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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by gman22 on December 24, 2009, at 12:18:47
After fruitlessly trying to get a pdoc to prescribe this combo (as recomended by an Aussie Dr. I talk to), my general physician has agreed.
He wasn't sure about dosages, though. I am on Lexapro 10mg now (which gave me about only a 50% response plus side effects). What would be the best way to get from lexapro to therapuetic dosages of Nor. and Sert.? Should I go straight from Lex to Sertranline, get to a good dose and then add Nort.? Or should I taper the lex while starting the Nort. and add sertraline later?
Just looking for some input from some veterans.
Posted by RocketMan on December 24, 2009, at 12:56:04
In reply to sertraline and nort., posted by gman22 on December 24, 2009, at 12:18:47
If it were me and I was taking Lexapro 10mg, I would switch directly over to zoloft 50mg, wait one week, and then add nortrip 25mg. I would then wait 2-3 weeks and see how I feel. Adjust dose accordingly. Maybe increase zoloft to 100mg if required.
Rocket
Posted by linkadge on December 24, 2009, at 14:07:27
In reply to Re: sertraline and nort. » gman22, posted by RocketMan on December 24, 2009, at 12:56:04
Wait! Have you tried lexapro and nortriptyline?
The addition of nortriptyline to an SSRI is a good augmentation strategy. The use of sertraline specifically, is probably no better than any other SSRI.
Lexapro can be a very effective SSRI, and unless it is doing zip for you, there would be no reason to suggest that sertraline would be more effective.
I would save yourself the double switch and try just adding nortriptyline first. Then, if this is innefective *perhaps* try switching to zoloft.
I didn't find zoloft all that effective. Celexa (for me) was much better with a TCA.
Linkadge
Posted by bleauberry on December 24, 2009, at 14:45:46
In reply to sertraline and nort., posted by gman22 on December 24, 2009, at 12:18:47
I agree with Linkadge. Since Lex is providing some benefit, add Nort to it. Zoloft could always be switched at a later date if needed. While there is generally a good synergy between Nort and SSRIs, the primary benefit of Zoloft is that is has the least amount of liver enzyme involvement, meaning that it is easier to follow Nort doses without another med increasing it or decreasing it more than you are aware is happening.
While all the SSRIs are similar, they have distinct differences. Therefore if Lex doesn't do as well as hoped, Zoloft could come in later. But for now, keep the variables as few as possible, which means stick with Lex.
A common scenario I've seen reported on the web is when someone decides to wean off an SSRI and titrate onto Nortiptyline as a replacement. But somewhere in the middle of that process they discover they work so well together that they keep both meds, both at lower doses than if either was monotherapy.
Just my two cents.
Posted by morganator on December 24, 2009, at 16:39:38
In reply to Re: sertraline and nort., posted by bleauberry on December 24, 2009, at 14:45:46
When you were taking nortriptyline did you dose it at night or in the morning? I would be interested to see if it would have a calming effect on me if I took it upon waking.
After getting used to Nortriptyline, will you always get the drowsy effect? I assume most do since they continue to take it at night and it helps them sleep. I've just never experienced taking an antidepressant that had a calming sleep inducing action for the first 8 or so hours and then a more stimulating antidepressant action the rest of the next day. With zoloft or prozac, I just took it in the morning and felt the same throughout the day and slept just fine at night.
Posted by linkadge on December 24, 2009, at 20:38:53
In reply to Re: sertraline and nort.-bleauberry, posted by morganator on December 24, 2009, at 16:39:38
Nortriptyline helped me sleep. According to its clinical profile it shouldn't, but it did. I would certainly take it at night.
Linkadge
Posted by morganator on December 25, 2009, at 1:14:35
In reply to Re: sertraline and nort.-bleauberry, posted by linkadge on December 24, 2009, at 20:38:53
Why didn't you keep taking it?
I wonder what it is about Nortriptyline that sedates first and then lifts and activates later.
Would this mean that if you did dose it in the morning and felt drowsy for much of the day, they may have a difficult time sleeping at night?
Posted by Brainbeard on December 25, 2009, at 9:20:14
In reply to Re: sertraline and nort.-bleauberry, posted by linkadge on December 24, 2009, at 20:38:53
> Nortriptyline helped me sleep. According to its clinical profile it shouldn't, but it did. I would certainly take it at night.
>
> LinkadgeThere are several reasons why nortriptyline would help people sleep:
* It's an NRI. Noradrenergic reuptake inhibition can have the paradoxical side-effect of making people sleepy. Atomoxetine (Strattera) is infamous for it. Geodon's (ziprasidone's) sedation is probably also noradrenergic for the bigger part.
* It has antihistaminergic i.e. sedating properties.
* It does some 5HT2A-antagonism, which promotes deep sleep.
See http://www3.interscience.wiley.com/cgi-bin/fulltext/121665024/main.html,ftx_abs#t3 for receptor affinities.
Posted by SLS on December 25, 2009, at 10:17:52
In reply to Re: sertraline and nort.-bleauberry, posted by Brainbeard on December 25, 2009, at 9:20:14
In the past, it has been the habit of doctors to administer the entire daily dose of nortriptyline at night.
I dose myself with nortriptyline using 50mg t.i.d. I do not notice any sedative or alerting effects.
- Scott
Posted by SLS on December 25, 2009, at 10:29:23
In reply to Re: sertraline and nort.-bleauberry, posted by Brainbeard on December 25, 2009, at 9:20:14
I am a rapid metabolizer of tricyclics. I'm guessing P450 2D6.
For me, I find that nortriptyline 150mg is clinically equivalent to desipramine 300mg.
- Scott
Posted by morganator on December 25, 2009, at 11:16:16
In reply to Re: sertraline and nort.-bleauberry, posted by Brainbeard on December 25, 2009, at 9:20:14
Thanks Brainbeard, I guess it just takes some time after the dosing before most people feel the uplifting/activating effect of Nortriptyline. Maybe once the brain has adjusted over those several hours, the same mechanisms begin to effect it differently? I'm just curious about this as I've never been on something that had this effect. Even with Zyprexa, I could dose it at night or in the morning and it didn't matter-I wouldn't get sleepy or feel less depressed, just maybe a little less anxious, which may be why people dose it at night.
Posted by morganator on December 25, 2009, at 11:21:55
In reply to Re: sertraline and nort.-bleauberry, posted by SLS on December 25, 2009, at 10:17:52
Thanks Scott, I wonder if it would have the same effect on me. But if it helped with sleep that may be a plus, though I don't sleep that poorly. I don't know why I'm so interested in being able to take it in the morning.
Posted by bleauberry on December 25, 2009, at 12:29:45
In reply to sertraline and nort., posted by gman22 on December 24, 2009, at 12:18:47
To answer a few questions, I agree with everyone else's comments here.
I found Nort to disturb my sleep the first 2 or 3 nights, definitely a higher NE thing and also I could sense some of that serotonin ssri insomnia thing, but it was all mild. Light sleep with several wakings. But after that, sleep was good. I developed an early morning waking, but slept good till then. I did not find Nort sedating in a way that it would knock me out at bedtime.
Actually I found the best time for me to dose it was between 4pm and 6pm in the afternoon. Bedtime was much too late for me.
I started it with 6.25mg zoloft and was feeling decent benefits alredy by day 3. For some stupid reason someone convinced me to just go with the nort. I hate ssri's anyway and agreed. I think that was a mistake because over the next couple weeks I didn't gain any new ground and then lost everything I had gained. The zoloft was an integral part of the plan. I need to redo this.
Savella (Milnacipran), heavy on NE, gave me great sleep. It however had much more peripheral NE effect than Nort. I think Nort is mostly nervous system focused, but Savella goes everywhere pretty strong. Nort didn't give me any of the heavy NE urinary side effects that Savella did.
In any case, I think NE reuptake inhibition helps sleep, probably through feedback loops, while NE stimulation and release (stimulants, remeron..though smothered out by potent antihistamine) these things worsen sleep. I don't know, that's my crude way of describing my experience.
Posted by RocketMan on December 25, 2009, at 12:36:05
In reply to Re: sertraline and nort.-bleauberry, posted by Brainbeard on December 25, 2009, at 9:20:14
I took 25mg at night... worst case of insomnia I've experienced. Just goes to show how differently we can react.
Rocket
Posted by gman22 on December 25, 2009, at 14:12:46
In reply to sertraline and nort., posted by gman22 on December 24, 2009, at 12:18:47
Not sure if the Lexapro is doing anything at this point....the 50% response I spoke of was in the past and after going back on it last month I'm not even getting that. Thats why I want to start zoloft. It sucks because the only 2 drugs I really tried before Lexapro worked fine-imipramine and Paxil. I'm just trying to get a full response with less se's. I wish I wouldn't have started f*ck*ng around with what was working.
Also re sertraline, I've read (maybe here) that a 8mg dose produces 50% reuptake of serotonin. Anyone know about this?
Posted by RocketMan on December 25, 2009, at 15:14:14
In reply to Re: sertraline and nort., posted by gman22 on December 25, 2009, at 14:12:46
> Also re sertraline, I've read (maybe here) that a 8mg dose produces 50% reuptake of serotonin. Anyone know about this?
That sounds like a very sub-therapeutic dose in my books. I would not take anything you read here, or any internet site, as the gospel. I would suggest a minimum starting dose of 25mg and titrate up as need be.
Rocket
Posted by Brainbeard on December 26, 2009, at 5:31:50
In reply to Re: sertraline and nort., posted by RocketMan on December 25, 2009, at 15:14:14
> > Also re sertraline, I've read (maybe here) that a 8mg dose produces 50% reuptake of serotonin. Anyone know about this?
>
> That sounds like a very sub-therapeutic dose in my books. I would not take anything you read here, or any internet site, as the gospel. I would suggest a minimum starting dose of 25mg and titrate up as need be.
>
> Rocket
>
>Principally agree with Rocket. What's the worth of 50% SRI? It may well have no therapeutic effect at all. But what are numbers worth anyway? I know of a research that showed that just 10mg of clomipramine (brand name Anafranil) already causes 80% occpancy of serotonin receptors, which is an occupancy similar to therapeutic doses of the SSRIs. Still, I know from my own experience that 10mg of clomipramine is NOT comparable to a therapeutic dose of an SSRI. Details do matter, and often we don't even know the details. And when 'we' (read: some obscure scientist) do, p-docs and the like are not interested in them.
Concerning sertraline: I know of a friend of mine who suffered from akathesia while combining bupropion (brand name Wellbutrin) and sertraline. She lowered her sertraline to 25 and even 12.5mg, but the akathesia persisted and only went away when she quit sertraline completely. So even a 12.5mg dose may have some effect.
8mg, on the other hand, seems like a borderline dose - a bit like kissing a Tylenol pill and hoping it will help your headache.Don't get me wrong - there ARE medications with which even very low doses may be therapeutic.
Prozac (fluoxetine) is a prime example; in the initial trials, a minimum effective dose couldn't be established since ALL doses, no matter how low, were effective. 5mg or even 2.5mg of Prozac a day can be an effective agent against dysthymia for some people. But the reason is that fluoxetine is a potent 5HT2C-antagonist, effective as such even in small doses.
So it all boils down to what a drug does and if it does that or anything else at lower doses.
Posted by gman22 on December 26, 2009, at 13:45:36
In reply to sertraline and nort., posted by gman22 on December 24, 2009, at 12:18:47
thanks Rocket and Brainbeard.
i talked to Dr. Gillman again yesterday, and he said do a straight switch from lex to zoloft 50mg, and then add nort. after 5 days, pretty much what Rocketman said.
I'd still like to throw in some mirapex to counteract side effects later on down the road.
Posted by Brainbeard on December 26, 2009, at 13:51:08
In reply to Re: sertraline and nort., posted by gman22 on December 26, 2009, at 13:45:36
> thanks Rocket and Brainbeard.
> i talked to Dr. Gillman again yesterday, and he said do a straight switch from lex to zoloft 50mg, and then add nort. after 5 days, pretty much what Rocketman said.
> I'd still like to throw in some mirapex to counteract side effects later on down the road.You talked to Dr. Gillman? How did you do that, do you guys skype or something? Or is he your father in law?
I'm not sure wether Mirapex is such a good idea. Could give you inadvertent sleep attacks in the middle of any kind of action - you'd better not drive while using that stuff. I'd recommend Trivastal (piribedil) instead, which doesn't seem to cause sleep attacks.
Posted by gman22 on December 26, 2009, at 14:06:00
In reply to sertraline and nort., posted by gman22 on December 24, 2009, at 12:18:47
I talk to him on Skype prob. about once a week. He is an awesome guy---great sense of humor, super smart, and willing to answer psychopharm questions and give unbiased advice for free.
If you want I can give you his email and Skype number.Tim
Posted by Brainbeard on December 26, 2009, at 16:25:18
In reply to Re: sertraline and nort. Brainbeard, posted by gman22 on December 26, 2009, at 14:06:00
> I talk to him on Skype prob. about once a week. He is an awesome guy---great sense of humor, super smart, and willing to answer psychopharm questions and give unbiased advice for free.
> If you want I can give you his email and Skype number.
>
> TimDoes he charge you for that?! I'm sure he's an awesome fellow - I love his writings on the web. I would appreciate getting his email and Skype number. Could you babblemail it? You could also email it to m e i t e _ u [at]hotmail.com (name before @ interspaced to fool spambots, @ replaced by bracketed text for same reason - the last time I put my email address here I was flushed by pharma spam!) Thanks.
-Meite U
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