![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 11 to 35 of 107. Go back in thread:
Posted by ed_uk on January 27, 2005, at 13:58:44
In reply to Re: Desipramine » ed_uk, posted by zeugma on January 27, 2005, at 13:42:48
>rapid heartbeat, chest pains, sudden dizzy spells after exertion, which lessened after lowering the nortrip dosage. also my heart rate was much more rapid at peak levels of Rit (late morning/early afternoon) causing fluctuations that could not have been good for my system.
Atenolol may be useful. Beta-blockers are unsafe in asthmatics. Your pdoc may be uncomfortable prescribing a beta blocker so you may need to go to your GP/PCP.
Ed.
Posted by zeugma on January 27, 2005, at 14:00:01
In reply to Re: the only reason I would switch to DMI » zeugma, posted by ed_uk on January 27, 2005, at 13:38:15
> Hi,
>
> >No, but it's metabolized to modafinil, so i would be wary of it.
>
> I know, but some people who can't tolerate modafinil seem to prefer it. See the archives.
>
> Did you see my previous post?
>
> Ed.
Yes, see above :)I'm not going to taker anything at this point that my pdoc doesn't prescribe for me, because I really feel that my life is in his hands. Adrafinil is not on the US formulary. not that that's the be-all and end-all, but I have to take what he says seriously because I simply don't have answers myself and I have reason to trust him. The effects of provigil were so weird and unsettling that I would be disinclined to use anything that metabolized to it. Admittedly I have not looked at the archives. But I'm sure you understand my reluctance.
I suppose something that I'm wondering about is whether I should scrap the TCA's entirely considering the fact that they have cardiovascular effects that can be compounded by a stimulant. What do you think about that issue?
thanks,
z
Posted by ed_uk on January 27, 2005, at 14:32:58
In reply to Re: the only reason I would switch to DMI » ed_uk, posted by zeugma on January 27, 2005, at 14:00:01
Hi Z!
>I'm not going to taker anything at this point that my pdoc doesn't prescribe for me....
I wasn't advising you to try it- I just wondered whether you had already tried it.
>I suppose something that I'm wondering about is whether I should scrap the TCA's entirely considering the fact that they have cardiovascular effects that can be compounded by a stimulant. What do you think about that issue?
I don't think it's a good idea. You need the nort to prevent sleep paralysis etc. I think that it would be perfectly possible to treat the cardiovascular side effects which may occur due to a stimulant. Did you have your blood pressure measured while you were taking methylphidate?
Tachycardia, chest pain and palpitations could be treated with atenolol or another cardioselective beta blocker. Most non-cardioselective beta-blockers (eg. propranolol) can cause vasoconstriction so it would be sensible to avoid them.
If you have hypertension, carvedilol may be useful. Carvedilol (Coreg) is both a beta-blocker and a vasodilator. It can be used to treat tachycardia and hypertension. Atenolol would be more appropriate if you don't have hypertension. I expect that you are not hypertensive because nort tends to lower blood pressure.
I am sure that you will find a solution to your problems :-)
Ed.
Posted by ed_uk on January 27, 2005, at 15:15:52
In reply to Re: Treating side effects » zeugma, posted by ed_uk on January 27, 2005, at 14:32:58
> Most non-cardioselective beta-blockers (eg. propranolol) can cause vasoconstriction so it would be sensible to avoid them.
Theoretically, it is possible that combining a non-cardioselective beta blocker with an amphetamine or methylphenidate may cause vasoconstriction and hypertension. The UK Dexedrine data sheet warns of this. Although atenolol would be expected to be safe, the UK data sheet for generic atenolol still suggests that it should not be combined with an amphetamine..... there are several possible reasons for this.......
1) The interaction has received little study.
2) Amphetamines are usually contra-indicated in people needing beta-blockers eg. patients with angina etc.
3) Amphetamines may reduce the beneficial effects of beta-blockers in the treatment of hypertension, angina etc.
4) Atenolol is not completely selective for the beta-1 receptor, it is theoretically possible that combining atenolol with an amphetamine may result in increased vasoconstriction and hypertension. Personally, I think this is highly improbable, atenolol would be more likely to reduce BP. In general, atenolol would be expected to be an effective and relatively safe treatment for the tachycardia and chest pain that stimulants can induce.Ed.
Posted by zeugma on January 27, 2005, at 18:59:13
In reply to Re: Treating side effects » zeugma, posted by ed_uk on January 27, 2005, at 14:32:58
hi ed,
Thanks for your kind and detailed replies. i really appreciate them.
The tachycardia, chest pain, etc. is very upsetting and troubling, obviously, and I did have my BP measured regularly during treatment. As you pointed out, NOR tends to reduce BP, and at no point was I hypertensive. But my heart rate fluctuated depending on time of day, and this was causing the chest pain etc. and making it impossible to exercise.
It was almost a side issue today, though, during my session with my pdoc. The worst problem has been the anxiety. It is causing unbearable stress that is endangering my job, if not my life. I increased the clonazepam this week, but that is not a real solution, since it doesn't mitigate the 'edginess' I feel on Ritalin, and it also aggravates the sleep paralysis and other narcoleptic symptoms. So I am raising the nortriptyline back to 75 mg, which should help with those symptoms, and also improve my mood and lessen the 'edginess' (nortrip has a subtle calming effect that is nothing like clonazepam, which is for all-out anxiety). I'm also adding back strattera at 25 mg tomorrow. I wonder what you think of this. On paper, this is somewhat redundant, since presumably they are both NE reuptake inhibitors, although clearly nortriptyline has other actions as well. My pdoc's theory is that strattera is selective for different regions of the brain (TCA's=brainstem, Strattera=cortex).
He told me, basically, that I am going to have to deal with the fatigue myself (exercise, and coffee). Hopefully, the chest pains will be gone completely soon, and I will be able to exercise.
it's interesting that norepinephrine seems to send some people over the edge with anxiety. in my case it seems to be dopamine. now there's the interesting exception of Provigil. Are you still considering trying it?
-z
Posted by zeugma on January 28, 2005, at 14:21:46
In reply to Re: Treating side effects » ed_uk, posted by zeugma on January 27, 2005, at 18:59:13
Aust N Z J Psychiatry. 1998 Oct;32(5):650-7.
Attention deficit hyperactivity disorder and anxiety: is there an association with neurodevelopmental deficits?Vance AL, Luk ES.
Maroondah Child and Adolescent Psychiatry Service, Victoria, Australia. avance@papyrus.mhri.edu.au
OBJECTIVE: The co-occurrence of attention deficit hyperactivity disorder (ADHD) and anxiety is a well-established clinical observation. However, its status as a clinical construct is debated. We review the prevalence of 'ADHD and anxiety', its definitions, and its clinical correlates and we hypothesise that neurodevelopmental deficits may be increased in 'ADHD and anxiety'. METHOD: The authors identified empirical studies in the psychiatric and psychological literature. The search categories included hyperactivity, attention deficit hyperactivity disorder, attention deficit disorder and anxiety. RESULTS: 'ADHD and anxiety' is considerably more common in clinical than epidemiological samples. There are a range of definitions which address the situational variation in both ADHD and anxiety symptoms and the use of categorical and continuous variables to define them. Yet the nature of the anxiety is still unclear. It is associated with a poor response to psychostimulant medication treatment, and alternative pharmacotherapy approaches have been suggested. There is a controversy about whether neurodevelopmental deficits are associated with hyperactivity alone, or anxiety, or both. CONCLUSIONS: 'ADHD and anxiety' is important clinically because it is common and less responsive to psychostimulant medication. Important research issues include its heterogeneity which necessitates the collection of parent, teacher, and child self-reports of symptoms' presence or absence and the hypothesis that neurodevelopmental deficits may be increased in this group of children.
It wouldn't matter if I were able to solve the cardiac side effects, since the anxiety is so overwhelming, and is only mitigated by being at peak plasma levels, which calms me- but then once they drop (and it's a quick drop) I'm anxious as h*ll again and would have to re-dose at an even higher level to calm down. It's not practical. And taking more klonopin is no solution. Off ritalin for 2 days I can't stay awake, but at least my anxiety is falling.
The only exception I would make to the statement in the abstract is Provigil. It woke me up AND did not worsen anxiety. If you are severely anxious and have ADD or some other condition requiring a stim, I would try that first. Failing that, a TCA or strattera or both.
-z
Posted by ed_uk on January 28, 2005, at 14:29:45
In reply to Re: Treating side effects » ed_uk, posted by zeugma on January 27, 2005, at 18:59:13
Hi Z!
>Thanks for your kind and detailed replies. i really appreciate them.
You're welcome :-)
>The tachycardia, chest pain, etc. is very upsetting and troubling, obviously, and I did have my BP measured regularly during treatment. As you pointed out, NOR tends to reduce BP, and at no point was I hypertensive. But my heart rate fluctuated depending on time of day, and this was causing the chest pain etc. and making it impossible to exercise.
Methylphenidate is an indirect-acting sympathomimetic. Pain on exertion is believed to result from the stimulation of beta-1 receptors in the heart. Atenolol is a selective beta-1 antagonist and is an effective treatment for tachycardia and angina ie. pain on exertion. I still think you should try it, how are you going to stay awake and alert without a stimulant? Start at 25mg/day atenolol and increase in steps of 25mg up to a maximum of 100mg/day if necessary. I expect you'd probably need 50-100mg. As I said, your pdoc is unlikely to be particularly familiar with atenolol, you may need to see a different doctor. As I said before, I would stay away from non-selective beta-blockers like propranolol.
>I increased the clonazepam this week, but that is not a real solution, since it doesn't mitigate the 'edginess' I feel on Ritalin...
Are you taking any MPH at all at the moment?
>I'm also adding back strattera at 25 mg tomorrow.
Why did you decide to try Strattera?
>I wonder what you think of this.
I must admit that I'm not the world's greatest fan of Strattera, it seems to make people fatigued and depressed.
>My pdoc's theory is that strattera is selective for different regions of the brain (TCA's=brainstem, Strattera=cortex).
Do you know whether there is any evidence to support this theory?
I have wondered whether Strattera may be more effective for some people because it lacks nort's antihistamine effect. Also, nort is a weak antimuscarinic. Antimuscarinic drugs impair cognitive functioning, memory and attention. Desipamine is less antimuscarinic than nort.
>He told me, basically, that I am going to have to deal with the fatigue myself (exercise, and coffee).
I don't really understand why your pdoc thought that it was ok to prescribe methylphenidate but won't let you try dextroamphetamine, I'm really not convinced that there is good logic behind this. Since it is theoretically possible that nortriptyline may potentiate the effects of dex, I would suggest that you start dex at a very low dose to see how it effects you eg. 1.25mg every four hours, three times a day. You could then increase the dose gradually as necessary. It might be necessary to combine it with atenolol.
Do the cardiovascular side effects of MPH cause you a lot of anxiety? If they do, perhaps atenolol would reduce your anxiety.
Ed.
Posted by zeugma on January 28, 2005, at 14:52:36
In reply to Re: Treating side effects » zeugma, posted by ed_uk on January 28, 2005, at 14:29:45
don't really understand why your pdoc thought that it was ok to prescribe methylphenidate but won't let you try dextroamphetamine, I'm really not convinced that there is good logic behind this.>
I'm not either. But I don't know all the premises!
Do the cardiovascular side effects of MPH cause you a lot of anxiety? If they do, perhaps atenolol would reduce your anxiety. >well, they do, but I have a lot of anxiety anyway :( And I am convinced at this point that stimulants will be anxiogenic for me, and that is a real, intractable problem. Of course dexedrine may be less anxiogenic than Ritalin. That's important for me to keep in mind, depending on what happens with Strattera.
About Strat: yes, it made me tired and depressed last year. And this time we didn't even discuss why strattera was better for ADHD than desipramine. The truth is that I don't think he knows either. On paper it looks like Strattera is desipramine with a short half-life. If that's the case, then I am trying desipramine after all :) I know it won't energize me, but MAYBE i can take afternoon naps to compensate for the tiredness- if I can get the Klonopin down, that is, and get my plasma levels of nort back up, plus the Strattera. Klonopin worsens the sleep paralysis stuff, that's why I'm not crazy about trying more anxiogenic drugs that will require higher doses of K to control the anxiety.I can find no reason for thinking strattera is more effective than a TCA for ADD. I only know that it was, for me, once upon a time.
-z
Posted by zeugma on January 28, 2005, at 14:59:44
In reply to Re: Treating side effects » ed_uk, posted by zeugma on January 28, 2005, at 14:52:36
On 100 mg nortriptyline, I had no 'word-finding' difficulties, etc., or other cognitive problems other than the ones I was born with. When I lowered the dose of nortrip, I experienced these kinds of difficulties, and I think they were due to the sleep disruption the lowered dose was causing. I know antimuscarinics have a bad reputation, but it seems my cholinergic system is literally in overdrive and that's why I get blasted with cataplexy etc. every time I lower the dose of the 'dumb-drug'.
-z
Posted by ed_uk on January 28, 2005, at 15:28:13
In reply to Re: Treating side effects » ed_uk, posted by zeugma on January 28, 2005, at 14:52:36
Hi,
>On paper it looks like Strattera is desipramine with a short half-life.
It is possible that the problem with atomoxetine may be due to its active metabolite rather than the parent compound. Kappa agonists cause dysphoria and fatigue- which is why they never achieved popularity as analgesics!
I think it would be good for you to try...
clonazepam + dextroamphetamine IR + atenolol + nortriptyline 100mg
Ed.
Posted by zeugma on January 28, 2005, at 17:01:43
In reply to Re: Treating side effects » zeugma, posted by ed_uk on January 28, 2005, at 15:28:13
> Hi Ed.
Hi,
>
> >On paper it looks like Strattera is desipramine with a short half-life.
>
> It is possible that the problem with atomoxetine may be due to its active metabolite rather than the parent compound. Kappa agonists cause dysphoria and fatigue- which is why they never achieved popularity as analgesics!
>
Yes, that's what i theorized when I read the report about 4-hydroxyatomoxetine's partial kappa agonism. And it may well be that this theory is correct and dysphoria and fatigue will hit me again. But just like I didn't throw out my Strattera from last year, and was able to use it PRN when I was forced off provigil suddenly (I have a lot of problems with stimulants, you see) my pdoc told me I could use Ritalin on weekends when my extreme jitteriness wouldn't be a problem (my job involves a lot of interpersonal interaction and the jitteriness is a major liability). I would only do that, though, if my GP or my pdoc agreed to prescribe me atenolol. And, actually, I would prefer not to do it at all, considering that 60 mg seems to be the minimum to get an effect, and it doesn't last all that long.
> I think it would be good for you to try...
>
> clonazepam + dextroamphetamine IR + atenolol + nortriptyline 100mg
>Yes, I think that is a good combination. the clonazepam needs to be kept to a minimum, because it aggravates my cataplexy (taking 1.5 mg for the last couple of days has made me a nervous wreck because of this in itself- it's so complicated) but if d-amph is less anxiogenic and atenolol keeps the cardiac problems under control, then I will definitely propose this combo to my pdoc if I have to d/c Strattera again, because of fatigue or dysphoria, or simply because i can't get anyhthing done because of exhaustion. One way that narcoleptics who can't tolerate stimulants manage the sleepiness is by scheduling naps during the day. Once all this clonazepam is out of my system and I'm back down to a maintainance level (1 mg) and the nortriptyline increase has kicked in, then Strattera might be genuinely useful for naps because I could take it at noon and its powerful NRI effect would let me nap in peace. That's my current thinking, but I'll have to see how it works out. Right now there's so much clonazepam in my system that I can't nap at all.
-z
> Ed.
Posted by ed_uk on January 29, 2005, at 17:26:59
In reply to Re: Treating side effects » ed_uk, posted by zeugma on January 28, 2005, at 17:01:43
Hi Z!
Good luck with the Strattera :-)
Have you ever taken more than 100mg of nortriptyline? I wondered whether you'd find it helpful for anxiety or ADD symptoms.
Also, have you tried any other benzos apart from clonazepam? Do they all worsen your cataplexy?
How long did you take Strattera for before it made you fatigued and depressed? The kappa agonists used as analgesics generally cause dysphoria and sedation with the first dose. Mmmm, I wonder what else Strattera is doing apart from acting as an NRI? I've often wondered the same thing RE reboxetine.
Ed.
Posted by zeugma on January 29, 2005, at 19:42:24
In reply to Re: Treating side effects » zeugma, posted by ed_uk on January 29, 2005, at 17:26:59
>
> Good luck with the Strattera :-)thanks!
>
> Have you ever taken more than 100mg of nortriptyline? I wondered whether you'd find it helpful for anxiety or ADD symptoms.
>It might be helpful for anxiety and even ADD, I don't know. 100 mg nortrip seems to be more stimulating than 75 mg, but nothing like the effects of Provigil or ritalin.
> Also, have you tried any other benzos apart from clonazepam? Do they all worsen your cataplexy?
No, I haven't, it was hard enough to get the clonazepam! Doctors may be less leery of prescribing benzos in the US than UK, but only slightly. Alprazolam is seen as having a much higher abuse potential than clonazepam, so it's much harder to get prescribed. What is interesting about clonazepam is the fact that it's a powerful antiepileptic, and the fact that it triggers cataplexy made me realize that my sleep disorder was probably REM rather than NREM related. >
> How long did you take Strattera for before it made you fatigued and depressed? The kappa agonists used as analgesics generally cause dysphoria and sedation with the first dose. Mmmm, I wonder what else Strattera is doing apart from acting as an NRI? I've often wondered the same thing RE reboxetine.
>
it was quite a while. I was on strattera for nearly a year before the fatigue and depression became severe. strattera distinctly does NOT have a sedating or dysphoric effect on first dose, in fact it strikes me as a powerful antidepressant that is neutral as regards sedation. The depression and fatigue that later hit is another story, and my pdoc attributed it to the fact that I needed a stimulant, and my physical energy simply gave out. that's plausible, but leaves me where I started: the fatigue has been constant for years, and I have not been able to tolerate ANY stimulating medication (Wellbutrin, Ritalin, cylert, Provigil). I think this strongly negative history with stims caused him to skip the amphetamines. Part of the problem, as I see it, is that stims produce positive effects only when plasma levels are highest, and on the up- or down-slope I would experience severe irritability, anxiety, and marginal cognitive benefit. I don't see any way around this conundrum.
I wonder what your view of the effectiveness of reboxetine is. have you ever tried it? Like i said before, I really don't know the justification for adding strattera as opposed to simply increasing nortrip beyond 100 mg, except for the lack of cardiotoxicity. I even wonder if some of my response to strattera was placebo. I know people sometimes combine SSRI's, but that there is no evident justification for this, and psychopharmacological orthodoxy counsels against this kind of redundancy.Are you still trying to get on some kind of stimulant? I know you highly favor d-amphetamine over methylphenidate. Is this because d-amph is less anxiogenic?
-z
> Ed.
Posted by ed_uk on January 29, 2005, at 21:12:57
In reply to Re: Treating side effects » ed_uk, posted by zeugma on January 29, 2005, at 19:42:24
Hi,
>> Have you ever taken more than 100mg of nortriptyline?
>It might be helpful for anxiety and even ADD, I don't know. 100 mg nortrip seems to be more stimulating than 75 mg.Try it!
>Doctors may be less leery of prescribing benzos in the US than UK, but only slightly.
Don't be so sure! One thing I have noticed is that MUCH higher doses seem to be prescribed in the US, for much longer periods of time!
> Part of the problem, as I see it, is that stims produce positive effects only when plasma levels are highest, and on the up- or down-slope I would experience severe irritability, anxiety, and marginal cognitive benefit. I don't see any way around this conundrum.
I think you could probably overcome this by taking small dose very frequently (every couple of hours)- this would avoid any major peaks or troughs.
>I wonder what your view of the effectiveness of reboxetine is. have you ever tried it?
I've never tried it. Although Edronax is marketed here it's rarely prescribed to be honest. Do you want to try it?
>Are you still trying to get on some kind of stimulant?
Yes, but I doubt I'll ever get one though, I might as well be asking for IV heroin!
I know you highly favor d-amphetamine over methylphenidate. Is this because d-amph is less anxiogenic?
It would be interesting to see some scientific evidence that d-amph is less anxiogenic- there doesn't seem to be any, all the evidence I've got is anecdotal. If I had the opportunity to try any stim, I think I might actually try Ritalin first because of the evidence that high doses of d-amph *may* be neurotoxic in animals. I suspect that I'd end up on d-amph though, most adults seem to prefer it to Ritalin.
Ed.
Posted by zeugma on January 31, 2005, at 16:29:47
In reply to Re: Treating side effects » zeugma, posted by ed_uk on January 29, 2005, at 21:12:57
anyway, im done with strattera, it is triggering a severe depression again and my pdoc doesn't want to hear about it. i feel completely hopeless.
-z
Posted by ed_uk on February 1, 2005, at 8:22:16
In reply to Re: Treating side effects, posted by zeugma on January 31, 2005, at 16:29:47
Hello Z,
>anyway, im done with strattera, it is triggering a severe depression again and my pdoc doesn't want to hear about it. i feel completely hopeless.
What do you mean when you say that your pdoc doesn't want to hear about it?
Don't feel hopeless, you have options :-)
a) Dex + atenolol.
b) Desipramine instead of nort- could be more stimulating.
c) Parnate- may relieve hypersomnia and cataplexy too.
d) Try a higher dose of nortriptyline.
e) Maybe even Desoxyn + atenolol!
f) Get a new pdoc!
g) Go to a sleep specialist.Do you drink coffee or take caffeine tablets? Maybe caffeine tablets would be bettter because you could take a more precise dose.
All the best,
Ed.
Posted by zeugma on February 1, 2005, at 16:37:34
In reply to Re: Treating side effects » zeugma, posted by ed_uk on February 1, 2005, at 8:22:16
hi ed, I just bought a package of NoDoz at the pharmacy. I am breaking down rapidly and losing the ability to function. I called a sleep doc and am trying to make an appointment. My pdoc didn't want to hear about problems with Strattera because he is convinced of its unique efficacy, which I am unable to account for. But it has a fatiguing effect which I cannot tolerate. I know I have pharma options but at this time have no mental health professional whom I trust, abd I am in a debilitated state right now. Hopefully the sleep doc will get back to me and I can make an appt. ASAP.
-z
Posted by zeugma on February 1, 2005, at 16:45:06
In reply to Re: Treating side effects » ed_uk, posted by zeugma on February 1, 2005, at 16:37:34
and 'by didn't want to hear about it', brushed aside depressogenic and fatiguing effects (which i experienced last year to a severe degree) and told me to simply titrate slower (although I was following his instructions by taking 25 mg am 3 days, then 40 mg yesterday morning. the sample packs he gave me of 25's and 40's have only 7 capsules, while I still have a lot of 40's from my last trial with this drug, so I planned (with his OK) to start at 25, then go to 40, then take 40 am and 25 pm for a couple of days. When I called in a state of despair he told me I was titrating too fast and stay at 25 for a while. That's what I mean by 'brushing aside my concerns.' admittedly I am in a desperate state, I also am going through stim withdrawal, and Strat seemed to be making it worse. I don't know what else to say. Hopefully I can find another doctor soon.
-z
Posted by ed_uk on February 2, 2005, at 7:20:00
In reply to Re: Treating side effects » zeugma, posted by zeugma on February 1, 2005, at 16:45:06
Hello Z,
>I am breaking down rapidly and losing the ability to function.
Do you think that your current fatigue and depression may be mainly caused by methylphenidate withdrawal? As you know, stim withdrawal can easily cause both these symptoms even in people with no history of depression or narcolepsy.
>I called a sleep doc and am trying to make an appointment.
Excellent- I hope s/he can see you quickly.
> know I have pharma options but at this time have no mental health professional whom I trust, abd I am in a debilitated state right now.
You do trust your current pdoc though, don't you? He may not be the best but I thought you still trusted him.
Can you take some time off work???
Best Regards,
Ed.
Posted by zeugma on February 2, 2005, at 15:51:05
In reply to Re: Stimulant withdrawal » zeugma, posted by ed_uk on February 2, 2005, at 7:20:00
> Hello Z,
>
> >I am breaking down rapidly and losing the ability to function.
>
> Do you think that your current fatigue and depression may be mainly caused by methylphenidate withdrawal? As you know, stim withdrawal can easily cause both these symptoms even in people with no history of depression or narcolepsy.
>
Hi Ed. yes I know, and it's nasty withdrawal, absolutely brutal to go from 60 mg to 0 with no taper. I essentially had no choice, because the stim itslef was interfering with my ability to work by causing extreme nervousness, irritability, etc., as well as physically wasting me away. I realized also that when the MPH was withdrawn, I had put the nortriptyline back to 75 from 50 mg as the cardiac interaction with MPH was no longer a danger. This was done with pdoc's consent, of course. THEN adding the Strattera onto that was putting my brain through so many changes at once that I think I was literally overwhelmed. Nortriptyline's effects are very dose dependent-I am apt to forget this as it is actually the most well-tolerated, over a wide dose range, psychotropic I have ever taken. I suppose I've adjusted the nortrip so many times that it seemed like nothing to put it back at 75 mg. Well, actually, I think a lot of the reason the Ritalin went bad was because of the nortrip going down to a sub-therapeutic dose. I am definitely feeling the effects of the 75 mg nortrip today, a definite antidepressant effect.yes, I still trust him, though whether he trusts me is an open question. I don't know about the strattera. Thinking now, I realize that just raising the NOR and going cold turkey off the MPH was in itself an enormous med change, the likes of which I've never experienced.
> >I called a sleep doc and am trying to make an appointment.
>
> Excellent- I hope s/he can see you quickly.Yes, but sleep clinics are enormously expensive. I am going to have to have a sleep study done, and it runs into the thousands of dollars. And I assume I will have to wash out my meds. I am in touch with one clinician and trying to work out a feasible way to proceed. At this point the sooner the better, so I will know by tomorrow which clinician I will see and what kind of washout it will entail.
>
> > know I have pharma options but at this time have no mental health professional whom I trust, abd I am in a debilitated state right now.
>
> You do trust your current pdoc though, don't you? He may not be the best but I thought you still trusted him.see above, I do, though I admit I am puzzled by his high regard for Strattera. As far as I am concerned nortriptyline is a far more trustworthy med.
>
> Can you take some time off work???
>I took some days off last week when I was literally flattened by stim withdrawal (yes, I'm speaking literally). And then going up 25 mg on nortrip plus 25 mg strattera- well, that's crazy. Though I don't fault my pdoc for this. His decision to pull the plug on the MPH was the correct one, and he advised me to take the rest of the week off, as he told me I wouldn't be feeling too great. Understatement of the millenium :)
> Best Regards,
> Ed.
>
In case you are interested, I have some info on Strat's pharmacology:Atomoxetine Ki values:
Ne transporter: 4.5 nM
5HT transporter: 152 nM
DA transporter: 1451 nM4-hydroxyatomoxetine:
NE transporter: 3.0 nM
5HT tranporter: 43 nM
kappa opiod receptor: 95 nM
mu, delta receptors: > or = 422 nM.Apparently, in extensive metabolizers 4-hydroxy plasma levels are higher than parent drug, and its half-life is 6-8 vs. 5 hrs. What do you think of this pharmacology? Thanks for all your support,
z
>
>
>
Posted by reefer on February 3, 2005, at 5:33:48
In reply to Re: Treating side effects » zeugma, posted by ed_uk on January 28, 2005, at 15:28:13
Oh that's why Buprenorphine works so good for me. Since it is a Kappa antagonist. I never really understood why Bupe didn't make me sedated like the other opiods do.
Posted by ed_uk on February 3, 2005, at 8:29:41
In reply to Re: Stimulant withdrawal » ed_uk, posted by zeugma on February 2, 2005, at 15:51:05
Hi Z!
I'm relieved that you're feeling a bit better today :-)
>Nortriptyline's effects are very dose dependent-I am apt to forget this as it is actually the most well-tolerated, over a wide dose range, psychotropic I have ever taken.
I wonder what dose of nortriptyline would be the most effective for you? Some people need up to 150mg. Have you ever had your serum level measured? Of course, the only way to truly find the optimum dose is to experiment!
> Well, actually, I think a lot of the reason the Ritalin went bad was because of the nortrip going down to a sub-therapeutic dose.
Perhaps if you were on a full dose of nort you could tolerate the Ritalin. I'm sure you'd need to combine it with a suitable cardiovascular drug. I wonder what suggestions a cardiologist might have.
>I will know by tomorrow which clinician I will see and what kind of washout it will entail.
Good luck :-) Keep me updated.
>kappa opiod receptor: 95 nM
I'm sorry, I'm not sure whether 95 is low enough to be significant.
>Thanks for all your support
It's a pleasure!
Ed.
Posted by CareBear04 on February 3, 2005, at 13:18:59
In reply to Re: Stimulant withdrawal » ed_uk, posted by zeugma on February 2, 2005, at 15:51:05
zeugma-- i hope you're feeling better! i think i remember reading in your posts awhile ago that you have problems eating on stimulants and that you've been experimenting to try to find one that doesn't speed you up too much? is that accurate or am i mixing you up with someone else?
what i've experienced and heard about strattera from my later pdoc is that it tends to work best for children and less well for adults. it didn't do much of anything for me. i went up to 80mg a day in split doses, then added provigil. i liked the provigil and it definitely helped me focus without ruining my sleep. however, with provigil and strattera together, i could take the strattera or not and couldn't feel any difference. have you tried provigil? it did make me a bit of a zombie as far as repetetive tasks or doing one thing for hours on end when i was alone in my dorm room. a good thing is that it suppressed my appetite, but when i made myself remember to eat, even setting alarms if necessary, i had no problem with working up an appetite to eat.
about your sleep-- do you think it's related to your meds or psych condition or related to a pulmonary problem? my sister is a few months from graduating from med school, and i actually had a conversation with her about sleep medicine yesterday. i was surprised when i learned recently that most sleep doctors are pulmonary specialists and not pdocs like i had previously thought. i guess the "true" sleep disorders originate in the lungs and breathing, while insomnia and restlessness of a psychiatric or medicine origin are best dealt with in therapy or with a pdoc. i don't know if this is relevant or not.
going from 60 to 0 cold turkey from any stim sounds like torture to me. i know that i should take vacations from my adderall and ritalin to make it more effective because i've worked up quite a tolerance to them. but the thought of being off them, being so sluggish and cranky, scares me and prevents me from taking even weekend breaks. how are you doing with this?
what other stims have you tried and what experiences have you had? i've tried high-dose wellbutrin, strattera, provigil, regular adderall and xr, regular ritalin and concerta. i once asked about focalin, but hardly any pharmacies around me carry it or can even order it for some reason. my pdoc had never heard of it either. i don't know what other options are. some people mentioned tricyclics to augment, but my drs won't prescribe them because of some heart abnormalities.
i'd like to hear more about your experience if you get a chance. thanks!
Posted by zeugma on February 3, 2005, at 17:06:18
In reply to Re: Stimulant withdrawal » zeugma, posted by ed_uk on February 3, 2005, at 8:29:41
hi Ed, just to let you know, I've been feeling better now that the nortriptyline has kicked in again. I've had this experience before: going below 75 mg plunges me into misery.
My blood levels were taken a couple of years ago when I was on 60 mg nortrip and experiencing a suboptimal response. My pdoc didn't tell me the exact level but said it was 'low' so I moved up to 75 mg and started feeling better. So I'm assuming 75 mg is the bottom threshold for therapeutic response.
I suppose I'll try 25 mg Strattera again tomorrow. I don't know if my current pdoc will see me any more, though. I didn't call the sleep doctor today but will have more time tomorrow (less full work schedule).
It's been really, really crazy lately with all the med changes and trying desperately to hang on to my job. I suppose I need to get used to the anxiety, or think about something like Seroquel. I just worry about movement disorders (I have a tic from the Ritalin) and I experienced a neuroleptic-like effect from >30 mg buspirone, and buspirone is a very weak D2 antagonist.
So yes, I'm feeling better, but I don't know if I currently have a pdoc, because the way I left it with him was that I would see a sleep doc instead. (I'm putting it mildly, of course. I was yelling at him on the phone, and this is not very cool behavior. this is part of why the Ritalin had such a bad effect on me. Instead of calming me down as is apparently the norm with ADHD patients it hyped me up.)
-z
Posted by zeugma on February 3, 2005, at 17:12:07
In reply to Re: Stimulant withdrawal » zeugma, posted by CareBear04 on February 3, 2005, at 13:18:59
hi carebear. I've tried wellbutrin, provigil, cylert, ritalin. I can't take any of them.
The Provigil was actually the best from the appetite point of view because I actually only lost a pound on it after a couple of months on it. It also seemed to be the opposite of Ritalin in that it slowed down my thought process and was anxiolytic, which were VERY good things. but unfortunately the sweating, feeling simultaneously hot and cold, queasy, and generally sick made it impossible for me to stick it out.
Right now I'm relying on caffeine pills to keep me alert. I suppose I've imbibed so much caffeine over the years that I've built up a tolerance to its anxiogenicity.
-z
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