![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 9 to 33 of 33. Go back in thread:
Posted by TamaraJ on July 11, 2005, at 9:02:24
In reply to Re: Zoloft - temporary problems or not?!?!? » TamaraJ, posted by SLS on July 11, 2005, at 8:29:46
You are wonderful optimist, and it is an inspiration to many on the board, myself included. Optimism aside, you also are a wealth of knowledge and of solid, reasoned advice, so I have no problem placing weight on what you have to say. I have tended to be an optimist throughout my life, but I guess I am feeling discouraged. I need to snap out of that.
The morbid thoughts about why should I bother to even go on, and the anger and hostility I am feeling within myself are relatively foreign to me, and that, I think, is why I am scared to continue with the Zoloft. And, although I was doing relatively well on the Wellbutrin/nortriptyline combo, there was still something missing, something I can't put my finger on or name, but I know is crucial to my recovery (could that make any less sense LOL). And, the combo didn't really touch the "nameless dread" that has developed after months and months of setbacks and my isolating as a result.
I just wonder how long these side effects will last? I am so bitchy and irritable that I would pity anyone who is brave enough to try to spend time with me right now, without being heavily medicated LOL. Also, my sleep has been really disrupted, and I wake up achy and exhausted. I wonder if it would be ok to take 25mg of nortriptyline before bed to ensure a good night's sleep while I adjust to the Zoloft, or would I be risking serotonin syndrome?
Thanks, Scott. You have a way of providing calm reassurance, coupled with sound, logical advice.
Tamara
> I tend to be an optimist, so don't place to much weight on what I have to say.
>
> First of all, SSRI + Wellbutrin is a good combination. I know people who fail to respond adequately to each separately who end up achieving remission using the combination of these medications.
>
> Second of all, anger and irritability are often an early indicator of a positive antidepressant response, as the lack of energy and passivity that are part of severe depression begin to improve. Things still suck, but now you have more energy to act on it. Think of it as being an "in-between" state that will shortly pass and leave you with a gradual process of improvement.
>
>
> - Scott
Posted by SLS on July 11, 2005, at 11:05:41
In reply to Re: Zoloft - temporary problems or not?!?!? » SLS, posted by TamaraJ on July 11, 2005, at 9:02:24
Hi Tamara.
Don't be scared to continue with Zoloft. As foreign as the feelings of anger and irritability are, I imagine so are the feelings of normalcy that you might *possibly* be headed for.
There are two, no, three, no, four alternate explanations.
1. These are side effects that may or may not disappear, perhaps due to an interaction with Wellbutrin. However, they do not represent an indicator that you are responding.
2. It is a sign that you are responding and improving. This phase will disappear within two weeks.
3. You are experiencing a point in your menstrual cycle that is producing a mood state that is now presenting because the Zoloft is beginning to work.
4. You really are a b*tch, but you just haven't felt well enough in the past to express it. LOL :-)
> And, although I was doing relatively well on the Wellbutrin/nortriptyline combo, there was still something missing, something I can't put my finger on or name, but I know is crucial to my recovery
Do you feel that you are missing a "mood brightener" that would give you the motivation to participate with cheer and get things done without it seeming like too much of a chore? My friend calls what SRIs do for her as giving her the "wanna do's". Wellbutrin gives her the mental energy to do them.
> And, the combo didn't really touch the "nameless dread" that has developed after months and months of setbacks
Does this include a background anxiety that is always there?
> and my isolating as a result.
Yeah, that's bad. I isolate when things get really bad.
Just because you experience setbacks does not mean that you must start all over again and begin an arduous climb from the bottom of the ladder. You do not lose the things that you have learned and internalized. You'd be surprised how much you retain, despite being in a chronic depressed state.
- Scott
Posted by TamaraJ on July 11, 2005, at 11:33:31
In reply to Re: Zoloft - temporary problems or not?!?!? » TamaraJ, posted by SLS on July 11, 2005, at 11:05:41
> Hi Scott,
>
> Don't be scared to continue with Zoloft. As foreign as the feelings of anger and irritability are, I imagine so are the feelings of normalcy that you might *possibly* be headed for.
>
-- That would be nice. I haven't felt normal for over a year. Well, actually, I was feeling quite a bit better once the severe iron deficiency I had been experiencing was finally adequately treated (10 week course of iron injections). Then, I was put on Depo, and that screwed me up really badly.> There are two, no, three, no, four alternate explanations.
>
> 1. These are side effects that may or may not disappear, perhaps due to an interaction with Wellbutrin. However, they do not represent an indicator that you are responding.
>
-- I suppose giving it 3 weeks should be enough time to make a decision as to whether I will be able to tolerate the med and would give me some kind of an indication of whether I will respond.> 2. It is a sign that you are responding and improving. This phase will disappear within two weeks.
>
-- That would be nice. I think I will try to stick it out.> 3. You are experiencing a point in your menstrual cycle that is producing a mood state that is now presenting because the Zoloft is beginning to work.
>
-- I never thought of that. I will check the calendar. I think it may be PMS time actually.> 4. You really are a b*tch, but you just haven't felt well enough in the past to express it. LOL :-)
>
-- ROTFLMAO!!! Or, maybe everybody has been too afraid to tell me :-) But, seriously, I have been pretty consistently a soft-spoken, mild-mannered person pretty much all my life, with the exception of the times I have had EXTREME PMS (hey, perhaps that should be a new reality t.v. show LOL).> Do you feel that you are missing a "mood brightener" that would give you the motivation to participate with cheer and get things done without it seeming like too much of a chore? My friend calls what SRIs do for her as giving her the "wanna do's". Wellbutrin gives her the mental energy to do them.
>
-- I think you hit it on the head. It's like things seem like a chore. I mean, I was always the type of person who could find pleasure in simple, little things, including grocery shopping or organizing a closet, and lately it's been like "why bother". I guess it is a case of the blahs. That's interesting that your friend says the SRIs give her the "wanna do's". I hear so much about people experiencing apathy on the SRIs. I never experienced apathy when I was on Paxil, and I stayed on it for about 6 or 7 years, although the last few years I only used a small dose.> Does this include a background anxiety that is always there?
>
-- I don't think it is really anxiety, as in generalized anxiety, but it is like I have become fearful. Like the thought of going out and doing stuff causes some kind of phobic reaction. Weird, I know. And, I have been feeding it, which is terrible.
> Yeah, that's bad. I isolate when things get really bad.
>
-- It is bad. I find that after a while, it's almost like I forget how to be social.> Just because you experience setbacks does not mean that you must start all over again and begin an arduous climb from the bottom of the ladder. You do not lose the things that you have learned and internalized. You'd be surprised how much you retain, despite being in a chronic depressed state.
>
-- I have to keep reminding myself of that. I am fortunate to have a good, patient pdoc, who always spends an entire hour with me when I have an appointment discussing meds and other issues. I am now looking into doing EMRD therapy, so that may make a difference in terms of the avoidant behaviours I have developed as a result of the depression.
>
One final question (sorry), do you think it would be ok if I continued to take 25mg of Nortriptyline for a couple of weeks while I get used to the Zoloft. I am finding that I am not sleeping very well since starting the Zoloft, and wake up feeling really drained and achy.Thanks again, Scott.
Tamara
Posted by linkadge on July 11, 2005, at 15:42:14
In reply to Re: Zoloft - temporary problems or not?!?!? » linkadge, posted by TamaraJ on July 11, 2005, at 7:07:13
The posessed feeling is a strange one. Unfortunately it didn't pass for me.
Thats kind of why I quit it. Not sure what to say. Don't want to assume that thats how it will be for you but I have to be honest with how it affected me.Linkadge
Posted by TamaraJ on July 11, 2005, at 15:45:35
In reply to Re: Zoloft - temporary problems or not?!?!? » TamaraJ, posted by linkadge on July 11, 2005, at 15:42:14
Thanks, Linkadge. I appreciate your honesty. I'd rather know the good and the bad, so if the bad does happen, I at least know why.
Tamara
> The posessed feeling is a strange one. Unfortunately it didn't pass for me.
> Thats kind of why I quit it. Not sure what to say. Don't want to assume that thats how it will be for you but I have to be honest with how it affected me.
>
> Linkadge
Posted by blueberry on July 11, 2005, at 19:00:04
In reply to Zoloft - temporary problems or not?!?!?, posted by TamaraJ on July 10, 2005, at 11:09:29
If it were me, I would cut a pill in half and just do a half the next time. Stay there a few days at least before moving up. That's what I would do anyway.
Wellbutrin is thought to be a dopamine reuptake inhibitor, and even though zoloft is a serotonin reuptake inhibitor, it actually does have some dopamine reuptake inhibition also. So maybe with the two combined you might experience something like a dopamine overload with rage and agitation and stuff. I would cut the dose back and approach it more gradually.
There could be withdrawals from nortriptyline mixed in there confusing things. I was on nortriptyline for just a couple weeks, but went through some fairly tough withdrawals.
Posted by TamaraJ on July 11, 2005, at 19:26:06
In reply to Re: Zoloft - temporary problems or not?!?!?, posted by blueberry on July 11, 2005, at 19:00:04
Thanks, Blueberry. Unfortunately, I can't cut the pill in half, they are caps. But, they are 25mg caps, so I could go back to 25mg for a few days. I also just thought that maybe I could reduce the Wellbutrin to 100mg for a few days, while I adjust to the 50mg of the Zoloft. Would that also make sense? The other thing that may be exacerbating the side effects is that I have not yet completely quit smoking, so perhaps there is even more dopamine activity going on because of the smoking.
And, as you say, part of the problem could still be nortriptyline withdrawal. I stopped just over a week ago, going immediately from 75mg to 0. I have a question for you, if you feel you can answer. As I am adjusting to the Zoloft, I am finding that my sleep is not very restorative, and I wake up achy, exhausted and foggy. I wonder if I could take 25mg of the nortriptyline for a few days, or would that be unwise with the Zoloft?
Thanks so much.
Tamara
> If it were me, I would cut a pill in half and just do a half the next time. Stay there a few days at least before moving up. That's what I would do anyway.
>
> Wellbutrin is thought to be a dopamine reuptake inhibitor, and even though zoloft is a serotonin reuptake inhibitor, it actually does have some dopamine reuptake inhibition also. So maybe with the two combined you might experience something like a dopamine overload with rage and agitation and stuff. I would cut the dose back and approach it more gradually.
>
> There could be withdrawals from nortriptyline mixed in there confusing things. I was on nortriptyline for just a couple weeks, but went through some fairly tough withdrawals.
Posted by SLS on July 11, 2005, at 21:05:55
In reply to Re: Zoloft - temporary problems or not?!?!? » blueberry, posted by TamaraJ on July 11, 2005, at 19:26:06
Hi Tamara.
As Blueberry suggested, it is possible that your withdrawal from nortriptyline might be a factor in what you are feeling. However, I would have expected these things to develop within three days of discontinuation rather than a week later. It is hard to know for sure.
There is nothing wrong with continuing on a reduced dosage of nortriptyline while taking Zoloft and Wellbutrin. Zoloft moderately increases the blood levels of nortriptyline, so 25mg would be a very reasonable dosage to remain on.
SRI + TCA can sometimes work well when SRI monotherapy does not. Don't neglect the possibility that Zoloft + nortriptyline might work. You would probably want to go to 50mg and then return to 75mg if you want to adequately explore the combination.
- Scott
Posted by TamaraJ on July 11, 2005, at 21:28:45
In reply to Re: Zoloft - temporary problems or not?!?!? » TamaraJ, posted by SLS on July 11, 2005, at 21:05:55
Thanks, Scott. It is probably start up side effects from the Zoloft, because it really hit me when I increased my dose to 50mg last Tuesday. I will use 25mg of nortriptyline for a few days, if only to help me get a good night's sleep while I adjust to the Zoloft. I feel like I have had a wicked hangover for a week now, and I don't even drink anymore :-) I am taking some ginger capsules to help with the nausea, so that should help.
Thanks again. And, I am so sorry that you are not having the response you had hoped for with the Trileptal :-( That really stinks!
Take care,
Tamara
> Hi Tamara.
>
> As Blueberry suggested, it is possible that your withdrawal from nortriptyline might be a factor in what you are feeling. However, I would have expected these things to develop within three days of discontinuation rather than a week later. It is hard to know for sure.
>
> There is nothing wrong with continuing on a reduced dosage of nortriptyline while taking Zoloft and Wellbutrin. Zoloft moderately increases the blood levels of nortriptyline, so 25mg would be a very reasonable dosage to remain on.
>
> SRI + TCA can sometimes work well when SRI monotherapy does not. Don't neglect the possibility that Zoloft + nortriptyline might work. You would probably want to go to 50mg and then return to 75mg if you want to adequately explore the combination.
>
>
> - Scott
Posted by TamaraJ on July 12, 2005, at 16:11:55
In reply to Re: Zoloft - temporary problems or not?!?!? » TamaraJ, posted by SLS on July 11, 2005, at 21:05:55
Hi Scott,
Just one last thing, if you have time and don't mind.
I had a look at the chart you created on psychtropic meds (great chart, by the way. I refer to it often). I noticed that Wellbutrin and Zoloft appear to be equal in terms of Dopamine reuptake or inhibition. I also read in a couple of places that Wellbutrin actually only has a mild effect on dopamine and norepiphedrine. Yet, Nortriptyline seems to be quite a potent or at least be a significant inhibitor of norepiphedrine. So, the question I have is that is Nortriptyline less activating than Wellbutrin because of its other mechanisms, which result in certain side effects? Also, which of the two, Wellbutrin or Nortriptyline, do you think would be better for melancholic depression with adhedonia?
Just wanted to keep myself informed in case I find the Wellbutrin/Zoloft combination continues to cause too much nausea.
Thanks.
Tamara
Posted by ed_uk on July 12, 2005, at 17:48:05
In reply to Question for Scott (if you have time) » SLS, posted by TamaraJ on July 12, 2005, at 16:11:55
Hi T!
Although Zoloft has a higher affinity for the dopamine transporter than Wellbutrin, only Wellbutrin has significant dopaminergic effects at therapeutic doses. Zoloft is a very potent serotonin reuptake inhibitor and a very 'weak' dopamine reuptake inhibitor. Therapeutic doses of Zoloft produce low levels of Zoloft in the brain, not enough to affect dopamine reuptake. Because therapeutic doses of Wellbutrin produce high drug levels in the brain, Wellbutrin is believed to inhibit the reuptake of dopamine at normal doses. Wellbutrin has a low affinity for the norepinephrine transporter. Nevertheless, it does have some effect on the reuptake of norepi at therapeutic doses because of the high drug levels produced. Bear in mind, the mechanism of action of Wellbutrin is not well understood. It's various active metabolites also contribute to its AD effect.
>Yet, Nortriptyline seems to be quite a potent or at least be a significant inhibitor of norepiphedrine.
True :-)
Ed xxx
Posted by linkadge on July 12, 2005, at 17:53:10
In reply to Re: Zoloft - temporary problems or not?!?!? » TamaraJ, posted by SLS on July 11, 2005, at 21:05:55
Zoloft + nortryptaline would be like a triple uptake inhibitor.
Linkadge
Posted by TamaraJ on July 12, 2005, at 18:14:25
In reply to Re: Question for Scott (if you have time) » TamaraJ, posted by ed_uk on July 12, 2005, at 17:48:05
Hey Ed!
Thanks, Ed. Just trying to decide whether the Zoloft/Nortriptyline combo may be more effective for me than the Wellbutrin/Zoloft combo. I know I certainly sleep better on Nortriptyline, but the disrupted sleep may go away once I adjust to the Zoloft. Would the nort be a more potent inhibitor of norepiphedrine than Wellbutrin? I guess, I am just investigating my options, so that I can keep the options open. One option that I can also consider, if the nausea from the Wellbutrin/Zoloft combo does not subside, is Zoloft/Nortriptyline with some L-Tyrosine and possibly DMAE along with the occassional dose of NADH. Oh, decisions, decisions. I am a flake :-(
Tamara xoxo
> Hi T!
>
> Although Zoloft has a higher affinity for the dopamine transporter than Wellbutrin, only Wellbutrin has significant dopaminergic effects at therapeutic doses. Zoloft is a very potent serotonin reuptake inhibitor and a very 'weak' dopamine reuptake inhibitor. Therapeutic doses of Zoloft produce low levels of Zoloft in the brain, not enough to affect dopamine reuptake. Because therapeutic doses of Wellbutrin produce high drug levels in the brain, Wellbutrin is believed to inhibit the reuptake of dopamine at normal doses. Wellbutrin has a low affinity for the norepinephrine transporter. Nevertheless, it does have some effect on the reuptake of norepi at therapeutic doses because of the high drug levels produced. Bear in mind, the mechanism of action of Wellbutrin is not well understood. It's various active metabolites also contribute to its AD effect.
>
> >Yet, Nortriptyline seems to be quite a potent or at least be a significant inhibitor of norepiphedrine.
>
> True :-)
>
> Ed xxx
Posted by TamaraJ on July 12, 2005, at 18:19:20
In reply to Re: Zoloft - temporary problems or not?!?!?, posted by linkadge on July 12, 2005, at 17:53:10
But, wouldn't Zoloft + Wellbutrin also be like a triple uptake inhibitor? In any event, in your opinion, which would have the potential for being a more effective combo: Zoloft + Wellbutrin or Zoloft Nortriptyline to deal with anergic depression with some adhedonia, coupled with some social and anticipatory anxiety and nameless dread? Also, what do you think of the Zoloft + Nortriptyline combo, with perhaps a low dose of L-Tyrosine, and perhaps some DMAE and NADH (a few times a week)?
Thanks, Link, your insights are appreciated.
Tamara
> Zoloft + nortryptaline would be like a triple uptake inhibitor.
>
> Linkadge
Posted by SLS on July 12, 2005, at 18:37:28
In reply to Question for Scott (if you have time) » SLS, posted by TamaraJ on July 12, 2005, at 16:11:55
> I noticed that Wellbutrin and Zoloft appear to be equal in terms of Dopamine reuptake or inhibition.
Actually, thinking simplistically, it is not surprising that you should get nausea from combining two pro-dopaminergic drugs. Nausea can occur for any number of reasons, but dopaminergic activation in certain areas of the brain does. Actually, I think that's why people have nausea attacks over the first few days of starting Effexor, a drug with a "weak" dopamine reuptake property. I once tried nomifensine (Merital), the most potent dopamine reuptake inhibitor antidepressant ever marketed in the U.S. I did not suffer any nausea with this drug. So much for being simplistic.
> I also read in a couple of places that Wellbutrin actually only has a mild effect on dopamine and norepiphedrine.
I don't know what the heck Wellbutrin does. Sheldon Preskorn, MD, is very adamant that Wellbutrin is a potent enough DA/NE reuptake inhibitor such that it explains its mechanism of action. Currently, I don't agree with him. I cannot offer an alternative, though.
> Yet, Nortriptyline seems to be quite a potent or at least be a significant inhibitor of norepiphedrine.
It is. It also tickles serotonin a wee bit.
> So, the question I have is that is Nortriptyline less activating than Wellbutrin because of its other mechanisms,
I don't find Wellbutrin to be activating at all. But that's just me and my enigmatic brain chemistry. It might be that its metabolite is the source for the activation and anxiety that Wellbutrin is known to frequently produce. So the question becomes: is Wellbutrin the active antidepressant compound or is it the metabolite or both? Is the metabolite the source of the amphetamine like effects? Can a Wellbutrin-like compound be synthesized that doesn't produce this metabolite and perhaps avoid the unwanted side effects? I don't know. I'm just thinking out loud.
Wellbutrin makes me feel worse.
Nortriptyline makes me feel better.
Nortriptyline has been associated with successful treatment of melancholic depression. However, I don't think Wellbutrin has been scrutinized in this area. It might be just as good, but I think I would opt for a TCA for melancholia with psychomotor retardation.
I doubt I threw any light on the subject. Just a ramble. Sorry.
- Scott
Posted by linkadge on July 12, 2005, at 19:58:52
In reply to Re: Question for Scott (if you have time) » TamaraJ, posted by SLS on July 12, 2005, at 18:37:28
Yeah, I think that nortryptaline is a more effective antidepressant.
Linkadge
Posted by TamaraJ on July 12, 2005, at 20:36:21
In reply to Re: Question for Scott (if you have time) » TamaraJ, posted by SLS on July 12, 2005, at 18:37:28
Thanks, Scott. Your musings were interesting and useful. It is incredible just how much conflicting information there is on this particular AD. I seem to recall reading in two places that it is a weak inhibitor of dopamine and norepinephrine. Yet, I have heard the opposite as well. It may well have to do with the metabolites, and even that is a mystery I think because I seem to recall reading that there is also a second metabolite but nobody is sure what exactly it does. I imagine that Wellbutrin must be quite hard on the liver with all the metabolism it goes through.
Until I get through the start-up side effects from the Zoloft, it is difficult to say if the Wellbutrin is making me fatigued. I know in the morning after I take my Wellbutrin/Zoloft, I get really tired for a couple of hours. So, I will keep an eye on that. It may turn out that Zoloft (for the anticipatory anxiety and nameless dread) and Nortriptyline (for the depression and adhedonia) may be the right combo, but I will stick with the Zoloft/Wellbutrin until I have made it through the worst of the start-up side effects.
Thanks again. Your insights are much appreciated.
Tamara
Posted by SLS on July 13, 2005, at 9:48:14
In reply to Re: Question for Scott (if you have time) » SLS, posted by TamaraJ on July 12, 2005, at 20:36:21
> Until I get through the start-up side effects from the Zoloft, it is difficult to say if the Wellbutrin is making me fatigued.
What you can do as an experiment is take the Wellbutrin when you first wake up and take your Zoloft 6-8 hours later and try to identify which is creating the fatigue that comes over you during those first few hours post dose. Of course, you need to be sure that you don't normally get fatigued during the time of day that comes 6-8 hours after wakening. If in doubt, just switch the order and compare. I recently used this type of an experiment to identify that someone was being underdosed with their antidepressant.
I think you have a good plan in place. The trick is trying to adhere to it when side effects appear or linger and relief has not yet arrived.
You've had some very talented minds commenting on your condition. It seems that there is a consensus among us that using nortriptyline in your next combination is worthy of consideration. I would go with the Zoloft + nortriptyline alternative.
Good luck.
- Scott
Posted by TamaraJ on July 13, 2005, at 12:30:24
In reply to Re: Question for Scott (if you have time) » TamaraJ, posted by SLS on July 13, 2005, at 9:48:14
> What you can do as an experiment is take the Wellbutrin when you first wake up and take your Zoloft 6-8 hours later and try to identify which is creating the fatigue that comes over you during those first few hours post dose. Of course, you need to be sure that you don't normally get fatigued during the time of day that comes 6-8 hours after wakening. If in doubt, just switch the order and compare. I recently used this type of an experiment to identify that someone was being underdosed with their antidepressant.
>
-- That sounds like a good idea. Tomorrow, I will take the Wellbutrin in the morning, as usual, and the Zoloft about 2 or 3 in the afternoon. I will do that for two days to see if it makes a difference in the amount of fatigue. If not, then I will try the reverse for a couple of days.
>
> You've had some very talented minds commenting on your condition. It seems that there is a consensus among us that using nortriptyline in your next combination is worthy of consideration. I would go with the Zoloft + nortriptyline alternative.
>
-- Yes, I certainly have, and I appreciate the input and advice from you incredibly wise and knowledgeable people. I agree that the Zoloft + nortriptylne would be the way to go next. I came across a couple of abstracts today, one of which said that of all the SSRIs, Zoloft was the only one that has demonstrated efficacy in treating melancholic depression (I don't think it was a particularly big sample though), and others that indicate that the TCAs, particularly nortriptyline in the case of women and those over 40 (if I am remembering right), appear most effective for melancholic depression. So, that sounds pretty compelling, on paper at least.-- I guess if I went for that combo, I would go with either 50mg or 75mg of Zoloft and 50mg or 75mg of Nortriptyline, right? Is there any danger of cardio side effects at those doses, particularly considering that, as I understand it, SSRIs potentiate TCAs?
Thanks again, ScottTamara
Posted by ed_uk on July 13, 2005, at 13:36:53
In reply to Re: Question for Scott (if you have time) » TamaraJ, posted by SLS on July 12, 2005, at 18:37:28
>Sheldon Preskorn, MD, is very adamant that Wellbutrin is a potent enough DA/NE reuptake inhibitor such that it explains its mechanism of action.
I'm not convinced either. I think he gives the impression that we know more about Wellbutrin than we actually do. Wellbutrin's psychotropic activity just doesn't seem to be entirely consistent with its proposed mechanism of action.
~Ed
Posted by ed_uk on July 13, 2005, at 13:40:34
In reply to Re: Question for Scott (if you have time) » ed_uk, posted by TamaraJ on July 12, 2005, at 18:14:25
Hi T!
>Would the nort be a more potent inhibitor of norepiphedrine (reuptake) than Wellbutrin?
Yes, almost certainly.
Ed xxx
Posted by SLS on July 13, 2005, at 16:18:36
In reply to Re: Question for Scott (if you have time) » SLS, posted by TamaraJ on July 13, 2005, at 12:30:24
Regarding the combination of Zoloft + nortriptyline, I would use the full therapeutic dosages of both together as if you were taking each one separately. Zoloft can increase the blood level of nortriptyline slightly, so you might want to get a blood test at 75mg to see if it falls within the range of 50-150 ng/ml. Alternatively, you can start at 50mg and titrate the dosage upwards if necessary. It is difficult to guess which individuals will need to make an adjustment for the interaction. In the elderly, though, the increase in blood levels can be as much as 40%, so an allowance should be made in this population.
Bottom line: Your guess was right!
I would titrate the dosage of Zoloft and increase it as tolerated to as close to 200mg as possible. Expect transient headaches. They are not an indication of blood pressure. I would start the nortriptyline at 50mg and get a blood level once your Zoloft reaches 100mg after a week. I would then raise the dosage to 75mg if the blood test results in a level of less than 100 ng/ml.
I don't think there are any concerns in combining these drugs with respect to cardiac effects.
- Scott
Posted by TamaraJ on July 13, 2005, at 19:48:28
In reply to Re: Question for Scott (if you have time), posted by SLS on July 13, 2005, at 16:18:36
Thanks so much, Scott. Sounds like a good plan, although I won't be able to discuss it with my pdoc (he is on holidays), However, he did have me taking Celexa + Nortriptyline when I first started the Nortriptyline, but the Celexa didn't seem to add much in terms of anxiety or nameless dread relief. When I dropped the Celexa, there was no noticeable difference. So, I am sure he won't mind my going back to Nortriptyline and dropping the Wellbutrin, if my experiments with dosage timing have no impact on the level of fatigue I am experiencing. He isn't a big fan of Wellbutrin anyway. He hasn't been exactly keen to do a blood test to check notriptyline blood plasma levels, but I will try to insist.
Take care,
Tamara
Posted by TamaraJ on July 13, 2005, at 19:50:36
In reply to Re: Question for Scott (if you have time) » TamaraJ, posted by ed_uk on July 13, 2005, at 13:40:34
Thanks so much Ed. I don't feel as discouraged or helpless when I know there are options that won't require my starting from scratch. Phew!
Tamara
xoxo
Posted by TamaraJ on July 15, 2005, at 12:50:23
In reply to Re: Question for Scott (if you have time) » ed_uk, posted by TamaraJ on July 13, 2005, at 19:50:36
So, I have discontinued the Wellbutrin, as of today, and I am not as physically exhausted, fatigued and nauseas as I have been the past 10 days. And, I will now take the Zoloft later in the day. I am going to reintroduce Nortriptyline tonight at 25mg, and hope for the best.
And, if the Zoloft + Nortriptyline combination does not give me the relief I am looking for, including a bit more energy needed for my motivation, I can look into trying Desipramine instead of Nortriptyline to see if that makes a further difference. And, there is also NADH, L-Tyrosine and DMAE which have helped me somewhat in the past.
I wanted to thank you all, Scott, Linkadge, Ed and Blueberry, for your advice, wisdom and patience. You all are great.
Tamara
This is the end of the 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.