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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 27 to 51 of 53. Go back in thread:
Posted by SLS on July 29, 2015, at 14:42:26
In reply to Re: low dose abilify as a add-on to move my butt, posted by Noa on July 29, 2015, at 11:38:52
Hi Noa.
It's nice to see you again.
Abilify can indeed produce metabolic changes. Weight-gain can be latent and insidious. It doesn't happen right away, and then sneaks up on you little by little. I take Abilify 10 mg/day. It helps with motivation. Abilify is a unique drug, though, and might be worth a try. If you don't like what you see, you can stop taking it. Weight gain is just as likely at 2.0 mg/day as it is at 20.0 mg/day.
I like Pristiq better than Effexor. Pristiq (desvenlafaxine) is the major active metabolite of Effexor. You can get a robust therapeutic effect at a much reduced dosage. You might be able to push the drug to 100 mg/day or higher without suffering cognitive side effects. 100 mg/day is very often the optimal dose.
Have you tried adding Wellbutrin or nortriptyline to Effexor? A friend of mine is doing very well with a combination of Pristiq 100 mg/day and Wellbutrin. She failed to respond to quite a few drugs, including Parnate.
You could try adding Lamictal 200 mg/day. It can help with both mental energy and motivation. Abilify and Lamictal seem to work well together.
If you decide not to go with Abilify immediately, the following plan might make some sense as an alternative:
1. Switch from Effexor to Pristiq
2. Add Wellbutrin
3. Add Lamictal
4. Switch from Wellbutrin to nortriptyline
5. Add Abilify
6. Smile and be happyLike I said, if you opt to go with Abilify now, you can always stop taking it if you don't like what you see. Just know that some people experience significant anxiety as a withdrawal effect. I couldn't guess as to how often this occurs.
Take care of yourself.
- Scott
Posted by phidippus on July 30, 2015, at 10:32:01
In reply to Re: low dose abilify as a add-on to move my butt, posted by Noa on July 29, 2015, at 11:38:52
Yes, Abilify can raise blood sugar levels, but it is less likely to do so than other atypicals. I have been taking Abilify for aa couple years and have had no impact to my blood sugar (I am diabetic). I don't know of its effects on cholesterol.
I would almost recommend replacing the Nefazadone with the Abilify, as both block 5ht2a receptors.
Eric
Posted by SLS on July 30, 2015, at 13:45:49
In reply to Re: low dose abilify as a add-on to move my butt, posted by Noa on July 29, 2015, at 11:38:52
Eric makes a good point regarding Abilify providing 5-HT2a antagonism, a property shared with nefazodone. On our simple laymens' paper models, You should be able to get rid of the nefazodone if you remain on a SRI like Effexor and begin taking Abilify. However, things are not always simple. If I recall, you tried a bunch of different drugs before finding nefazodone. Had you previously tried a combination of a SRI with Remeron? "On paper", that should work too as a replacement for nefazodone. It should be noted, though, that nefazodone and trazodone are both metabolized to mCPP. Other antidepressants are not. One would not think that mCPP contributes to the therapeutic effects, but who can say for sure?
Can you describe how you came to add nefazodone to your treatment regime? It might help people to come up with suggestions.
- Scott
Posted by Noa on December 24, 2015, at 12:14:37
In reply to Re: low dose abilify as a add-on to move my butt » Noa, posted by SLS on July 30, 2015, at 13:45:49
So I finally got around to talking to the MD about adding Abilify. He agreed and said he would add it to my current cocktail rather than replacing the nefazodone.
As for why I started on Nefazodone in the first place---I needed more AD effect but couldn't go higher on the Effexor dose (issues with memory, word retrieval, muscle spasm, sleep). I think it was the 5Ht2 antagonist action that was supposed to be key because I was having terrible restless legs at night (I also take Lorazepam for this).
I just started the Abilify..only on 1 mg so far, with plan to go up to 2 mg. I started by taking it in the morning but found myself feeling drowsy (a little high even), so I switched to taking it at night, which the doctor had suggested. But last night I had restless legs for no other apparent reason (hadn't had caffeine, etc.) and I am wondering if I should go back to taking the Abilify in the day. But if it has 5 HT2 antagonist effects, it shouldn't be causing restless legs, should it?
Posted by SLS on December 24, 2015, at 20:09:24
In reply to Re: low dose abilify as a add-on to move my butt » SLS, posted by Noa on December 24, 2015, at 12:14:37
Hi, Noa.
It's nice to see your name magically appear.
:-)
> So I finally got around to talking to the MD about adding Abilify. He agreed and said he would add it to my current cocktail rather than replacing the nefazodone.
>
> As for why I started on Nefazodone in the first place---I needed more AD effect but couldn't go higher on the Effexor dose (issues with memory, word retrieval, muscle spasm, sleep). I think it was the 5Ht2 antagonist action that was supposed to be key because I was having terrible restless legs at night (I also take Lorazepam for this).
>
> I just started the Abilify..only on 1 mg so far, with plan to go up to 2 mg. I started by taking it in the morning but found myself feeling drowsy (a little high even), so I switched to taking it at night, which the doctor had suggested. But last night I had restless legs for no other apparent reason (hadn't had caffeine, etc.) and I am wondering if I should go back to taking the Abilify in the day. But if it has 5 HT2 antagonist effects, it shouldn't be causing restless legs, should it?5-HT2a antagonism by itself shouldn't cause or reverse RLS. It might be caused by dopamine D3 receptor blockade and some D2 blockade.
Abilify can cause RLS as a side effect. I am a bit surprised to learn this. Maybe it is a startup side effect. A lot of people experience akathisia-like symptoms during the first week or two of taking Abilify. It usually dissipates completely. Maybe the same is true of the side effect you are experiencing.
There is a new FDA-approved Abilify-like drug called Rexulti (brexpiprazole). It might have a reduced tendency to produce RLS, but I'm not sure. It blocks D2 more than D3 compared to Abilify, but retains the dopamine receptor partial agonist property. Apparently, Rexulti has some biological effects that are similar to those of antidepressants.
What are you taking right now?
- Scott
Posted by Noa on December 25, 2015, at 2:08:35
In reply to Re: low dose abilify as a add-on to move my butt » Noa, posted by SLS on December 24, 2015, at 20:09:24
Adderall XR 30mg
Venlafaxine XR 300mg
Nefazodone 500mg
Lorazepam 1mg
liothyronine 25mcg
levothyroxine 50mcg
metformin XR 2000mg
Posted by SLS on December 25, 2015, at 9:03:22
In reply to Re: low dose abilify as a add-on to move my butt » SLS, posted by Noa on December 25, 2015, at 2:08:35
> Adderall XR 30mg
> Venlafaxine XR 300mg
> Nefazodone 500mg
> Lorazepam 1mg
> liothyronine 25mcg
> levothyroxine 50mcg
> metformin XR 2000mgNoa, that is a very well orchestrated treatment.
I don't recall, do you have hypothyroidism, or are the thyroid drugs being used specifically as augmenters of the antidepressants?
Have you ever tried Remeron at dosages of 45 mg/day or higher combined with Effexor? What about Wellbutrin 300 mg/day? Wellbutrin is sometimes used for ADD or ADHD also.
I hope your RLS subsides. Although RLS has been reported a few times in the literature with Abilify, I have yet to see a single person here report it.
By the way, metformin can cause RLS.
Brintellix does a lot of stuff. It is not a very potent serotonin reuptake inhibitor, either. I guess that's why your doctor was not concerned about serotonin syndrome. It is unusual as it is a full agonist at 5-HT1a. Other drugs like Abilify tend to be partial agonists. Like Brintellix, Abilify also blocks 5-HT7 receptors, a property gaining interest in the treatment of depression. Both Abilify and Brintellix are 5-H2a receptor antagonists. The reason I bothered list all of this stuff is because there is some important overlap between the two drugs. If you respond to Abilify and can tolerate it, you might eventually be able to discontinue the Brintellix. I really can't be sure.
One last question: How did you react to TCAs?
Let me know how you progress.
- Scott
Posted by Noa on December 25, 2015, at 18:58:45
In reply to Re: low dose abilify as a add-on to move my butt » Noa, posted by SLS on December 25, 2015, at 9:03:22
Hi, Scott. I had tried a few other ADs years ago, including Wellbutrin, and don't remember why it was not right for me. Tried Tricyclics even longer ago, found them both agitating and sedating at the same time...imagine being a zombie who needs to bounce off the walls.
Just found out today that the pharmacist managed to get a one time override for the Abilify because the insurance co. denied it. And, apparently, the insurance wanted me to try something else first. Well, the something else is Seroquel, which I know I won't take because I accidentally took it a few years ago when a different pharmacy gave me a vial of Synthroid with a few Seroquels mixed in!! They look almost exactly alike, unless you look real close at the writing on the pill. What an awful experience!! Depersonalization...suddenly felt like my arms and legs were very far away from me. Felt totally bizarre and zombied out, slept 24/7 for a couple of days afterward. And besides I haven't heard that Seroquel has the same mobilizing effects that Abilify does.
Posted by Noa on December 25, 2015, at 19:08:42
In reply to Re: low dose abilify as a add-on to move my butt » Noa, posted by SLS on December 25, 2015, at 9:03:22
Scott, to address a couple of other things in your message....
I've never heard of Brintillex.
I've not tried Remeron.
I do have hypothyroidism but only really found out about it because a previous psychopharm thought adding cytomel (liothyronine) would help boost the AD effects of my ADs, and with subsequent testing and consulting with an endo, discovered that I was hypothyroid. Treating that really helped me turn a major corner (was back in about 2000 or so).
As for the Abilify trial...I decided after another hard night to go back to taking the Abilify in the daytime--did so today, and have not felt the drowsiness that I did the first couple of days I tried it. So, now I'm hoping sleep will get back to normal tonight.
Thanks again for all your input!!
Posted by SLS on December 25, 2015, at 21:15:06
In reply to Re: low dose abilify as a add-on to move my butt » SLS, posted by Noa on December 25, 2015, at 19:08:42
Sorry, Noa.
Even with your list right in front of me, I thought for some reason that you were currently taking Brintellix.
<sigh>
Anyway, Brintellix seems like a good drug to keep in mind. It is seen as being more of a serotonin system modulator than a simple reuptake inhibitor. It is a cognitive enhancer. It has a much reduced potential for producing sexual side effects, and weight gain tends not to be a problem. As is with many other antidepressants, it increases norepinephrine and dopamine in various brain regions.
It is encouraging that you are beginning to tolerate the Abilify. A generic version has been approved, but I don't know when it will become available. Perhaps your insurance would cover that.
Brintellix (vortioxetine) and Abilify have a few important properties in common:
5-HT1a agonism (Abilify = partial agonism)
5-HT2a antagonism
5-HT7 antagonismYou might be sensitive to drugs that are norepinephrine reuptake inhibitors (NRI). That could explain your reactions to Seroquel and TCA. The major metabolite of Seroquel is a NRI. If this is true, Wellbutrin may have produced anger or anxiety, and Ritalin would not have treated you very well. This is just a guess. Also, higher dosages of Effexor also become NRI.
FYI, thyroid hormones increase the sensitivity of norepinephrine receptors. For me, Cytomel (T3) made me insanely worse while Synthroid (T4) made me feel somewhat better. I never researched this.
I hope you feel better soon. Sorry I couldn't be of more help.
- Scott
Posted by Noa on December 26, 2015, at 11:21:58
In reply to low dose abilify as a add-on to move my butt -Oops » Noa, posted by SLS on December 25, 2015, at 21:15:06
Thanks, Scott. I always learn so much from you!
Posted by Lamdage22 on December 30, 2015, at 12:40:37
In reply to Re: low dose abilify as a add-on to move my butt -Oops » SLS, posted by Noa on December 26, 2015, at 11:21:58
Noa,
arent you scared because of the Nefazodone?
It sounds miraculous.. except for potential fatal liver damage?
Posted by SLS on December 30, 2015, at 12:51:49
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Lamdage22 on December 30, 2015, at 12:40:37
> Noa,
>
> arent you scared because of the Nefazodone?
>
> It sounds miraculous.. except for potential fatal liver damage?"1 case of liver failure resulting in death or transplant per 250,000 - 300,000 patient-years"
It is a relative rare occurrence.
- Scott
Posted by Lamdage22 on December 30, 2015, at 12:52:59
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by SLS on December 30, 2015, at 12:51:49
I dont really understand what that means. Ive read but i didnt get it.
> 250,000 - 300,000 patient-years"
>
> It is a relative rare occurrence.
>
>
> - Scott
Posted by SLS on December 30, 2015, at 15:22:46
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Lamdage22 on December 30, 2015, at 12:52:59
> "1 case of liver failure resulting in death or transplant per 250,000 - 300,000 patient-years"
> It is a relative rare occurrence.
As best as I understand it, liver fatality occurs in 1 out of 300,000 people per year OR once every 300,000 years for any one person.
This number is considered to represent a "rare" occurrence according to most references, but knowing the statistic itself allows you to decide for yourself if the risk is worth the benefit. Of course, you can take a very simple blood test regularly to reduce your risk of serious injury. From what I read, if it is going to occur, the appearance of major liver damage will emerge between 6 weeks and 8 months. I am assuming that after taking nefazodone for 8 months, if it doesn't appear, the risk goes down considerably. Some people do demonstrate a modest elevation in liver enzymes, but most do not have to stop taking the drug.
If you were to take nefazadone for the next 100 years, there is a 1 in 3000 chance of developing liver failure. Obviously, even if nefazodone works, you most likely won't have to take it for 100 years. By that time, I think you can count on new treatments to become available, so nefazodone would really be acting as a bridge between now and then.
http://www.wisegeek.org/what-are-patient-years.htm
- Scott
Posted by Noa on December 30, 2015, at 20:14:10
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Lamdage22 on December 30, 2015, at 12:40:37
> arent you scared because of the Nefazodone?
>
> It sounds miraculous.. except for potential fatal liver damage?No, not scared. Was concerned when the warnings first came out, but discussed it with my psychopharm and my understanding is that if the serious issues with liver damage would have happened, it would be early in treatment. I was already on nefazodone for a long time before the black box warning came out. I have my liver function tested every few months just in case.
As for being miraculous, I wouldn't say that...it is like all the other meds in that it has pluses and minuses. I has worked for me as one element in my treatment.
Posted by Lamdage22 on January 12, 2016, at 11:07:58
In reply to Re: low dose abilify as a add-on to move my butt -Oops » Lamdage22, posted by Noa on December 30, 2015, at 20:14:10
Thanks, Scott.
Posted by Noa on January 12, 2016, at 11:27:16
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Lamdage22 on January 12, 2016, at 11:07:58
Yes, I'll second Lamdage's thought: thanks Scott, for the explanations.
Posted by Lamdage22 on January 12, 2016, at 11:34:25
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Noa on January 12, 2016, at 11:27:16
http://www.drugs.com/comments/nefazodone/
do you know how good this score is??
Posted by Noa on January 12, 2016, at 11:53:07
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Lamdage22 on January 12, 2016, at 11:34:25
Update: Still at 1 mg Abilify. Dr. got insurance to cover it, yay.
It seems to be making a modest difference in my executive functioning. Things like, I finally got a datebook and am using it to mark down appointments and to make lists/reminders of things to do, and am doing some of those things, though still procrastinating on many of them. Also, spontaneously cleaned up some recycling, etc. and took it out. These things are so small and hardly make a dent in the overall situation but they're a start, I hope. Abilify still makes me feel a bit sleepy during the day but interferes with sleep if I take it later in the day or at night. So I take it early in the morning, and am just trying to work through the sleepiness (without succumbing to the urge to nap). The earlier dosing has done away with the insomnia at night, which is good. I don't know why I seem to have this mixed reaction to various meds---sleep/not-sleep (like with the tricyclics, where I was very sedated but super hyper at the same time---picture sleepy zombie with eyes closed bouncing off the walls).
If the sleepy side effects goes away, I might consider going up to the full pill--ie 2 mg--dose, but holding at 1 mg for now.
Posted by SLS on January 12, 2016, at 13:26:00
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Lamdage22 on January 12, 2016, at 11:34:25
> http://www.drugs.com/comments/nefazodone/
>
> do you know how good this score is??I would be careful about interpreting the numbers quoted as being statistics of efficacy. I doubt 9 out of 10 people who take nefazodone attain remission. If this were true... well.
I guess you have to ask yourself what type of person would bother to write a review. Are people who remain hopelessly depressed going to have the energy or enthusiasm to do such things? I don't think so. Part of the 9.5 number for nefazodone might represent happiness with its side effect profile. I don't know. At best, the two most potent antidepressants available, Nardil and Anafranil, get 6.5 out of 10 people well who have not already demonstrated treatment resistance (TRD).
Having said all of that, I recommend that you include nefazodone on your list of things to try. It really does work for some people who are otherwise TRD. Why would any doctor or patient wish to use nefazodone as their first choice when it has the potential to cause liver failure? They wouldn't. It is much more likely that nefazodone would be chosen after other drugs have failed. So, basically, nefazodone can help people who are TRD. Just not 9.5 out of 10 of them.
Nefazodone is only a weak serotonin reuptake inhibitor, so it should not cause serotonin syndrome when combined with Effexor. I know of no contraindication for the combination. If you come across any, please let me know.
Do I recall correctly that you had a bad reaction to fluvoxamine (Luvox)? Akathisia? Fluvoxamine is supposed to have a reduced risk of akathisia compared to other SSRIs, although there are rare reports of this happening. It would be a logical choice to try fluvoxamine for psychotic depression. Perhaps this is the result of it being the only antidepressant that is a sigma-1 receptor agonist. Interestingly, sertraline (Zoloft) is a sigma-1 antagonist, and is generally thought of as being the SSRI most likely to produce akathisia. Even more interesting is that fluvoxamine has been shown to actually reverse akathisia.
http://www.annals-general-psychiatry.com/content/9/1/11
Much more information than you asked for...
By the way, I started taking resveratrol 250 mg/day.
- Scott
Posted by Lamdage22 on January 12, 2016, at 13:28:14
In reply to Re: low dose abilify as a add-on to move my butt -Oops » Lamdage22, posted by SLS on January 12, 2016, at 13:26:00
Yeah but with Nefazodone playing a number on dopamine i think i better stay clear of it.
Posted by SLS on January 12, 2016, at 14:19:32
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Lamdage22 on January 12, 2016, at 13:28:14
> Yeah but with Nefazodone playing a number on dopamine i think i better stay clear of it.
I read that nefazodone very slightly affects both DA and NE, but I think that was in laboratory setting at high dosages. I don't know. You know, most antidepressants increase dopamine and norepinephrine activity downstream from the direct effect, even if that direct effect is purely serotonergic.
- Scott
Posted by Lamdage22 on January 12, 2016, at 14:22:20
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by SLS on January 12, 2016, at 14:19:32
Well it makes sense. Even mediocre dosages of most of them make me (pre)psychotic, so... Thats why i am waiting for Rapastinel.
I just dont trust what they say that it doesnt make people psychotic. It may be (mostly) true for people with major depression, but how does it look when we are talking about people with both psychosis and depression?
Posted by SLS on January 12, 2016, at 14:41:38
In reply to Re: low dose abilify as a add-on to move my butt -Oops, posted by Lamdage22 on January 12, 2016, at 14:22:20
> Well it makes sense. Even mediocre dosages of most of them make me (pre)psychotic, so...
Interesting observation. I hadn't thought of that.
> I just dont trust what they say that it doesnt make people psychotic. It may be (mostly) true for people with major depression, but how does it look when we are talking about people with both psychosis and depression?
Good point.
- Scott
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