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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by shellie on November 8, 2000, at 13:55:24
I'm trying serzone with nardil; I am up to 250mg of serzone and my muscles ALL over are killing me. This didn't happen when I took the serzone by itself. Right now I can barely get myself to move, let alone go out of the house. It's even hard to just sit at the computer, but my muscles hurt even when I'm lying down.
I have looked through the serzone web info and the PB babble archives, and have found this as a side effect to SSRIs and serzone. (Flu syndrome' ). The few people who wrote about it discontinued the med. I'm wondering if anyone had these symptoms, and after a certain amount of time had the symptoms go away.
I don't want to stop the serzone prematurely, but this is so hard to go through, especially workwise. It is also making me feel like I just want to give up on everything--I feel so discouraged and defeated.
Any info would be appreciated. Shellie
Posted by SLS on November 8, 2000, at 19:50:31
In reply to Serzone and Aching Muscles-PLEASE HELP, posted by shellie on November 8, 2000, at 13:55:24
It may be a manifestation of serotonin syndrome. Get on the Internet and see what you come up with. I don't think it is necessary to have all the symptoms listed. If you find the description of muscle aches as being exactly the same as what you are experiencing, you may want to abort.
Do you have a mild fever?
- Scott> I'm trying serzone with nardil; I am up to 250mg of serzone and my muscles ALL over are killing me. This didn't happen when I took the serzone by itself. Right now I can barely get myself to move, let alone go out of the house. It's even hard to just sit at the computer, but my muscles hurt even when I'm lying down.
>
> I have looked through the serzone web info and the PB babble archives, and have found this as a side effect to SSRIs and serzone. (Flu syndrome' ). The few people who wrote about it discontinued the med. I'm wondering if anyone had these symptoms, and after a certain amount of time had the symptoms go away.
>
> I don't want to stop the serzone prematurely, but this is so hard to go through, especially workwise. It is also making me feel like I just want to give up on everything--I feel so discouraged and defeated.
>
> Any info would be appreciated. Shellie
Posted by SLS on November 8, 2000, at 20:32:08
In reply to Serzone and Aching Muscles-PLEASE HELP, posted by shellie on November 8, 2000, at 13:55:24
Shellie,
MAOI + serotonin reuptake inhibitor = Serotonin Syndrome
Serzone is a serotonin reuptake inhibitor, even though it is much less potent than the SSRIs. Perhaps it is more potent than its sister drug, trazodone, which is often chosen as a sleep-aid for insomnia associated with Parnate. I don't remember trazodone specifically being used by anyone with Nardil, but I imagine it is. I get the feeling that Nardil may be more potent than Parnate as an inhibitor of the MAO-A enzyme, which is responsible for breaking-down serotonin.
Muscle rigidity and hypertonia?
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http://www.vnh.org/EmergPsychHB/MedEmergSerotonin.html
The serotonin syndrome is a potentially dangerous adverse reaction which can occur during administration of serotonergic agents. It is attributed to a toxic hyperserotonergic state which is believed to result in hyperstimulation of the brain stem and spinal chord 5HT1A and 5HT2 receptors.
The syndrome has been documented in the medical literature since the 1960s. However, it appears that this adverse drug reaction may not be well recognised or be confused with other adverse events such as neuroleptic malignant syndrome or the hypertensive crisis manifested in the MAOI/tyramine reaction. In addition, manifestations of the syndrome may vary from mild changes in mental status, motor system changes and autonomic instability to potentially fatal reactions including rhabdomolysis and disseminated intravascular coagulopathy.1 Consequently the true incidence of the serotonin syndrome is not known.
In view of the popularity of the SSRIs clinicians should be aware of the signs and symptoms (see Table 1) and potential for occurrence of the serotonin syndrome.After evaluating the available literature Sternbach 2 and more recently Keltner 3 proposed that the following criteria be met for its diagnosis.
A. Symptoms must coincide with the initiation or increase in dose of a serotonergic agent.B. At lease THREE of the signs or symptoms attributed to the Serotonin Syndrome must be present :-
C. Other aetiologies such as metabolic disorders, infection, substance abuse or withdrawal must be excluded.
Table 1: Signs and Symptoms of the Serotonin Syndrome 1-3
Mental status/behavioural changes Altered muscle tone Autonomic instabilityAgitation
Myoclonus
Hypertension
Restlessness
Tremor
Hypotension
Confusion
Shivering Tachycardia
Incoordination
Rigidity
Sweating
Hypomania
Hyperreflexia
Fever
Possible seizures
Diarrhoea
ComaThe serotonin syndrome is most commonly reported with concomitant use of a MAOI (which blocks the metabolism of serotonin among other amines ) and either an SSRI (which blocks the reuptake of serotonin) or tryptophan , a serotonin precursor. 2 However, the combination of MAOIs with other serotonergic agents such as tricyclic antidepressants (clomipramine or amitriptyline ), pethidine, lithium and fenfluramine have been implicated. Both nonselective MAOIs and the newer selective MAOIs ( moclobemide and selegeline) have been associated with the serotonin syndrome. 3-4.
in the lower limbs.Autonomic and other clinical features include fever, sweating, nausea, vomiting, diarrhoea and hypertension.
Life-threatening acute complications include coma, seizures, rhabdomyolysis and disseminated intravascular coagulation (DIC).
--------------------------------------------------
http://www.intox.org/pagesource/treatment/serotoninsyndrome.htm
CLINICAL FEATURESOnset of clinical features may be from hours to days after exposure to the causative agent(s). The classic triad of clinical features includes mental status, motor and autonomic changes. The combination of features observed is extremely variable between individual cases.
Mental status changes reported include anxiety, agitation, confusion, restlessness, hypomania, hallucinations and coma.
Motor changes include tremor, myoclonus, hypertonia, hyperreflexia and incoordination. Increased muscle tone is often most prominentThe Serotonin Syndrome
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Posted by shellie on November 8, 2000, at 22:18:19
In reply to Re: Serzone and Aching Muscles-PLEASE HELP » shellie, posted by SLS on November 8, 2000, at 20:32:08
Hi Scott, thanks. It never even crossed my mind that this could be serotonin syndrome. I've read what you've sent me, and looked on some other internet sites, and I'm not sure. My temperature IS up, my muscles ache (but I don't know if they are rigid--not sure exactly what that means), my bp has been down, which I did attribute to the serzone. No sweating. Also I have no mental impairment, or confusion or hypomanic symptoms, so I just don't know. I already have a call in to my pdoc for tomorrow--she left her office early and I didn't think it was something that couldn't wait until tomorrow morning so I didn't page her. I didn't take my nardil this afternoon and won't today. I will probably discontinue the serzone.
It's strange--I took this combination about six years ago, got hypotension but nothing else. Is this what old age does?
Anyway, Scott, thanks again. I was totally focused on the serzone and not the combination. If I do have seratonin syndrome, I think it is mild at this point (although my body says, "no this is not mild"--I really hurt). Shellie
Posted by SLS on November 9, 2000, at 6:29:39
In reply to Re: Serzone and Aching Muscles- » SLS, posted by shellie on November 8, 2000, at 22:18:19
Shellie,
If I were you, I would keep taking Nardil and just discontinue the Serzone. This is assuming that none of your side effects were present prior to adding Serzone. It is desirable to try to keep the level of MAO inhibition that is therapeutically effective for you. Levels of Serzone should drop quickly.
Just a thought...
- Scott>
>
> Hi Scott, thanks. It never even crossed my mind that this could be serotonin syndrome. I've read what you've sent me, and looked on some other internet sites, and I'm not sure. My temperature IS up, my muscles ache (but I don't know if they are rigid--not sure exactly what that means), my bp has been down, which I did attribute to the serzone. No sweating. Also I have no mental impairment, or confusion or hypomanic symptoms, so I just don't know. I already have a call in to my pdoc for tomorrow--she left her office early and I didn't think it was something that couldn't wait until tomorrow morning so I didn't page her. I didn't take my nardil this afternoon and won't today. I will probably discontinue the serzone.
>
> It's strange--I took this combination about six years ago, got hypotension but nothing else. Is this what old age does?
>
> Anyway, Scott, thanks again. I was totally focused on the serzone and not the combination. If I do have seratonin syndrome, I think it is mild at this point (although my body says, "no this is not mild"--I really hurt). Shellie
Posted by shellie on November 9, 2000, at 16:14:23
In reply to Re: Serzone and Aching Muscles- » shellie, posted by SLS on November 9, 2000, at 6:29:39
Scott, my pdoc called this morning and agreed with your evaluation. Not exactly serotonin syndrome, but definitely a serotinon reaction-said to cut out serzone, stay on nardil for now. Then when I've gotten back to normal-- stay at 100mg of serzone. So you were exactly right.
So, if I ever run out of money, you will have to be my pdoc.
By the way, when I was reading some old posts about serzone I came upon a post where you mentioned Nathan Klein. If I wasn't in such a bad place now, I would write him (is he still alive?) to tell him he saved my life when I was 22. I saw him on PBS after getting out of shepard pratt hospital with no improvement and he talked about MAOIs. Then after I got my doctor to prescribe them, in his book he said don't give up after three weeks, sometimes the effects aren't noted until six weeks. I read that page every day for two weeks and kept with the nardil. And sure enough nardil took effect for me in the 5th week. I couldn't take tricyclics (which they kept giving me at the hospital), and no one there, or my psychiatrist outside had even mentioned MAOIs even though I was in a horrible depression. So it was luck that I caught him on PBS and his encouragement that keep me on the MAOI after four weeks.
Thanks again. I am doing really badly. I hope you are doing better than me. Let me know. Shellie
Posted by SLS on November 9, 2000, at 20:49:52
In reply to Re: Serzone and Aching Muscles-Dr.Scott (SLS), posted by shellie on November 9, 2000, at 16:14:23
Dear Shellie,
> I am doing really badly.
I'm sorry.
Hang in there.
It is so easy to say - almost too easy. I know how many times people have said that to me when I was doing really badly. Although it doesn't take any of the pain away, hearing it seems to offer hope that it will soon end. I know it will. Hearing it also helps me to remember that I have people around me (even if it is only you :-)) who care, who are supportive, and who are available to reach out to and communicate my pain and suffering to.
I wish I could do more for you than type a few words.
My dearest Shellie, I think it may be time to consider either Lamictal and/or Risperdal (I don't recall for sure, but didn't you have a problem with Risperdal)?. Both usually produce only mild to moderate weight gain. If raising the dosage of Nardil to 90mg does not produce substantial relief - which may not show up for two weeks after a dosage change - I think it may be time to f_ck the weight gain and get better.
You may not know to what degree dietary and exercise changes will combat the weight gain until you try.
If you did have a problem with Risperdal, can you describe in exact details what you experienced?
I won't even try to push Zyprexa down your throat at this point. :-o My gut tells me that Zyprexa may be generally more efficacious for depression than the others, although the others do work. Seroquel certainly represents a viable alternative since it produces much less weight gain and is less likely than Risperdal to cause EPS. However, Risperdal is the least likely to produce weight-gain.
Hopefully, ziprasidone (Zeldox) will be released by spring 2001. It is sort of like a Zyprexa without weight-gain. I will be interested in trying it myself so long as cardiac side effects don't become an issue. I'll let you know how much weight I gain, if any (wishful thinking).
I want very badly to change from Parnate to Nardil. Parnate makes me feel somewhat flat and unmotivated. It helps me to stay off the bottom and gives me mental energy. However, my doctor wants to try a couple "quick" augmenting strategies first. From what I am beginning to see, low dosages of the atypical neuroleptic antipsychotics (Clozaril, Risperdal, Zyprexa and Seroquel) are particularly effective when combined with an MAOI.
I am now taking Parnate 80mg + desipramine 300mg + Lamictal 300mg.
I now realize that I was beginning to feel better during the week I had added Risperdal. I stopped after a week because it affected the way I walked, and I was concerned that it was EPS. My doctor felt pretty confident that it was not. He gave me the option of trying either Zyprexa or Risperdal first, and cross over to the other if the first one did not work. After 3 days, I can say that I feel slightly better for having added Zyprexa. I am starting at 2.5mg. 5mg will probably turn out to be optimal, but we'll see. I had a hard time deciding between the two drugs. The only thing about Zyprexa that caused me hesitate taking it was the GD weight-gain. I am vain too.I have already begun to change my eating habits in anticipation of the battle. If Zyprexa works great with Nardil (once I change over), I think it will be worth the trade-off. This idea doesn't seem so terminal at the moment because I anticipate being able to try switching to Zeldox in six months.
> I hope you are doing better than me.
I guess we have something in common. I hope you are doing better than me.
Love,
Scott---------------------------------------------------------------
2: Acta Psychiatr Scand 2000 Jun;101(6):416-32
Atypical antipsychotics and weight gain--a systematic review.
Taylor DM, McAskill R
Maudsley Hospital, London, UK.
OBJECTIVE: To review systematically data relating to weight changes with atypical antipsychotics. METHOD: We conducted a Medline search on October 29 1999 and covered the period 1980-99. All recovered papers were examined for further relevant reports. In addition, we wrote to pharmaceutical manufacturers and 10 practising clinicians to ask them to provide other relevant reports known to them. RESULTS: Eighty reports mentioning change in body weight were retrieved. Data relating to weight changes were of variable quality. Weight changes were indicated by a variety of measures. The majority of reports related to short-term changes. CONCLUSION: All atypical drugs, with the exception of ziprasidone, have been associated with weight increases. Clozapine seems to have the highest risk of weight gain, followed by olanzapine and quetiapine. There is probably a lower risk with risperidone, sertindole and zotepine and a still lower risk with amisulpride. Ziprasidone appears not to be associated with weight gain. In the absence of more compelling data, these rankings must be considered approximate and preliminary. Longer, more robust trials are needed.
Publication Types:
Review
Review, tutorialPMID: 10868465, UI: 20324317
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Posted by Sunnely on November 11, 2000, at 0:11:26
In reply to Serzone and Aching Muscles-PLEASE HELP, posted by shellie on November 8, 2000, at 13:55:24
Hi Shellie,
Scott, more than likely, is correct - serotonin syndrome.
Just curious. Are you taking other meds? Some meds may cause muscle aches/pains which may signal a potentially serious medical problem ("rhabdomyolysis"), muscle cells are breaking down. If worsens, you should have your CPK checked.
Posted by shellie on November 11, 2000, at 19:44:44
In reply to Re: Serzone and Aching Muscles-Dr.Scott (SLS) » shellie, posted by SLS on November 9, 2000, at 20:49:52
Hi Scott,
Concerning increasing naradil and taking lamictal:
I want to try nardil with 100mg serzone and add pindolol. My pdoc on Friday said no to the addition because she thought I hadn't been on serzone with nardil long enough. But I've been on the combination for a month now, up to 250mg for two days, now starting again with 100mg.I can't go any higher than 45mg of nardil and really can't even stay that high or I have severe sleep difficulties and whiteouts. Whiteouts meaning that when I go from a inside to out when I have been on 45mg for a while, everything turns white and I can't see at all. It's really scary--last time it happened I was on the sidewalk and couldn't see the street and I had to ask some construction workers to help me cross. I'm sure they thought I was drunk. Then after just about 30 seconds, everything is normal again. That happens after I am on 45mg for several months.
If pindolol doesn't help then I will consider going back on lamictal. The problem is that I am already about 25lbs overweight, but I lose fairly easily when I do the treadmill and watch (not obsessively) what I eat. When I was on lacmictal I was working out a lot and eating well, and still gained a few lbs. Within ten days after I got off, I lost 9 lbs. Also, it made my breasts really hurt all the time. But if I can keep it to just an extra ten lbs, it is probably my best solution. Last year I was dating for the first time in a long time and I felt really self-conscious about the extra weight. But it's coming down to not a lot of choices left for me.
> If you did have a problem with Risperdal, can you describe in exact details what you experienced?
>I only took risperdal for one day and my arms and legs felt like they each weighed 100 lbs. I think the reaction was related to EPS and my pdoc took me right off it. All other antipsychotics make me totally disoriented. I never tried zyprexa because of weight gain, but both ampisulpride and serequel made me disoriented and I wouldn't have been able to work (I tried them on days that I knew I didn't have to work.)
On the bright side of life, I am able to work in the arts, create beautiful black & white portraits and get paid for it. Running the business by myself is sometimes really hard because there is no one to fall back on. But I am never depressed when I am shooting. It's like this amazing thing to me, no matter how depressed I feel that day, when I am taking portraits, the depression completely receeds for that time period. So even in the worse times, there is some relief.
It seems like you are feeling very comfortable with your new pdoc. True? I don't always understand the exact nature of your depression. Would you describe it as a flatness to everything and a lack of joy? Do you feel pain physically in relation to the depression? Please don't answer if these are uncomfortable questions.
I'll let you know if I add pindolol and how that goes. Please keep in touch with how you are doing. Goodnight for now. Shellie
Posted by shellie on November 11, 2000, at 19:54:15
In reply to Re: Serzone and Aching Muscles-PLEASE HELP, posted by Sunnely on November 11, 2000, at 0:11:26
> Hi Shellie,
>
> Scott, more than likely, is correct - serotonin syndrome.
>
> Just curious. Are you taking other meds? Some meds may cause muscle aches/pains which may signal a potentially serious medical problem ("rhabdomyolysis"), muscle cells are breaking down. If worsens, you should have your CPK checked.
Hi Sunnely. Yes, my pdoc agreed with Scott. I stopped the serzone for two days and my muscles feel much better. Tomorrow I start to take Nardil with just 100mg of serzone and will see how that goes. Thanks for the feedback, Shellie
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