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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by SLS on August 4, 2002, at 13:25:26
Nardil + imipramine = serotonin syndrome
I had been adding Nardil to a combination of Lamictal 300mg and imipramine 300mg. I never had any problem with a similar combination using high dosages of Parnate. My muscles became rigid, especially around the neck. I had difficulty walking and was very weak and unsteady on my feet. My leg muscles were rigid. I experienced tremors throughout my whole body and sweated profusely. I became dysphoric and found it difficult to focus on what was going on around me. I thought these things were due to the NE reuptake inhibition and anticholinergic effects of imipramine. After some consideration, my doctor decided that it was the onset of serotonin syndrome. I was OK until the dosage of Nardil was raised from 45mg to 60mg. I had been titrating very slowly, having reached 60mg after at least 8 weeks.
I guess I have been underestimating the potency of tertiary tricyclic TCAs to inhibit the reuptake of serotonin. The only problems I ever had using Nardil with desipramine, an extremely selective NE reuptake inhibitor, was low blood pressure and urinary hesitancy.
I guess the lesson is that a healthy respect for the serotonergic properties of TCAs is warranted when combining them with MAOIs, particularly Nardil.
- Scott
Posted by Iago Camboa on August 6, 2002, at 2:47:35
In reply to Nardil + imipramine = serotonin syndrome, posted by SLS on August 4, 2002, at 13:25:26
Hi Scott,
Ouch! I'm sure it was no 'sweet pear' that one! Are you defying the devil? 300mg imipramine and 60mg phenelzine even carefully titrated (let alone the Lamictal) may be enough to knock out a bison! I think you are lucky to be alive...
How have you proceeded? Did you lay down on bed and waited it to end? Had your doc provided some pill for just in case? Have you any stubborn treatment-resistent depression? Have you tried Nardil + Dexedrine + Lamictal? Or clomipramine/Anafranil + Dexedrine + Lamictal?I wish you the very best of luck.
Iago>
> Nardil + imipramine = serotonin syndrome
>
> I had been adding Nardil to a combination of Lamictal 300mg and imipramine 300mg. I never had any problem with a similar combination using high dosages of Parnate. My muscles became rigid, especially around the neck. I had difficulty walking and was very weak and unsteady on my feet. My leg muscles were rigid. I experienced tremors throughout my whole body and sweated profusely. I became dysphoric and found it difficult to focus on what was going on around me. I thought these things were due to the NE reuptake inhibition and anticholinergic effects of imipramine. After some consideration, my doctor decided that it was the onset of serotonin syndrome. I was OK until the dosage of Nardil was raised from 45mg to 60mg. I had been titrating very slowly, having reached 60mg after at least 8 weeks.
>
> I guess I have been underestimating the potency of tertiary tricyclic TCAs to inhibit the reuptake of serotonin. The only problems I ever had using Nardil with desipramine, an extremely selective NE reuptake inhibitor, was low blood pressure and urinary hesitancy.
>
> I guess the lesson is that a healthy respect for the serotonergic properties of TCAs is warranted when combining them with MAOIs, particularly Nardil.
>
>
> - Scott
>
Posted by SLS on August 7, 2002, at 7:54:42
In reply to Re: Nardil + imipramine = SS » SLS, posted by Iago Camboa on August 6, 2002, at 2:47:35
Hi Iago.
> Ouch! I'm sure it was no 'sweet pear' that one! Are you defying the devil? 300mg imipramine and 60mg phenelzine even carefully titrated (let alone the Lamictal) may be enough to knock out a
bison! I think you are lucky to be alive...I wish I were a bison. Using such combinations over the last 12 years have not made much of a dent in my condition. In fact, I often feel nothing at all when using them - no stimulation of any kind.
I have not been particularly fearful of taking such combinations. I have been treated with similar regimes in the past.
> How have you proceeded? Did you lay down on bed and waited it to end?
Well, I have pretty much been laying in bed for two decades waiting for the beast of depression to be driven away. I did have to remain recumbent because the low blood pressure resulting from the combination of Nardil and imipramine did not allow me to stand up without passing out. However, this effect is probably related to the NE alpha1 blocking and anticholinergic effects of imipramine rather than serotonin syndrome. I found that the quickest way to relieve this condition along with the serotonin syndrome was to discontinue the imipramine. It takes a long time for the MAO inhibition action of Nardil and Parnate to dissipate. It was quicker to reduce the serotonin reuptake inhibition produced by imipramine by stopping it.
> Had your doc provided some pill for just in case?
No, but that's an excellent idea. I'll ask my doctor about it next week when I see him. Over the last few years, I have seen several different remedies suggested for serotonin syndrome. I wish I had written them down.
> Have you any stubborn treatment-resistent depression? Have you tried Nardil + Dexedrine + Lamictal? Or clomipramine/Anafranil + Dexedrine + Lamictal?
I have a very refractory case of a severe and chronic unremitting bipolar depression. Unfortunately, a desparate situation requires desparate measures. I had once taken a combination of Parnate 150mg + desipramine 300mg + amphetamine 20mg + thyroxine (T4).
The only thing that ever worked well and for more that just a few weeks was a combination of Parnate 60mg + desipramine 150mg. Unfortunately, my doctor at the time decided to discontinue my medication after only 9 months. I relapsed within 2 months and have not responded to the same combination since. Damn. It's hard to believe that such a seemingly small treatment decision has cost me so much.
> I wish you the very best of luck.
Thanks, Iago.
Sincerely,
Scott
Posted by SLS on August 7, 2002, at 7:55:58
In reply to Re: Nardil + imipramine = SS, posted by SLS on August 7, 2002, at 7:54:42
What are some strategies to treat serotonin syndrome?
Thanks.
- Scott
Posted by cybercafe on August 7, 2002, at 23:12:03
In reply to How do you treat serotonin syndrome?, posted by SLS on August 7, 2002, at 7:55:58
> What are some strategies to treat serotonin syndrome?
wild guess? i'd say keep subject in cold bath to prevent hyperpyrexia...
likewise treat other symptoms as applicable
Posted by Sunnely on August 9, 2002, at 21:39:28
In reply to How do you treat serotonin syndrome?, posted by SLS on August 7, 2002, at 7:55:58
Serotonin syndrome is usually mild and resolves over 12-24 hours with drug discontinuation and general supportive therapy.
However, serious complications have also been reported including severe hyperthermia, seizures, respiratory failure and death.
If serotonin syndrome is suspected, the offending drugs should be stopped immediately.
Other treatments are usually symptomatic. For example, cooling blanket for hyperthermia; anticonvulsants for seizures; benzodiazepine (e.g., clonazepam) for agitation and myoclonus; anti-hypertensive (e.g., nefidipine) for high blood pressure.
The use of an anti-serotonergic drug (e.g., cyproheptadine or Periactin) can also hasten recovery.
> What are some strategies to treat serotonin syndrome?
>
> Thanks.
>
> - Scott
Posted by ross on August 10, 2002, at 22:11:12
In reply to Re: How do you treat serotonin syndrome? » SLS, posted by Sunnely on August 9, 2002, at 21:39:28
klonopin does not work as studies have provided.
the best known to date is Valium. do a xheck on SS and you'll see.
ross
Posted by Sunnely on August 10, 2002, at 23:23:14
In reply to klonopin a no-no in serotonin syndrome, posted by ross on August 10, 2002, at 22:11:12
Would you kindly post your reference specifically indicating that Klonopin does not work for myoclonus and agitation. Thanks.
> klonopin does not work as studies have provided.
> the best known to date is Valium. do a xheck on SS and you'll see.
> ross
Posted by cybercafe on August 11, 2002, at 4:47:48
In reply to Re: klonopin a no-no in serotonin syndrome, posted by Sunnely on August 10, 2002, at 23:23:14
> Would you kindly post your reference specifically indicating that Klonopin does not work for myoclonus and agitation. Thanks.
sorry to bud in here -- but i believe klonopin does have affinity for serotonin receptors, so it may not be the best med for a system that is already having problems dealing with an excess of serotonin (that the serotonin effects would outweigh the GABA-A effects is just a guess, though)
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