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Dr. Bob is Robert Hsiung, MD,
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Posted by Lou Pilder on July 18, 2010, at 13:18:10
In reply to Re: Lou's reply, posted by inanimate peanut on July 18, 2010, at 12:40:46
> Nortriptyline and Parnate can be dangerous in combination, but there's also plenty of academic literature as well as people on this board who have demonstrated the safety and efficacy of this combination if used correctly.
inanimate peanut,
You wrote,[...Nortrptyline and Parnate can be dangerous in combination...plenty of academic liturature..people on this board..safety and efficacy..used correctly...]
I am unsure as to what you are wanting to mean here. If you could post answers to the following, then I could have the opportunity to respond accordingly.
A. What kind of danger is there in as you know when combining Parnate and Nortriptyline?
B. in the academic lituratur tha you mention here, could you post some links to those here?
C. I can not remember anyone here advocating to take the two drugs together. Could you post a link to one of the posts for such?
C. What is the correct use of taking the two drugs together to constitute {using correctly}?
D.If the drugs are central nervous system depressants, and could cause heart problems, (redactedby respondent)
E. other answers not related to the questions above.
Lou
Posted by inanimate peanut on July 18, 2010, at 13:28:41
In reply to Lou's reply-pschohmeidahmho » inanimate peanut, posted by Lou Pilder on July 18, 2010, at 13:18:10
Below are the abstracts of using TCA/MAOIs together. As for naming people on this board, you'll have to search the archives as I'm not going to start calling people out (although I can think of 2 in particular who are/have been on the combo). Here's your abstracts:
Prog Neuropsychopharmacol Biol Psychiatry. 1988;12(4):523-32.
Combined MAO-inhibitor and tri- (tetra) cyclic antidepressant treatment in therapy resistant depression.
Schmauss M, Kapfhammer HP, Meyr P, Hoff P.
Department of Psychiatry, University of Munich, West Germany.
1. One aspect of using MAO-inhibitors - combining them with tricyclic antidepressants in the treatment of therapy resistant depression - has always been controversely discussed in regard to its unusual toxicity and efficacy. 2. To obtain detailled information about safety and efficacy of such a combined treatment, the charts of 94 inpatients treated with a tranylcypromine - tri- (tetra) cyclic antidepressant combination were reviewed. 3. Within a mean treatment period of 21.9 days, 68% of the patients demonstrated a very good or good improvement to combined treatment, the most effective combination being tranylcypromine + amitriptyline. 4. The incidence of side effects among the patients on the combined regimen was slightly, but not significantly lower as compared to the patients on single tri- (tetra) cyclic antidepressant treatment. 5. Our retrospective study supports the general safety and efficacy of combined MAOI-TCA treatment and suggests that combined treatment, if properly administered, leads to neither serious complications nor an inordinate number of side effects.
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.
Encephale. 1996 Nov-Dec;22(6):450-60.
[The tolerability and efficacy of combined antidepressant therapy: literature review]
[Article in French]
Taleb M, Gorwood P, Bouleau JH, Rouillon F.
Service de Psychiatrie, Hôpital René-Dubos, Pontoise.
There are many pharmacological strategies in order to manage depressed patients with treatment resistance. Combined antidepressants therapy is currently prescribed, mostly for depressions which resist to a single antidepressant, or to another therapeutic, such as electric-convulsive-therapy. Combined treatments are usually considered to have a more rapid action than monotherapy, although mainly is based on personal experience. It is generally admitted that the better efficacy of combined antidepressants therapy with different biochemical characteristics is explained by the synergic action of both norepinephrine and serotonin systems. The combination treatment of MAOI and tricyclic agents has been widely studied, sometimes on hundreds of patients. Numerous studies showed a good efficacy, and the toxicity of such an association was exaggerated, thus they are nevertheless rarely prescribed. As reversible MAOI-A are now available, combination treatment with tricyclic antidepressants is theoretically safer. The combination treatment of SSRI and tricyclic antidepressants is more frequently reported in the recent literature. Studies analysing such an association are however insufficient, and cannot lead to any clear conclusion. The combined treatment of mianserin and tricyclic antidepressants have also been quoted, with an efficacy that has been confirmed on randomized placebo-controlled studies. Resistant depressions are the main indication for combined antidepressants therapy. Anxious disorders have recently been considered as interesting new indications, such as panic disorder or obsessive compulsive disorder, with or without a comorbid mood disorder. In conclusion, controlled studies devoted to the analysis of combined antidepressants therapy are relatively few, and do not allow to draw any conclusion about their efficacy. Nevertheless, as this type of prescription is frequent, scientific evaluation of their specific efficacy is needed.
Fortschr Neurol Psychiatr. 1996 Oct;64(10):390-402.
[Combination therapies in antidepressive drug refractory depression--an overview]
[Article in German]
Schmauss M, Erfurth A.
Bezirkskrankenhaus Augsburg, Universität München.
Despite the availability of a wide range of effective antidepressant drugs, nearly 30% of depressed patients fail to respond to antidepressant treatment. Various pharmacological strategies have been developed to treat such refractory depression, of which augmentation therapies are one of the most important. This article reviews both benefits and risks of all known augmentation therapies. Among these treatment strategies the efficacy of lithium augmentation is very well documented by a large number of controlled studies - lithium augmentation can therefore be recommended in depression refractory to antidepressant treatment. The efficacy of triiodothyronine (T3) augmentation and the combination of different antidepressants - like a TCA-MAOI combination - is described in a large number of case reports and uncontrolled studies; the number of placebo controlled double blind studies, confirming the efficacy of these treatment strategies, is however relatively small. T3 augmentation and combined antidepressant treatment may therefore be considered in the treatment of refractory depression; in contrast to lithium augmentation these combination therapies are however only second-line strategies. Other augmentation therapies (TCA + stimulants, TCA + reserpine, TCA + yohimbine, TCA + fenfluramine, SSRI + buspirone) are very interesting clinical research strategies, but don't have too much importance in clinical practice at the moment.
J Affect Disord. 1995 Jun 8;34(3):187-92.
A 3-year follow-up of a group of treatment-resistant depressed patients with a MAOI/tricyclic combination.
Berlanga C, Ortega-Soto HA.
Division of Clinical Research, Mexican Institute of Psychiatry, México, DF.
Treatment-resistant depression is a clinical complication that not infrequently affects a certain number of patients. Within the treatment strategies proposed for this condition, the association of a MAO inhibitor (MAOI) with a tricyclic antidepressant has gained reputation both for its unusual efficacy, as for its potential toxicity. However, when cautions are taken, it may be safely administered. Most reports on this combination have been carried in nonresistant patients and, when resistant patients are included, only the acute phase of the treatment is reported. In this study, a group of well-defined resistant patients received an open trial with the association of isocarboxazide and amitryptiline (n = 25). Those who responded were followed during the next 3 years (n = 12) and every 6 months an attempt was made to discontinue the MAOI and continue only with amitryptiline. At the end of the study, 4 patients maintained response with single medication, 6 still required both drugs and 2 relapsed. No clinical differences were apparent between the outcome groups, except that those who maintained their response only with the 2 combined drugs had more previous depressive episodes than the others. The isocarboxazide/amitryptiline combination may be a good treatment option for at least some forms of resistant depression. The safety of this treatment modality is confirmed, even when given for long periods of time. The study also suggest that there are no clinical characteristics in resistant depression that may predict the treatment outcome but, perhaps in some patients, a combined treatment is required to obtain a broader biochemical effect that could convert them from nonresponders to responders.
Acta Psiquiatr Psicol Am Lat. 1994 Dec;40(4):314-20.
[Combined therapy with tricyclic and MAOI antidepressants in the treatment of resistant major depression]
[Article in Spanish]
Rosan TA, Mesones HL, Brengio F.
This paper shows the results of associating tricyclic and MAOI antidepressants in the treatment of resistant major depression. Forty five patients from private practice with diagnosis of major depression according to DSM III R criteria, with negative response to separate tricyclic or MAOI treatment, were given both types associated. They improved without dangerous side effects.
Posted by ed_uk2010 on July 18, 2010, at 13:53:40
In reply to Re: You hangin in there peanut? » ed_uk2010, posted by inanimate peanut on July 18, 2010, at 12:55:09
>I can't go off the perphenazine since it would then not work if I needed it in the future.......
I know you believe this to be the case....but I suspect that it's actually not.
Some points to consider....
1. You may have experienced the phenomenon of meds not working the second time around in the past. This does not mean that the same will apply to completely unrelated drugs eg. perphenazine.
2. A drug which does not work the second time around may not have worked the first time around either. For example, are you sure that perphenazine is actually helping you sleep? Since you are on so many meds, it is not possible to know.
3. What possible mechanism could there be behind ALL meds not working the second time around? It does not make pharmacological sense.
4. Your belief that no med will work the second time around is causing you to stay on meds which could be making you more depressed. Perphenazine is an example.
5. Some meds can actually work better after you've been off them for a while eg. benzodiazepines. This is because your tolerance is reduced after a med-free period.
6. The perceived efficacy of psych meds is controlled by psychological factors as well as the clinical effects of the med. If you strongly believe that a med won't work again, then it probably won't. This is like the reverse of the placebo effect.
Posted by inanimate peanut on July 18, 2010, at 14:15:55
In reply to Re: You hangin in there peanut?, posted by ed_uk2010 on July 18, 2010, at 13:53:40
I can't explain it, and maybe it is psychological, but every time I have tried to go back on a drug that I've quit, it won't work. TRUST ME, I wish this was not the case, but it always has been. Drugs that I've left and gone back to with no effect include effexor, lithium, wellbutrin, seroquel xr, and lexapro. There are many things we can't explain about the brain, and this is one of them about mine. You are completely right that it is keeping me on perphenazine and also lamictal (which I don't think is helping but am scared to go off just in case it is doing something and I stop and then can't go back on it). That's why I'm on so many meds, because you can add them but I won't allow them to be taken away because then they can't be added back. I would give anything to have either Wellbutrin or lithium work again, but neither does. Lunesta seems to be an exception to this rule, and I'm not sure why that would be. Also, PRNs like ativan work and I don't take them daily, so I don't know how to explain that either.
In other words, I think your logic is impeccable, but I'm the way I am now because of going off meds and having them not work when I went back on them. When I was on lithium, I had a great job, a townhome, a fiance, a normal life like I wasn't even bipolar at all and I've lost it all by going off lithium and not being able to go back on it or find anything that works like it. Every med I go off that won't work that we can't replace, I just get a little worse until I'm how I am now, which is nothing. So I've been burned enough that I'll stick with my theory.
Posted by Lou Pilder on July 18, 2010, at 14:37:25
In reply to Re: Lou's reply-pschohmeidahmho » Lou Pilder, posted by inanimate peanut on July 18, 2010, at 13:28:41
inanimate peanut,
I heave read such reports and there are different camps in relation to taking the two classes of drugs together.I lean to the camp that says that the two taken together could be very dangerous. In your situation, there are also other drugs being combined that are central nervous system depressants which brings in that the reports that you cited were taking the two classes of drugs together without consideration as to if a CNS-depressant was added. I also do not consider those type of reports to be significant because of the small population used. I give credence when the population is in the thousands.
Here is a link to an article and there is the list of classes of drugs that are dangerous when combined with the other class.
Lou
http://bipolar.about.com/od/maois/a/maois_profile.htm
Posted by ed_uk2010 on July 18, 2010, at 14:51:07
In reply to Re: You hangin in there peanut? » ed_uk2010, posted by inanimate peanut on July 18, 2010, at 14:15:55
>I would give anything to have either Wellbutrin or lithium work again, but neither does.
I don't think you should rule out the possibility that they might work again in future. If nortriptyline doesn't work out, you could consider another trial of lithium.
>Lunesta seems to be an exception to this rule, and I'm not sure why that would be. Also, PRNs like ativan work and I don't take them daily, so I don't know how to explain that either.
It makes sense. Even if some drugs don't work for you the second time around, this won't apply to all drugs. Benzos and night sedatives often work best if they're used for short courses or PRN. Continuous daily use can lead to tolerance and loss of efficacy. A med-free period can allow the drug to be effective again.
>So I've been burned enough that I'll stick with my theory.
I understand, but you need to be careful about staying on meds which might actually be making you worse, such as perphenazine. Could it be the perphenazine rather than nortriptyline which is causing you to cry more often?
Posted by Lou Pilder on July 18, 2010, at 14:53:26
In reply to Lou's reply-huzrhepsrch? » inanimate peanut, posted by Lou Pilder on July 18, 2010, at 14:37:25
> inanimate peanut,
> I heave read such reports and there are different camps in relation to taking the two classes of drugs together.
>
> I lean to the camp that says that the two taken together could be very dangerous. In your situation, there are also other drugs being combined that are central nervous system depressants which brings in that the reports that you cited were taking the two classes of drugs together without consideration as to if a CNS-depressant was added. I also do not consider those type of reports to be significant because of the small population used. I give credence when the population is in the thousands.
> Here is a link to an article and there is the list of classes of drugs that are dangerous when combined with the other class.
> Lou
> http://bipolar.about.com/od/maois/a/maois_profile.htminanimate peanut.
Here is a link to an article concering the danger of combining the two classes of drugs. I would like if you read it to look at 4.4 (Contra-idications and 4.4 (special warnings) that include suicide and suicidal thoughtss and clinical worsening.
There is what is called hypertensive crisis which also is a dangerous possibility when taking both of the drugs together.
Lou
http://www/goldshield-pharmaceuticals.com/csp/gsh/pharma/pdf/spc/42/3.pdf
Posted by inanimate peanut on July 18, 2010, at 14:57:42
In reply to Re: You hangin in there peanut?, posted by ed_uk2010 on July 18, 2010, at 14:51:07
If the nortriptyline didn't work out, I was going to try lithium again. I had always been on lithium carbonate, but I wonder if my body will view lithium citrate as a "different drug" and thus allow it to work. I don't think the perphenazine is making me cry, because I've been on it for several months now and the crying is brand new. Now, it could be part of a combination that's making me cry-- anything's possible with the number of drugs I'm on. I'll try sleeping with the lunesta alone and see if it works.
Posted by morgan miller on July 18, 2010, at 15:00:35
In reply to Re: You hangin in there peanut? » ed_uk2010, posted by inanimate peanut on July 18, 2010, at 12:55:09
Do you think the perphenazine is really helping you sleep? If stopping it might alleviate your depression and you think you could find other more effective ways to treat your insomnia with less side effects, wouldn't it be worth it to drop it from the huge load of meds you are taking? What do you think is more important right now, your depression or your insomnia? I guess if you don't sleep for long enough it can start to make you more depressed. There seems to be a bit of a catch 22 going on here.
Sorry you're struggling with this. I have a feeling things will get better over the next few months. Definitely find a good doc and work hard with them to resolve some of these issues. Good luck!
Morgan
Posted by inanimate peanut on July 18, 2010, at 15:00:59
In reply to Lou's reply-hileighdaynguruz, posted by Lou Pilder on July 18, 2010, at 14:53:26
I really do appreciate your concerns. I'm aware of the risks. I take my BP so often that my arm looks like I stuck it through a tunnel of nails. Both my BP and temperature have remained rock solid. Clinical worsening is always a risk and is what I'm dealing with now possibly. I've had no suicidal thoughts but promise to go to the hospital if I do.
Posted by inanimate peanut on July 18, 2010, at 15:03:53
In reply to Re: You hangin in there peanut?, posted by morgan miller on July 18, 2010, at 15:00:35
Thanks Morgan. I tried to balance the depressive effects of the perphenazine by taking only 8mg of it. It is a hard choice between sleep and feeling a bit more depressed (not huge difference). I'm seriously considering trying to sleep with the lunesta alone and seeing what happens.
Posted by Lou Pilder on July 18, 2010, at 15:04:48
In reply to Lou's reply-hileighdaynguruz, posted by Lou Pilder on July 18, 2010, at 14:53:26
> > inanimate peanut,
> > I heave read such reports and there are different camps in relation to taking the two classes of drugs together.
> >
> > I lean to the camp that says that the two taken together could be very dangerous. In your situation, there are also other drugs being combined that are central nervous system depressants which brings in that the reports that you cited were taking the two classes of drugs together without consideration as to if a CNS-depressant was added. I also do not consider those type of reports to be significant because of the small population used. I give credence when the population is in the thousands.
> > Here is a link to an article and there is the list of classes of drugs that are dangerous when combined with the other class.
> > Lou
> > http://bipolar.about.com/od/maois/a/maois_profile.htm
>
> inanimate peanut.
> Here is a link to an article concering the danger of combining the two classes of drugs. I would like if you read it to look at 4.4 (Contra-idications and 4.4 (special warnings) that include suicide and suicidal thoughtss and clinical worsening.
> There is what is called hypertensive crisis which also is a dangerous possibility when taking both of the drugs together.
> Lou
> http://www/goldshield-pharmaceuticals.com/csp/gsh/pharma/pdf/spc/42/3.pdfcorrection:
Lou
http://www.goldshield-pharmaceuticals.com/csp/gsh/pharma/pdf/spc/42/3.pdf
Posted by morgan miller on July 18, 2010, at 15:04:52
In reply to Re: You hangin in there peanut? » ed_uk2010, posted by inanimate peanut on July 18, 2010, at 14:15:55
I think you should keep going back to lithium to see if it will work again. Just because it did not work the last time you went back to it does not mean it will not work again for you. It doesn't have to work magic. A small dose like 300 mg may do something subtle but good enough to justify staying on it as an adjunct.
Posted by morgan miller on July 18, 2010, at 15:09:13
In reply to Re: You hangin in there peanut? » morgan miller, posted by inanimate peanut on July 18, 2010, at 15:03:53
> Thanks Morgan. I tried to balance the depressive effects of the perphenazine by taking only 8mg of it. It is a hard choice between sleep and feeling a bit more depressed (not huge difference). I'm seriously considering trying to sleep with the lunesta alone and seeing what happens.
Good luck!
I totally support you in your attempt with Nortriptyline. I think Lou means well but I believe he is anti-med and is quite biased against any kind of experimentation or going outside convention. I think he needs to leave it alone now and accept that you are going to do what you are going to do.
Posted by jade k on July 18, 2010, at 15:20:28
In reply to Re: You hangin in there peanut?, posted by jade k on July 17, 2010, at 19:39:07
Hey peanut,
So, looks like you are hanging in there. The following is part of one of Lou's links. Just keep it handy. I'll check the other links as well. Not trying to scare you, just think you should know exactly what to look for.
Danger Signals
Stop taking your MAOI and get emergency help immediately if you experience any of the following symptoms of a hypertensive crisis:Severe chest pain; severe headache; stiff or sore neck; enlarged pupils; fast or slow heartbeat; increased sensitivity of eyes to light; increased sweating (possibly with fever or cold, clammy skin); nausea and vomiting.
You'll probably be fine, but watch for these and get help if you need it.
~Jade
Posted by inanimate peanut on July 18, 2010, at 15:35:23
In reply to Re: You hangin in there peanut?, posted by morgan miller on July 18, 2010, at 15:09:13
Thanks-- i was starting to feel a little beat up (not just Lou but in general). Not that I don't appreciate people caring, because I do. But it's good to have someone in support of peanut... :-)
Posted by jade k on July 18, 2010, at 15:44:15
In reply to Re: You hangin in there peanut?, posted by jade k on July 18, 2010, at 15:20:28
peanut,
I didn't find anything else that hasn't already been covered in terms of what to watch for...just remember these things also:
-Drink plenty of water
-Remember the food list, if your tired you may forget.
-Are you eating? Eat a little if you can, even if you aren't hungry.
-Please don't increase your Parn or Nort, even if you start to feel bad.
-Just a suggestion, make a comprehensive list of all that you have, and are taking, just in case you end up at ER or Docs office. If you get a hypertensive headache (ouch) believe me you won't do it. Many med facilities are unfamiliar with MAOI's and particularly their use with tca's.Good to be prepared, let me know if you need a new restricted food list.
~Jade
Posted by jade k on July 18, 2010, at 15:52:11
In reply to Re: You hangin in there peanut?, posted by jade k on July 18, 2010, at 15:44:15
What??!!
We're all in support of you peanut! We're also in support of you being safe. And being depression free. In that order :-)~Jade
Posted by inanimate peanut on July 18, 2010, at 16:07:58
In reply to Re: You hangin in there peanut?, posted by jade k on July 18, 2010, at 15:44:15
Posted by ed_uk2010 on July 18, 2010, at 16:09:21
In reply to Re: You hangin in there peanut? » ed_uk2010, posted by inanimate peanut on July 18, 2010, at 14:57:42
>If the nortriptyline didn't work out, I was going to try lithium again. I had always been on lithium carbonate, but I wonder if my body will view lithium citrate as a "different drug" and thus allow it to work.
It shouldn't make any difference whether you take the carbonate salt or the citrate salt. Only the lithium ion itself has activity on the central nervous system. Different brands of lithium tablets have varying release characteristics, but this is due to different 'slow release' technology being used, not due to the lithium salt itself.
>I don't think the perphenazine is making me cry, because I've been on it for several months now and the crying is brand new.
It could be the high doses of sedatives taken at night. Crying has been reported as a side effect of high dose Ativan, for example.
Posted by Roslynn on July 18, 2010, at 16:59:19
In reply to Re: You hangin in there peanut?, posted by jade k on July 18, 2010, at 15:44:15
Jade,
I'm sorry to bother you, but do you know of a good restricted food list? I am seeing contradictions in some various lists. I think I am starting Parnate soon.
Thank you!
Roslynn
>
> Good to be prepared, let me know if you need a new restricted food list.
>
> ~Jade
>
Posted by nadezda on July 18, 2010, at 17:20:11
In reply to Re: Lou's reply, posted by inanimate peanut on July 18, 2010, at 12:40:46
Could you please refer me to these articles, becaue I can't find them.
thanks,
Posted by jade k on July 18, 2010, at 17:57:58
In reply to Re: You hangin in there peanut? » jade k, posted by Roslynn on July 18, 2010, at 16:59:19
Hi Roslynn,
No bother, I'd be happy to. I'll post it back to you in a bit. These lists have been posted many times and I'll want the best one. The restrictions are much simpler than a lot of sights still post.
~Jade
Posted by inanimate peanut on July 18, 2010, at 19:45:43
In reply to Re: To Roslynn » Roslynn, posted by jade k on July 18, 2010, at 17:57:58
It might be a good idea just to post it under a MAOI food list thread or something easily searchable so others who have questions like Roslynn's can easily find it. I know I lost my good list and have been looking for a good one (one that doesn't still ban mozzarella cheese and other outdated things)
Posted by Phillipa on July 18, 2010, at 19:58:07
In reply to Re: To Roslynn » jade k, posted by inanimate peanut on July 18, 2010, at 19:45:43
So many bipolars at one time or another discontinue their lithium my deceased ex-father in law was one and he'd go into mania and then depression really bad. But each time this happened his lithium when restarted after a while did kick in and work again. Phillipa
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