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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 6 to 30 of 30. Go back in thread:
Posted by TriedEveryMedication on June 23, 2018, at 0:33:55
In reply to Re: Let's talk about combing SSRIs and TCAs, posted by SLS on June 23, 2018, at 0:15:03
> Moclobemide monotherapy is not terribly impressive as an antidepressant. Many people experience a very strong therapeutic effect during the first week at low dosages. Very few side effects are reported.funny you mention this. I've experienced just that on moclo... I wonder if there's a way to reset that therapeutic action, the way some augmenters can reset ssri poop out.
> I am currently mixing nortriptyline with Trintellix (vortioxetine). If that doesn't work, I will combine nortriptyine with Effexor (venlafaxine). I received a partial response from this combination, but at dosages that were too low. I expect that I will need a minimum of 300 mg/day of Effexor with 100 mg/day of nortriptyline. I am also taking lithium, prazosin, and Lamictal now. I wasn't taking these drugs during my previous Effexor/nortriptyline trial. I would consider taking Abilify or Latuda if necessary.
>
> I am open to all suggestions. I could use a few more.
>
I've tried these: vortioxetine + desipramine. paroxetine + desipramine. effexor + desipramine. prozac + desipramine. I think out of that bunch, prozac + desipramine works the best. I definitely feel better, though I feel like I could feel even better and I've hit a plateau. Only real problem with this combo as I mentioned before is potential QTc prolongation. effexor + desipramine seemed to work, but my mood would crash towards the end of the day.
Posted by SLS on June 23, 2018, at 1:16:41
In reply to Re: Let's talk about combing SSRIs and TCAs » SLS, posted by TriedEveryMedication on June 23, 2018, at 0:33:55
> I've tried these: vortioxetine + desipramine. paroxetine + desipramine. effexor + desipramine. prozac + desipramine. I think out of that bunch, prozac + desipramine works the best. I definitely feel better, though I feel like I could feel even better and I've hit a plateau. Only real problem with this combo as I mentioned before is potential QTc prolongation. effexor + desipramine seemed to work, but my mood would crash towards the end of the day.Effexor + desipramine:
What dosages of each?
How did you divide your dosages.I experience a deterioration in mood at the end of the dosing period when I take Effexor XR only once a day. I take both drugs in divided doses. My mood is more consistent when I do this.
How did you react to the combination of vortioxetine + desipramine? I started vortioxetine 5 mg/day today in combination with drugs that will hopefully work synergistically to effect a robust improvement in my bipolar depression.
Currently:
Trintellix (vortioxetine) 5 mg/day
nortriptyline 100 mg/day
Lamictal 300 mg/day
lithium 300 mg/day
prazosin 30 mg/dayI recently discontined Abilify for increase body weight and high triglycerides.
I discontined Panate because the partial improvement I experienced early in treatment slowly disappeared and represented a dead end. At higher dosages, Parnate actually made me feel lazy (reduced interest and little motivation), and got nothing done.
- Scott
Posted by sigismund on June 23, 2018, at 1:26:21
In reply to Re: Let's talk about combing SSRIs and TCAs, posted by SLS on June 23, 2018, at 1:16:41
I recall Maxime saying, 'I have to accept that the Parnate is no longer helping'.
Posted by ed_uk2010 on June 23, 2018, at 3:57:12
In reply to Let's talk about combing SSRIs and TCAs, posted by TriedEveryMedication on June 21, 2018, at 23:47:33
>According to epocrates, this should kill me, either with serotonin syndrome or prolonged heart QT intervals or whatever.
Electronic interaction checkers (and some textbooks) often treat all TCAs as if they were the same. You therefore get shown side effects which are not relevant to all medications in the group eg. serotonin syndrome when adding the non-serotonergic desipramine.
Posted by ed_uk2010 on June 23, 2018, at 5:15:38
In reply to Let's talk about combing SSRIs and TCAs, posted by TriedEveryMedication on June 21, 2018, at 23:47:33
>How about an SSRI and moclobemide?
This combination has been tried. Unlike SSRI + phenelzine or tranylcypromine, it does not routinely cause life threatening serotonin toxicity.
What this combination does cause, however, is a very high incidence of adverse effects, mostly serotonergic, and agitation.
Posted by SLS on June 23, 2018, at 8:19:05
In reply to Re: Let's talk about combing SSRIs and TCAs » SLS, posted by sigismund on June 23, 2018, at 1:26:21
> I recall Maxime saying, 'I have to accept that the Parnate is no longer helping'.
Your point is well-taken, Sigi. Right now, my depression has stabilized such that it is no worse now than it was on Parnate 80 mg/day. Reducing anxiety with Ativan has helped a great deal at turning off the catastrophic and suicidal thinking. I definitely experienced an increase in the severity of depression immediately after discontinuing Parnate, but I recovered. Perhaps it was a rebound withdrawal effect. In retrospect, I would have taken 3 weeks to taper and use Ativan for anxiety.
I began taking Trintellix (vortioxetine) yesterday.
- Scott
Posted by ed_uk2010 on June 23, 2018, at 10:34:49
In reply to Re: Let's talk about combing SSRIs and TCAs » sigismund, posted by SLS on June 23, 2018, at 8:19:05
Hi Scott,
>I began taking Trintellix (vortioxetine) yesterday.
Excellent. Any initial side effects? How do you plan to titrate up on it?
Posted by SLS on June 23, 2018, at 13:50:53
In reply to Re: Let's talk about combing SSRIs and TCAs » SLS, posted by ed_uk2010 on June 23, 2018, at 10:34:49
> Hi Scott,
>
> >I began taking Trintellix (vortioxetine) yesterday.
>
> Excellent. Any initial side effects? How do you plan to titrate up on it?
>
>I think I feel a bit numb and slowed-down. It is hard to tell. It is nothing that I am concerned about at this juncture.
I think Ill stay at 5 mg/day for a week and then go up to 10 mg/day. Slow. I guess the target is 20 mg/day. Do you have any recommendations?
- Scott
Posted by Lamdage22 on June 24, 2018, at 7:19:58
In reply to Re: Let's talk about combing SSRIs and TCAs » sigismund, posted by SLS on June 23, 2018, at 8:19:05
Good luck, Scott. Its good to see you up and running again. I didnt realize that Parnate was doing so little to help you.
Posted by Lamdage22 on June 24, 2018, at 7:20:34
In reply to Re: Let's talk about combing SSRIs and TCAs, posted by Lamdage22 on June 24, 2018, at 7:19:58
TCA and SSRI sounds like the ultimate sex killer to me
Posted by linkadge on June 24, 2018, at 13:12:15
In reply to Let's talk about combing SSRIs and TCAs, posted by TriedEveryMedication on June 21, 2018, at 23:47:33
I combined amitriptyline and escitalopram before with good success.
Yes, go for the regular checkups, but drugs like notriptyline or desipramine are somewhat common adjuncts.
Linkadge
Posted by TriedEveryMedication on June 24, 2018, at 14:36:22
In reply to Re: Let's talk about combing SSRIs and TCAs, posted by linkadge on June 24, 2018, at 13:12:15
> I combined amitriptyline and escitalopram before with good success.
>
> Yes, go for the regular checkups, but drugs like notriptyline or desipramine are somewhat common adjuncts.
>
> Linkadge
>Thanks. I notice on epocrates it is kinda inconsistent which SSRIs get QTc warnings.
amitriptyline + lexapro = no QTc warning.
amitriptyline + fluoxetine = QTc warning
desipramine + lexapro = QTc warning.
desipramine + fluoxetine = QTc warning.
My doctor is being strict about me getting testing after my Stevens-Johnson incident, so it would be nice to come up with a combo that doesn't have the cardiac warnings. I'll have a look at lexapro + amitriptyline.Thanks.
Posted by TriedEveryMedication on June 24, 2018, at 14:39:30
In reply to Re: Let's talk about combing SSRIs and TCAs » TriedEveryMedication, posted by ed_uk2010 on June 23, 2018, at 3:57:12
> >According to epocrates, this should kill me, either with serotonin syndrome or prolonged heart QT intervals or whatever.
>
> Electronic interaction checkers (and some textbooks) often treat all TCAs as if they were the same. You therefore get shown side effects which are not relevant to all medications in the group eg. serotonin syndrome when adding the non-serotonergic desipramine.Thanks, Ed.
so how to know for sure? my doctor relies heavily on epocrates... I guess I could trawl through studies, etc. but some of those papers seem very low quality.
Posted by linkadge on June 24, 2018, at 15:43:14
In reply to Re: Let's talk about combing SSRIs and TCAs » linkadge, posted by TriedEveryMedication on June 24, 2018, at 14:36:22
Lexapro itself can cause QTc issues (especially in doses above 10mg). I was only taking 5-10mg of Lexapro with 25mg of amitriptyline.
SSRI + TCA can be very effective for some people.
Linkadge
Posted by linkadge on June 24, 2018, at 15:46:42
In reply to Re: Let's talk about combing SSRIs and TCAs » ed_uk2010, posted by TriedEveryMedication on June 24, 2018, at 14:39:30
I would think any risk of serotonin syndrome would present itself quickly (if it does), upon introduction or dose escalation.
Desipramine does have a metabolite which is more serotonergic. That being said, the combination of 2 reuptake inhibitors is usually safe. Like you say, desipramine mostly affects the norepineprine transporter.
Linkadge
Posted by rjlockhart37 on June 24, 2018, at 22:46:09
In reply to Re: Let's talk about combing SSRIs and TCAs » SLS, posted by sigismund on June 23, 2018, at 1:26:21
she did say that, i remember reading her posts about 10-12 years ago about her struggles with severe depression.....it sad she could not make it through to today, i always will remember her
Posted by ed_uk2010 on June 25, 2018, at 13:49:37
In reply to Re: Let's talk about combing SSRIs and TCAs » ed_uk2010, posted by TriedEveryMedication on June 24, 2018, at 14:39:30
> > >According to epocrates, this should kill me, either with serotonin syndrome or prolonged heart QT intervals or whatever.
Serotonin syndrome can occur when adding a strongly serotonin-elavating drug to an SSRI eg. an MAOI.
Desipramine is mainly a noradrenergic antidepressant, although one of its metabolites might act as an SRI like Link pointed out. Even so, severe cases of serotonin syndrome (rather than just serotonergic side effects) only occur due to combining two or more drugs which elevate sertonin by different mechanisms. That is why MAOI plus SSRI is such an issue. Even combining two potent SSRIs would generally only cause side effects, rather than a major case of serotonin syndrome. There is only so much you can elevate serotonin just via reuptake inhibition...
>heart QT intervals
This depends on...
a) does the two antidepressants elevate each other's blood levels through a metabolic interaction. For example, fluoxetine can increase desipramine levels, and desipramine prolongs the QTc interval.
b) do the individual drugs both affect the QTc interval? Most tricyclic antidepressants can increase the QTc interval if the blood level is high. Among the SSRIs, citalopram (Celexa) and escitalopram (Lexapro) are the ones which directly increase the QTc interval.
The main issue with your fluoxetine + desipramine combination is that fluoxetine can alter the metabolism of desipramine. Cautious desipramine dose increases are therefore important to avoid the risk of unexpectedly high desipramine levels - which could lead to cardiac effects. It sounds like you've had a blood level to check this. You can also do an ECG (EKG).
I am not aware of any cases of serotonin syndrome with your combination, and it would not be expected.
Posted by TriedEveryMedication on June 25, 2018, at 14:46:19
In reply to Re: Let's talk about combing SSRIs and TCAs » TriedEveryMedication, posted by ed_uk2010 on June 25, 2018, at 13:49:37
> The main issue with your fluoxetine + desipramine combination is that fluoxetine can alter the metabolism of desipramine. Cautious desipramine dose increases are therefore important to avoid the risk of unexpectedly high desipramine levels - which could lead to cardiac effects. It sounds like you've had a blood level to check this. You can also do an ECG (EKG).
>my blood levels of desipramine have been very low. my doc is kinda baffled by this because fluoxetine is supposedly such a strong 2D6 inhibitor.
Posted by sigismund on June 26, 2018, at 1:54:43
In reply to Re: Let's talk about combing SSRIs and TCAs » sigismund, posted by SLS on June 23, 2018, at 8:19:05
>Ativan has helped a great deal at turning off the catastrophic and suicidal thinking.
And goodness me, where you draw the line? Because things are not, and perhaps never have been, OK. But in my lifetime never as bad as now.
>I began taking Trintellix (vortioxetine) yesterday.
I'm interested in the mind clearing effects (if any).
I actually had a better than usual day on ashwaganda and rhodiola. With other herbals to minimise benzo need.
Posted by ed_uk2010 on June 26, 2018, at 18:37:16
In reply to Re: Let's talk about combing SSRIs and TCAs » ed_uk2010, posted by TriedEveryMedication on June 25, 2018, at 14:46:19
Hi,
>my blood levels of desipramine have been very low.
In that case, if you need to increase desipramine to help relieve depression, be guided by:
1. Typical desipramine adverse effects such as elevated heart rate (can easily monitor this), very excessive sweating etc. If these appear, consider reducing desipramine again.
2. Your ECG/EKG. Consider checking after dose increases. Can measure the QTc interval and other cardiac indices.
Increasing the dose in small steps is advisable.
Posted by ed_uk2010 on June 26, 2018, at 18:41:30
In reply to Let's talk about combing SSRIs and TCAs, posted by TriedEveryMedication on June 21, 2018, at 23:47:33
>I'm having EKGs every couple weeks to check for QTc prolongation
Is that because you've been making dosage increases? Once you're established on a particular dose, I'm unsure why you'd need to have an ECG so often unless something had changed (either the dosage of one of your other medications, your physical health, or something else).
Posted by bleauberry on June 27, 2018, at 7:00:12
In reply to Let's talk about combing SSRIs and TCAs, posted by TriedEveryMedication on June 21, 2018, at 23:47:33
Just my opinion, but I think all of us here get much better improvement of quality of mood when we start combining anti-inflammatories and antimicrobials with our prescriptions. Several common lyme herbs, for example, do all that and more. Instead of limiting your thinking to making cocktails of prescriptions, start making cocktails with OTC products that address all of the issues you are not currently addressing - all of which cause symptoms like yours.
If you are not specifically targeting systemic inflammation from various angles - not a single drug, single mechanism, or single herb - then you cannot reach your best potential.
If you are not specifically targeting your immune system, to strengthen it, fortify it, and balance it, if you aren't doing that, there is no way you can ever reach your mood goals.
The common Lyme herbs do all this stuff and it really doesn't matter whether you have lyme or not. Inflammation and microbes are a huge part of the psychiatric arena and most of us totally ignore it all. We focus only on mono-amine levels which is extremely limited, finite and incomplete if you ask me.
Examples: Let's say you add a product called Resveratrol and it is made from Polygonum Cupsidatum not from grapes. With that you get strong anti-inflammatory and anti-microbes, in addition to balancing the immune system from being too hot or too cold. It is the 2nd most common herb used to treat Lyme. It also helps to mop up toxins floating around hitting brain receptors. Ok so you start this herb and then a couple month later you say that you have improved maybe 1/2 of 1 point on a 1 to 10 scale. With 10 being the most depressed, and 1 being remission, let's say you go from 8 to 7 1/2 with Resveratrol. You then take a professional multi with all the good co-factors in it and you improve maybe another 1/4 point. so now you are at 7 1/4. You add another herb, maybe Phyto-Biotic which is a combination of three different sources of the chemical Berberine. And 2 months later you are at 6 1/2.
That's not bad! 8 to 6 1/2 with safe, healthy OTC items.
You try some things that don't help. So you don't do those any more. Your bottle runs out and you don't order any more. But then in a few days you realize that herb was doing some good for you, and you have slipped since you stopped it. So you start that one again and you call it a keeper.
Eventually you find the things that make your cocktail. And you know for a fact that every one of them is worth at least a 1/4 point or a 1/2 point for your progress.
I went from about a 9 to about a 2 with antibiotics and herbs. I still take a lot of herbs. I know which ones help me and which are a waste of money.
I'm just saying that as I scan the posts here, I see a whole lot of people putting all of their eggs in one basket. And that is never a good thing.
opinion
Posted by bleauberry on June 27, 2018, at 7:03:52
In reply to Re: Let's talk about combing SSRIs and TCAs, posted by bleauberry on June 27, 2018, at 7:00:12
IN my experience with all these drugs I found that the NSRI Savella (Milnacipran) was way better, way smoother, way less side effects, than any combinations of SSRI+TCA. Duloxetine sucked. Or sucks, whichever.
Savella is a great medicine and I am amazed it is not hardly ever utilized.
My best cocktail was Prozac+Zyprexa+Modafinil. But Savella all by itself did better than all that.
Posted by TriedEveryMedication on June 28, 2018, at 5:05:25
In reply to Re: Let's talk about combing SSRIs and TCAs, posted by bleauberry on June 27, 2018, at 7:03:52
my doc just gave me a script for levomilnacipran...
we shall see
Posted by bleauberry on June 28, 2018, at 14:20:56
In reply to Re: Let's talk about combing SSRIs and TCAs » bleauberry, posted by TriedEveryMedication on June 28, 2018, at 5:05:25
Cool. Makes more sense than any of the lame SSRIs if you ask me. Might work, might not, but a good choice. imo
I just wanted to add that when it worked pretty good for me, the highest dose I ever took was lower than the lowest dose! I don't remember what it was. I broke pills in quarters, and capsules into equal sized piles of powder. The lowest starting dose actually made me feel worse. But a lower dose felt like Ritalin and it felt good. So anyway, just keep in mind that the 'suggested' doses by the doc may or may not be appropriate for you.
> my doc just gave me a script for levomilnacipran...
>
> we shall see
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