 2014, at 16:07:02
In reply to Re: Polypharmacy/How many is too many?, posted by alexandra_k on June 15, 2014, at 15:57:20
Hi, I always said only 2, but ended up on 3-Remeron 7.5mg, Zoloft 25mg, Klonopin .5mg, all once a day, at night. I stayed on that for 2 1/2 yrs. Tapered Remeron, and Zoloft,then after 3 more yrs, c/o to 10mg Valium to taper off Klonopin. I wouldn't do psych meds long term unless theres no other options.
Posted by Phillipa on June 15, 2014, at 20:57:09
In reply to Re: Polypharmacy/How many is too many?, posted by gadchik on June 15, 2014, at 16:07:02
I agree with Gadchik unfortunately 43 years on a low dose of a benzo looks like long term. Who would have thought as for a number of years took none at all after taking them. So from personal experience know it's reasonable to take none. Phillipa
Posted by SLS on June 17, 2014, at 7:50:03
In reply to Polypharmacy/How many is too many?, posted by MuseMemento on June 15, 2014, at 15:09:34
> For whatever reason, I'd been opposed to using more than two meds at a time to treat my condition until last fall. Even with additional meds I haven't had anywhere near the type of relief I believe I could. I wonder, though, if each med in one's cocktail has a clear and distinct purpose, and mode of action, how many meds is too many? In hindsight, I can determine that approximately 7 meds have helped to some degree. If there are minimal interactions between them all and side effects aren't overwhelming, would it be in my best interest to take them all simultaneously? Any opinions are welcome!
How many is too many? To answer that question, one would have to set an arbitrary number that may not reflect the optimal clinical treatment for an individual. Some people think that there is no reason to take more than one antidepressant. Other people demonstrate an absolute need for two or more. The people who subscribe to a school of thought rejecting polypharmacy may waste their entire lives suffering as they stubbornly adhere to a personal opinion that is not supported by neuroscience.
I don't think that taking a combination of the 7 drugs that individually produced a partial improvement is the most rational method of choosing a treatment regime. First of all, most antidepressants have multiple modes of action, even though they may not be well understood. It is conceivable that two drugs in combination would replicate all of the mechanisms found additively in your 7 drugs. It is also conceivable that the actions of your 7 drugs overlap such that taking all 7 would produce redundant and toxic effects.
If you list the 7 drugs that you found helpful, perhaps someone can parse their properties and suggest more rational treatments. It may be that the addition of a mood stabilizer or an antipsychotic with antidepressant properties would convert a modest improvement into a robust improvement.
- Scott
Posted by MuseMemento on June 17, 2014, at 14:38:49
In reply to Re: Polypharmacy/How many is too many? » MuseMemento, posted by SLS on June 17, 2014, at 7:50:03
Thanks, SLS. I think that was the response I needed to read. The conditions I'm attempting to treat are major depressive disorder, OCD, GAD and EDNOS. The following are the medications that I've tried and had a partial response to:
Wellbutrin (cognition and energy)
Zoloft (only in combination with Wellbutrin)
Paxil (again, only in combination with Wellbutrin)
Celexa (long ago and recently failed a trial of lexapro)
Pregabalin (anxiety and OCD)
Modafinil (energy level, OCD, cognition)
Quetiapine (anxiety, OCD and sleep but increased appetite seemed to make it untenable for long-term treatment)
Lamotrigine (it's early in my trial but it seems to be assisting with anxiety and OCD)
ephedrine (not technically a psych med but aided energy and mood at one time)
lorazepam (anxiety and sleep)
trazodone (sleep)Meds I've tried without response or with poor side effects:
escitalopram, mirtazapine, nortriptyline, clomipramine (about six and a half weeks at 100 mg and not sure I've noticed any improvement), lithium, venlafaxine, desvenlafaxine, aripiprazole, methylphenidate, fluoxetine, propranolol. It seems like there must be more but those are the ones I can currently think of. I'm interested in trying an MAOI at some point but my cognition is so poor at the moment and my eating disorder so unstable that I don't know if I could actually adhere to the MAOI diet. Any assistance would be most appreciated!
Posted by SLS on June 21, 2014, at 9:02:38
In reply to Re: Polypharmacy/How many is too many? » SLS, posted by MuseMemento on June 17, 2014, at 14:38:49
Wellbutrin + SNRI?
I would consider combining Pristiq 100 mg/day with Wellbutrin 300 mg/day. Effexor 300 mg/day might work just as well. However, people report that Pristiq is more tolerable and perhaps somewhat more effective. I have not been a big fan of Cymbalta in the past, but some people respond well to it. Wellbutrin can be combined with Cymbalta, too.
- Scott
Posted by MuseMemento on June 22, 2014, at 12:56:49
In reply to Re: Polypharmacy/How many is too many? » MuseMemento, posted by SLS on June 21, 2014, at 9:02:38
Thanks, Scott. I'll seriously consider it. I'm curious as to when fetzima is going to be available in Canada. Do you think six weeks at 100 mg of clomipramine is enough to see a response if I'm likely to respond to it?
Posted by phidippus on June 22, 2014, at 14:24:54
In reply to Polypharmacy/How many is too many?, posted by MuseMemento on June 15, 2014, at 15:09:34
My rule of thumb is only take as many drugs until your thinking is noticeably affected in a negative way. I take 5 drugs and start to feel the 'weight' of any more. What 7 drugs are you taking?
Eric
Posted by MuseMemento on June 22, 2014, at 18:20:06
In reply to Re: Polypharmacy/How many is too many? » MuseMemento, posted by phidippus on June 22, 2014, at 14:24:54
Oh, I'd meant that I'd only ever experienced a partial response to 7 drugs taken at different times. Currently, I'm on 300 mg wellbutrin xl, 100 mg clomipramine and 75 mg lamotrigine. No noticeable improvement since switching from escitalopram at 20 mg to the clomipramine.
Posted by SLS on June 22, 2014, at 23:08:03
In reply to Re: Polypharmacy/How many is too many? » SLS, posted by MuseMemento on June 22, 2014, at 12:56:49
> Thanks, Scott. I'll seriously consider it. I'm curious as to when fetzima is going to be available in Canada. Do you think six weeks at 100 mg of clomipramine is enough to see a response if I'm likely to respond to it?
That's a good question. Some doctors thought that they could see a small improvement by the end of the first week with tricyclics. I doubt that very many of these patients had reached a stable therapeutic dosage by then. My guess is that one can experience a very short improvement during the first week that will fade until a final therapeutic dosage is reached and allowed to work for a few weeks. I think one can go as high as 250 mg/day with clomipramine if it is tolerated. If you feel absolutely nothing at 100 mg/day, I don't think you can prognosticate how you will eventually feel at 250 mg/day. I would push the dosage at the appropriate time. Because side effects can be pronounced with clomipramine, a gradual titration is suggested.
http://www.rxlist.com/anafranil-drug/indications-dosage.htm
- Scott
Posted by phidippus on June 23, 2014, at 13:25:07
In reply to Re: Polypharmacy/How many is too many? » phidippus, posted by MuseMemento on June 22, 2014, at 18:20:06
100 mg is a relatively low dose of clomipramine. Your Lamictal dose is far below the minimum therapeutic dose of 200 mg.
Eric
Posted by MuseMemento on June 23, 2014, at 14:15:29
In reply to Re: Polypharmacy/How many is too many? » MuseMemento, posted by phidippus on June 23, 2014, at 13:25:07
Yeah, we're still titrating the dosage of lamictal. As for the clomipramine, I already sometimes have a resting heart rate above 100 bpm following taking it. I'm not sure I'm able to tolerate a higher dosage. I tried 150 mg for three days but felt significantly more lethargic, although it didn't improve much following reduction to the previous level of 100 mg. I want to give it a sufficient chance but my mood's about as bad as it's ever been.
Posted by MuseMemento on June 23, 2014, at 14:41:11
In reply to Re: Polypharmacy/How many is too many? » phidippus, posted by MuseMemento on June 23, 2014, at 14:15:29
Would dividing the doses of clomipramine throughout the day affect tolerance? I've been taking the 100 mg all in the late evening and also did so when I tried the 150 mg but noticed the increased lethargy. Any chance I would respond better if I were to stagger the doses throughout the day?
Posted by phidippus on June 25, 2014, at 18:27:33
In reply to Re: Polypharmacy/How many is too many? » phidippus, posted by MuseMemento on June 23, 2014, at 14:15:29
I'm just thinking the clomipramine at 100 mg is not going to be therapeutic enough. You really need to be taking 200-250 mg.
How long have you been on it?
Eric
Posted by phidippus on June 25, 2014, at 18:29:20
In reply to Re: Polypharmacy/How many is too many?, posted by MuseMemento on June 23, 2014, at 14:41:11
You can try splitting the dose. 100 in the morning and 100 mg at night.
Eric
Posted by MuseMemento on June 25, 2014, at 20:12:29
In reply to Re: Polypharmacy/How many is too many? » MuseMemento, posted by phidippus on June 25, 2014, at 18:27:33
Approaching eight weeks now.
Posted by phidippus on June 28, 2014, at 16:16:58
In reply to Re: Polypharmacy/How many is too many? » phidippus, posted by MuseMemento on June 25, 2014, at 20:12:29
Yeah, I think the dose is too low.
Eric
Posted by MuseMemento on June 30, 2014, at 17:16:52
In reply to Re: Polypharmacy/How many is too many? » MuseMemento, posted by phidippus on June 28, 2014, at 16:16:58
Thanks. I'll discuss it with the pdoc on Wednesday. I tried dividing the doses the past two days but I became overwhelmed with fatigue both days. I may have to take it all at once even with the increase.
Posted by MuseMemento on July 2, 2014, at 13:09:48
In reply to Re: Polypharmacy/How many is too many? » MuseMemento, posted by phidippus on June 28, 2014, at 16:16:58
Yeah, we're going to keep titrating up on the lamotrigine at 25 mg/day/week and the clomipramine as long as I can tolerate it. I hope this yields a more positive response.
Posted by MuseMemento on July 8, 2014, at 17:05:50
In reply to Re: Polypharmacy/How many is too many? » MuseMemento, posted by phidippus on June 25, 2014, at 18:29:20
So, we're going to try 200 mg clomipramine starting tomorrow which is about as high as I'm willing to go with the wellbutrin interaction. Up to 125 mg Lamictal on Thursday.
Posted by LostBoyinNC45 on July 11, 2014, at 23:41:32
In reply to Polypharmacy/How many is too many?, posted by MuseMemento on June 15, 2014, at 15:09:34
This is just me, but polypharmacy never much worked for me. Ive gotten best results from focusing on one drug for my Axis 1 disorder, pushing the dose up as high as I can stand it, treating my sleep apnea with CPAP, weight loss and exercise.
Exceptions to my "polypharmacy does not work for me" include some vitamins. Ive found that iron pills added in to my antidepressant at one time really, really made a difference. Also, once when I was real low in vitamin D (very common), taking the prescription strength drisdol vitamin D 50,000 IU twice per week really boosted my mood good.
But generally, when I throw a bunch of psych meds together, I feel way worse (awful, actually) rather than better.
Others seem to thrive on polypharmacy and most psychiatrists seem to like polypharmacy. It just never worked for me, at all.
Eric
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.