![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 28. This is the beginning of the thread.
Posted by Phidippus on November 21, 2009, at 12:08:58
I'm having a tough time getting my OCD under control. So far I have tried Zoloft, which gave me panic attacks, Luvox which did nothing and am on Lexapro getting a partial response. I am augmenting with Geodon. Should I try Anafranil instead or another SSRI?
P
Posted by desolationrower on November 21, 2009, at 15:45:51
In reply to Treatment resistant OCD, posted by Phidippus on November 21, 2009, at 12:08:58
did you get up to max dose on those for >1 month?
-d/r
Posted by Phillipa on November 21, 2009, at 16:54:53
In reply to Treatment resistant OCD, posted by Phidippus on November 21, 2009, at 12:08:58
Luvox first time on it worked well at 250mg. Not the second time though. Seems they say all the SSRI's are good for OCD? Get up to 200mg on the zoloft? Love Phillipa
Posted by Kimbersaur on November 21, 2009, at 18:55:30
In reply to Re: Treatment resistant OCD » Phidippus, posted by Phillipa on November 21, 2009, at 16:54:53
Things that have worked for me:
SNRIs, including Effexor, Pristiq, and Cymbalta
Prozac
NOT Paxil - that made me manic
Seroquel helps with other stuff, not much with OCD though
The natural supplement Inositol - helped at a high dose but not a whole lot.I'm at 3 months on Pristiq now and I am just starting to notice really significant improvement.
Things that have not worked for me that I've tried for OCD:
Abilify
Namenda/Memantine
Anafranil (side effects hit me like a ton of bricks)
Ultram/TramadolI've heard Klonopin can be helpful, but I'm hesitant to try things that may be addictive.
Posted by CreekGeek on November 21, 2009, at 19:44:36
In reply to Re: Treatment resistant OCD, posted by Kimbersaur on November 21, 2009, at 18:55:30
I am on anafranil for OCD and I love it. :) It has truly been a wonder drug for me. My OCD is more OCD thoughts less compulsions. (well I would be lying if I said I had no compulsions) anyway I love anfranil. I just started Klonopin so I think it is too soon to tell but it seems to really help with my anxiety but makes me so sleepy :( I dont know it if the Dr. will want me to stay on it. So so sleepy.
Posted by Phillipa on November 21, 2009, at 20:12:43
In reply to Re: Treatment resistant OCD, posted by CreekGeek on November 21, 2009, at 19:44:36
Seriously I found klonopin depressing for me. What about a shorter acting benzo. Personally I like xanax. Ativan was good also. No I don't get high and have never had to raise the doses of either. Even my docs wanted higher doses said no. Love Phillipa so glad the anafranil works well for you.
Posted by SLS on November 21, 2009, at 23:04:52
In reply to Treatment resistant OCD, posted by Phidippus on November 21, 2009, at 12:08:58
> I'm having a tough time getting my OCD under control. So far I have tried Zoloft, which gave me panic attacks, Luvox which did nothing and am on Lexapro getting a partial response. I am augmenting with Geodon. Should I try Anafranil instead or another SSRI?
I recently read of the combining of Anafranil with an SSRI for treatment-resistant OCD. There was no mention of serotonin syndrome.
- Scott
Posted by hopefullynow on November 22, 2009, at 0:04:56
In reply to Re: Treatment resistant OCD » Phidippus, posted by SLS on November 21, 2009, at 23:04:52
> I recently read of the combining of Anafranil with an SSRI for treatment-resistant OCD. There was no mention of serotonin syndrome.
>
>
> - ScottHy Scott,
Can you mention at what dosage of Anafranil and the augumentor(med and dosage), please ?Or a link with the abstract? Thanks a lot
Posted by SLS on November 22, 2009, at 7:13:42
In reply to Re: Treatment resistant OCD, posted by hopefullynow on November 22, 2009, at 0:04:56
Here is the protocol used for a recently completed study of OCD.
http://clinicaltrials.gov/ct2/show/NCT00564564
The results are here:
http://jop.sagepub.com/cgi/content/abstract/0269881108099423v1
Personally, I think the 75mg dosage of Anafranil (clomipramine) used in this study was too low.
------------------------------------------------------------
"Initial Treatment/Dose Adjustment (Adults)
Treatment with Anafranil should be initiated at a dosage of 25 mg daily and gradually increased, as tolerated, to approximately 100 mg during the first 2 weeks. During initial titration, Anafranil should be given in divided doses with meals to reduce gastrointestinal side effects. Thereafter, the dosage may be increased gradually over the next several weeks, up to a maximum of 250 mg daily. After titration, the total daily dose may be given once daily at bedtime to minimize daytime sedation."
-----------------------------------------------------------
___________________________________________________________
___________________________________________________________
Here is a study that demonstrated a greater improvement in OCD using the combination of citalopram and clomipramine. Unfortunately, dosages are not detailed in the abstract.
----------------------------------------------------
Citalopram for treatment-resistant obsessive-compulsive disorderS. Pallanti1, L. Quercioli2, R. S. Paiva2 and L. M. Koran3
1 Istituto di Neuroscienze and University of Florence Medical School, Florence, Italy
2 Istituto di Neuroscienze Florence, Florence, Italy
3 Department of Psychiatry and Behavioral Sciences, Stanford Medical Center, Stanford, CA, USA
AbstractWe investigated the comparative efficacy of citalopram vs. citalopram administered with clomipramine, in treatment-resistant obsessive-compulsive disorder (OCD).
Sixteen adult outpatients participated in a 90-day, randomized, open-label trial. Eligible patients were aged 18 to 45 years, had moderate to severe DSM-III-R OCD of = one year's duration, a baseline Yale-Brown scale (Y-BOCS) score of = 25 and no other active axis I diagnosis, and had failed adequate clomipramine and fluoxetine trials.
The citalopram-plus-clomipramine group (n = 9) experienced a significantly larger percent decrease in mean Y-BOCS score by day 90 than the citalopram alone group (n = 7). Only one citalopram patient decreased her score by = 35%, and two by = 25%. All nine citalopram-plus-clomipramine patients experienced decreases of 35%. Side effects were mild to moderate in both groups. We also treated with citalopram six OCD patients who had not tolerated fluoxetine alone and clomipramine alone; three achieved Y-BOCS score decreases of = 35% at 90 days.
Since citalopram does not significantly affect clomipramine metabolism, the improvement in the combined drug group is unlikely to have resulted from increased plasma clomipramine levels. Double-blind controlled trials are needed of citalopram in OCD, and of combining citalopram with clomipramine in treatment-resistant OCD.
----------------------------------------------------- Scott
Posted by hopefullynow on November 22, 2009, at 11:44:11
In reply to Re: Treatment resistant OCD » hopefullynow, posted by SLS on November 22, 2009, at 7:13:42
Thanks so much, Scott, interesting...
> Personally, I think the 75mg dosage of Anafranil (clomipramine) used in this study was too low.
I subscribe, at 75 mg/day, you have all the chances to catch only the side effects which are indeed tough, at least in the first month.
> Treatment with Anafranil should be initiated at a dosage of 25 mg daily and gradually increased, as tolerated, to approximately 100 mg during the first 2 weeks. During initial titration, Anafranil should be given in divided doses with meals to reduce gastrointestinal side effects. Thereafter, the dosage may be increased gradually over the next several weeks, up to a maximum of 250 mg daily. After titration, the total daily dose may be given once daily at bedtime to minimize daytime sedation."For me, it's hard to sleep at more than 150 mg given at bedtime.It feels very activating, too activating to sleep, too sedating to take the entire dose in the morning.I'm thinking of combining 100-150 mg of Clomi with 20 mg Prozac, for a punch via 5-HT2C mechanism for an underlying bad anhedonia.What do you think, could be any problems of combining the two regarding their CYP metabolism?
Best regards
Posted by Phidippus on November 22, 2009, at 13:34:41
In reply to Re: Treatment resistant OCD, posted by desolationrower on November 21, 2009, at 15:45:51
> did you get up to max dose on those for >1 month?
>
> -d/r3 months on Luvox up to 300 mg. Lexapro I've been on for about a month at 20 mg. Zoloft had me all screwed up about two weeks in.
P
Posted by Phidippus on November 22, 2009, at 13:35:29
In reply to Re: Treatment resistant OCD » Phidippus, posted by Phillipa on November 21, 2009, at 16:54:53
Zoloft worsened my anxiety and gave me panic attacks at 100 mg.
P
Posted by Phidippus on November 22, 2009, at 13:36:54
In reply to Re: Treatment resistant OCD, posted by Kimbersaur on November 21, 2009, at 18:55:30
I've been thinking of trying Pristiq.
P
Posted by Phidippus on November 22, 2009, at 13:38:35
In reply to Re: Treatment resistant OCD » CreekGeek, posted by Phillipa on November 21, 2009, at 20:12:43
I suffer paradoxical reactions to benzos. 2 doses of Xanax landed me in the hospital.
P
Posted by Phidippus on November 22, 2009, at 14:01:13
In reply to Re: Treatment resistant OCD » SLS, posted by hopefullynow on November 22, 2009, at 11:44:11
>I'm thinking of combining 100-150 mg of Clomi with 20 mg Prozac, for a punch via 5-HT2C mechanism for an underlying bad anhedonia.What do you think, could be any problems of combining the two regarding their CYP metabolism?
No CYP problems that I can find of between Flouxetine and Clomipramine.
Would this approach work with Lexapro?
P
Posted by Phillipa on November 22, 2009, at 19:04:47
In reply to Re: Treatment resistant OCD » Phillipa, posted by Phidippus on November 22, 2009, at 13:38:35
Oh my may I ask what happened? Phillipa
Posted by hopefullynow on November 23, 2009, at 5:41:33
In reply to Re: Treatment resistant OCD » hopefullynow, posted by Phidippus on November 22, 2009, at 14:01:13
> No CYP problems that I can find of between Flouxetine and Clomipramine.Hy,
Regarding Anafranil plus Prozac combo, I found something:Clomipramine and Fluoxetine
Clomipramine is a serotonin reuptake inhibitor while its principalmetabolite, desmethylclomipramine is a noradrenalin reuptake inhibitor. Paroxetine and fluoxetine (and its principal metabolite norfluoxetine) are strong inhibitors of CYP2D6 preventing the breakdown of desmethylclomipramine. As levels of this metabolite increase the anti-OCD benefits of clomipramine (associated primarily with its serotonergic activity) are reduced. Additionally, blocking CYP2D6 also lowers levels of 8-hydroxyclomipramine, which has significant serotonergic activity and may play a part in the overall activity of clomipramine. Note 5301 Reviewed 2009-02-03.
From what I understand, norfluoxetine prevents the breakdown of desmethylclomipramine, the "serotonergic metabolite" of Anafranil,lowering its serotonergic properties, so this combo become more NSRI than SNRI, which is not benefic for OCD and anxiety.
>
> Would this approach work with Lexapro?Lexapro plus Prozac?
I am pretty sure that it will work, Lexapro is in its class of SSRI what Anafranil is as TCA.Regarding CYP interactions, there are some, it seems that Lex and Prozac potentiates each other:-Prozac levels rise 0-25% because of Lexapro
-Norfluoxetine (active metabolite) levels rise 75-150% because of Lexapro-Lexapro levels rise 0-25% because of Prozac
Posted by hopefullynow on November 23, 2009, at 5:54:43
In reply to Re: Treatment resistant OCD » Phidippus, posted by hopefullynow on November 23, 2009, at 5:41:33
> Lexapro is in its class of SSRI what Anafranil is as TCAOne big mistake, I was thinking at Luvox (fluvoxamine), not Lexapro.
Regarding intreactions between Lexapro and Prozac, they are correct.
I've found them here http://www.genemedrx.com/, the most comprehensive drug-drug interactions checker website i've found.They have an 30 days trial of their web based program.
Posted by SLS on November 23, 2009, at 7:27:00
In reply to Re: Treatment resistant OCD, posted by hopefullynow on November 23, 2009, at 5:54:43
Neither Celexa nor Lexapro inhibit CYP450 2D6 at all. So, Lexapro might make an ideal drug to combine with full therapeutic dosages of Anafranil. The study I cited used Celexa, but with only 75mg of Anafranil. 250mg should have been the maximum dosage tested.
With Paxil, the dosages of TCA should be reduced by 50%. That would indicate that dosages of Anafranil up to 125mg can be used. Prozac is a less potent 2D6 inhibitor than is Paxil, so the same 50% dosage reduction formula should be safe.
If it were me, I would use the maximum dosages of those SSRIs that have shown efficacy in treating OCD, and gradually titrate the Anafranil afterwards.
- Scott
Posted by Phidippus on November 23, 2009, at 21:19:06
In reply to Re: Treatment resistant OCD » Phidippus, posted by hopefullynow on November 23, 2009, at 5:41:33
>Paroxetine and fluoxetine (and its principal metabolite norfluoxetine) are strong inhibitors of CYP2D6 preventing the breakdown of desmethylclomipramine.
Does this hold true for Lexapro? I'd like to augment my Lexapro with Anafranil.
P
Posted by Phidippus on November 23, 2009, at 21:22:21
In reply to Re: Treatment resistant OCD » Phidippus, posted by Phillipa on November 22, 2009, at 19:04:47
> Oh my may I ask what happened? Phillipa
When I took Xanax I had horrible intrusive thoughts and had abrupt internal voices telling me to "Murder them all". I was very agitated.
P
Posted by SLS on November 24, 2009, at 5:16:06
In reply to Re: Treatment resistant OCD » hopefullynow, posted by Phidippus on November 23, 2009, at 21:19:06
> >Paroxetine and fluoxetine (and its principal metabolite norfluoxetine) are strong inhibitors of CYP2D6 preventing the breakdown of desmethylclomipramine.
>
> Does this hold true for Lexapro? I'd like to augment my Lexapro with Anafranil.Like I said above, you can use full therapeutic dosages of Anafranil with Celexa and Lexapro. Celexa and Lexapro are not inhibitors of 2D6. However, if you believe that Paxil or Prozac would be more effective, you can still add Anafranil. You would just need to reduce the dosage by 50%.
- Scott
Posted by SLS on November 24, 2009, at 5:20:26
In reply to Re: Treatment resistant OCD » Phillipa, posted by Phidippus on November 23, 2009, at 21:22:21
> > Oh my may I ask what happened? Phillipa
>
> When I took Xanax I had horrible intrusive thoughts and had abrupt internal voices telling me to "Murder them all". I was very agitated.This happens from time to time. It was probably due to a phenomenon called "disinhibition". Xanax might be more likely than other benzodiazepines to produce this reaction. I know someone who reacted to Xanax with severe agitation, uncontrollable anger and impulsive behaviors. Yet this same person was sedated very well with Ativan.
- Scott
Posted by hopefullynow on November 24, 2009, at 8:12:21
In reply to Re: Treatment resistant OCD » Phidippus, posted by SLS on November 24, 2009, at 5:16:06
> > >Paroxetine and fluoxetine (and its principal metabolite norfluoxetine) are strong inhibitors of CYP2D6 preventing the breakdown of desmethylclomipramine.
> >
> > Does this hold true for Lexapro? I'd like to augment my Lexapro with Anafranil.
>
> Like I said above, you can use full therapeutic dosages of Anafranil with Celexa and Lexapro. Celexa and Lexapro are not inhibitors of 2D6. However, if you believe that Paxil or Prozac would be more effective, you can still add Anafranil. You would just need to reduce the dosage by 50%.
>
>
> - Scott
Scott,
Thanks a lot for clarifying these OCD/depression combos.I have one question: i'm on Anafranil, working up from 125 to 150 and Prozac 20 mg/day and I begin to have real big problems in the sexual department, increased hunger and muscular weakness which really ruin my lovely workouts.In fact i'm not working out right now, I feel like a jelly.Can I combine wellbutrin SR 300 mg/day with Anafranil 150 + mg, without affecting their metabolism?I'm planning to go as higher as possible with Anafranil (maybe 250 mg), but the lack of sexual interest, the muscular weakness and constant hunger make me to think that wellbutrin would help here without interfering too much with clomipramines anti-OCD properties.To sum, now i'm on:
-Anafranil 150 mg
-Prozac 20 mg
-lithium 400 mg
-Klonopin 2mg at bedtime.
I would like to exchange 20 mg Prozac with 300 mg Wellbutrin and maybe add some Mirapex if Wellbutrin is not enough.
What do you think?All the best
Posted by SLS on November 24, 2009, at 13:58:14
In reply to Re: Treatment resistant OCD » SLS, posted by hopefullynow on November 24, 2009, at 8:12:21
You should probably remain at 150mg of Anafranil. Wellbutrin can be added. However, you might react to it with anxiety, which can actually exacerbate the OCD. You won't know until you try.
- Scott
Go forward in 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.