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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 34 to 58 of 60. Go back in thread:
Posted by Kingston on December 2, 2009, at 19:37:01
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 18:20:52
Monica,
Thought I'd ask why you are switching from the EMSAM patch? and why have you chosen Parnate over Nardil when Nardil is considered the safer and more efficacious of the two? I really want to believe in Parnate but i've yet to run into anyone that will explain why it is any better than EMSAM. So far, all i keep reading is that Parnate makes you feel good, eliminates depression but insomnia is a hallmark. Why isn't everyone taking Parnate if it is so great. There must be some downside to it? Someone be honest please and give me the low down on their long term experience with this drug? Can you or can't you sleep on it and if not, have you continued use and what did you do to resolve the sleep issue? Most importantly, how does it effect sex drive? Can you take Viagra with Parnate? How does Parnate effect your cognition? I just don't wan't to start taking something that makes me feel great(i have no doubt that Parnate will do wonders in that regard) but comes with a library's worth of side effects. Cocaine makes you feel good but that doesn't mean you should take it on a daily basis. Although I know plenty of people that actually do mini-bumps of cocaine all day long as a means of self-medicating(many of which are high functioning individuals), cocaine is not practical for most; particularly someone such as myself with biopolar spectrum issues.The only reason i'm even switching to 'possibly parnate', maybe even Nardil, is because of cost; Otherwise I would stick with EMSAM. The attraction of ESAM is that it should theoretically work like the other MAOis but with fewer side effects. Even at 12mg where dietary restrictions come into play, Selegeline just has fewer side effects in general. It's apparently the fountain of youth and will actually slow down the aging process when taken chronically(at least it does in rats but who knows if the effect is the same in humans. The idea of it sounds nice and was motivation enough for me to stick with EMSAM long enough for it to pay out. And that's all i suggest to anyone that reacts poorly to EMSAM. Give it a chance. It took a month of heightened anxiety and mood swings and another 2 months of nothing before EMSAM started working like I theorized and I think that's partially b/c the 6mg dose I started off at was the wrong starting dose. I found that starting at 3mg(cutting the patch in half) worked best, mainly targeting dopamine. After three weeks at 3mg, I went straight to 9mg, bypassing the 6mg patch. There isn't enough balance between MAO-a and MAO-b at 6mg. MAO-b is getting hit big time, releasing tons of dopamine which is overstimulating for most but MAO-b is only being brushed slightly. Serotonin and NE release is not enough to combat the dopamine shakes/ irritability(unless you are just someone who is severely deprived of dopamine).
I actually noticed that I became calmer, less anxious at 9mg EMSAM then at 3 and 6 mg. The true efficacy of the patch wasn't fully revealed until a 12 mg dose was reached. My blood pressure dropped drastically though so I augmented with two 15 mg Dex spansule to set my BP back to normal 115/76. Without the Dex, I would actually hate EMSAM as you do and would find myself hating life, very lethargic. Bp was at 86/31. However, the stim-MAOi combo is superior to anything i've ever tried. I've actually strapped on two 12 mg patches , 24mg total and found this to be Pandora; what I assume Parnate or Nardil must feel like. The current EMSAM doses are just too low for most people with years of major depression on their side; especially rapid acetylaters such as myself and a good portion of the Caucasian population. I also augment with 30-50mg of Lamictal which is another amazing find with zero side effects and 1mg of Klonopin which takes care of the GABA that both Parnate and EMSAM lack that Nardil targets.
Unfortunately, my insurance will only cover a 6mg patch( and they only cover 50% of the cost) and now that i'm tapped out($2000max), i can't even afford that. I'm actually thinking of using Zelepar until my insurance kicks in at the beginning of Jan...but then there's Parnate. I mean what if it works? I thinking from a purely financial perspective here. If Parnate works like EMSAM, well, obviously I'll take the Parnate given that it is about 490 dollars cheaper/ month. It sickens me when I think what cool stuff i could buy with a month's supply of EMSAM.
If finances weren't an issue, 12mg EMSAM, alow dose of stimulant, low dose Lamictal and low dose of Klonopin with either Namenda or Aricept or both would be my ideal cocktail. I like this for several reasons: the main being the lack of side effects. Other than low blood pressure and some initial acne, there haven't been any side effects. 2)cognition isn't dulled; if anything this combo boosts your IQ a few domains on the Richter scale. 3)enhanced athletic performance. LAMICTAL and Klonopin block the sensation of pain while EMSAM and a Stimulant increase stamina and strength.
What worries me about Parnate is just that it's going to come at a cost: liver damage and sexual dysfunction as well as insomia. Anyways Monica, sorry for the diatribe. I just start writing and well, don't have time to edit. Stream of conscious is what you get I suppose. Keep me updated on your progress with Parnate b/c i may follow your path if you find that it is working.
Posted by Monica L on December 2, 2009, at 19:58:39
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 19:37:01
I'm switching from the emsam patch because I just dont like how it won't stick good and I thought it was suppose to work quicker. I've tried every medication out there and they all have seem to work right away, that's why I was so discouraged with the emsam not working quickly. The first time I ever took a medication for depression, which was prozac, it changed my life within 20 min. No one ever believes me but it's true. I took the prozac for a while, but had to keep increasing the dosage and it eventually just stopped. Do you know how long the parnate takes to kick in? I'm willing to wait for the parnate to kick in because it's in pill form and not a patch that you dont know if it's on right or what. I was told the parnate would be faster. I went to a reg doc to see if they would by some chance switch me to the parnate, but of course they didnt. My next appt with the pdoc wasnt until the 14th of dec, no way could I wait that long. But she did prescribe me xanax, which has been helping along with the ritalin I already had. I am going to stop the ritalin tomorrow and hopefully I can start the parnate, if I get it, tomorrow. I'm almost scared to ask this, but is there a difference in the generic and brand name parnate? Well, thanks for the response and I'll keep you posted!
Posted by Kingston on December 2, 2009, at 21:37:44
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on December 2, 2009, at 19:58:39
Monica,
Yeah...I believe your Prozac story. Are you bipolar? A lot of the initial success stories and books such as 'Listening to Prozac' were written about patients like us; people who rapidly responded to prozac within days, taking on superhuman tasks as if born again with the energy of ten men. Naturally, this is what psychiatrists trying to sell books are going to write about. You don't hear about these patients five years down the road. And all the Prozac hype and the books that came with was before people understood bipolar spectrum disorder: patients who showed no signs of bipolar beofre SSRI treatment would show all the symptoms shortly after. They don't know what to call this so they just call Bipolar Spectrum Disorder. Off SSRIs, i'm completely normal and entirely boring.I react almost instantly to all of the SSRIs. My favorite was Zoloft. I wrote a 500 page novel in under a month the first time I took Zoloft; a novel which clearly wasn't garbage b/c it's sitting in Barnes and Nobles right now. I wasn't delusional. Just energized and on task. Zoloft changed my life.
We both have what is called SSRI induced hypomania. Sounds to good to be true and it is. The hypomania that allowed me to write a novel turned sour after ten months solid before dumping down the SSRI sewer pipes and into the fire-breathing cesspits of hell.
I never had suicidal thoughts until I went on Zoloft. Jumping from one SSRI to the next, my brain was fried when I finally met up with Prozac. Prozac rejuvenated me though and sent me on another hypomanic surge and I polished off book number two in a week flat.
Two months later, I was standing on a chair in my garage with a rope wrapped around my neck. SSRIs nearly destroyed my life but i'll spare you the lengthy tale and trail of mass chaos that me and my SSRIs left behind.
As for Parnate, it won't work immediately but it is one of the fastest acting anti-depressants. If it does boost you into a euphoria right away, be weary. I too have a chemical romance with euphoric states of mind, hypomanic, seemingly superhuman states where everything seems possible and it literally is(b/c in the end, doubt is what prevents people from achieving their goals). Take away doubt as Zoloft and Prozac once did for me and what do I do? I write two books. Been trying to get back to that state of mind ever since for book three but so far, no cigar. I am now forever caught in a torturous search, desperately trying to find true pharmaceutical love again, "the holy grail of pharmaceutical weaponry that will make me feel invincible again".
But yeah...if you've been on EMSAM for two weeks or more, you've already done most of the leg work by deactivating a lot of monamine oxidase in your body. Since EMSAM is irreversible in it's effect, it will take another two weeks for the monamine oxidase to reactivate. You've only been off the EMSAM a week right? so you might get still have some deactive MAO and get an instant reaction to Parnate. Parnate will likely be stronger and deactivate much more MAO too.
As for brand v generic....if i were going out of my way to take something like Parnate, I would want the best and unfortunately there will always be a difference between generic and brand. Here's a good explanation of why:
"a generic must have between 80 percent and 125 percent bioequivalency to its name-brand producta window of 20 percent less or 25 percent greater potency. Generally, that kind of variation is not going to make a difference in terms of efficacy or toxicity. But imagine a large pharmacy that negotiates with different generic manufacturers and buys a generic formulation from one manufacturer that has 80 percent bioequivalency to the name brand. Then imagine the pharmacy switches manufacturers to one that markets a generic that has 125 percent bioequivalency. That's a 45 percent difference in bioequivalency that theoretically can make a significant difference for the patient. If it's a downward shift, it could affect efficacy; if it's an upward shift, it could affect toxicity. It is also not impossible for particularly sensitive individuals to have variable reactions to the inert materials in a compound. Individuals can sometimes be allergic and react differently to whatever substance goes into making up the capsule or the tablet."
So my advice would be get brand name if you can. Fortunately i've discovered a very reliable pharmacy in Canada called Jan's Drugs if you aren't covered for brand or don't have insurance. I'd post a link but i'm sure i'll get in trouble for soliciting. Do a google search. You can get a month supply of 100x(10mg) brand Parnate pills for 60 dollars if you take 30 mg/day. Or 200x(10mg) for $100 dollars if you take 60mg/day. That price is not bad considering that it is brand name Parnate(Glaxo- my favorite pharm company). Now if your insurance will cover brand then you're good and no need to order from Canada. If you choose the brand when a generic is available, you will be responsible for the difference in cost between the brand and the generic in addition to your generic copay for most plans. Drugstore.com is selling 100 tabs of 10mg brand Parnate for 151 dollars and generic for 112. That means 10 dollar copay + 151-112 = 50 dollars. Actually, that's not bad considering my copay for brand is 35 dollars. So go with brand if you can afford between 50-60 dollars out of pocket for a 30 day supply of 30 mg and 80-100 for 60mg supply.
Posted by Phillipa on December 2, 2009, at 23:03:52
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 21:37:44
Kingston did anyone welcome you to babble? If not I'm welcoming you. Would love to hear from you. If so click on my name in blue and voila a screen appears you type a private e-mail go to bottom of that screen and click send babblemail no one but me can read it. You might also wish to turn your's on by going back to registration and merely clicking yes turn my babblemail on. Love Phillipa. Bet those novels are great reads!!!!
Posted by inanimate peanut on December 3, 2009, at 15:14:25
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 19:37:01
I just chose to switch from EMSAM to Parnate this morning. All I've been reading about on this site for days is about how wonderful Parnate is and how well it's working for people. I've been on EMSAM for 2 weeks with little results and I was ready for something different. Maybe I made the wrong choice but i needed to try something.
Posted by floatingbridge on December 3, 2009, at 15:56:39
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on December 3, 2009, at 15:14:25
Hey, so your pdoc agreed to the switch--. Drug trials can be so trying. Hope you're hanging in there, that your washout is (very) brief and you are feeling more relief soon(er!). We're pulling for you!
fb
> I just chose to switch from EMSAM to Parnate this morning. All I've been reading about on this site for days is about how wonderful Parnate is and how well it's working for people. I've been on EMSAM for 2 weeks with little results and I was ready for something different. Maybe I made the wrong choice but i needed to try something.
Posted by annabamma on December 3, 2009, at 20:12:42
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on December 2, 2009, at 19:58:39
Just wanted to add my two-cents worth- after trying and having to stop the EMSAM patch (skin reaction) I tried the oral selegine pills. I've been on them now for three months and- dare I provoke the depression gods?- I am feeling a lot better! I was very miserable with NO energy, NO motivation, 'whats-the use-of anything' type feelings. I'm currently on 15 mgs. Yeah, the diet is kind of a pain, but you get used to it. plus it's helping me lose weight-35+ so far! So, for some people, the pills DO work. After 30 years of trying MANY meds, these seem to help! Maxine, hang in there, I hope you are feeling better-I could feel the pain in your post-good luck.
Posted by annabamma on December 3, 2009, at 20:17:54
In reply to Re: Add anything to help with the EMSAM wait...., posted by annabamma on December 3, 2009, at 20:12:42
OOPss! I meant that for MONICA
Posted by Phillipa on December 4, 2009, at 19:33:16
In reply to Re: Add anything to help with the EMSAM wait...., posted by annabamma on December 3, 2009, at 20:12:42
Seriously don't recall anyone ever reporting on how the pills worked. You lost all that weight congratulations to you!!! Phillipa
Posted by amee200 on January 11, 2010, at 12:32:25
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on December 3, 2009, at 15:14:25
Just to post a comment on usage of Parnate, I've been on it for almost a year and it is a very powerful drug. My doctor added ritalin to it and the combo is excellent. I took ritalin with the Nardil as well but didn't notice the difference as with Parnate. Nardil was too sedating for me and the weight gain was too intense. So, ritalin plus parnate is an excellent safe combo. I take a high dosage of both, 90mg parnate and 40 mg ritalin which can be a risk according to my pdoc. But I am careful about timing and the food I eat and he monitors me closely. Sometimes I feel like it makes me feel too good, I'm not used to it.
Posted by floatingbridge on January 11, 2010, at 13:01:37
In reply to Re: Add anything to help with the EMSAM wait...., posted by amee200 on January 11, 2010, at 12:32:25
Ammee,
May I ask what symptoms or conditions you are treating w/ your combo?
Thanks, too, for the success story--glad to hear you're feeling good.
fb
Posted by amee200 on January 11, 2010, at 23:57:49
In reply to parnate success » amee200, posted by floatingbridge on January 11, 2010, at 13:01:37
I've been diagnosed with Anxiety Disorder, refractory depression and ADD
I've tried every other antidepressant out there- SSRIs, Tricyclics, Wellbutrin, different combos....It is not perfect of course, I did have a food reaction once and the insomnia is bad if I don't time the dosage properly. So it is not without its risks but is effective in many cases.
Posted by floatingbridge on January 12, 2010, at 10:16:47
In reply to Re: parnate success, posted by amee200 on January 11, 2010, at 23:57:49
> I've been diagnosed with Anxiety Disorder, refractory depression and ADD
> I've tried every other antidepressant out there- SSRIs, Tricyclics, Wellbutrin, different combos....It is not perfect of course, I did have a food reaction once and the insomnia is bad if I don't time the dosage properly. So it is not without its risks but is effective in many cases.
Thanks Ammee, How wonderful to have a working treatment! My dx is major depression severe, recurrent. Anxiety is huge, and there is also add. Fatigue is intractable as well. Sounds like your doc is a good one!
Best,fb
Posted by Warped on December 13, 2014, at 21:22:44
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 4:24:05
I know this has been a dead thread for ages now, I was wondering if anyone could provide me any information as to how to convince my doctor to prescribe me a stimulant with Emsam. I was actually will to just switch to Parnate, as it has the properties of both meds, but he was unwilling to prescribe any MAOI besides Emsam. He did say that he would look into the idea much further if I were to provide him with contact information of any doctor that has prescribed the combo, so I would be truly grateful if anyone were willing to do that. I of course would not mention where I received the information from. At this point in my treatment, I've exhausted all other options to the point that he essentially told me he couldn't further help me and recommended I go see a different doctor. So that will be my next step, and hopefully I will find someone more understanding and willing to try this augmentation. Any information that I could present to the doctor would greatly aid my health.
Posted by Warped on December 13, 2014, at 21:23:46
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 4:24:05
I know this has been a dead thread for ages now, I was wondering if anyone could provide me any information as to how to convince my doctor to prescribe me a stimulant with Emsam. I was actually will to just switch to Parnate, as it has the properties of both meds, but he was unwilling to prescribe any MAOI besides Emsam. He did say that he would look into the idea much further if I were to provide him with contact information of any doctor that has prescribed the combo, so I would be truly grateful if anyone were willing to do that. I of course would not mention where I received the information from. At this point in my treatment, I've exhausted all other options to the point that he essentially told me he couldn't further help me and recommended I go see a different doctor. So that will be my next step, and hopefully I will find someone more understanding and willing to try this augmentation. Any information that I could present to the doctor would greatly aid my health.
Posted by SLS on December 14, 2014, at 2:18:04
In reply to Re: Add anything to help with the EMSAM wait...., posted by Warped on December 13, 2014, at 21:23:46
http://www.ncbi.nlm.nih.gov/pubmed/15554766
http://www.dr-bob.org/tips/split/MAOIs-in-high-doses-and-wi.html
http://www.ncbi.nlm.nih.gov/pubmed/3997787
http://www.ncbi.nlm.nih.gov/pubmed/2056139
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http://www.dr-bob.org/cgi-bin/pb/mget.pl?post=/babble/20050510/msgs/497069.html
Psycho-Babble Medication Thread 495845Shown: posts 1 to 10 of 10. This is the beginning of the thread.
documention of *high dose* Parnate?Posted by iforgotmypassword on May 9, 2005, at 23:27:34
when i was on parnate my doctor only let me go up to 40mg, is there any documentation out there that i may be able to share with him demostrating efficacy and safety of high dose treatment?
Re: documention of *high dose* Parnate? » iforgotmypasswordPosted by SLS on May 10, 2005, at 7:26:38
In reply to documention of *high dose* Parnate?, posted by iforgotmypassword on May 9, 2005, at 23:27:34
> when i was on parnate my doctor only let me go up to 40mg, is there any documentation out there that i may be able to share with him demostrating efficacy and safety of high dose treatment?
Jay Amsterdam, MD at the University of Pennsylvania has used high-dosage Parnate (tranylcypromine) for many years in treatment resistant cases:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2710808
Personally, I think the "normal" range of Parnate should lie between 40-80mg. 40mg is the minimum that people with severe or resistant depression tend to respond to. I need 60mg to get any kind of relief and 80mg to optimize it.
- Scott
Re: documention of *high dose* Parnate?Posted by BIGDaddyachmed69 on May 10, 2005, at 7:58:27
In reply to documention of *high dose* Parnate?, posted by iforgotmypassword on May 9, 2005, at 23:27:34
> when i was on parnate my doctor only let me go up to 40mg, is there any documentation out there that i may be able to share with him demostrating efficacy and safety of high dose treatment?
I mentioned Parnate to my pdoc, and he said that in general he's had to prescribe it in high doses to see a significant benefit in severely depressed patients. He's very experienced in his field, one of the best...he's had a lot of experiencing with MAOIs and knows what he's talking about.
Re: documention of *high dose* Parnate?Posted by Phillipa on May 10, 2005, at 17:05:11
In reply to Re: documention of *high dose* Parnate?, posted by BIGDaddyachmed69 on May 10, 2005, at 7:58:27
Scott, Are you taking Parnate now? Is it working for you? I hope so, you've been through a lot. Fondly, Phillipa
Re: documention of *high dose* Parnate? » SLSPosted by Chairman_MAO on May 11, 2005, at 20:20:33
In reply to Re: documention of *high dose* Parnate? » iforgotmypassword, posted by SLS on May 10, 2005, at 7:26:38
The therapeutic dose for MDD is 0.8mg/kg, IIRC. Does that jive with your 80mg/day?
Re: documention of *high dose* Parnate?Posted by EERRIICC on May 11, 2005, at 21:23:46
In reply to documention of *high dose* Parnate?, posted by iforgotmypassword on May 9, 2005, at 23:27:34
Google "depression central", there is documentation of the efficacy of high dose parnate on that site somewhere.
Re: documention of *high dose* Parnate?Posted by Maxime on May 12, 2005, at 19:10:41
In reply to Re: documention of *high dose* Parnate?, posted by EERRIICC on May 11, 2005, at 21:23:46
Hi, here is some info on using Parnate with Stims, and high doses of Parnate. Also, if you go to Depression Central you will find some stuff there under Treatment Resistant Depression.
Hope this helps.
Maxime
1: J Clin Psychopharmacol. 1991 Apr;11(2):127-32.
CNS stimulant potentiation of monoamine oxidase inhibitors in
treatment-refractory depression.Fawcett J, Kravitz HM, Zajecka JM, Schaff MR.
Department of Psychiatry, Rush-Presbyterian-St. Luke's Medical Center,
Chicago,
Illinois.We report on our clinical experience with a combination of a CNS stimulant (either pemoline or dextroamphetamine) and a monoamine oxidase inhibitor (MAOI) for treating 32 depressed patients (mainly outpatients) refractory to standard
antidepressant pharmacotherapy. This combination, though not approved by the FDA, appears to be safe and effective. Twenty-five (78%) of these patients experienced at least 6 months of symptom remission with a stimulant + MAOI combination. Many patients required adjunctive antidepressant treatment, including tricyclics and lithium. Side effects were not excessive, though 6 patients (3 unipolar and 3 bipolar) cycled to mania (N = 1) or hypomania (N = 5). None developed hypertensive crises. With properly motivated and complaint patients and careful clinical monitoring by the prescribing psychiatrist, stimulant potentiation of MAOIs may be a viable option for treatment-resistant depressed patients.PMID: 2056139 [PubMed - indexed for MEDLINE]
2: J Clin Psychiatry. 1985 Jun;46(6):206-9.Combined MAOI, TCA, and direct stimulant therapy of treatment-resistant depression.
Feighner JP, Herbstein J, Damlouji N.
Patients with "treatment resistant" depression who do not respond to standard methods or relapse over time have a moral and legitimate right to innovative
therapy. Combined treatment with monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), and stimulants has been resisted by practitioners because of hypertensive and hyperthermic crises noted in certain cases. This paper reports a case series demonstrating the safety and efficacy of adding a stimulant to an MAOI or to a combination of TCA and MAOI in the treatment of intractable depression.PMID: 3997787 [PubMed - indexed for MEDLINE]
MAOIs in high doses and with stimulantsDate: Sat, 1 Apr 1995 13:33:03 -0800 (PST)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Non-response to tranylcypromineThe commonest reason people do not respond to tranylcypromine (Parnate) is an inadequate dose. When using an MAOI I follow platelet MAO levels and keep increasing the dose is sufficient to reduce those levels almost to zero. This often takes > 60 mg/day of tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant improvement, the next thing I usually do is to add a psychostimulant such as methylphenidate or dextroamphetamine to the cocktail. Starting with small doses, the dose is gradually increased until the patient is taking about 30 mg/day of dextroamphetamine, or twice as much methylphenidate.
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: MAOIs in high doses and with stimulantsThere are recently been a number of warnings posted there that MAOIs should not be prescribed together with psychostimulants. While that is the conventional wisdom, if universally implemented, it would deprive many severely and intractably depressed people from relief.
In the olden days, the early 1960s, we used to treat some patients with resistant depressions with up to 200 mg/day of tranylcypromine and if that was not effective potentiate it with dextroamphetamine, starting with 2.5 mg once a day and gradually increasing to 15 or 20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine was only able to continue in his professional work by taking 170 mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since the isocarboxazid became unavailable, he has been doing almost as well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is often necessary to use combinations [and doses] of medication that are conventionally considered to be contraindicated.
From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
From: Donald Franklin Klein <dfk2@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine . Very useful for orthostatic hypotension.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder.
From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regimen, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulantsBy the way, I do not get signed consent. I do not think that that holds up very well anyway. Well documented clear chart notes indicating the clinical rationale and including what is told to the patient should always be standard practice and especially with atypical treatment modalities such as this.
Re: documention of *high dose* Parnate? » MaximePosted by Phillipa on May 12, 2005, at 19:29:38
In reply to Re: documention of *high dose* Parnate?, posted by Maxime on May 12, 2005, at 19:10:41
Hi Maxime. You're back! Fondly, Phillipa
Re: documention of *high dose* Parnate?Posted by Maxime on May 12, 2005, at 19:56:03
In reply to Re: documention of *high dose* Parnate? » Maxime, posted by Phillipa on May 12, 2005, at 19:29:38
> Hi Maxime. You're back! Fondly, Phillipa
Yeah, my block is finished. I have walk on eggshells though because I will be on Dr. Bob's radar now.
Such is life. Whatever.
Maxime
Re: documention of *high dose* Parnate? » Chairman_MAOPosted by SLS on May 12, 2005, at 21:13:02
In reply to Re: documention of *high dose* Parnate? » SLS, posted by Chairman_MAO on May 11, 2005, at 20:20:33
> The therapeutic dose for MDD is 0.8mg/kg, IIRC. Does that jive with your 80mg/day?
I am ignorant of this formula. To follow it would place me at 60mg and not at the 80mg I need to get the full effect. I wish I could say that my case was typical and representative of the mainstream, but it isn't. However, after being on and off Parnate for 23 years, I have gleaned much about its usage from the doctors I have seen and from my personal experience with this drug. I think you will find that with Parnate, only a clinical titration will give you the answer to the question, "how much does the individual patient need". The doctors I have seen in the past who are experienced with MAOIs and not bashful about using them indicate that it is often necessary to go beyond 60mg to achieve remission. 40-80mg seems to be a more realistic range of dosages when treating severe depression than what the PDR would indicate.
- ScottThis is the end of the thread.
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[dr. bob] Dr. Bob is Robert Hsiung, MD, dr-bob@uchicago.edu
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Copyright 2006-08 Robert Hsiung.
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Posted by Elanor Roosevelt on December 21, 2014, at 7:39:54
In reply to Re: Add anything to help with the EMSAM wait...., posted by Warped on December 13, 2014, at 21:23:46
if you are in or around NYC columbia pres has a study involving high doses of Parnate. If you are not nearby perhaps there is info online. Dr Stewart is one of the participating shrinks.
Posted by Warped on December 21, 2014, at 16:52:46
In reply to Re: Add anything to help with the EMSAM wait...., posted by Elanor Roosevelt on December 21, 2014, at 7:39:54
This is extremely relevant information! Thank you for bringing it to my attention. I'm hoping that it's possible I can find a doctor closer that will prescribe either the augmentation or Parnate before I move onto looking in the city. I live in New York, actually, but it's about an hour and half drive to there, and my anxiety is extremely bad when I go there. I'm finding it difficult to even find a doctor in my area willing to listen to me without immediately saying no, though, so it's very likely I will need to travel for help. Saving my life is totally worth suffering the anxiety for the trip.
Posted by Warped on December 21, 2014, at 17:00:44
In reply to Re: Add anything to help with the EMSAM wait.... » Warped, posted by SLS on December 14, 2014, at 2:18:04
I thank you greatly for taking the time to provide me with this information. I hope it proves useful, as the doctors I have seen in my area seem reluctant to even listen to me speak about this therapy. It seems silly that they're more concerned with medicine killing me than they are with me killing myself. My previous doctor actually chuckled when I said that exact thing to him, which I found very disrespectful. The benefits far outweigh the risks, so it's very difficult when you've run out of options and you cannot receive the type of help that you know works. Hopefully the new doctor I made an appointment with is willing to consider it. I've been prescribed just about every SSRI, SNRI, AAP, Mood Stabilizer, and TCA with no benefit, so I don't understand why it's such a fight. The EMSAM actually helps me quite a bit, especially with the suicidal thoughts, but I am completely numb to any pleasure and suffer from Chronic Fatigue as well.
Posted by Amee200 on December 21, 2014, at 19:26:26
In reply to Re: Add anything to help with the EMSAM wait...., posted by Warped on December 21, 2014, at 17:00:44
I posted a couple of years ago when I was taking Parnare and Ritalin together. While the combo did alleviate my depression, it did little for my anxiety. It's a conundrum since like you I have treatment resistant depression which is driven largely by anxiety and phobias. Parnate did seem to give me a slightly euphoric reaction which I think wasn't always the best thing for me- I ended up slightly over manic and overwhelmed...and in need of benzo's. For depression and anxiety Nardil was actually much more effective. I got spooked by the weight gain, although ultimately gained even more weight with Parnate. I also had a lot of panic attacks when I took Ritalin and Parnate as well, probably because they are both considered to be activating.
Not to discourage you on what you are searching for. It may help you, but doctors don't like to prescribe them. My doctor was at the time out of the Mass General in Boston. I actually had an adverse reaction and it was pretty scary. I had some cheese or something and it hit immediately. After that I stayed on it for a bit but I think he was a bit freaked out. I still see him but we both decided to discontinue it, not because of the reaction but because of water retention and major weight gain. Now a cocktail of Prozac and Adderall works pretty well. I don't know if you take a stimulant now, but I have to say that they are powerful as antidepressants. It's controversial but when anxiety is so bad that you're paralyzed from experiencing life, then it's worth it. So if you can't get a doctor to prescribe the MAOI combo, maybe a low dose SSRI with a stimulant will help almost as well. I wish you luck, since Im locates in Boston and may have one of the few psychiatrists who would prescribe these meds and I don't even know if he still does with other patients.
Posted by Amee200 on December 21, 2014, at 19:38:45
In reply to Re: Add anything to help with the EMSAM wait...., posted by Amee200 on December 21, 2014, at 19:26:26
I forgot to tell you what my dosage was - 90mg. My doctor felt Parnate was more effective for social anxiety at higher doses and in my case he was right. From my experience 40 mg is a very low dose. I was on that to start and felt no benefit until I got up to at least 60, with the most benefit at 90.
Posted by Warped on December 21, 2014, at 20:02:55
In reply to Re: Add anything to help with the EMSAM wait...., posted by Amee200 on December 21, 2014, at 19:26:26
I actually like being on the EMSAM, so that's why I would prefer to add a stimulant to it, and just increase or add onto something that is already working rather than just starting over. I know that it is awful that I did this, but I had actually previously been prescibed Adderall in the past and had terrible withdrawal symptoms from it daily, so I only took it for about a week. A few weeks into taking EMSAM, I decided to add the Adderall at 7.5mg once a day. Obviously I did some research to confirm that people have done this before with success and safety. I know it's terrible to do this without the doctor's consent, but I was desperate as I have a personality disorder as well, and I never feel like myself, largely because I'm always too tired to speak. The combination made me feel just the way I did before I had ever had even a single sign of bipolar or anything. The odd thing about it was that the combo completely eliminated the side effects that I had while on Adderall alone. I took this combo for 2 weeks and didn't even have a withdrawal after stopping completely when I had withdrawal symptoms after 3 days previously. I need something stimulating, which, unfortunately normally has a negative side effect on anxiety, but for me, it strangely converts into a comfortable bearable anxiety. Surprisingly, my doctor wasn't mad that I had done this on my own, and he did look into giving it to me again, but was instantly turned off as soon as he read it was contraindicated without any further research.
I truly appreciate the anecdote, though. I generally get much worse when I take SSRI's, so that's not an options for me. I'm fairly confident my depression mainly stems from a dopamine issue, so I'd rather avoid anything that strongly affects serotonin.
I just don't understand when a doctor would rather give up on a patient then prescribe him something that is hypothetically dangerous if the proper procedure is not followed. I also have terrible anger issues, so that isn't especially helpful when I get in a conflict with a doctor as I quickly turn unreasonable. Surprisingly, my anger was greatly reduced on the combo as well, which most people seem to say they're more angry on stimulants.
At a certain point in treatment, when all options are exhausted, it seems reasonable to make decisions at the discretion of the patient, rather than stubborn doctors.
Posted by Amee200 on December 21, 2014, at 22:57:55
In reply to Re: Add anything to help with the EMSAM wait...., posted by Warped on December 21, 2014, at 20:02:55
I understand and agree. My doctor told me that though it's contraindicated, in much research and his own experience it is safe and effective. Obviously the patient has to be responsible and he monitored me closely. He was more concerned about me eating cheese again than he was having a reaction to the med cocktail. Regarding SSRIs, I have the same tendency as you - they make me more depressed. Only Prozac at a low dose and with a stimulant is ok for me. I had so much hope for the Parnate and Ritalin but I couldn't handle he other side effects (unrelated to the stimulant).
I think there are good psychiatrists out there that think outside the box, but you have to look hard. If you decide to look for a new pdoc then I'd consider looking for one with a special interest in research and treatment resistant depression. That's where I think you'll find more doctors who consider unconventional or cutting edge treatment.
Posted by former poster on December 29, 2014, at 19:29:05
In reply to Re: Add anything to help with the EMSAM wait...., posted by Warped on December 13, 2014, at 21:22:44
I can relate to the long wait you are going through. First time I tried Nardil it took 2 months before it started working. I'm glad the Dr. told me to keep taking it even though I couldn't feel it working. Emsam, like other MAOI's generally take longer to kick in than other AD's. You will feel the stimulating side-effect on the first or second dose. This can be deceiving. The real AD effects take weeks or months.
I'm currently on Emsam 6mg. patch and Vyvanse 30mg. Since Emsam is so stimulating this combo is redundant but tolerable and effective if it doesn't make you over stimulated.
Rhodiola may be an option. I recall taking it with MAOI before. Not sure if the safety status has changed with these 2 combined.
I read that 5http "may be" safe to take with a MAOI. Get a professional opinion about that too.
Posted by Warped on January 9, 2015, at 16:19:28
In reply to Re: Add anything to help with the EMSAM wait...., posted by Amee200 on December 21, 2014, at 22:57:55
Firstly, I just wanted to thank everyone for all of the extremely useful advice, help, and sources. I started seeing my new pdoc about 3 weeks ago, and it turns out that he required absolutely no convincing to give me the adderall 15mg.
Unfortunately, taking the combination this time around feels completely different when it works, and it is often very weak or I do not feel the effects at all of the adderall. This has made me extremely disappointed, especially after the miraculous success when I had trialed it 2 months previous.
Essentially, I came back here looking for further advice. I would to try some other possible options before switching to parnate. For some reason, I have a feeling that the generic I got this time around it garbage. I use CVS pharmacies, and I went on the website to check which generic I was given previously and now, and it says that they are the same ones, but the ones I have now look different from the others. I had actually been given enough 15mg to take it twice a day, and I have been messing around with what time I take them and such, but even if I take both at the same time, it feels very weak and crappier than the first time around with just the one 15mg. So I guess really what I wanted to know is whether or not I will notice a difference if I get the brand name adderall next time, or if I should just look into getting desoxyn or dexedrine instead? It's also possible that the EMSAM could be pooping out on me, but it seems to be helping keep the depression at bay. Unfortunately, it pretty much makes me emotionless and unable to enjoy anything, and it no longer provides any stimulation at all, which I desperately need because I also suffer from chronic fatigue.
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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.