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Dr. Bob is Robert Hsiung, MD,
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Posted by bulldog2 on May 2, 2008, at 14:47:11
In reply to Emsam insomnia and spaciness, posted by LongRoad on May 2, 2008, at 11:59:41
> Hi all. First time poster, long time reader :)
>
> I am primarily a depressive.
>
> Have tried all SSRI's, and also Lamictal, Gabappentin, Neurontin, Wellbutrin, effexor, and some of the anti-psychotics. Most have had some or even good success for a period of time but the good ones eventually washed-out.
>
> Currently I'm on the 12mg patch of Emsam. 6mg did very little, 9 helped more, and 12 seems to be doing a good job at keeping away the depression. The problem is the one I keep reading about - insomnia. It started at 9mg, I hoped it would go away, but no dice. I've been taking 4mg of Lunesta, and it knocks me out, but I wake up a couple hours later. I've started taking the patch off around 6 (get to bed around midnight) and still take the Lunesta. It's been slightly better these last couple of days - when I do wake up, I can kind of get back to a semi, restless sleep till morning. But it's still pretty bad.
>
> I don't want to take benzos (primarily because I really DO want to - I'm a recovering addict). So I was wondering about other combinations. Geodon was something I thought of. I wanted to know what people's experiences are. I also have ADD inattentive type. I've been off the stims for awhile now b/c of irritability that eventually began and have been dealing ok with it. But the Emsam is worsening the ADD. And if I can't sleep now, adding dexedrine into the mix, probably won't help things :)
>
> So any experience or advice around this med would be appreciated. Has anyone conquered the insomnia?One person in here used trazadone for sleep and she was on emsam 12 mg.
Posted by bleauberry on May 2, 2008, at 17:43:20
In reply to Emsam insomnia and spaciness, posted by LongRoad on May 2, 2008, at 11:59:41
Top choices I can think of would be:
Double the dose of Lunesta.
Seroquel 25mg-50mg.
Trazodone 25mg-50mg.
Remeron 7.5mg-15mg.
Restoril, unsure of dose.
Amitriptyline 10mg-25mg.Also consider combining low doses of two different sedating meds of your chocie. What happens a lot is that the synergy of two meds works better than double or triple doses of either one alone, with not much more side effects than just one of the low dose meds.
Posted by d0pamine on May 3, 2008, at 1:44:57
In reply to Emsam insomnia and spaciness, posted by LongRoad on May 2, 2008, at 11:59:41
With several years of the 12MG EMSAM patch under my belt I'd have to say the most effective insomnia remedy I've found is pulling it off to sleep. For me this is 100% effective about 80% of the time. That is to say that I still end up only getting 4 or 5 hours of sleep one or two nights a week, but the rest of the week I sleep a good 8 hours.
Posted by LongRoad on May 3, 2008, at 14:48:20
In reply to Re: Emsam insomnia and spaciness, posted by d0pamine on May 3, 2008, at 1:44:57
> With several years of the 12MG EMSAM patch under my belt I'd have to say the most effective insomnia remedy I've found is pulling it off to sleep. For me this is 100% effective about 80% of the time. That is to say that I still end up only getting 4 or 5 hours of sleep one or two nights a week, but the rest of the week I sleep a good 8 hours.
I appreciate the response. I have started doing this also. Let me ask you, how long before you sleep do you pull it off, and do you remember how long it took once you started taking it off before you started getting more sleep? It's been a few days for me and still have trouble. Thanks.
Posted by LongRoad on May 3, 2008, at 14:52:47
In reply to Re: Emsam insomnia and spaciness, posted by LongRoad on May 2, 2008, at 14:30:15
> Have tried benadryl - made me drowsy, but couldn't sleep.
>
> Is Periactin better? Might be worth a shot. Thanks.Tried this last night...OMFG, worked too well. I've been shot all day today. May try halving the dose to 2mg. Thanks though. Did sleep pretty well, woke up less during the night and was always able to fall back asleep. I just can't handle the hangover...
Posted by bulldog2 on May 3, 2008, at 14:56:26
In reply to Re: Emsam insomnia and spaciness » d0pamine, posted by LongRoad on May 3, 2008, at 14:48:20
> > With several years of the 12MG EMSAM patch under my belt I'd have to say the most effective insomnia remedy I've found is pulling it off to sleep. For me this is 100% effective about 80% of the time. That is to say that I still end up only getting 4 or 5 hours of sleep one or two nights a week, but the rest of the week I sleep a good 8 hours.
>
> I appreciate the response. I have started doing this also. Let me ask you, how long before you sleep do you pull it off, and do you remember how long it took once you started taking it off before you started getting more sleep? It's been a few days for me and still have trouble. Thanks.I wonder if it's a psychosomatic response. I read all the med is released the first 12 hours.
Posted by LongRoad on May 3, 2008, at 15:08:54
In reply to Re: Emsam insomnia and spaciness, posted by bulldog2 on May 3, 2008, at 14:56:26
maybe psychosomatic. or maybe this:
DRUG INTERACTIONS
MAO inhibitors prolong and intensify the anticholinergic effects of antihistamines.
Posted by undopaminergic on May 3, 2008, at 17:35:49
In reply to Re: Emsam insomnia and spaciness » bulldog2, posted by LongRoad on May 3, 2008, at 15:08:54
> maybe psychosomatic. or maybe this:
>
> DRUG INTERACTIONS
> MAO inhibitors prolong and intensify the anticholinergic effects of antihistamines.
>
> (from: http://www.rxlist.com/cgi/generic/cyprohept_ad.htm)
>Take that statement with a grain of salt, as it is at the very least an overgeneralisation - to begin with, there are several different MAOIs and numerous antihistamines, some of which have no anticholinergic effects whatsoever.
Anyway, I don't think selegiline prolongs the duration of cyproheptadine's sedative effects, as it generally has negligible effects on the metabolism of other drugs.
Posted by LongRoad on May 3, 2008, at 19:16:30
In reply to Re: Emsam insomnia and spaciness, posted by undopaminergic on May 3, 2008, at 17:35:49
It doesn't even matter, the day was pretty wasted because I felt like I was underwater all day. I certainly wasn't imagining that. As far as placebo effect, I didn't even expect it to work. Nothing has so far.
Hopefully, taking the patch off early will end up helping. Still trying to figure out how long I should give it to see if that is working.
Posted by undopaminergic on May 3, 2008, at 19:51:03
In reply to Re: Emsam insomnia and spaciness » undopaminergic, posted by LongRoad on May 3, 2008, at 19:16:30
> It doesn't even matter, the day was pretty wasted because I felt like I was underwater all day. I certainly wasn't imagining that. As far as placebo effect, I didn't even expect it to work. Nothing has so far.
>
> Hopefully, taking the patch off early will end up helping. Still trying to figure out how long I should give it to see if that is working.
>I think he (bulldog2?) meant the benefit of taking off the patch might be imagined (placebo) - not that you were imagining the drowsiness.
Posted by aaaaalex on May 7, 2008, at 22:17:33
In reply to Emsam insomnia and spaciness, posted by LongRoad on May 2, 2008, at 11:59:41
Hello,
I also had spaciness and insomnia on Emsam. I found that Ambien (Zolpidem) worked acceptably for sleeping, though it too did not knock me out for very long. Perhaps this is worth a try? One thing I did not try but should have is re-dosing once waking up in the middle of the night.
Posted by d0pamine on May 11, 2008, at 2:14:46
In reply to Re: Emsam insomnia and spaciness » d0pamine, posted by LongRoad on May 3, 2008, at 14:48:20
> I appreciate the response. I have started doing this also. Let me ask you, how long before you sleep do you pull it off, and do you remember how long it took once you started taking it off before you started getting more sleep? It's been a few days for me and still have trouble. Thanks.It worked right away for me. You might also try waiting until you feel you're getting the full response that you expect from EMSAM then begin to cut the patch and only use fractions of it to find the best balance between the ability to sleep during the night and survive the day. Unfortunately this will be a slow process as my experience indicates a 4 week lag in cutting the patch and seeing a decrease in daytime effectiveness. So moving too fast could quickly result in a restored ability to sleep but a looming inability to live. Then by the time you realize you've cut too much off, you have to wait another 4 to 6 weeks to feel better by adding some back.
Posted by BrightEyed+Blueberry on May 12, 2008, at 0:17:54
In reply to Re: Emsam insomnia and spaciness, posted by d0pamine on May 3, 2008, at 1:44:57
To the person with several years of the 12 MG EMSAM patch under the belt...are there "many of you?"
I don't have a long-term (or anything more than a short-term) impression about how many people EMSAM "works" for..by "working" I suppose I mean...at least a year...ideally longer...I know it was only released in 2006? And its barely 2 years, and on top of THAT, it's not often prescribed --
--though maybe its only this board, anyone getting the feeling that its being used more and more? I know there was the fear it was going to be "taken away" cuz it "didn't work" and the company wasn't making any money (try not charging half a grand for a month's worth)....Though I think the main thing was / is (though its lessening) MAOI "fear" on doctors behalves....
And if there are "long-termers" out there, do you note (or does anyone) the similarities in these follks that may point as to "who" it may work for?
You know, comparing type of depression (atypical, treatment resistant, melancholic, dyphoric, anxietal, with ADD, with substance (a)buse [and which kind], chronic, recurrent, mild, moderate...+meds history in terms of what tried and what tended to work (say, folks who PAxil really worked for, or, the Wellbutrin solo/augmenting folks, or Prozacers, Effexors, augmenters of Strattera, other ADD meds - psychostims like Adderal...benzo use...antipsychotics (I refuse), Modaf, TCAs, other MAOIs....+sleepers or insomniacs....bipolar II maybes...mix of all...
I guess I'd say I'm an atypical depressive, recurrent mod depression, 1st love PAxil (eventual party pooper - first AD/SSRI benefit only?), other SSRIS 40% "remission" (ha!) not worth it (what's sex? ehh), apathetic Effexorite who eventually returned/gained control of her hosted body and escaped soul death...Wellbutrin augmenter through it all for energy and "awakeness,(i only appreciated it recently, holding on for dear life as I washed out of Effexor so I could try EMSAM--it is a "clean drug" for me, not stunting uh, "me", not hijacking my soul, nor my sex life, and works quick and is out of my body quick, tho I was still Wellbutrin irritable/mean at times, a 50% drug.... methamphetamine drug of choice when twas around, xanax for social phobia....hate Ambien and never hallucinated on it (one of the few who never saw/felt the hovering presences/fairies/spirits)
Interesting if there's enough past EMSAM messages to compile into an EMSAM/Selegilene section and enough current posting to do that...maybe this website uses tagging or some other feature I'm not aware of to keep up that way....would be interesting as its a newer drug...perhaps with growing uses (add, smoking tobacco/marijuana cessation, stim abuse aid and neuro "repair"...what have you all those clinical trials.
BTW, in terms of longevity (life lengthening--our does is too high? We killing the rat or getting a little benefit?!)
...i DIGRESS....back to point - anyone have long-term impressions of other "long-term" or mid-term EMSAM users from this board -- and do they stay or disappear...and if they disappear, could we guess its cuz it worked and they felt no need to stay on....?
OK, compter OFF now, patch has been off an hour, and I have blockaged the windows and aiming to sleep shortly.
L/L
-Bright
6mg EMSAM for 6 weeks
Tonight - no Xananx or Neurontin (cross fingers) or anything for sleep***
> With several years of the 12MG EMSAM patch under my belt I'd have to say the most effective insomnia remedy I've found is pulling it off to sleep. For me this is 100% effective about 80% of the time. That is to say that I still end up only getting 4 or 5 hours of sleep one or two nights a week, but the rest of the week I sleep a good 8 hours.
Posted by bonbon on May 29, 2008, at 0:34:23
In reply to Emsam insomnia and spaciness, posted by LongRoad on May 2, 2008, at 11:59:41
I'm not sure it i'm on the right thread or not (i'm not really sure how message boards work, but i've been here before and gotten some good advice!). Anyway, I've been on Emsam 6mg for about 4 months and have had surprisingly good results - i actually feel better. But about 3 weeks ago insomnia hell started. I've had mild insomnia since i started but this is totally unbearable. I took 3 Lunesta (2 mg) and 2 Klonopin .5 one night and still only got about an hour and a half sleep. My doc has now told me to try putting on a new patch every third day in an effort to combat insomnia. She gave me a script for Trazadone but my pharmacist said no, they couldn't be used together. Has anyone had any experience with Emsam/Trazadome? I thought I saw someone mention it somewhere.
Any help greatly appreciated!
Posted by BrightEyed+Blueberry on June 5, 2008, at 2:01:01
In reply to Re: Emsam insomnia and spaciness, posted by bonbon on May 29, 2008, at 0:34:23
Hi - I didn't know that pharmacists could over-rule doctors...couldn't you take your script to the Walgreens/Longs or your doc's "in house" pharmacy (associated hospital pharmacy)?
Or insist the pharmacist call and talk to your doc?
Or, is it up to you, once a pharmacists overrules a doctor, to then call your doctor and explain what the pharmacist said and did? And, now I'd be curious about my doctors response (hopefully its not, "Oh, I forgot to look that up, let me double check, oops sorry, pharmacist was right, my bad").
I would ask my doctor to please explain to me why he believes it is safe for me to take trazodone with EMSAM though technically contraindicated. You may find his answer satisfactory - perhaps he has experience with this same combination, or his colleagues have, or....blah blah (I'm obv not a doc!). Myself, I've noticed lots of people are augmenting EMSAM with various contraindicated meds--I think I've read on these boards about people on EMSAM also taking doctor-prescribed adderal, maybe modafanil and possibly wellbutrin--all forms of stimulants, and all I assumeon the lengthy contraindicted EMSAM medications list. (But don't quote me--check these boards its where ive read various augmentation strategies from EMSAM users)...
Maybe it's the mildest contraindication? I mean, who has more knowledge - I THOUGHT doctors did. Maybe I'm wrong, but don't pharmacists only have 2 years training?
Lastly, EMSAM is a new drug - it even comes to mind that I thought I read that the contraindicated medicines listed for EMSAM are based on the contraindicated meds for the standard MAOIS - the older ones like nardil and parnate. Can that ...assumption be made, or its the best warning to go by that they can give to the consumer/patient until further studies/tests/deaths (G-Forbid) have occurred? Or is EMSAM (selegiline) still an MAOI where drug restrictions occur? Since its only an inhibitor of B at the lowest dose, maybe that causes some diffeferences in contraindications? Though at 9 and up, when supposedly , as I understand it, MAOI-A begins to be inhibited, then EMSAM joins the gang (nardil/parnate, etc.)as a "TRUER" MAOI.
so , curious, what did your doctor say and do to get you your trazodone, and has it worked out for you?
> I'm not sure it i'm on the right thread or not (i'm not really sure how message boards work, but i've been here before and gotten some good advice!). Anyway, I've been on Emsam 6mg for about 4 months and have had surprisingly good results - i actually feel better. But about 3 weeks ago insomnia hell started. I've had mild insomnia since i started but this is totally unbearable. I took 3 Lunesta (2 mg) and 2 Klonopin .5 one night and still only got about an hour and a half sleep. My doc has now told me to try putting on a new patch every third day in an effort to combat insomnia. She gave me a script for Trazadone but my pharmacist said no, they couldn't be used together. Has anyone had any experience with Emsam/Trazadome? I thought I saw someone mention it somewhere.
> Any help greatly appreciated!
>
Posted by avoidant rob on June 5, 2008, at 11:49:05
In reply to Re: Emsam insomnia and spaciness » bonbon, posted by BrightEyed+Blueberry on June 5, 2008, at 2:01:01
most pharmacists have 6 years of school now, used to be 5. The pharmacist should've called the Dr. and discussed it.
Posted by bonbon on June 7, 2008, at 0:21:54
In reply to Re: Emsam insomnia and spaciness » bonbon, posted by BrightEyed+Blueberry on June 5, 2008, at 2:01:01
Actually, I guess I didn't quite make myself clear on the trazadone/emsam issue. The doc did research the emsam for trazadone contraindications, but she told me to check with the pharmacist just in case. The pharmacist checked the trazadone site and printed out the warnings - he didn't actually tell me that I couldn't have it, just that it wasn't recommended.
As for the "who knows more" question - the pharmacist is usually more up to date on drug interactions, etc. than the doctor. Sorry for the confusion. But....has anyone ever taken the two together?
Posted by aaaaalex on June 12, 2008, at 1:36:14
In reply to Emsam insomnia and spaciness, posted by LongRoad on May 2, 2008, at 11:59:41
I had a similar experience on Emsam. I don't see Remeron on your list - perhaps that would be worth experimenting with (not in conjunction with Emsam, of course)? You might be able to find a good balance between its sedation and activation.
Posted by dcruik518 on June 16, 2008, at 19:45:23
In reply to Re: Emsam insomnia and spaciness, posted by aaaaalex on June 12, 2008, at 1:36:14
The whole thing about trazodone being contraindicated with MAOI's is b*llsh*t. I took Parnate, Nardil, and Selegeline all with Trazadone and never had a problem--although one or two pharmacists mentioned it. The threat of serotonin syndrome is only with the SSRI's of which Trazodone is not one! It's perfectly safe and likely the only drug strong enough to overcome your insomnnia. Go to a different pharmacy!!!
Posted by Crotale on June 17, 2008, at 20:27:33
In reply to Trazadone is perfectly safe with Emsam!!, posted by dcruik518 on June 16, 2008, at 19:45:23
Agreed; trazodone *might* not be safe with MAOIs in much higher doses, like 300 or 400mg (at which it *is* a serotonin reuptake inhibitor), but the 50mg or so usually used for insomnia is fine with MAOIs.
Personally I found that trazodone (and most other drugs that are sedating because they antagonize type-1 histamine receptors -- like Benadryl, tricyclic antidepressants, Atarax, antipsychotics like Mellaril and Zyprexa, etc.) stopped working after a few days when I tried to use it for insomnia. I kept having to increase the dose or the sleeping pills stopped working. So in the end they didn't really work out for me. But trazodone helps a lot of people who get insomnia on MAOIs (a very common side effect, as well as a common symptom of depression).
> The whole thing about trazodone being contraindicated with MAOI's is b*llsh*t. I took Parnate, Nardil, and Selegeline all with Trazadone and never had a problem--although one or two pharmacists mentioned it. The threat of serotonin syndrome is only with the SSRI's of which Trazodone is not one! It's perfectly safe and likely the only drug strong enough to overcome your insomnnia. Go to a different pharmacy!!!
Posted by Nadezda on June 18, 2008, at 0:54:17
In reply to Re: Trazadone is perfectly safe with Emsam!! » dcruik518, posted by Crotale on June 17, 2008, at 20:27:33
This isn't a hard and fast thing-- I got serotonin syndrome with a 50 mg dose of trazadone-- with an Maoi. So it can happen.
It probably wouldn't happen. However, my pdoc, who's very careful, told me it to be aware of the possible interaction-- because I have a high sensitivity to serotonin drugs--and immediately told me to stop.
To be sure, I was taking a high dose of the Maoi, and these interactions can be dose-related.
But, while it's generally safe enough to give it a try, trazadone isn't completely safe with Maois.
Nadezda
Posted by Crotale on June 18, 2008, at 1:01:27
In reply to Re: Trazadone is perfectly safe with Emsam!!, posted by Nadezda on June 18, 2008, at 0:54:17
> This isn't a hard and fast thing-- I got serotonin syndrome with a 50 mg dose of trazadone-- with an Maoi. So it can happen.
Wow. That's curious. What were your symptoms?
Also, which MAOI and what dose?
I hope you were okay. Central serotonin syndrome can be a very serious medical emergency.
You make an excellent point: different people have different sensitivities to these things.
Posted by SLS on June 18, 2008, at 4:57:59
In reply to Re: Trazadone is perfectly safe with Emsam!! » Nadezda, posted by Crotale on June 18, 2008, at 1:01:27
> > This isn't a hard and fast thing-- I got serotonin syndrome with a 50 mg dose of trazadone-- with an Maoi. So it can happen.
>
> Wow. That's curious. What were your symptoms?
>
> Also, which MAOI and what dose?
>
> I hope you were okay. Central serotonin syndrome can be a very serious medical emergency.
>
> You make an excellent point: different people have different sensitivities to these things.I experienced what doctors at the NIH considered to be the beginnings of SS when a small dose of trazodone was added to an MAOI to treat insomnia.
- Scott
Posted by dcruik518 on June 18, 2008, at 18:19:26
In reply to Re: Trazadone is perfectly safe with Emsam!!, posted by SLS on June 18, 2008, at 4:57:59
I don't understand this very well, but my doctor mentioned and recently read something interesting about why certain people may be more susceptible to serotonin syndrome. There is a genetic liver abnormality in about 7% of caucasians, an inability to properly metabolize drugs of the cyp450 class, I believe, and this leads sometimes to blood levels of up to 30 times what one would normally expect.
Also, according Stahl, the MAOI + Trazadone combo should only be done under close supervision by a very experienced p-doc.
For me though, it was never ever a problem, even taking 300 mg trazadone at night and 90mg of Nardil in the day.
~DRC
Posted by Crotale on June 19, 2008, at 22:24:40
In reply to Re: Trazadone is perfectly safe with Emsam!!, posted by dcruik518 on June 18, 2008, at 18:19:26
> I don't understand this very well, but my doctor mentioned and recently read something interesting about why certain people may be more susceptible to serotonin syndrome. There is a genetic liver abnormality in about 7% of caucasians, an inability to properly metabolize drugs of the cyp450 class, I believe, and this leads sometimes to blood levels of up to 30 times what one would normally expect.
Cytochrome P450 is a class of liver enzymes which catalyze the metabolism of certain drugs. A small percentage of mainly Caucasians have a deficiency in a particular cytochrome p450 enzyme, specifically cytochrome p4502d6. Therefore these individuals don't metabolize certain drugs normally, namely those whose metabolism is catalyzed by this enzyme. (Different cytochrome enzymes are involved in the metabolism of different types of drugs.) I gather that this enzyme deficiency is quite rare.
Drugs can also competitively inhibit one or more cytochrome p450 enzymes. This is how drug interactions occur in which one drug causes the serum level of another one to rise. Prozac and Paxil are especially notorious for causing such interactions.
When I took desipramine, I had a seizure. The hospital measured my serum desipramine level and found that it was several times what it was supposed to be. The reason was a mystery, as none of the other drugs I was taking were known to have a pharmacokinetic interaction with TCAs. They thought I might have this enzyme deficiency, and I had to go off the desipramine as a result. It was a bummer, since it was working for me pretty well.
Crotale
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