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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by jonh kimble on September 12, 2005, at 15:36:16
I know the monograph says amphetamines are a no-no, and maybe for every good reason. On the other hand, maybe low doses (15mg xr of dexedrine in a day) arent a problem. Im sure banging meth is going to give you some trouble, but the drug company is going to want to save themselves from lawsuits and over extend all the contradictions.
Tom
Posted by CamW on September 12, 2005, at 18:38:36
In reply to Low dose dexedrine contra. with nardil?, posted by jonh kimble on September 12, 2005, at 15:36:16
John - No, this is one of those instances where the drug/drug interaction is real. Several deaths have been documented in the literature as a result of Nardil™ (phenelzine) and Dexedrine™ (dextroamphetamine) have been taken concomittantly.
CNS stimulants (centrally-acting sympathomimetic agents), like amphetamines or even decongestants when mixed with MAOIs (monoamine oxidase inhibitors like phenelzine) can result in severe hypertensive reactions (sudden dramatic increases in blood pressure) ). Death has occurred in some reported cases.
The mechanism of this interaction is a synergistic sympathomimetic effect due to the Nardil™ enhancing norepinephrine storage in adrenergic neurons by decreasing the rate of metabolism of the norepinephrine; as well as an increase in the neuron's release of the norepinephrine or (more likely) a decreased reuptake of norepinephrine (and other catecholamines) due to the Dexedrine's™ central sympathomimetic activity.
Also, the choice of using the long-acting formulation of dextroamphetamine (ie. Dexedrine Spansules) could be a fatal one, as it is harder to eliminate from the body due to the slower absorption resulting in extended action in the brain. As a result, if a hypertensive crisis resulted from combined ingestion of Nardil™ and Dexedrine Spansules™ would be much harder to treat.
I hope that this is of some help. - Cam
Posted by jonh kimble on September 12, 2005, at 19:55:54
In reply to Re: Low dose dexedrine contra. with nardil? » jonh kimble, posted by CamW on September 12, 2005, at 18:38:36
That certainly was helpful. Thank you very much for the warning, that was specific enough for me to take it seriously, unlike many others.
Also, how did you type the TM symbol?
Tom
Posted by gromit on September 12, 2005, at 20:43:23
In reply to Re: Low dose dexedrine contra. with nardil?, posted by jonh kimble on September 12, 2005, at 19:55:54
> Also, how did you type the TM symbol?
Google™ for windows alt key codes.
© Rick
Posted by SLS on September 12, 2005, at 23:48:40
In reply to Re: Low dose dexedrine contra. with nardil? » jonh kimble, posted by CamW on September 12, 2005, at 18:38:36
Dear Cam.
I hope all is well with you.
> John - No, this is one of those instances where the drug/drug interaction is real. Several deaths have been documented in the literature as a result of Nardil™ (phenelzine) and Dexedrine™ (dextroamphetamine) have been taken concomittantly.
Before discussing this further, I would like to know if you feel the same adverse reaction with a similar risk can occur with the addition of Dexedrine to Parnate.
- Scott
Posted by Sarah T. on September 13, 2005, at 0:10:08
In reply to Re: Low dose dexedrine contra. with nardil? » jonh kimble, posted by CamW on September 12, 2005, at 18:38:36
Hi CamW,
I haven't seen you in ages! You are the same Cam that used to post here, aren't you? Welcome back!
Thanks for your post. I'm surprised to learn that dexedrine and Nardil are contraindicated. A long time ago, I took Parnate and Ritalin. Although Parnate was just not the right medicine for me, with or without Ritalin, the Ritalin did help a lot, and I didn't have any adverse interactions. I was afraid I would, and just before adding Ritalin to the Parnate, I went out and bought my first blood pressure monitor. For weeks, I was compulsive about checking my blood pressure, but I never had a problem with those two meds. It's very interesting to learn that Nardil and Dexedrine are so strongly contraindicated. Although I doubt I would have ever tried Nardil and Dexedrine together, I do have to mention that I was on Dexedrine for a long time, and I had extreme difficulty combining Dexedrine with ANYTHING. I have difficulty with most med. combinations, but for some reason, Dexedrine plus anything else was particularly troublesome for me. I don't know why. Most of the problem combinations I tried had absolutely no warnings in the literature. I mentioned this problem to a neuropsychiatrist, who said he had seen similar problems (i.e., Dexedrine plus other meds) in a few of his other patients.
Posted by Chairman_MAO on September 13, 2005, at 8:42:29
In reply to Low dose dexedrine contra. with nardil?, posted by jonh kimble on September 12, 2005, at 15:36:16
In most cases, the dangers are markedly exaggerated. I have taken oral methamphetamine (15mg doses approximately) on 200mg tranylcypromine without incident. I have taken 60-80mg MDMA along with high-dose Parnate as well, and all I experienced were good effects. As a matter of fact, due to their greater peripheral activity, decongestants (ephedrine, PPA, etc) are way more dangerous than amphetamine/methylphenidate/cocaine along with an MAOI.
The reason the contraindications are there IMHO are because the amount of amphetamine someone can take before they have an adverse reaction varies widely. Simply apply appropriate caution, start low, go slow, and have some nifedipine, clonidine, or phentolamine around, and you'll be fine.
Posted by Tom Twilight on September 13, 2005, at 13:04:55
In reply to Re: Low dose dexedrine contra. with nardil? » jonh kimble, posted by Chairman_MAO on September 13, 2005, at 8:42:29
Hey everyone
I have to say from the start that I've never combined an irreversible MAOI with a stimulant myself.
However I think Chairman MAOI is right, Nardil can be combined with Dexedrine so long as one is very carefull.
His point about Decogestants having more effect on blood pressure than cleaner stimulants is also very good.Of coure it wouldn't be a good idea to try this combination if one already has high blood pressure!
Here is a list of Stimulant plus MAOI combinations, that have been documented
http://www.dr-bob.org/babble/20050516/msgs/499763.html
Hope this helps
Tom
Posted by Maxime on September 14, 2005, at 23:57:56
In reply to Low dose dexedrine contra. with nardil?, posted by jonh kimble on September 12, 2005, at 15:36:16
> I know the monograph says amphetamines are a no-no, and maybe for every good reason. On the other hand, maybe low doses (15mg xr of dexedrine in a day) arent a problem. Im sure banging meth is going to give you some trouble, but the drug company is going to want to save themselves from lawsuits and over extend all the contradictions.
> TomHi Tom. I posted an article a while ago about taking Parnate or Nardil with a stimulant and it's okay as long as you know the sign of hypertension. I take it with Parnate.
Maxie
Posted by gardenergirl on September 15, 2005, at 1:31:57
In reply to Re: Low dose dexedrine contra. with nardil?, posted by Maxime on September 14, 2005, at 23:57:56
Hope you are doing well...
gg
Posted by jonh kimble on September 15, 2005, at 16:27:21
In reply to Maxime!!!!!!! Great to see you post!!!! » Maxime, posted by gardenergirl on September 15, 2005, at 1:31:57
Thanks for the new spin. I should say before anything that the reason I asked in the first place is cause I was sure I had heard it was contradicted BUT I also knew people were doing it. I think adderall would be more dangerous than dexedrine because it (l-amphetamine) has much more effect on the peripherial ns than straight d amphetamine or m amphetamine I believe. Thanks all, feel free to tell me I am wrong to go ahead with trying a 15 mg. of dex. Finally, if I or anyone am to do this, no tyramine messing around at the same time as I dont want a cummulative effect. My bp is low to start with and on maois it goes even lower, I frequently stand up and immediatly cant see and get really dizzy. So im at a safe starting point.
Tom
Posted by CamW on September 16, 2005, at 3:41:03
In reply to Re: Low dose dexedrine contra. with nardil? » jonh kimble, posted by Chairman_MAO on September 13, 2005, at 8:42:29
Chairman - After doing an extensive literature search I have to agree with you that combining MAOIs with stimulants is a viable alternative in certain instances. Individual genetic variations in monoamine oxidase activity must be taken into account, and may account for many instances of reported hypertensive crisis with this combination.
Most amphetamine/MAOI deaths reported were from the 1960s, with very few being reported in the recent literature. More recent deaths seem to be reported when MAOIs have been mixed with MDMA (eg. moclobemide/MDMA (2003); phenelzine/MDMA (1987). Deaths from MAOI/MDMA seem to result from hypertensive crisis and/or serotonin syndrome. I would not recommend using MDMA (aka Ecstasy) while taking an MAOI; I doubt that the benefits outweigh the risks.
While the dangers of MAOI/stimulant may be overstated, I would not say that the risk is "markedly exaggerated". Appropriate caution does need to be taken, and if anyone would decide to try this combination, I would strongly recommend not undertaking a trial without close monitoring by a physician.
Also, I think that you'd agree that the use of Dexedrine Spansules would be contraindicated in favor of the shorter acting version of the drug. And you are very correct that "low and slow" is the way to go.
- Cam
Posted by CamW on September 16, 2005, at 4:20:15
In reply to Re: Low dose dexedrine contra. with nardil? » CamW, posted by SLS on September 12, 2005, at 23:48:40
Hey Scott - I'm not doing too bad. I've been med-free and in remission (more or less) for better than a year and a half. Cool, huh? Who'd a thunk it, eh?
So, how are you doing, buddy? I've been thinking of you off and on (still at the same email?; mine's change, but I can still be reached through the old one). As I've told you last time we exchanged short notes; I no longer specialize in strictly in psychiatry. I have been following the advances in consciousness research, as a hobby. In a way, psychopharmacology and consciousness are related.
Anyway, I posted a reply to Chairman MAO (I think that I forgot to direct the post to him), showing the results of a literature search. I haven't done that in a long time. It was sorta fun.
Parnate™ (tranylcypromine) and Dexedrine™ (dextroamphetamine) is not as contraindicated as I had thought, but there is a real danger of hypertensive crisis, especially within the first couple weeks of therapy. It seems that genetics plays a roll in the vulnerability to this side effect, as well as some cases of pronounced and persistent hypotension (beyond the ordinary and transient ataxia and dizziness that is common with MAOI therapy). You do need someone to follow your progress until stabilized, but that should only be needed for a month or so. Perhaps starting at 2.5mg once daily and slowly increase.
Really, I'd like to see a few more controlled studies done before I am comfortable recommending this combination for anyone with less of an understanding of psychopharmacology than you. If you do decide to try this combination, be careful.
When I look back at my own therapy, I do realize that the addition of 10 mg of Dexedrine Spansules (am & noon) really did augment the 300mg of Wellbutrin™ (bupropion) and 450 mg of Effexor XR™ (venlafaxine). It was not until after the addition of the Dexedrine that I acheived full remission. I don't think that I really appreciated the skill of my psychiatrist at the time; the Dexedrine was his idea. At the time I just thought that the stimulant was just off-setting the "sludge-brained" hangover effect of the high dose Effexor, so that I was able to go to work before 2:00 pm. Perhaps there was more to the mechanism of action than I realized.
Take care &, if you like, email me and I'll send you a couple of the interesting papers that I found. - Cam
Posted by CamW on September 16, 2005, at 4:24:31
In reply to Re: Low dose dexedrine contra. with nardil? » jonh kimble, posted by Chairman_MAO on September 13, 2005, at 8:42:29
Posted by Chairman_MAO on September 16, 2005, at 10:56:51
In reply to Re: Low dose dexedrine contra. with nardil?, posted by CamW on September 16, 2005, at 3:41:03
Actually, the spansules might be better due to gradual time to peak plasma (think of analogy to bupropion's seizure risk in IR vs. SR vs. XL formulation).
In any case, if you have IV phentolamine around, you could take tyramine and abort it and live most likely, heh. The BEST stimulant to try in this case would be methamphetamine due to its ratio of central to peripheral effects. Too bad Desosyn gradumet is no longer on the market.
Posted by JaneB on September 16, 2005, at 14:02:25
In reply to Post of 16/08/05 (2 up) is to you (nm) » Chairman_MAO, posted by CamW on September 16, 2005, at 4:24:31
Cam, do I remember correctly that you are a pharmacist? I need to know if all SSRI's raise cholesterol levels or just Zoloft. Do all AD's have the same cholesterol raising side effect? So glad to see you back and in remission. I was in remission but now need to reconsider restarting an AD. I am just going to a family practice doctor so I want to go with a suggestion other than zoloft or paxil. I am in my 60's. Also have painful degenerative arthritis and know elavil would help the pain but don't want to be a zombie. I have too many delightful grandchildren. I take .50 clonazepam for sleep and anxiety. Any suggestions?
Posted by CamW on September 16, 2005, at 19:27:53
In reply to Re: Low dose dexedrine contra. with nardil? » CamW, posted by Sarah T. on September 13, 2005, at 0:10:08
Hi Sarah - Thanks for the WB. Thanks for the info. As I said in the above posts, the MAOI/stimulant interaction isn't as deadly as the drug interaction resource references (eg. websites, texts, etc) all claim. Most of the deaths occurred in the 1960s and involved methamphetamine (aka "speed", "ice", "crank" methedrine, methylamphetamine, & various other street names, which elude me at the moment) with an MAOI (like Parnate™ - tranylcypromine & Nardil™ - phenelzine).
Most of the MAOI/stimulant deaths of the 1960s were due to cardiac arrest (heart stoppage) resulting from "hypertensive crisis". Basically, the clinical definition is a sudden drastic increase in blood pressure exceeding 210/120 mm Hg, where the "ideal" blood pressure for an adult is 120/80 mm Hg.
Characteristic symptoms of a hypertensive crisis begin may include severe headache, vertigo (dizziness), diplopia (double vision), tinnitus (ringing in the ears), nosebleed, muscle twitches, tachycardia (increase in heart rate), nausea, &/or vomiting. If treatment is not initiated fairly quickly, the afflicted may become confused, irritated, &/or stuporous (unresponsive); potentially followed by convulsions, coma, myocardial infarction, &/or renal (kidney) failure. If not treated by this point, cardiac arrest or stroke may occur; resulting in the afflicted person having a very bad day.
Street drugs, such as methamphetamine, are often are adulterated(ie. "cut") with inactive fillers or cheaper, readily available chemicals that superficially mimic the actions of the street drug, in order to increase profit. Methamphetamine is sometimes adulterated with legal decongestants (eg. pseudoephedrine - Sudafed™), that sorta mimic methamphetamine's pharmacologic action, but to a much lesser extent. The drugs share the same basic, underlying molecular structure, but have differing side groups attached, and it is this that determines which receptor sub-type and to where in the body each drug will act, and how potent each drug will be.
Amphetamines and decongestants are both sympathomimetic amines that indirectly activate alpha-adrenergic and beta-adrenergic receptors. The difference in activity between the two is that the methamphetamine has much greater activity at receptors in the central nervous system in the brain, while the pseudoephedrine preferentially binds to receptors in the nasal mucosa outside the brain.
The reason that methamphetamine adulterated with a decongestant (in the 1960s there were 2 other decongestants available - ephedrine & phenylpropanolamine - which have been since removed from the market) is more deadly than when added to an MAOI is that the decongestant inhibits the catabolism (metabolic breakdown) of amphetamine-like psychostimulants (eg. methamphetamine).
Ordinarily, when pseudoephedrine is added to methamphetamine to increase profit for the "crank dealer" nothing happens to the person buying and using the adulterated methamphetamine (except getting less "bang for their buck"). But, if that person is also taking an MAOI, the risk of hypertensive crisis is increased because both the pseudoephedrine and the methamphetamine both need the enzyme, monoamine oxidase (MAO), in order to be metabolized (& thus excreted - eliminated from the body). The monoamine oxidase inhbitor (MAOI - eg. Phenelzine™) binds to monoamine oxidase (MAO) making the enzyme inactive, thus "inhibiting" it's action (hence MAOI). Therefore, the little MAO that is available now has to metabolize both the methamphetamine and pseudoephedrine (as well as the neurotransmitters that MAO naturally metabolizes). The effects of both methamphetamine and pseudoephedrine are extended, since both retain activity and remain in the body until they are metabolized.
Also, since pseudoephedrine (as well as ephedrine) has the same basic molecular structure as methamphetamine, the decongestant can be changed into speed through a relatively simple chemical reduction reaction. The chemicals (&/or their reaction by-products) used to do this are toxic and moderately dangerous to handle, and depending upon which dosage form is being made (eg. injectible, smokeable, etc) for every 1 kg of methamphetamine "cooked" 5 kg of hazardous waste are produced (just a cool factoid I came across).
Another interesting tid-bit of information I came across is how to tell if a meth lab is close by (& thus be able to stay far enough away in case it blows up, and also allows you to try to keep clear of any of that hazardous waste. Apparently, a meth lab in production gives off a very strong odor of cat pee. And you thought that crazy old lady down the street just really like her pussy. ;^P
So, perhaps one reason that so many people died from the MAOI/methamphetamine combination in the 1960s may have been due to pseudoephedrine adulteration of the speed. This may have contributed to the perception that the MAOI/amphetamine drug-drug interaction is more dangerous and deadly than it really is.
Another possible explanation for the decrease in mortality over the past 40 years is the advances in the treatment of hypertensive crisis, both in efficacy and safety of the newer medications, as well as improvements in the delivery of emergency medicine.
I just thought I'd better clarify and update my last post. I hope that this is of some use to you. - Cam
Posted by Sarah T. on September 16, 2005, at 19:55:48
In reply to Re: Low dose dexedrine contra. with nardil? » Sarah T., posted by CamW on September 16, 2005, at 19:27:53
> > > Another interesting tid-bit of information I came across is how to tell if a meth lab is close by (& thus be able to stay far enough away in case it blows up, and also allows you to try to keep clear of any of that hazardous waste. Apparently, a meth lab in production gives off a very strong odor of cat pee. And you thought that crazy old lady down the street just really like her pussy. ;^P>> > . - Cam>
Hi Cam,
Wow! Thank you for that very interesting reply!!!
As for the last tidbit, I'm surprised that meth labs give off a strong odor of cat urine. I wonder why. When I took introductory biology, we learned that cat urine doesn't start to smell until a certain temperature is eached, a temperature at which an enzyme breaks down some of the substances in the urine and causes that characteristic odor. I thought ammonia caused that odor, but perhaps I'm mistaken. Is ammonia a byproduct of methamphetamine production?By the way, I've read that if you have cats, you shouldn't wash the floor with ammonia because when the cats smell the ammonia residue, they'll think it's urine and they'll "assume" that the entire floor is a giant litter box.
Thanks again for your very helpful post.
S.
Posted by Maxime on September 19, 2005, at 13:25:49
In reply to Re: Low dose dexedrine contra. with nardil?, posted by jonh kimble on September 15, 2005, at 16:27:21
Actually Adderall XR is better for me with the Parnate. The Dexedrine will sometimes give me a headache. Adderall XR was pulled from Canada but now it's coming back. I hope I can get on it again. It really helped.
Maxime
> Thanks for the new spin. I should say before anything that the reason I asked in the first place is cause I was sure I had heard it was contradicted BUT I also knew people were doing it. I think adderall would be more dangerous than dexedrine because it (l-amphetamine) has much more effect on the peripherial ns than straight d amphetamine or m amphetamine I believe. Thanks all, feel free to tell me I am wrong to go ahead with trying a 15 mg. of dex. Finally, if I or anyone am to do this, no tyramine messing around at the same time as I dont want a cummulative effect. My bp is low to start with and on maois it goes even lower, I frequently stand up and immediatly cant see and get really dizzy. So im at a safe starting point.
> Tom
Posted by bigcat on September 27, 2005, at 0:30:13
In reply to Low dose dexedrine contra. with nardil?, posted by jonh kimble on September 12, 2005, at 15:36:16
I was on 90 mg nardil with 90mg dexedrine, no problems, no side effects, just a solid remission that eventually faded
This is the end of the thread.
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