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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by Noa on July 3, 2001, at 20:58:49
A good friend of mine is trying to figure out a good med combo. Here is what she has tried so far:
Wellbutrin---noticed improved energy level at 150/day, got agitated when increased to 300, so reduced to 150 and added celexa.
Celexa---added celexa to wellbutrin, noticed improved cognitive functioning and mood, but lower energy level. Doesn't know if this is due to lowered Wellbutrin or from the Celexa. Is only taking half standard dose. Has muscle twitches, severe jaw clenching (and headaches) since starting Celexa.
Had taken Prozac a few years ago, gained a lot of weight. Discontinued because of this and because she had felt better. Did fine for a few years, until current episode.
Other symptoms: anxiety, insomnia, hormone-related mood changes.
Other meds: synthroid (has autoimmune thyroid disorder), oral contraceptives (for hormonal mood fluctuations), allergy/asthma medications, including steroid inhalers.
Significant family history: Father has bipolar disorder (with manic and explosive anger symptoms as well as depression) and alcoholism. Brother--ADHD, alcoholism, possibly bipolar-spectrum explosive anger disorder.
Any ideas?
Posted by Phil on July 3, 2001, at 21:29:18
In reply to Friend trying to find right med combo, posted by Noa on July 3, 2001, at 20:58:49
Hey Noa, I know that you have recommended sleep studies before so I assume y'all talked about that.
As you know, I'm not one of the science guys here but my vote would be to try Nortriptyline with the Wellbutrin. Nortrip. would help with the anxiety and sleep difficulties.
Posted by SalArmy4me on July 4, 2001, at 21:22:39
In reply to Friend trying to find right med combo, posted by Noa on July 3, 2001, at 20:58:49
Nortriptyline might have severe anticholinergic side-effects. I suggest Mirtazapine which has antidepressant action, anti-anxiety efficacy, and increased libido due to its action on the Alpha-2 NE receptor.
--Mirtazapine can be used for all types of depression, anxiety, OCD, and insomnia.
--It is convienient because it is taken only once at bedtime.
--You can take Remeron with most antidepressants except MAOIs.
--It has none of the anticholinergic effects of SSRIs.
--It has gained recognition as a very useful medication from psychiatrists in only four years of FDA approval.I myself started Remeron at 60 mg right away and had no side-effects. I had no weight gain or sedation during the day.
http://www.dr-bob.org/tips/split/Mirtazapine-for-SSRI-ADRs.html
www.remeron.com
http://www.rxlist.com/cgi/generic/mirtaz.htm
Posted by Noa on July 5, 2001, at 8:47:43
In reply to Re: Friend trying to find right med combo, posted by SalArmy4me on July 4, 2001, at 21:22:39
Thanks.
I hadn't thought of the sleep study angle, btw. Thanks for the reminder.
I am pretty sure she will balk at nortrip, because she is afraid of tricyclics due to her family history of bipolar.
At the moment, she says she feels the wellbutrin is not effective at all at the lower dose. And of course, at higher dose she is agitated.
What do you guys think about this?
-lower the celexa
-add a stimulant
-get more in-depth thyroid tests to see what her T3 levels are. Possibly add T3The Remeron idea is a possibility, too, I guess. She is concerned about weight gain, tho.
Posted by judy1 on July 5, 2001, at 9:21:52
In reply to Re: Friend trying to find right med combo, posted by Noa on July 5, 2001, at 8:47:43
Hi Noa,
I just posted an AD study below about AD's in bipolar disorder. I realize your friend is not dxed bipolar (or is she?), but with her loaded genetics that should be enough to raise the caution flag when it comes to AD's of all classes. The several bipolar experts I have seen all felt that AD's were extremely destabilizing in bipolar disorder; personally I noticed a significant decrease in my rapid cycling once they were removed from my regimen. Which leaves of course how to treat depression, and my favorite in this case- lamictal. Hope all is well with you and your friend begins to feel better- judy
Posted by medlib on July 5, 2001, at 17:25:48
In reply to Re: Friend trying to find right med combo, posted by Noa on July 5, 2001, at 8:47:43
Hi Noa--
If your friend finds 300 mg. Wellbutrin agitating, I wouldn't recommend adding a stimulant. I'm surprised to learn that she's taking Celexa; I thought that it has a worse weight-gain profile than Prozac. A number of people have found a Well.-Prozac combo synergistic. Together, they should be neutral re weight gain, especially at lower levels of Prozac (10-20mg/day. I'd try Well. 225mg + Prozac 20mg. before giving up on the Well. Tho rarely sufficient by itself, W.'s a good augmenter.
2 other points: Your friend's allergy/asthma meds quite likely are sedating--most antihistamines are--but she should check to make sure that she is taking the least sedating alternatives available. And, if she tries Remeron, it's less sedating and less likely to cause weight gain at higher doses (30-45 mg.); this is one med you *don't* want to ramp up.
Your idea for more extensive thyroid testing sounds helpful, too. Since, as you know, internists and pdocs frequently have quite different notions of what constitutes euthyrold levels, these probably are best scheduled through a pdoc, if she has one.
Your friend's lucky to have you on her side!---medlib
Posted by Phil on July 5, 2001, at 18:17:44
In reply to Re: Friend trying to find right med combo » Noa, posted by medlib on July 5, 2001, at 17:25:48
Noa, What's helped me the most over the years has been Ritalin. I'm also taking Wellbutrin SR 150 mg a day, Klonopin 2mg a day, and Amitriptyline 225mg a day. Hell of a cocktail.
Anyway, the point I was getting to was the possibility of adding Ritalin. I get very agitated if I go too high on Wellbutrin but don't have that problem at all with Ritalin.
When I was taking Remeron at 60 mg a day..no weight gain or sedation. I agree with the other post; don't ramp up with Remeron. If you start at 15mg, it's coma time. Unfortunately, Remeron didn't do the trick for me. Good luck.
Posted by Noa on July 5, 2001, at 18:25:45
In reply to Re: Friend trying to find right med combo, posted by Phil on July 5, 2001, at 18:17:44
What do y'all mean about not ramping up--do you mean she would start at a higher dose right off the bat?
I wonder what it is that is agitating about the Welbutrin--could it be the norepiniphrine effects? I was thinking that was a possibility given that she already has norepiniphrine activity from her asthma inhalers, and therefore might be sensitive to this in the wellbutrin.
The serotonin effects of the celexa seem to help her mood a lot, although she can't take too much of it, because of sensitivity to the increased muscle action effects from the serotonin.
But medlib, your point about 225 wellbutrin is a good one. I think she was limited to 150 or 300--is that how the Wellbutrin SR comes?
Posted by medlib on July 5, 2001, at 18:26:15
In reply to Re: Friend trying to find right med combo » Noa, posted by medlib on July 5, 2001, at 17:25:48
Noa--
Re: possible Wellbutrin-Prozac combo
If your friend is interested in trying this combo, s/he probably should start at lower doses than I mentioned above--say Prozac 10mg + Well. 150mg. Although W. and P. are metabolized by different liver enzymes, W. can inhibit the enzyme that one isomer of P. needs for metabolism. The net result is that blood levels of Prozac when taken with Well. will be higher than the same dose of P. taken alone.I know 3 people happy with this combo (at higher doses), so it's not contraindicated, but it's usually better to "start low, go slow".
Well wishes---medlib
Posted by Phil on July 5, 2001, at 19:09:31
In reply to Re: Friend trying to find right med combo, posted by Noa on July 5, 2001, at 18:25:45
Noa..Wellbutrin SR comes in a 100mg. I tried 100mg a.m. and 100mg p.m. but, like I read from another post, my left eyelid, below the eye, would twitch for a few minutes a couple of times a day!!
Not to make light of folks with this problem but if it kept up I was thinking about auditioning for the Ally McBeal show. Now, if I could just make my nose whistle.Phil
Posted by medlib on July 5, 2001, at 20:04:47
In reply to Re: Friend trying to find right med combo, posted by Noa on July 5, 2001, at 18:25:45
> What do y'all mean about not ramping up--do you mean she would start at a higher dose right off the bat?
--Yeah, I started at 30mg., ramped to 60mg.
> I wonder what it is that is agitating about the Welbutrin--could it be the norepiniphrine effects? I was thinking that was a possibility given that she already has norepiniphrine activity from her asthma inhalers, and therefore might be sensitive to this in the wellbutrin.--It could be either the NE or dopamine effects. If any of the a/a meds contain ephedrin, they *could* have additive effects w. Well.'s NE action. If that's the case, results would be similar with a stimulant. If W.'s dopamine action is responsible for the agitation, a stim. such as Ritalin might be a good replacement for the W.
> The serotonin effects of the celexa seem to help her mood a lot, although she can't take too much of it, because of sensitivity to the increased muscle action effects from the serotonin.--Celexa is the "purest" and most potent ssri--no NE effect. All the others have varying amounts of action on NE receptors, though at much lower levels than their actions on seratonin.
> But medlib, your point about 225 wellbutrin is a good one. I think she was limited to 150 or 300--is that how the Wellbutrin SR comes?--That's true of the SR form; but, several I know take SR in the morning and an IR bolus in the afternoon.
The reason I mentioned Prozac is because your friend had done well on it in the past (as I did), and combining it with W. allows one to take a lower level of Prozac with little/no wt. gain. I've found it helpful to "add back" a low dose of P. to my med combo. Individual results vary so widely, though, reasoned prediction is almost useless; there sure are no "should work"s.
Although I'm *very* happy you've found something that works, I'm envious of your stable combo. Guess I'm with Tina right now--endless experimentation eventually gets to be a real drag.---medlib
Posted by Phil on July 5, 2001, at 21:19:00
In reply to P.P.S., posted by medlib on July 5, 2001, at 20:04:47
> Although I'm *very* happy you've found something that works, I'm envious of your stable combo. Guess I'm with Tina right now--endless experimentation eventually gets to be a real drag.---medlibYou can add me to that list too, medlib. It has been a rough couple of years for me. Feel okay one day but no consistent relief.
Phil
Posted by Noa on July 6, 2001, at 9:06:35
In reply to Re: P.P.S. medlib, posted by Phil on July 5, 2001, at 21:19:00
Thanks, medlib and Phil. My friend saw the pdoc yesterday and he suggested lowering the celexa dose, and keeping the Wellbutrin at 150. It might work for her. She seems to be quite sensitive to relatively small doses. And I do thing that too much NE action doesn't go well with her asthma meds, which I think already prime her for anxiety.
I really appreciate all the great info!
I am grateful that I currently have a stable mix of meds and am doing well. It isn't perfect. I have had to decide to tolerate some side effects that, in the scheme of things, are not hard to deal with, considering the benefit I am getting. But I do still hold out hope that an even better combo will come along in a couple of years, and eventually that custom made precision pill, of course--hopefully not to far off in the future!
I do hope both of you will find something that works better for you.
This is the end of the thread.
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