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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 linkadge on July 30, 2009, at 17:18:22
What other TCA's have you ever tried? How did they affect you? What worked or works better with the nortriptyline?
Linakdge
Posted by SLS on July 30, 2009, at 18:07:05
In reply to SLS - what other TCA's have you tried?, posted by linkadge on July 30, 2009, at 17:18:22
> What other TCA's have you ever tried? How did they affect you? What worked or works better with the nortriptyline?
Right now, by HR is 80 bpm.
imipramine
desipramine
amoxapine
amitriptyline
nortriptyline
protriptyline
trimipramineProtriptyline was a bad drug for me, I'm not sure why. It is probably the most anticholinergic. I didn't monitor my HR while I was on it. It made me feel much worse.
I have never tried doxepin.
You might want to examine trimipramine (Surmontil). I wish I had monitored my HR while I was on it. One would think that it would be less cardiotoxic given that it doesn't inhibit the reuptake of norepinephrine. I cannot be sure, though. I think you will find that most of the references to individual tricyclics are actually taken from a general description of the drug class as a whole. Therefore, one cannot be sure if trimipramine is any better or any worse than other TCAs when reading these "stock" drug descriptions.
Here is one study comparing maprotiline and trimipramine:
Also:
"The side effect profile of trimipramine is in some ways similar to those of the tertiary amine TCAs with a preponderance of anticholinergic and sedative effects. Its cardiotoxic properties are minimal, with some findings suggesting a very favourable profile."
I wish I could help you pick the right drug. Trimipramine might have a reduced cardiotoxic profile, but your concerns over genotoxicity might disuade you from trying it.
Because I have been on nortriptyline for so long, and knowing that people have been on it for decades, I can't help but to encourage you to continue with it. Like I said before, you are not married to the drug. If your EKG is normal, I don't think you really have anything to worry about. Keep researching these issues. But try to look for information that includes statistics representing the frequency of untoward events.
- Scott
Posted by linkadge on July 30, 2009, at 18:52:08
In reply to Re: SLS - what other TCA's have you tried? » linkadge, posted by SLS on July 30, 2009, at 18:07:05
What was imipramine like for you?
Linkadge
Posted by SLS on July 31, 2009, at 6:25:07
In reply to Re: SLS - what other TCA's have you tried?, posted by linkadge on July 30, 2009, at 18:52:08
> What was imipramine like for you?
>
> LinkadgeIt was the first drug I was place on once I was diagnosed.
This gets complicated. I was an ultra-rapid cycler at the time. I cycled once every 11 days; 8 days of depression followed by 3 days of relief (as opposed to mania). I responded to the imipramine by seeing my upswing persist for 7 or 8 days at a time. This lasted for a month or two, whereupon lithium was added. It did a lovely job of preventing the cycling, but left me stuck in an unremitting depression. Continued treatment with imipramine did not help. I have tried it a few times since, but a pattern of my responses to reuptake inhibitors became established to brief robust improvements that lasted exactly 3 days before relapsing again.
There is only one TCA that has shown itself to produce a greater proportion of remissions than imipramine - clomipramine.
Where are you at in your decision-making process?
- Scott
Posted by linkadge on July 31, 2009, at 14:27:52
In reply to Re: SLS - what other TCA's have you tried? » linkadge, posted by SLS on July 31, 2009, at 6:25:07
Thanks for the inquiry. About 3 weeks ago I saw a good psychiatrist for the first time. He has been dealing with my mother and doing a good job.
I went to him while taking ritalin and sertraline. What you describe is almost identical to what I described to him. I said I am depressed for about a week (or a little longer) then feel ok for about 3 days or so. The main symptoms I have are feeling extremely fatiqued, somewhat worthless, with much anhedonia. I said the sertraline helped initially, but seemed to stop working. I said they tried higher doses in the hospital which always left me agitated. I also said I have zero sexual function on it.
We discussed nortriptyline since this recomendation was made by the previous psychiatrist. He told me to come off the sertraline for a month, see what happens then likely go with a nortriptyline trial.
I have one more week before I see him for this. The sertraline withdrawl has produced more anxiety than depression. Infact, my depression is about the exact same. The doctor mentioned that we might need to go to imipramine depending on the response to nortriptyline.
I am concerned about an imipramine trial becuase of the genotoxicity, but on the other hand I know it can be a very effective AD for some. I am hesitant to tell him about my concerns because traditionally my relationship with psychiatrists has soured when I start to express knowledge / concernes with specific recomendations.
I am willing to do a trial of nortriptyline or amitriptyline, but would like to avoid the others if at all possible.
Linkadge
Posted by SLS on July 31, 2009, at 15:46:13
In reply to Re: SLS - what other TCA's have you tried?, posted by linkadge on July 31, 2009, at 14:27:52
> Thanks for the inquiry. About 3 weeks ago I saw a good psychiatrist for the first time. He has been dealing with my mother and doing a good job.
>
> I went to him while taking ritalin and sertraline. What you describe is almost identical to what I described to him. I said I am depressed for about a week (or a little longer) then feel ok for about 3 days or so. The main symptoms I have are feeling extremely fatiqued, somewhat worthless, with much anhedonia. I said the sertraline helped initially, but seemed to stop working. I said they tried higher doses in the hospital which always left me agitated. I also said I have zero sexual function on it.
>
> We discussed nortriptyline since this recomendation was made by the previous psychiatrist. He told me to come off the sertraline for a month, see what happens then likely go with a nortriptyline trial.
>
> I have one more week before I see him for this. The sertraline withdrawl has produced more anxiety than depression. Infact, my depression is about the exact same. The doctor mentioned that we might need to go to imipramine depending on the response to nortriptyline.
>
> I am concerned about an imipramine trial becuase of the genotoxicity, but on the other hand I know it can be a very effective AD for some. I am hesitant to tell him about my concerns because traditionally my relationship with psychiatrists has soured when I start to express knowledge / concernes with specific recomendations.
>
> I am willing to do a trial of nortriptyline or amitriptyline, but would like to avoid the others if at all possible.
That's understandable. To your doctor's credit, he would consider imipramine should your trial with nortriptyline be unsatisfactory. Back in the old days, doctors noticed a trend in that desipramine responders did not respond to nortriptyline and vice versa.In your mind, I know that genotoxicity is a concern as is cardiotoxicity. The cardiotoxicity thing only really comes into play if one has a predisposing condition or in overdose. To my knowledge, there is no cumulative damage produced at therapeutic dosages. I wish I could speak to the issue of genotoxicity with certainty. I know about the breast cancer thing in Canada, but that post hoc analysis makes assumptions regarding the drugs used to treat depression that they could not verify. Since depression itself might increase one's chances of getting cancer, presumably because it affects the immune system, I don't think that study is a reliable index of genotoxicity. It is probably a more reliable index of the incidence of depression in cancer patients. Obviously, the risk of genotoxicity, unlike cardiotoxicity, is cumulative. People who have been on TCA the longest would have the greatest risk for contracting cancer. A great many individuals have been taking tricyclics for decades, though. I might be wrong to make such an assumption, but I should think that if the cancer risk was so great, someone would have noticed by now. I know it doesn't always work that way. I imagine there a great many things that have escaped the attention of medicine.
Obviously, you know what my decisions have been as I have weighed the risks versus benefits of taking a variety of different drugs. For me, the depression is so painful and so incapacitating, I really don't have any better alternatives but to take whatever works, especially when the risks can be quantified, as is the case with cardiotoxicity. As it relates to genotoxicity, I consider the risks involved with taking TCA to be more theoretical than actual.
I think you have to ask yourself how urgent is the need to improve your condition and what alternatives you have remaining. At age 49, I would drink horse piss if I thought it might help. Don't wait too long. You are very bright and can contribute much to society, including the contributions that you will be able to make into your own bank accounts.
Good luck.
- Scott
Posted by linkadge on July 31, 2009, at 16:18:26
In reply to Re: SLS - what other TCA's have you tried?, posted by SLS on July 31, 2009, at 15:46:13
We'll just see how things go next saturday.
I'll keep people informed.
Linkadge
Posted by bulldog2 on July 31, 2009, at 17:23:14
In reply to Re: SLS - what other TCA's have you tried?, posted by SLS on July 31, 2009, at 15:46:13
> > Thanks for the inquiry. About 3 weeks ago I saw a good psychiatrist for the first time. He has been dealing with my mother and doing a good job.
> >
> > I went to him while taking ritalin and sertraline. What you describe is almost identical to what I described to him. I said I am depressed for about a week (or a little longer) then feel ok for about 3 days or so. The main symptoms I have are feeling extremely fatiqued, somewhat worthless, with much anhedonia. I said the sertraline helped initially, but seemed to stop working. I said they tried higher doses in the hospital which always left me agitated. I also said I have zero sexual function on it.
> >
> > We discussed nortriptyline since this recomendation was made by the previous psychiatrist. He told me to come off the sertraline for a month, see what happens then likely go with a nortriptyline trial.
> >
> > I have one more week before I see him for this. The sertraline withdrawl has produced more anxiety than depression. Infact, my depression is about the exact same. The doctor mentioned that we might need to go to imipramine depending on the response to nortriptyline.
> >
> > I am concerned about an imipramine trial becuase of the genotoxicity, but on the other hand I know it can be a very effective AD for some. I am hesitant to tell him about my concerns because traditionally my relationship with psychiatrists has soured when I start to express knowledge / concernes with specific recomendations.
> >
> > I am willing to do a trial of nortriptyline or amitriptyline, but would like to avoid the others if at all possible.
>
>
> That's understandable. To your doctor's credit, he would consider imipramine should your trial with nortriptyline be unsatisfactory. Back in the old days, doctors noticed a trend in that desipramine responders did not respond to nortriptyline and vice versa.
>
> In your mind, I know that genotoxicity is a concern as is cardiotoxicity. The cardiotoxicity thing only really comes into play if one has a predisposing condition or in overdose. To my knowledge, there is no cumulative damage produced at therapeutic dosages. I wish I could speak to the issue of genotoxicity with certainty. I know about the breast cancer thing in Canada, but that post hoc analysis makes assumptions regarding the drugs used to treat depression that they could not verify. Since depression itself might increase one's chances of getting cancer, presumably because it affects the immune system, I don't think that study is a reliable index of genotoxicity. It is probably a more reliable index of the incidence of depression in cancer patients. Obviously, the risk of genotoxicity, unlike cardiotoxicity, is cumulative. People who have been on TCA the longest would have the greatest risk for contracting cancer. A great many individuals have been taking tricyclics for decades, though. I might be wrong to make such an assumption, but I should think that if the cancer risk was so great, someone would have noticed by now. I know it doesn't always work that way. I imagine there a great many things that have escaped the attention of medicine.
>
> Obviously, you know what my decisions have been as I have weighed the risks versus benefits of taking a variety of different drugs. For me, the depression is so painful and so incapacitating, I really don't have any better alternatives but to take whatever works, especially when the risks can be quantified, as is the case with cardiotoxicity. As it relates to genotoxicity, I consider the risks involved with taking TCA to be more theoretical than actual.
>
> I think you have to ask yourself how urgent is the need to improve your condition and what alternatives you have remaining. At age 49, I would drink horse piss if I thought it might help. Don't wait too long. You are very bright and can contribute much to society, including the contributions that you will be able to make into your own bank accounts.
>
> Good luck.
>
>
> - Scott
>
>Scott have you ever tried clomipramine? I have a book on psyschotropic drugs at home and clomipramine seems like it could be a very effective drug.
Its potency and selectivity for Norepinehprine is
3.6.
Its potency and selectivity for serotonin is
18.
So it's about 5 times more potent at blocking serotonin reuptake than norepinephrine.This drug is somewhat weaker than the other tcas on NE reuptake but the most potent at SE reuptake of the tcas. Almost as potent as setraline which is a 29 at SE reuptake.
So you get SE and NE reuptake which has advantages but more SE for those who need serotonin but not as much as the ssris.So this drug is unique in what it offers.
Posted by bulldog2 on July 31, 2009, at 17:44:58
In reply to Re: SLS - what other TCA's have you tried?, posted by bulldog2 on July 31, 2009, at 17:23:14
> > > Thanks for the inquiry. About 3 weeks ago I saw a good psychiatrist for the first time. He has been dealing with my mother and doing a good job.
> > >
> > > I went to him while taking ritalin and sertraline. What you describe is almost identical to what I described to him. I said I am depressed for about a week (or a little longer) then feel ok for about 3 days or so. The main symptoms I have are feeling extremely fatiqued, somewhat worthless, with much anhedonia. I said the sertraline helped initially, but seemed to stop working. I said they tried higher doses in the hospital which always left me agitated. I also said I have zero sexual function on it.
> > >
> > > We discussed nortriptyline since this recomendation was made by the previous psychiatrist. He told me to come off the sertraline for a month, see what happens then likely go with a nortriptyline trial.
> > >
> > > I have one more week before I see him for this. The sertraline withdrawl has produced more anxiety than depression. Infact, my depression is about the exact same. The doctor mentioned that we might need to go to imipramine depending on the response to nortriptyline.
> > >
> > > I am concerned about an imipramine trial becuase of the genotoxicity, but on the other hand I know it can be a very effective AD for some. I am hesitant to tell him about my concerns because traditionally my relationship with psychiatrists has soured when I start to express knowledge / concernes with specific recomendations.
> > >
> > > I am willing to do a trial of nortriptyline or amitriptyline, but would like to avoid the others if at all possible.
> >
> >
> > That's understandable. To your doctor's credit, he would consider imipramine should your trial with nortriptyline be unsatisfactory. Back in the old days, doctors noticed a trend in that desipramine responders did not respond to nortriptyline and vice versa.
> >
> > In your mind, I know that genotoxicity is a concern as is cardiotoxicity. The cardiotoxicity thing only really comes into play if one has a predisposing condition or in overdose. To my knowledge, there is no cumulative damage produced at therapeutic dosages. I wish I could speak to the issue of genotoxicity with certainty. I know about the breast cancer thing in Canada, but that post hoc analysis makes assumptions regarding the drugs used to treat depression that they could not verify. Since depression itself might increase one's chances of getting cancer, presumably because it affects the immune system, I don't think that study is a reliable index of genotoxicity. It is probably a more reliable index of the incidence of depression in cancer patients. Obviously, the risk of genotoxicity, unlike cardiotoxicity, is cumulative. People who have been on TCA the longest would have the greatest risk for contracting cancer. A great many individuals have been taking tricyclics for decades, though. I might be wrong to make such an assumption, but I should think that if the cancer risk was so great, someone would have noticed by now. I know it doesn't always work that way. I imagine there a great many things that have escaped the attention of medicine.
> >
> > Obviously, you know what my decisions have been as I have weighed the risks versus benefits of taking a variety of different drugs. For me, the depression is so painful and so incapacitating, I really don't have any better alternatives but to take whatever works, especially when the risks can be quantified, as is the case with cardiotoxicity. As it relates to genotoxicity, I consider the risks involved with taking TCA to be more theoretical than actual.
> >
> > I think you have to ask yourself how urgent is the need to improve your condition and what alternatives you have remaining. At age 49, I would drink horse piss if I thought it might help. Don't wait too long. You are very bright and can contribute much to society, including the contributions that you will be able to make into your own bank accounts.
> >
> > Good luck.
> >
> >
> > - Scott
> >
> >
>
> Scott have you ever tried clomipramine? I have a book on psyschotropic drugs at home and clomipramine seems like it could be a very effective drug.
> Its potency and selectivity for Norepinehprine is
> 3.6.
> Its potency and selectivity for serotonin is
> 18.
> So it's about 5 times more potent at blocking serotonin reuptake than norepinephrine.
>
> This drug is somewhat weaker than the other tcas on NE reuptake but the most potent at SE reuptake of the tcas. Almost as potent as setraline which is a 29 at SE reuptake.
> So you get SE and NE reuptake which has advantages but more SE for those who need serotonin but not as much as the ssris.
>
> So this drug is unique in what it offers.By the way Imipramine is 7.7 on NE and 2.4 on SE. So this gold standard tca is about twice as potent on NE than clomipramine but much weaker than clomipramine on SE.
It seems that clomipramine is almost as potent as a ssri with some NE action.
Posted by linkadge on July 31, 2009, at 19:19:08
In reply to Re: SLS - what other TCA's have you tried?, posted by bulldog2 on July 31, 2009, at 17:44:58
The other thing to keep in mind with clomipramine, is that the metabolite has the reverse profile i.e. much stronger NE reuptake inhibition than serotonin reuptake.
Thats what I noticed when I took the drug is that after some time after a dose it would really start to produce provide some umph.
Linkadge
Posted by linkadge on July 31, 2009, at 19:20:54
In reply to Re: SLS - what other TCA's have you tried?, posted by bulldog2 on July 31, 2009, at 17:44:58
Thats the other thing I don't get. I've heard both imipramine and amitrityline being refered to as "the gold standard". Do they have equal efficacy?
As a side note, one study suggested that amitriptyline was slightly more efficacious than nortriptyline.
Linkadge
Posted by bulldog2 on August 1, 2009, at 13:10:02
In reply to Re: SLS - what other TCA's have you tried?, posted by linkadge on July 31, 2009, at 19:20:54
> Thats the other thing I don't get. I've heard both imipramine and amitrityline being refered to as "the gold standard". Do they have equal efficacy?
>
> As a side note, one study suggested that amitriptyline was slightly more efficacious than nortriptyline.
>
> LinkadgeMost studies show equal efficacy. But Imipramine has a better side effect profile in terms of weight gain and sedation. That would be my pick.
This is the end of the thread.
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