![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 34. This is the beginning of the thread.
Posted by tensor on December 28, 2004, at 8:49:43
Hi,
What would be a good choice to combine a mood stabilizer with? I'm currently at remeron+zoloft and i've tried them at high doses with no success. The adding of is mood stab is imminent. Would it be wise to just add a mood stabilizer to that combo or should i start with something else? Maybe nortrip+lithium? Your experiences and ideas appreciated.
Thanks,
Mattias
Posted by Ritch on December 28, 2004, at 14:50:25
In reply to What to combine with a mood stabilizer?, posted by tensor on December 28, 2004, at 8:49:43
> Hi,
>
> What would be a good choice to combine a mood stabilizer with? I'm currently at remeron+zoloft and i've tried them at high doses with no success. The adding of is mood stab is imminent. Would it be wise to just add a mood stabilizer to that combo or should i start with something else? Maybe nortrip+lithium? Your experiences and ideas appreciated.
>
> Thanks,
> MattiasYou might want to consider getting off the Remeron and Zoloft before trying a mood stabilizer. You said that you had 'no success' with Rem+Zoloft. You might try withdrawing first from the one that appears to be least effective. Then withdraw from the other one. Then try just lithium (or lamictal) by itself and see what happens. Then consider the nortriptyline. I suggest withdrawing from the ineffective drugs first, so that taking them doesn't cloud your response to the mood stabilizer and so that you don't make too many changes at the same time that will muddy the waters also. Just a thought or two. Good luck.
Posted by tensor on December 28, 2004, at 15:03:57
In reply to Re: What to combine with a mood stabilizer? » tensor, posted by Ritch on December 28, 2004, at 14:50:25
Hi Ritch!
> You might want to consider getting off the Remeron and Zoloft before trying a mood stabilizer. You said that you had 'no success' with Rem+Zoloft. You might try withdrawing first from the one that appears to be least effective.
It seems that none of them is effective, i've been on remeron for a long time and the add on of zoloft last spring made me recover from that relapse. So it's hard to say which is least effecient.
>Then try just lithium (or lamictal) by itself and see what happens.I think my doctor would disagree with this, for depression, isn't lithium used as an augmentor to an AD?
>Then consider the nortriptyline. I suggest withdrawing from the ineffective drugs first, so that taking them doesn't cloud your response to the mood stabilizer and so that you don't make too many changes at the same time that will muddy the waters also.
Yes i agree, must give each combo a fair trial, but it's taking so much time. Would really need an antidepressant fast. Have you any experience of nortrip?
Kind regards,
Mattias
Posted by Ritch on December 28, 2004, at 18:37:31
In reply to Re: What to combine with a mood stabilizer? » Ritch, posted by tensor on December 28, 2004, at 15:03:57
> It seems that none of them is effective, i've been on remeron for a long time and the add on of zoloft last spring made me recover from that relapse. So it's hard to say which is least effecient.
> >Then try just lithium (or lamictal) by itself and see what happens.
>
> I think my doctor would disagree with this, for depression, isn't lithium used as an augmentor to an AD?
>
> >Then consider the nortriptyline. I suggest withdrawing from the ineffective drugs first, so that taking them doesn't cloud your response to the mood stabilizer and so that you don't make too many changes at the same time that will muddy the waters also.
>
> Yes i agree, must give each combo a fair trial, but it's taking so much time. Would really need an antidepressant fast. Have you any experience of nortrip?
>
> Kind regards,
> Mattias
>
>Aha!, So the Remeron by itself wasn't doing much and you added Zoloft and got some improvement. I would suggest leaving in the Zoloft and ditching the Remeron, wait a little bit for it to wash out (2 weeks or so), THEN add the nortriptyline to the Zoloft, mess with lithium or whatever later on after you'be been on Zoloft+nortriptyline for a while. Get blood levels done on the nortriptyline. The Zoloft will boost it-you need to make sure not to let it (nortriptyline plasma levels) get too high. Your pdoc will know the "window" that you need to be in. I think that's your best bet... drop the Remeron, add the nortriptyline to the Zoloft, get the dose right (of the nt) and see what happens. Lithium by itself would probably not be a good idea for a unipolar depressive (I thought you were bipolar-sorry about that). Yes, I've had experience with nortriptyline. Easiest to tolerate TCA I've taken. The only one that didn't give me orthostatic hypotension (dizziness standing up suddenly). In fact... combined with Zoloft (in particular), it worked rather well. Hope this helps some.
Posted by banga on December 29, 2004, at 10:59:30
In reply to Re: What to combine with a mood stabilizer? » tensor, posted by Ritch on December 28, 2004, at 18:37:31
I actually have had a very nice effect for both depression and anxiety with Lamictal....though some here say the antidepresant effect could fade. So even if ultimately the goal would be to add an antidepressant, I think there can be great gain already in the meantime with the mood stabilizer alone. In fact, some may argue that adding the drugs one by one is better to understand which drug helps in what way.
I am on 100mg of Lamictal with a very nice beginning both for my anxiety and depression. I intend to add an antidepressant..in fact, I did add nortryptiline, but I am pretty discouraged--RAPID weight gain, and I already dont eat much so dieting wont do the trick. I do not want an SSRI again, Wellbutrin has not done anything in the past. Zonegran is a fairly new mood stabilizer that perhaps could help with the weight issue for me.
Posted by tensor on December 29, 2004, at 13:24:37
In reply to Re: What to combine with a mood stabilizer? » tensor, posted by Ritch on December 28, 2004, at 18:37:31
Hi Ritch!
> Aha!, So the Remeron by itself wasn't doing much and you added Zoloft and got some improvement. I would suggest leaving in the Zoloft and ditching the Remeron, wait a little bit for it to wash out (2 weeks or so), THEN add the nortriptyline to the Zoloft, mess with lithium or whatever later on after you'be been on Zoloft+nortriptyline for a while. Get blood levels done on the nortriptyline.
I was actually thinking of get rid of both remeron and zoloft. And then start with nortrip+mood stab. But do have i have to check blood levels for nortrip?
>Lithium by itself would probably not be a good idea for a unipolar depressive (I thought you were bipolar-sorry about that). Yes, I've had experience with nortriptyline. Easiest to tolerate TCA I've taken. The only one that didn't give me orthostatic hypotension (dizziness standing up suddenly). In fact... combined with Zoloft (in particular), it worked rather well. Hope this helps some.
>Yes, thanks it helps! I did respond to clomipramine once, but it has a severe s/e profile. It seems that nortrip does about same but is merely a pro-sexual than anti..
Kind regards,
Mattias
Posted by tensor on December 29, 2004, at 13:30:20
In reply to Re: What to combine with a mood stabilizer?, posted by banga on December 29, 2004, at 10:59:30
Hi banga,
In fact, some may argue that adding the drugs one by one is better to understand which drug helps in what way.
I agree with that.
> I am on 100mg of Lamictal with a very nice beginning both for my anxiety and depression. I intend to add an antidepressant..in fact, I did add nortryptiline, but I am pretty discouraged--RAPID weight gain, and I already dont eat much so dieting wont do the trick.Did it help you for depression/anxiety?
Kind regards,
Mattias
Posted by ed_uk on December 29, 2004, at 15:03:04
In reply to Re: What to combine with a mood stabilizer? » banga, posted by tensor on December 29, 2004, at 13:30:20
Hi Mattias,
Checking plasma levels is not *usually* vital with nortriptyline.
Plasma level monitoring is useful for all patients who have not responded to treatment with nort ie. to ensure that the plasma level is in the therapeutic range. Also, plasma level monitoring is recommended for people taking >100mg/day.
Regards,
Ed.
Posted by theo on December 29, 2004, at 15:06:48
In reply to Re: What to combine with a mood stabilizer?, posted by banga on December 29, 2004, at 10:59:30
Just curious, when do you take your Lamictal, morning or evening or split dose?
Posted by Ritch on December 29, 2004, at 17:03:42
In reply to Re: What to combine with a mood stabilizer? » Ritch, posted by tensor on December 29, 2004, at 13:24:37
> I was actually thinking of get rid of both remeron and zoloft. And then start with nortrip+mood stab. But do have i have to check blood levels for nortrip?
Some people don't get them checked if they show no signs of toxicity and they are responding to the nortriptyline (as Ed mentioned). I just thought it might be a good idea should you combine the Zoloft with it--- because the Zoloft (and other SSRI's) will inhibit liver enzymes that break down the nortriptyline, which may cause very high levels of the nortriptyline at a "standard" dosage and possible toxicity. Some people are "poor metabolizers" of TCA's like nortiptyline as well (without taking an SSRi). Combining SSRI and TCA can raise blood levels of the TCA ten-fold in some cases. Just being cautious. When I took Zoloft+Nortiptyline I was only taking 20-30mg of NT, didn't get blood level done, the only side effects I got from nortrip. besides some dry mouth was a little shakiness with "pins and needles" skin sensations(like from watching a scary movie) and an elevated heart rate. Oh, you might get a decent mood boost when you stop the Remeron.. I definitely did! Good luck!
Posted by banga on December 29, 2004, at 17:12:59
In reply to Re: What to combine with a mood stabilizer? » banga, posted by tensor on December 29, 2004, at 13:30:20
>
> Did it help you for depression/anxiety?
>
> Kind regards,
> MattiasIf you mean did nortryptiline help me, I haven't been on it long enough to find out. I did not have any other side effects other than the weight gain. My body seems to not mind tricyclics.
I also have some cognitive dysfunction..with the nortryp, I had hoped for some activating effects, perhaps for my mind too. I may be adding a stimulant down the line...
>
Posted by ed_uk on December 29, 2004, at 17:31:12
In reply to Re: What to combine with a mood stabilizer? » tensor, posted by Ritch on December 29, 2004, at 17:03:42
> Some people don't get them checked if they show no signs of toxicity and they are responding to the nortriptyline (as Ed mentioned). I just thought it might be a good idea should you combine the Zoloft with it--- because the Zoloft (and other SSRI's) will inhibit liver enzymes that break down the nortriptyline, which may cause very high levels of the nortriptyline at a "standard" dosage and possible toxicity. Some people are "poor metabolizers" of TCA's like nortiptyline as well (without taking an SSRi). Combining SSRI and TCA can raise blood levels of the TCA ten-fold in some cases. Just being cautious. When I took Zoloft+Nortiptyline I was only taking 20-30mg of NT, didn't get blood level done, the only side effects I got from nortrip. besides some dry mouth was a little shakiness with "pins and needles" skin sensations(like from watching a scary movie) and an elevated heart rate. Oh, you might get a decent mood boost when you stop the Remeron.. I definitely did! Good luck!
Hi Mattias,
Ritch is right, getting a plasma level is more important if you were going to combine nort with sertraline. In my last post I was assuming that you'd be taking the nort on its own.
Although sertraline certainly can raise nort plasma levels, it is considerably less problematic than some of the other SSRIs in this respect. Here is a summary of a little study...........
'A study in 14 elderly patients on nortriptyline found that when additionally given 50 mg sertraline daily, the median increase in plasma nortriptyline levels was only 2% (with a range of –26 to 117%), but two of them showed increases of 51% and 117% respectively, changes the authors considered clinically meaningful. For those taking higher doses of sertraline (100 to 150 mg daily) the median increase in nortriptyline plasma levels was 40% (with a range of −12% to +239%).'
Because some people are very sensitive to nortriptyline (eg. poor metabolizers) it is important to start with a very low dose and to increase gradually if necessary. Careful dose titration based on efficacy and tolerability is in many ways as useful as plasma concentration monitoring. People who suffer 'strong' side effects at very low doses are likely to be poor metabolizers.
A suitable starting dose for nortriptyline is 10mg. In the absense of other medication, most people need 50-100mg/day of nort to get a good antidepressant effect. As ever, YMMV, some people will need more (it is unusual to exceed 150mg/day) and others will do well on less. As Ritch said, lower doses of nort may be sufficient for a person taking sertraline.
If severe side effects are present at very low doses it would be useful to get a plasma level- a high plasma conc would suggest that the person may be a poor metabolizer.
If a person fails to improve on nort, a plasma level can tell you whether you should increase or decrease the dose in order to maximize effectiveness. With nort, too high a dose may make the treatment less effective ie. it has a 'therapeutic window'.
Ed.
Posted by ed_uk on December 29, 2004, at 18:34:13
In reply to Re: What to combine with a mood stabilizer?, posted by banga on December 29, 2004, at 17:12:59
Hi!
You may prefer desipramine to nort. Desipramine is more 'activating' than nort and should be less likely to cause weight gain! Have you tried desip already?
Regards,
Ed.
Posted by linkadge on December 31, 2004, at 14:56:36
In reply to To banga, posted by ed_uk on December 29, 2004, at 18:34:13
Why is desipramine considered more activating than nortryptaline ??
Desipramine is a mixed ser/nor reuptake inhibitor while nortryptaline is selective to the norepinephrine transporter.
Linkadge
Posted by ed_uk on December 31, 2004, at 15:25:30
In reply to to Ed_UK, posted by linkadge on December 31, 2004, at 14:56:36
Desipramine is a selective norepinephrine reuptake inhibitor, as is nortriptyline. Nortriptyline has a greater affinity for H1 receptors than desipramine, which might explain why nort sometimes causes drowsiness. As far as I know, nortriptyline also blocks 5-HT2 receptors, which might possibly cause drowsiness as well.
Ed.
Posted by banga on December 31, 2004, at 16:24:18
In reply to Re: TCAs » linkadge, posted by ed_uk on December 31, 2004, at 15:25:30
I have not tried desipramine. If it causes less weight gain, wow it could be a great option. Somehow I find it easier to find detailed info on SSRIs than on TCAs, except for one article that describes how much each acts on serotonin as opposed to norepinephrine.
But in terms of 5HT2a blocking...doesn't that help with anxiety in some cases? I also looked at notrtyp because this seems to be a common element in many (well, "many" being rather relative!)drugs that have helped me w/anxiety (clomipramine, geodon). Of course this was just a guess, that this mechanism is helpful for me...
But thanks for the desipramine hint. Now I have to think how I will pose this to my pdoc after just convincing her that nortryp is the next logical choice.
Posted by ed_uk on December 31, 2004, at 17:04:27
In reply to Re: TCAs-desipramine, posted by banga on December 31, 2004, at 16:24:18
> I have not tried desipramine. If it causes less weight gain, wow it could be a great option.
Hi Banga!!
Weight gain isn't often reported with desipramine but I'm sure that it's possible! Some people have even reported weight loss. As far as I know, desipramine is a weaker antihistamine than nortriptyline and also a weaker 5-HT2 antagonist- this suggests that it would be less likely to cause weight gain.
> But in terms of 5HT2a blocking...doesn't that help with anxiety in some cases?
Yes, I think that it probably does in some cases. Noradrenergic drugs such as nortriptyline, lofepramine and desipramine do at times cause anxiety as a side effect. On the other hand, NRIs can be useful in treating panic disorder. Personally, I haven't noticed any change in my anxiety since I've been taking lofepramine.
> But thanks for the desipramine hint. Now I have to think how I will pose this to my pdoc after just convincing her that nortryp is the next logical choice.
Well, it is usually necessary to try several different drugs to see which you prefer..... if only our responses to drugs were more predictable.
Regards,
Ed.PS. Happy New Year!
Posted by ed_uk on December 31, 2004, at 17:22:31
In reply to Re: TCAs » banga, posted by ed_uk on December 31, 2004, at 17:04:27
You might be interested in this.......
J Clin Psychiatry. 1987 Jan;48(1):27-8.
The effect of desipramine on body weight in depression.
Levitt AJ, Joffe RT, Esche I, Sherret D.
Twenty-six patients with major depressive disorder were treated with desipramine for 4 weeks to determine the effect of the drug on body weight. Responders to desipramine showed a weight gain only at Weeks 3 and 4; nonresponders had a nonsignificant loss of weight. The increase in body weight of the responders was independent of dosage, sex, and hospitalization status. These findings suggest that the small increase in body weight that occurs in patients taking desipramine is associated with treatment response. In addition, desipramine may be a valuable treatment alternative for those patients in whom excessive weight gain is undesirable.
Posted by ed_uk on December 31, 2004, at 17:41:13
In reply to Re: TCAs » banga, posted by ed_uk on December 31, 2004, at 17:04:27
On the other hand this is not good.....
Fernstrom and Kupfer (Psychiatry Research, 26: 256-271, 1988) compared weight change in patients treated with amitriptyline, nortriptyline, desipramine, and zimelidine. They reported weight gain in 89% of patients treated with amitriptyline, 67% of patients treated with nortriptyline, 58% of patients treated with desipramine, and 8% of those treated with zimelidine.
Well, at least desipramine wasn't as bad as nortriptyline! I still think that you should try it!
Ed.
Posted by banga on January 3, 2005, at 0:59:24
In reply to Re: TCAs..... to Banga, posted by ed_uk on December 31, 2004, at 17:41:13
Thank you Ed for the info! I know of course no antidepressant is a guarantee for working; and the nortryp--and maybe then desipramine--will be a first try in the more norepinephrine direction..I suppose on the one hand I should be thankful that TCAs seem to agree with me, as my pdoc said--she was mightliy impressed that the only side effect I had at all from clomipramine was weight gain..and some mild postural hypotension. For the brief time on nortryptiline, I did not notice anything bothersome other than the weight. I will see my pdoc Tuesday, discuss options...perhaps adding zonegran to counteract TCA weight gain? Right now I am only on 100 mg lamictal, amazing I am doing so well, although the past few days I fear I may be losing effectiveness.
Posted by banga on January 3, 2005, at 19:59:51
In reply to Re: TCAs -ed_uk, posted by banga on January 3, 2005, at 0:59:24
Now about TCAs and sexual side effects...does it seem as though the less serotogenic ones, say like desipramine, have less effect on libido etc? or is that just wishful thinking?
Posted by ed_uk on January 3, 2005, at 20:20:45
In reply to Re: TCAs-desipramine, posted by banga on January 3, 2005, at 19:59:51
Hi!
Yes, desipramine does seem to have less effect on libido than most ADs.
BTW, have you considered maprotiline (Ludiomil)? It is a NRI which would be expected to cause little weight gain or sexual side effects.
Regards,
Ed.
Posted by banga on January 3, 2005, at 20:59:16
In reply to Re: TCAs-desipramine » banga, posted by ed_uk on January 3, 2005, at 20:20:45
Ludiomil--that's a really old one, isn't it? I dont know why some of these old ones are simply not heard about these days. If you know off-hand any links with info on it, let me know! Ill do a search myself now, it's just that I am not search engine whiz kid of the century. Plop me in a physical med library, it's a different story.
Thanks yet again for the advice.
Posted by KaraS on January 3, 2005, at 22:00:48
In reply to Re: TCAs-desipramine, posted by banga on January 3, 2005, at 20:59:16
> Ludiomil--that's a really old one, isn't it? I dont know why some of these old ones are simply not heard about these days. If you know off-hand any links with info on it, let me know! Ill do a search myself now, it's just that I am not search engine whiz kid of the century. Plop me in a physical med library, it's a different story.
>
> Thanks yet again for the advice.
I used to take a small amount of maprotiline/Ludiomil (25-50 mg. I think) for several years to help me sleep. I found it very easy to tolerate. I didn't feel as drugged in the morning as I used to on doxepin. That little bit would keep me from having anxiety problems and panic attacks. I did gain weight on it though.
Posted by ed_uk on January 3, 2005, at 22:14:20
In reply to Re: TCAs-maprotiline » banga, posted by KaraS on January 3, 2005, at 22:00:48
>I did gain weight on it though.
Oh dear! Maybe desipramine would be better.
Ed.
Go forward in thread:
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.