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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by temoigneur on May 5, 2005, at 20:55:24
Hey all, in crisis here, I'm supposed to start full time summer study on Tues. and the med combo I'm on leaves me fairly drowsy, vegetative.
I was on 125mg Clomipramine - it worked well to control OCD - but numbed my mind, and dulled all ambition - the doctor added prozac - initially the first two days, it was activating, and although a little on edge I thought I might be alright.
I know that SSRI's can raise blood levels of TCA's. now on 20mg prozac, and 115mg clomipramine, I'm exhausted, sleep all day as if I was on 200mg clomipramine. My question is does anyone have any idea to what degree prozac may raise blood levels of clomipramine - maybe more importantly the active metabolites that are causing the sedation. Anyone with pharm experience have any suggetn on on how far back I should cut the clomipramine, to retain clinical gains, :) and get rid of sedation. Does anyone know on average how the prozac changes the clomp. prozac ratio, and on average how long this takes to reach stabilize.
Thanks so much. I don't have a pdoc right now, I asked if it would be good to get a blood level test, and track the level of clomipramine, but the consulting pdoc said no no, it's nothing to worry about, sometimes it can be a concern with luvox~:(
Ben
Posted by ed_uk on May 6, 2005, at 6:28:01
In reply to Clomipramine + prozac = HELP:!!, posted by temoigneur on May 5, 2005, at 20:55:24
Hi Ben!
Prozac can produce very large increases in clomipramine serum levels. It will be necessary for you to reduce your clomipramine dose. If you continue to take 115mg clomipramine in combination with Prozac, your serum clomipramine level may continue to rise. If I were you, I'd reduce the clomipramine dose immediately, as little as 25mg a day might be sufficient- although you will definitely need to experiment. You could try taking 25mg or 50mg clomipramine for the next day or two. If you start to suffer from withdrawal symptoms you will know to increase the dose. If you still feel sedated or if other (clomipramine) side effects are present, you could reduce the dose even further.
Fluoxetine-induced tricyclic toxicity: extent and duration.
Westermeyer J.
Department of Psychiatry and Behavioral Sciences, University of Oklahoma, Oklahoma City 73190.
Combined fluoxetine-tricyclic medication has been recommended for patients who are partial responders or nonresponders to tricyclic medication alone. Three cases were encountered in which the addition of fluoxetine to tricyclic medication resulted in toxic, potentially dangerous elevations in tricyclic blood level, amounting to approximately 100-300% increases over recent tricyclic levels. In reducing the tricyclic dosage after fluoxetine, blood level decreases were behind dosage decreases; and blood level and dosage decreases were not well correlated with each other. Symptoms associated with toxic levels are described. Due to the long half-life of fluoxetine, such increases in tricyclic medication must be anticipated well in advance of initiating treatment with these two compounds. Based on these few cases, a procedure is tentatively recommended for patients on combined fluoxetine-tricyclic regimens, until such time as a definitive regimen can be developed.
'The interactions of fluoxetine with amitriptyline, clomipramine, desipramine, imipramine and nortriptyline are established and clinically important. Monitor concurrent use (measure plasma levels), be alert for any evidence of antidepressant toxicity and reduce the dosage appropriately. Initial dosage reductions to a quarter have been advised if 20 mg fluoxetine daily is added, and regular monitoring for several weeks or even months.'
Kind regards,
Ed.
Posted by darkhorse on May 6, 2005, at 9:24:07
In reply to Re: Clomipramine + prozac = HELP:!! » temoigneur, posted by ed_uk on May 6, 2005, at 6:28:01
> Hi Ben!
>
> Prozac can produce very large increases in clomipramine serum levels. It will be necessary for you to reduce your clomipramine dose. If you continue to take 115mg clomipramine in combination with Prozac, your serum clomipramine level may continue to rise. If I were you, I'd reduce the clomipramine dose immediately, as little as 25mg a day might be sufficient- although you will definitely need to experiment. You could try taking 25mg or 50mg clomipramine for the next day or two. If you start to suffer from withdrawal symptoms you will know to increase the dose. If you still feel sedated or if other (clomipramine) side effects are present, you could reduce the dose even further.
>I agree with ED.
I have tried Prozac20 with Clomipramine 75mg and the side effects was too strong (tremor,sweating...)it was like taking 200-300mg of Clo.
Paxil and Prozac increase all TCA's very much.
I tried Prozac with imipramine and kept imipramine at 25mg and felt like it was 75mg.
I also tried Nortriptyline 25mg with Prozac 20 but the effects was very very strong. Nort 10 mg was still powerful...so take care mixing Prozac with Nort.
The least (for some reason) that P did not affect strongly were Amitriptyline and maprotiline.
P.S. Be very cautious when combinnig a TCA with Fluvoxamine(Luvox/Faverin) as it inhibits lots of enzymes except 2D6, so theoratically the safest TCA combo with Fluvoxamine would be Nort. and Desipramine.DH
Posted by temoigneur on May 6, 2005, at 14:50:26
In reply to Re: Clomipramine + prozac = HELP:!!, posted by darkhorse on May 6, 2005, at 9:24:07
Thank you so much Ed and Darkhorse, I could hardly coherently search for any imperical data - thanks a million, I'll keep you posted
Ben
Posted by ed_uk on May 7, 2005, at 9:34:43
In reply to Re: Clomipramine + prozac = HELP:!! » darkhorse, posted by temoigneur on May 6, 2005, at 14:50:26
Hi Ben,
I hope the decrease is successful :-) If you decrease the dose too much, withdrawal symptoms are likely to occur- you may need to increase the dose somewhat. The 10mg pills could be useful for titration.
Kind regards,
Ed.
Posted by 4WD on May 11, 2005, at 22:28:58
In reply to Re: Clomipramine + prozac = HELP:!! » temoigneur, posted by ed_uk on May 6, 2005, at 6:28:01
> Hi Ben!
>
> Prozac can produce very large increases in clomipramine serum levels. It will be necessary for you to reduce your clomipramine dose. If you continue to take 115mg clomipramine in combination with Prozac, your serum clomipramine level may continue to rise. If I were you, I'd reduce the clomipramine dose immediately, as little as 25mg a day might be sufficient- although you will definitely need to experiment. You could try taking 25mg or 50mg clomipramine for the next day or two. If you start to suffer from withdrawal symptoms you will know to increase the dose. If you still feel sedated or if other (clomipramine) side effects are present, you could reduce the dose even further.
>
> Fluoxetine-induced tricyclic toxicity: extent and duration.
>
> Westermeyer J.
>
> Department of Psychiatry and Behavioral Sciences, University of Oklahoma, Oklahoma City 73190.
>
> Combined fluoxetine-tricyclic medication has been recommended for patients who are partial responders or nonresponders to tricyclic medication alone. Three cases were encountered in which the addition of fluoxetine to tricyclic medication resulted in toxic, potentially dangerous elevations in tricyclic blood level, amounting to approximately 100-300% increases over recent tricyclic levels. In reducing the tricyclic dosage after fluoxetine, blood level decreases were behind dosage decreases; and blood level and dosage decreases were not well correlated with each other. Symptoms associated with toxic levels are described. Due to the long half-life of fluoxetine, such increases in tricyclic medication must be anticipated well in advance of initiating treatment with these two compounds. Based on these few cases, a procedure is tentatively recommended for patients on combined fluoxetine-tricyclic regimens, until such time as a definitive regimen can be developed.
>
> 'The interactions of fluoxetine with amitriptyline, clomipramine, desipramine, imipramine and nortriptyline are established and clinically important. Monitor concurrent use (measure plasma levels), be alert for any evidence of antidepressant toxicity and reduce the dosage appropriately. Initial dosage reductions to a quarter have been advised if 20 mg fluoxetine daily is added, and regular monitoring for several weeks or even months.'
>
> Kind regards,
> Ed.Ed,
Would this be true for Celexa plus nortriptyline as well? I.e. would Celexa increase blood levels of nortriptyline? I am on 25mg nort and 10mg Celexa. I desperately need the anxiolytic effect of the nortr., asked my pdoc if I should go up on the dose, he said no but then my 15 minutes were up and I couldn't ask why not. I am also taking Inderal for anxiety and I fear that it will cancel out the effects of the nort. since inderal blocks norepinephrine in the brain, doesn't it?
I couldn't ask him about that either. I did ask if it would contribute to my depression and he said we'd just have to wait and see.This board is where I get my questions answered = not from the guy I pay money to.
Marsha
Posted by darkhorse on May 12, 2005, at 5:22:22
In reply to Re: Clomipramine + prozac = HELP:!! » ed_uk, posted by 4WD on May 11, 2005, at 22:28:58
>
>
> Ed,
>
> Would this be true for Celexa plus nortriptyline as well? I.e. would Celexa increase blood levels of nortriptyline? I am on 25mg nort and 10mg Celexa. I desperately need the anxiolytic effect of the nortr., asked my pdoc if I should go up on the dose, he said no but then my 15 minutes were up and I couldn't ask why not. I am also taking Inderal for anxiety and I fear that it will cancel out the effects of the nort. since inderal blocks norepinephrine in the brain, doesn't it?
> I couldn't ask him about that either. I did ask if it would contribute to my depression and he said we'd just have to wait and see.
>
> This board is where I get my questions answered = not from the guy I pay money to.
>
> MarshaHi,
In my experience, there was no problem at all with TCA + Citalopram.SSRIs' that most likekly to affect TCA blood levels are in this order :
-Fluvoxamine : can raise TCA's in a toxic level (except Nortriptyline and desipramine).
-Paroxetine and Fluoxetine : Also raise them,so TCA has to be taken at lowest dose(10mg), then increase slowely.
- Sertraline : raise TCA's but to a much lesser degree(no major problem)- Citalopram,Escitalopram & Venlafaxine : their effect on TCA's are minimum.(no problem!)
-(All medications mentioned I've already tried them,so this is my experience more than what books say!)
*I'm sure ED has much more input and would be a pleasure reading his comments.
Just my own experience, nothing more,nothing less!!!
Best Regards.
DH.
Posted by ed_uk on May 12, 2005, at 5:33:43
In reply to Re: Clomipramine + prozac = HELP:!! » ed_uk, posted by 4WD on May 11, 2005, at 22:28:58
Hi Marsha and darkhorse!
AFAIK, citalopram can produce a relatively modest increase in the blood levels of nort.
>I desperately need the anxiolytic effect of the nortr., asked my pdoc if I should go up on the dose, he said no but then my 15 minutes were up and I couldn't ask why not.
Perhaps your pdoc would allow you to gradually increase your nort dose using the 10mg pills.
>I am also taking Inderal for anxiety and I fear that it will cancel out the effects of the nort. since inderal blocks norepinephrine in the brain, doesn't it?
Inderal sometimes worsens depression. Nadolol (Corgard) might be a better choice of beta blocker.
Regards,
Ed.
Posted by 4WD on May 12, 2005, at 13:36:54
In reply to Re: Clomipramine + prozac = HELP:!! » 4WD, posted by ed_uk on May 12, 2005, at 5:33:43
Thanks Ed & DH
Actually I was hoping the Celexa *would* increase the nortript. levels and then maybe I would get more effect from a lower dose = less side effects?
I'd love to ask the pdoc for a different beta blocker but I have to wait til my next appointment to ask. No phone questions accepted. No questions answered without an appt. I dont guess I can get too much increase in depression in just a month on Inderal. I was mainly worried that the nortript and the inderal would be working at cross purposes re NE receptors in the brain. And that it might delay or negate the AD effect of the nortript. which I just started.
Anyway...
Thanks,
MarshaMarsha
Posted by temoigneur on May 12, 2005, at 20:04:32
In reply to Re: Clomipramine + prozac = HELP:!! » 4WD, posted by ed_uk on May 12, 2005, at 5:33:43
> Hi Marsha and darkhorse!
>
> AFAIK, citalopram can produce a relatively modest increase in the blood levels of nort.
>
> >I desperately need the anxiolytic effect of the nortr., asked my pdoc if I should go up on the dose, he said no but then my 15 minutes were up and I couldn't ask why not.
>
> Perhaps your pdoc would allow you to gradually increase your nort dose using the 10mg pills.
>
> >I am also taking Inderal for anxiety and I fear that it will cancel out the effects of the nort. since inderal blocks norepinephrine in the brain, doesn't it?
>
> Inderal sometimes worsens depression. Nadolol (Corgard) might be a better choice of beta blocker.
>
> Regards,
> Ed.Hi Ed, - I started keeping a record of my experience with prozac and reduced clomip. Unfortunately I got quite bad diahhrea yesterday, and hadn't got up until 4 pm today - I've gotten. Reducing the Clomipramine from 125 to 30mg produced quite bad Diarrhea~: today I've just been up for over 1 1/2 hours, but I seem to have almost no symptoms, That being said however, the prozac causes some insomnia, - I'm hoping by some far fetched logic, that the prozac is uniquely responsive to the immovane, and it will work bettter, once the initial side effects from clomipramine go down. I hope this simply because immovane worked perfectly while the prozac worked for fourth months years ago - but I know this could be wishful thinking.
Ed, I was wondering do you know if a dose of prozac above 20mg, can produce a higher increase in tricylic blood levels, or does the augmentation platues at a low dose of prozac. I was just wondering because on clomipramine the anxiety is gone, but I'm semi vegative, sleeping all day, can't think it's kind of like a 'dumb:) low level europhia, - as I'm going back to school on Friday, I need my mind. so I was taking 50mg prozac/day with the 30mg clomipramine, as I said on the second day, I had the bad side effects. I guess I'll wait, and see how I adjust. Unfortunately I don't have a psychiatrist right now, but the 'anxiety specialist' pdoc who perscribed the Prozac told me there was nothing to worry about concerning Prozac and increase of bloodlevel TCA's.
Anyway basically I was wondering about whether prozac's TCA augmenting effects platued at a low dose, 10 or 20 milligrams, or whether there was thought to be a significantly further increase in TCA blood levels when prozac is raised to 50 - 80mg.
To clomipicate things further, i've been taking trazadone, before immovan to sleep at high levels, (550mg), I'm being really foolish, I know, but it seems to me, I have to an aweful lot to get initial symptoms of seratonin syndrom
but maybe the gastro intestinal issue is seratonin toxicity.Ben
Posted by ed_uk on May 13, 2005, at 7:40:57
In reply to Re: Clomipramine + prozac = HELP:!!, posted by temoigneur on May 12, 2005, at 20:04:32
Hi Ben!
Did you get my email??
>I started keeping a record of my experience with prozac and reduced clomip.
Good idea :-)
>Reducing the Clomipramine from 125 to 30mg produced quite bad Diarrhea.....
Sounds like the so-called 'cholinergic rebound'.
>.....if a dose of prozac above 20mg can produce a higher increase in tricylic blood levels.......
I would expect that it probably does. You may have to decrease your clomipramine dose as you increase your Prozac dose. In addition, the effect of a given Prozac dose on clomipramine blood levels may increase during the first few weeks of being on that particular Prozac dose, further decreases in your clomipramine dose might be needed.
Kind regards,
Ed.
Posted by ed_uk on May 13, 2005, at 11:25:34
In reply to Re: Clomipramine + prozac = HELP:!!, posted by temoigneur on May 12, 2005, at 20:04:32
Hi again,
I just wanted to make some suggestions.........
Could you reduce your fluoxetine dose? 50mg of fluoxetine might be aggravating your insomnia. The insomnia is probably contributing to your daytime fatigue. If you reduced your fluoxetine dose, you'd probably be able to reduce your trazodone dose as well. Trazodone often causes daytime fatigue, especially at high doses. Perhaps you could go back down to 20mg fluoxetine for a minimum of a few weeks. During this time (on a stable fluoxetine dose), you could concentrate on finding the best dose of clomipramine.
Kind regards,
Ed.
Posted by temoigneur on May 13, 2005, at 15:35:50
In reply to Re: Clomipramine + prozac = HELP:!!, posted by temoigneur on May 12, 2005, at 20:04:32
> >
Hi Ed,Thank you so much for the feedback. It's strange you know the CLomipraine symptoms seem to be gone, even though I've increased prozac to 50mg. Clomipramine 30, I'm just righting on a hopeful whim that the immovane will continue to work, I took almost about 12 or 13 mg last night, and I slept very well, I just still feel dull on the clomipramine, but I realize that it may be the best for now. I think the prozac definately is helping, and probably making my insomnia worst - I have the luxury of staying with it for the immediate, now that my symptoms have subsided, I'm thinking I'll ask a doctor if I can add bromocriptine if the prozac starts to loose it's effect. I've read that SSRI's over an extended period may cause dopamine blockage/dysfunction in some individuals. And about the trazadone, I didn't take any last night, and slept well, I think it could have been adding to serotonin problems.
The reason why I'm anxious to pursue prozac, is that for one semester in college I felt great on it, and was doing very well in college. Then it just "pooped-out" fairly rapidly, and I've never found the stability since. Now that I've reintroduced prozac after being off them SSRi's/SNRI's for 8 months or so, I guess it makes sense that it may work intially I'm just hoping I can keep it from dying with a dopamine agonist. And thanks for advice about prozac dose and clomipramine blood levels. Perhaps if I get up to 70 mg I'll have to even consider cutting back further on the clomipramine - I'll phone the university speciailists - and I know I need to get a specialist. I'm don't want to go back to my old psychiatrist - I was hoping to get in with someone who's purportedly very good. We'll see Thanks a lot
Ben
Hi Marsha and darkhorse!
> >
> > AFAIK, citalopram can produce a relatively modest increase in the blood levels of nort.
> >
> > >I desperately need the anxiolytic effect of the nortr., asked my pdoc if I should go up on the dose, he said no but then my 15 minutes were up and I couldn't ask why not.
> >
> > Perhaps your pdoc would allow you to gradually increase your nort dose using the 10mg pills.
> >
> > >I am also taking Inderal for anxiety and I fear that it will cancel out the effects of the nort. since inderal blocks norepinephrine in the brain, doesn't it?
> >
> > Inderal sometimes worsens depression. Nadolol (Corgard) might be a better choice of beta blocker.
> >
> > Regards,
> > Ed.
>
> Hi Ed, - I started keeping a record of my experience with prozac and reduced clomip. Unfortunately I got quite bad diahhrea yesterday, and hadn't got up until 4 pm today - I've gotten. Reducing the Clomipramine from 125 to 30mg produced quite bad Diarrhea~: today I've just been up for over 1 1/2 hours, but I seem to have almost no symptoms, That being said however, the prozac causes some insomnia, - I'm hoping by some far fetched logic, that the prozac is uniquely responsive to the immovane, and it will work bettter, once the initial side effects from clomipramine go down. I hope this simply because immovane worked perfectly while the prozac worked for fourth months years ago - but I know this could be wishful thinking.
>
> Ed, I was wondering do you know if a dose of prozac above 20mg, can produce a higher increase in tricylic blood levels, or does the augmentation platues at a low dose of prozac. I was just wondering because on clomipramine the anxiety is gone, but I'm semi vegative, sleeping all day, can't think it's kind of like a 'dumb:) low level europhia, - as I'm going back to school on Friday, I need my mind. so I was taking 50mg prozac/day with the 30mg clomipramine, as I said on the second day, I had the bad side effects. I guess I'll wait, and see how I adjust. Unfortunately I don't have a psychiatrist right now, but the 'anxiety specialist' pdoc who perscribed the Prozac told me there was nothing to worry about concerning Prozac and increase of bloodlevel TCA's.
>
> Anyway basically I was wondering about whether prozac's TCA augmenting effects platued at a low dose, 10 or 20 milligrams, or whether there was thought to be a significantly further increase in TCA blood levels when prozac is raised to 50 - 80mg.
>
> To clomipicate things further, i've been taking trazadone, before immovan to sleep at high levels, (550mg), I'm being really foolish, I know, but it seems to me, I have to an aweful lot to get initial symptoms of seratonin syndrom
> but maybe the gastro intestinal issue is seratonin toxicity.
>
> Ben
Posted by ed_uk on May 13, 2005, at 17:51:51
In reply to Re: Clomipramine + prozac = HELP:!!, posted by temoigneur on May 13, 2005, at 15:35:50
I hope it works out :-)
Ed.
This is the end of the thread.
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