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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by matt sanz on April 21, 2009, at 20:35:57
I just started taking Effexor XR three weeks ago and I'm already on the maximum dose for the med, 300mg. My doc said I would be able to find out faster if its going to work by going to a high dose quickly. But my question is this: Is it true that sometimes lower doses work better for people than the highest dose? If so than why didn't he give the lower doses a chance to work and just go right to the maximum dose? Thanks.
Posted by Sigismund on April 21, 2009, at 20:47:11
In reply to Are maximum doses more effective?, posted by matt sanz on April 21, 2009, at 20:35:57
It's not the way I'd do it.
I think the best dose is the minimum one that is effective, and that is going to vary among people quite a lot.
Posted by Phillipa on April 21, 2009, at 21:42:13
In reply to Re: Are maximum doses more effective? » matt sanz, posted by Sigismund on April 21, 2009, at 20:47:11
Agree with above. Phillipa
Posted by sowhysosad on April 22, 2009, at 7:03:17
In reply to Are maximum doses more effective?, posted by matt sanz on April 21, 2009, at 20:35:57
Sounds like he wants the noradrenergic and dopaminergic effects to kick in, which'll only happen with a high dose. It's basically just an SSRI at low doses.
However, in ramping the dose so quickly there's a danger you'll be overwhemed by side effects and will quit before you get any benefit, so it seems an odd way of doing things!
> I just started taking Effexor XR three weeks ago and I'm already on the maximum dose for the med, 300mg. My doc said I would be able to find out faster if its going to work by going to a high dose quickly. But my question is this: Is it true that sometimes lower doses work better for people than the highest dose? If so than why didn't he give the lower doses a chance to work and just go right to the maximum dose? Thanks.
Posted by SLS on April 22, 2009, at 8:30:37
In reply to Are maximum doses more effective?, posted by matt sanz on April 21, 2009, at 20:35:57
What you are describing is called a "therapeutic window". It is a condition where a drug exerts its therapeutic effect within a range of dosages and not above or below. Nortriptyline is an example of an antidepressant drug that has a therapeutic window. Most people respond to 75-100mg. These same people lose their response at 125mg and above.
To my knowledge, Effexor is not such a drug. If you have been tolerating the drug well, it might not be a bad strategy to save time by moving up quickly. I guess it depends on your treatment history. Once you respond, you can then reduce the dosage methodically to find the minimum effective dosage.
In general, I don't think other antidepressants have efficacy windows as does nortriptyline. However, they still have a therapeutic index that must be evaluated. It is a way to weigh therapeutic response versus adverse effect. Lithium has very narrow therapeutic index. One can suffer intolerable side effects or become toxic at dosages not very much higher than are known to be effective.
- Scott
Posted by manic666 on April 22, 2009, at 12:20:29
In reply to Re: Are maximum doses more effective?, posted by SLS on April 22, 2009, at 8:30:37
i went from 10 mg lorazepam to nil in 1 day? an put on 225 venlafaxin in a week , TWO things i dont want to experience ever again,
Posted by SLS on April 22, 2009, at 12:37:56
In reply to Re: Are maximum doses more effective?, posted by manic666 on April 22, 2009, at 12:20:29
> put on 225 venlafaxin in a week,
In my opinion, that was pretty reckless. Does this doctor always work so "aggressively"?
- Scott
Posted by yxibow on April 22, 2009, at 23:53:19
In reply to Re: Are maximum doses more effective?, posted by SLS on April 22, 2009, at 12:37:56
> > put on 225 venlafaxin in a week,
>
> In my opinion, that was pretty reckless. Does this doctor always work so "aggressively"?
>
>
> - ScottAlmost a full dose of Effexor in a week?? That's beyond the pale.
Not that I can take the stuff, its like IV coffee.
Minimum /effective/ doses are what should be used for any psychoactive substance, especially those with the most liability (side effects).
If that means for an individual that it /exceeds/ what is normally placed on the PI for a maximum level, then the doctor is hopefully taking that all into consideration and believes that a higher dose can be used -individually- because perhaps the person metabolizes it fast.
But like most agents, except heroic hospital events, I don't think that any psychiatric medication should be ramped up so quickly.
Its jarring on the patient, and the higher the blood level, the greater the side effects, in general.
-- Jay
Posted by bleauberry on April 23, 2009, at 16:36:57
In reply to Are maximum doses more effective?, posted by matt sanz on April 21, 2009, at 20:35:57
I know a girl who's therapeutic dose of Lexapro is 3mg (liquid).
A clinical study showed low dose Milnacipran was just as effective as high dose, with the only difference being that the low dose took longer.
Personally, I seem to get significant benefit out of a mere 5mg Parnate once every 3 days. Maybe someone else needs 100mg every day. But how does one know if they shoot right to the top in a hurry?
And there are many other examples.
At askapatient.com or revolutionhealth.com you'll find people who did well with just 37.5mg or 75mg effexor.
I think it is absurd for a doctor to somehow have a magical target in mind without a clue where things are going to go.
I like my doctor's way of doing it. That is, start very conservative, judge what has happened, and don't make any plans on anything until then. If he were to start me on Lexapro for example, and him knowing my history, I know his strategy would be 2.5mg every other day for a couple weeks. He would not even speculate on what to do after that until he had assessed every detail of that two weeks. And we would have no preconceived notion whether the final dose I end up on being well is that same dose or 40mg per day or anything inbetween.
Let your reactions make the decision making. Maybe you need a high dose, maybe you only need a tiny dose. You'll never know if you shoot right to the highest doses as fast as possible. That just sets the patient up for more side effects, more expensive, worse withdrawals, than they might have needed to be exposed to.
I tend to agree wtih Dr Gillmans beliefs that in really severe depression, ssris and snris should be avoided completely, unless combined with a TCA. He just has not seen them having enough power or staying power to treat severe depression. Patients get somewhat better, but hardly ever really well (on ssris/snris). That's his take, his experience, not mine, though I do tend to agree. It takes a ssri+tca, or an maoi, to get the job done.
Effexor though does have something different about it that the others don't, so that is in your favor.
Posted by sowhysosad on April 23, 2009, at 19:00:36
In reply to Re: Are maximum doses more effective?, posted by bleauberry on April 23, 2009, at 16:36:57
> I like my doctor's way of doing it. That is, start very conservative, judge what has happened, and don't make any plans on anything until then. If he were to start me on Lexapro for example, and him knowing my history, I know his strategy would be 2.5mg every other day for a couple weeks. He would not even speculate on what to do after that until he had assessed every detail of that two weeks. And we would have no preconceived notion whether the final dose I end up on being well is that same dose or 40mg per day or anything inbetween.
That sounds like a really sensible strategy. Some 8 months on I'm still suffering a rebound depression from ramping sertraline too quickly, which also had the added downside of preventing me tolerating other serotonergic meds. I regret my doc and I underestimating how powerful SSRI's can be. We only allowed a week before assessing the dose increase, which wasn't nearly enough,
> I tend to agree wtih Dr Gillmans beliefs that in really severe depression, ssris and snris should be avoided completely, unless combined with a TCA. He just has not seen them having enough power or staying power to treat severe depression. Patients get somewhat better, but hardly ever really well (on ssris/snris). That's his take, his experience, not mine, though I do tend to agree. It takes a ssri+tca, or an maoi, to get the job done.
I agree with Ken Gillman's opinion's on the lack of efficacy of "dual action" drugs, and he's a great champion of MAOI's which, I agree, are certainly under-used in this day and age.
But I think perhaps he overstates the role of norepinephrine in "severe" depression. Mine's been pretty "severe" but noradrenergic meds have just made me worse. Depression is undoubtedly a wide range of similar conditions where different neurotransmitters play distinct roles in each person, which is why we none of us respond identically to the same meds.
Posted by manic666 on April 24, 2009, at 13:00:43
In reply to Are maximum doses more effective?, posted by matt sanz on April 21, 2009, at 20:35:57
when treated in england years ago by my lady g.p she used to max every med i went on , she didnt no in them days , an thought i was that bad i needed max of every thing.now im a crazy an scrambled , the damage it must of done i carnt remember years never mind days,my wife an kids use to find me in strange an weird places, so i dont think in my luppy opinion max is best
Posted by manic666 on April 26, 2009, at 12:24:45
In reply to Re: Are maximum doses more effective? » SLS, posted by yxibow on April 22, 2009, at 23:53:19
the 225 mg velafaxine was administered in hospital in a week , just after the third world doc had stopped all the 10 loz, an i overdosed you no the story , he was unsupervised, incompitent,an is still there ,not my doc now a few choise words made sure of that, ooooooo an dont forget the 6 mg of valium a day to calm my down in 2 mg tabs 3 times a day .not even the amount of 1 mg loz.see what us brits put up with
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