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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 53. This is the beginning of the thread.
Posted by dragonblack on July 24, 2011, at 17:04:46
Hi All,
So, I've been at 60 mg of Parnate for several months now and I am pretty sure I am going to throw in the towel. The main problems for me are a very partial response, with my remaining symptoms (I'm BPII/GAD/PD) being deal-breakers, and extreme daytime fatigue, which is killing whatever benefit I'm getting from it or any drug (also take Ativan, .5 mg/day; Abilify, 2mg/day; just stopped Klonopin). If I was able to either increase or augment Parnate with a stimulant, I would stick with it. I've explored both options and neither is feasible. My new augment/mood stabilizer, Abilify, does suggest that I should wait and titrate up before discarding Parnate, but I hate the idea of holding onto this drug with major downsides and little efficacy as I trial Abilify - to the extent Abilify acts as an AD augment, I want an AD that I think is doing something on board. Otherwise, maybe I get a benefit from Abilify and it gets rationalized as helping Parnate "kick in," when in fact that's just speculation. Anyway, I digress.
So, I think I want to pick another AD to switch to. I feel like I've been on the med-go-round forever, and my life is slipping away before my eyes, so I've decided that I've got to set some sort of deadline. I can try med combos forever. So, I want to give the med route maybe another year or two and then just seek ECT. So now I am thinking that I need to have enough AD experience under my belt to justify resorting to ECT at some point. I've been on 3 or 4 SSRI's, Effexor, Wellbutrin, and now Parnate. I've never tried a TCA or Remeron.
I'm thinking that Remeron is my next stop, despite the fact that fatigue and tiredness are huge issues for me. I have them anyway, might as well be expected sides. Is there a case for asking for a TCA? I've never sought one, and one has never been offered or suggested by any provider, I would guess due to the increased risk of manic switch, but this represents a major class I have no experience with. Is it necessary for me to try one before asking for ECT down the road, if it turns out to be necessary? Just trying to to think beyond this week.
Since Remeron is known for weight gain, it makes me wonder if I ought not consider Nardil (which I would normally pass on due to the weight gain issue, which is big for me). But Parnate left me completely unimpressed with the MAOIs. Maybe I have like tons of MAO.... : )
All replies appreciated!!!
Posted by linkadge on July 24, 2011, at 19:16:14
In reply to Giving up on Parnate: what's next before ECT?, posted by dragonblack on July 24, 2011, at 17:04:46
Having taken both TCAs and Remeron, I personally believe that the TCAs are superior as antidepressants. I think one might get a good balance with a TCA + SSRI or venlafaxine.
The reason the MAOIs cause the daytime fatigue is because they cause such significant disturbances in sleeping patterns.
Linkadge
Posted by manduh on July 24, 2011, at 19:47:52
In reply to Giving up on Parnate: what's next before ECT?, posted by dragonblack on July 24, 2011, at 17:04:46
I've been on Remeron for about 5 wks. It's probably one of the better ones I've tried during my med-go-round. The side effect profile is pretty minimal compared to other meds.
crazymeds said it makes you crave sugar like a stoned teenager, and I've found that to be occasionally true (but not a constant thing). So I haven't gained much weight on it thus far.
Posted by morgan miller on July 24, 2011, at 22:04:25
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by linkadge on July 24, 2011, at 19:16:14
I think Link is right, TCA plus SSRI might be the best option. Nortriptyline + Zoloft, Prozac, or Lexapro.
Posted by dragonblack on July 24, 2011, at 22:26:59
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by linkadge on July 24, 2011, at 19:16:14
> Having taken both TCAs and Remeron, I personally believe that the TCAs are superior as antidepressants. I think one might get a good balance with a TCA + SSRI or venlafaxine.
>
> The reason the MAOIs cause the daytime fatigue is because they cause such significant disturbances in sleeping patterns.
>
> LinkadgeHi Linkadge, thanks for your reply. Oddly, I never experienced any insomnia on Parnate, and never found it to be stimulating at all. I know I'm the exception, here, but if anything my sleep was much more regular and closer to what a person is supposed to get (averaging 6.5 hrs, whereas I used to sleep from 0-10 in an utterly sporadic manner). I think my fatigue was from residual depression and the half life of Parnate, which left me feeling like I crashed after each dose, and I tried every dosing schedule under the sun. My caffeine intake has just steadily risen until it's back at college finals levels but I'm still tired all the time. This is probably the biggest issue for me. A stimulant might be the answer, but the "answer" was no.
I'm worried about side effects with TCAs. Is there any particular one you would suggest? In the past the only AD I really responded to was Wellbutrin XL (and for a while, SAM-e). The SSRIs were poor to awful for me, and Effexor was mildly helpful for anxiety but did nothing for depression. Everything serotonergic gave me sexual dysfunction.
I'm also wondering about combining Wellbutrin with Remeron, as a means of combating the sides of each, and given that Wellbutrin worked for me for a time but stopped working well (but probably still kept me out of the gutter).
Thanks for your input.
DB
Posted by dragonblack on July 24, 2011, at 22:32:22
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by manduh on July 24, 2011, at 19:47:52
> I've been on Remeron for about 5 wks. It's probably one of the better ones I've tried during my med-go-round. The side effect profile is pretty minimal compared to other meds.
> crazymeds said it makes you crave sugar like a stoned teenager, and I've found that to be occasionally true (but not a constant thing). So I haven't gained much weight on it thus far.I'm glad you are having success with it. Reading anecdotal accounts of Remeron trials is unsettling...here and there people report no to minimal weight gain, but SO many people report massive weight gain that it's hard to feel like it's not necessarily going to be that way for me. I can't deal with substantial weight gain, I'm pretty sure that is a truism about myself.
Take care,
DB
Posted by dragonblack on July 24, 2011, at 22:38:46
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by morgan miller on July 24, 2011, at 22:04:25
> I think Link is right, TCA plus SSRI might be the best option. Nortriptyline + Zoloft, Prozac, or Lexapro.
Hmm, I had given up on the SSRIs completely, I didn't consider combining them with a TCA. They never worked for me, but I could see maybe trying one again if I had on board something that could combat sexual dysfunction (Remeron, Dopamine agonist, not Wellbutrin, tried that, didn't work), but seems like that would be a problem with a TCA. Maybe a low dose of something like Lexapro would work well with nortrip, that's an interesting idea.
Thanks for posting, take care.
DB
Posted by jono_in_adelaide on July 24, 2011, at 23:34:44
In reply to Giving up on Parnate: what's next before ECT?, posted by dragonblack on July 24, 2011, at 17:04:46
Have you considered augmenting Parnate with either nortriptyline or desipramine?
Posted by dragonblack on July 24, 2011, at 23:55:56
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by jono_in_adelaide on July 24, 2011, at 23:34:44
> Have you considered augmenting Parnate with either nortriptyline or desipramine?
Yeah, prior to my last appointment I put together a memo of sorts, emailed ahead of time, regarding options I was considering, and I included TCAs as possible Parnate augments (noting that while they are officially contraindicated, the combo is used by plenty of pdocs, especially people specializing in the treatment of refractory depression). I had a bunch of research too, but they couldn't open a Word 2007 doc. I was told that MAOI plus TCA was a no-no, and given the impression that it was not about to be considered. I can't just go somewhere else, though, I go to a free clinic that it took forever to get into, and have no means to do otherwise. I've heard the combo is dynamite, though.
Posted by JONO_IN_ADELAIDE on July 25, 2011, at 0:18:54
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by dragonblack on July 24, 2011, at 23:55:56
Have you considered or tried other combos, such as
- Cymbalta 60mg plus Remeron 45mg
- Zoloft 100mg plus Welbutrin 300nmg
Posted by JONO_IN_ADELAIDE on July 25, 2011, at 0:21:34
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by dragonblack on July 24, 2011, at 23:55:56
I guess you *could* go to a walkin clinic and get a script for nortriptyline, I'm pretty sure you'd get one fairly easily, it isnt a drug of abuse or anything.
The usual way of taking it with Parnate is to stop the parnate, and wait a week, then start taking Parnate 10mg and Nortriptyline 25mg, and slowly incrase to nortriptyline 100mg per day and Parnate xxxmg/day over a couple of weeks.
I'm nor advising you to do this, or saying it would be wise, just pointing out a slightly dishonest option
Posted by Phillipa on July 25, 2011, at 0:24:32
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by JONO_IN_ADELAIDE on July 25, 2011, at 0:21:34
I feel both Link and Morgan are very knowledgeable so think about what they wrote. Phillipa
Posted by dragonblack on July 25, 2011, at 14:01:55
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by JONO_IN_ADELAIDE on July 25, 2011, at 0:18:54
> Have you considered or tried other combos, such as
>
> - Cymbalta 60mg plus Remeron 45mg
>
> - Zoloft 100mg plus Welbutrin 300nmg
>
>Well, I had not been considering trying another SSRI, but I don't want to rule anything out. I am curious about Cymbalta, I know some people who love it, plus I have heard that it is "strong," in the words of some doctor, and that it hopefully wouldn't just be Effexor the Experiment Part 2. I think Cymbalta plus Wellbutrin, which a family member takes, with some success, would be an interesting combo. It's been years since I tried Zoloft, but back in the day when I was misdiagnosed as MDD and took it as monotherapy, it left me with completely flat affect and total anorgasmia. I don't remember it helping at all really, except that maybe I was more sedate and less out of control for a while. My situation has changed such that I need something stimulating at this point.
Posted by dragonblack on July 25, 2011, at 14:08:52
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by JONO_IN_ADELAIDE on July 25, 2011, at 0:21:34
> I guess you *could* go to a walkin clinic and get a script for nortriptyline, I'm pretty sure you'd get one fairly easily, it isnt a drug of abuse or anything.
>
> The usual way of taking it with Parnate is to stop the parnate, and wait a week, then start taking Parnate 10mg and Nortriptyline 25mg, and slowly incrase to nortriptyline 100mg per day and Parnate xxxmg/day over a couple of weeks.
>
> I'm nor advising you to do this, or saying it would be wise, just pointing out a slightly dishonest optionI appreciate the idea, and the caveat. I have been trying to do this 'by the book,' for various reasons, and resisting the urge to substitute my own judgment and go ahead with a plan I can't get approved. It's tough to give up on Parnate without exploring some of these other options, though, I would love to avoid a situation where I ended up on a med that I previously discontinued due to failure to properly augment it before giving up. My life situation right now is such that it would be tough and stressful to try to hide what I was really doing, but it is tempting to try something like that. Maybe I'll try asking again and make sure I'm very specific about going through a washout and using a non-serotonergic TCA.
Posted by policebox on July 26, 2011, at 1:32:06
In reply to Giving up on Parnate: what's next before ECT?, posted by dragonblack on July 24, 2011, at 17:04:46
If you have had any positive response to Parnate at all, then I might suggest seeing if you can stick with it while titrating your dosage upward. The 60 mg maximum dosage... I'm not really sure where they got that from. From my readings about Parnate, the therapeutic dosage is something along the lines of 1 mg per 1.5 kg of the patient's weight. For me at 175 lbs, that means I should be taking anything up to around 120 mg as a therapeutic dose (or possibly more).
Parnate is a very safe medication, provided you avoid anything that's contraindicated. Many people on this board have had success with "high" doses of Parnate and even report that many of the adverse side-effects disappear once they get above 60 mg.
Anyway, sorry this was so long. I just wanted to pass that thought along as a suggest for you to consider. I wish you the best.
Shannon
Posted by floatingbridge on July 26, 2011, at 6:34:22
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by policebox on July 26, 2011, at 1:32:06
I second police box here. The maoi Parnate can take longer to settle in. To me, the fact you are sleeping on it is excellent. Don't many add a safe stimulant like pro vigil?
This is my opinion, but you are sounding a little desperate. If this is true, it's not the best place to make major drug changes unless it really can't be helped. Why not stick out the parnate a little longer and push that clinic to augment if necessary.
Just my opinion. Best to you DB.
Oh. Did you mention abilify? Why? The clinic suggest it? Not sure it's the best augmenter, though clinics and docs hand it out like it's Halloween and it's a treat. Not knocking it when it works, but it is indicated originally for mood stability.....
> If you have had any positive response to Parnate at all, then I might suggest seeing if you can stick with it while titrating your dosage upward. The 60 mg maximum dosage... I'm not really sure where they got that from. From my readings about Parnate, the therapeutic dosage is something along the lines of 1 mg per 1.5 kg of the patient's weight. For me at 175 lbs, that means I should be taking anything up to around 120 mg as a therapeutic dose (or possibly more).
>
> Parnate is a very safe medication, provided you avoid anything that's contraindicated. Many people on this board have had success with "high" doses of Parnate and even report that many of the adverse side-effects disappear once they get above 60 mg.
>
> Anyway, sorry this was so long. I just wanted to pass that thought along as a suggest for you to consider. I wish you the best.
>
> Shannon
Posted by g_g_g_unit on July 26, 2011, at 8:14:47
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by JONO_IN_ADELAIDE on July 25, 2011, at 0:21:34
Are you in Adelaide, Australia? I lived in New Zealand for a while, where the prescribed ceiling dose for Parnate was 30mg, which seemed unusually low in comparison to the US. I was just wondering if the same thing applied here (I'm currently in Melbourne) ..
> I guess you *could* go to a walkin clinic and get a script for nortriptyline, I'm pretty sure you'd get one fairly easily, it isnt a drug of abuse or anything.
>
> The usual way of taking it with Parnate is to stop the parnate, and wait a week, then start taking Parnate 10mg and Nortriptyline 25mg, and slowly incrase to nortriptyline 100mg per day and Parnate xxxmg/day over a couple of weeks.
>
> I'm nor advising you to do this, or saying it would be wise, just pointing out a slightly dishonest option
Posted by floatingbridge on July 26, 2011, at 10:01:48
In reply to Giving up on Parnate: what's next before ECT?, posted by dragonblack on July 24, 2011, at 17:04:46
DB, I misread your post. I am truly sorry about that. (my excuse was being up almost all night. But still...:-/)
So you are on abilify. 2mg. For how long? And will you take it to 5mg? Or 10mg? Do you feel anything from it yet for better or worse?
It could help if you are finding your thoughts moving toward ECT. But I still think an alerting agent still sounds indicated. Is you chief worst symptom of the depression your fatigue?
I thought provigil/nuvigil was easier to come by than aderall or amphetamine stimulant..I know someone who did reasonably well on parnate, provigil, and let me think what tea it was. Didn't take much tca. Let me see if I can find out. (But those tca's seems so idyosyncratic and particular person to person.)
Still wishing you the best.
Posted by dragonblack on July 26, 2011, at 10:57:14
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by policebox on July 26, 2011, at 1:32:06
> If you have had any positive response to Parnate at all, then I might suggest seeing if you can stick with it while titrating your dosage upward. The 60 mg maximum dosage... I'm not really sure where they got that from. From my readings about Parnate, the therapeutic dosage is something along the lines of 1 mg per 1.5 kg of the patient's weight. For me at 175 lbs, that means I should be taking anything up to around 120 mg as a therapeutic dose (or possibly more).
>
> Parnate is a very safe medication, provided you avoid anything that's contraindicated. Many people on this board have had success with "high" doses of Parnate and even report that many of the adverse side-effects disappear once they get above 60 mg.
>
> Anyway, sorry this was so long. I just wanted to pass that thought along as a suggest for you to consider. I wish you the best.
>
> ShannonHi Shannon,
I've looked into going up on Parnate and I can't pull it off without doing it on my own, which I don't have the money to do. I hate stopping before reaching what might be a therapeutic dose for me, or at least dose-limiting sides that let me know one doesn't exist, but there it is. It's doubly frustrating having read about the successes some here have with high dose Parnate. Oh well, you go to war with the army you have, not the army you want.
Thanks for writing back. Take care.
P.S. What's your handle from? Cool name.
DB
Posted by dragonblack on July 26, 2011, at 11:01:58
In reply to Re: Giving up on Parnate: what's next before ECT? » policebox, posted by floatingbridge on July 26, 2011, at 6:34:22
> I second police box here. The maoi Parnate can take longer to settle in. To me, the fact you are sleeping on it is excellent. Don't many add a safe stimulant like pro vigil?
>
> This is my opinion, but you are sounding a little desperate. If this is true, it's not the best place to make major drug changes unless it really can't be helped. Why not stick out the parnate a little longer and push that clinic to augment if necessary.
>
> Just my opinion. Best to you DB.
>
> Oh. Did you mention abilify? Why? The clinic suggest it? Not sure it's the best augmenter, though clinics and docs hand it out like it's Halloween and it's a treat. Not knocking it when it works, but it is indicated originally for mood stability.....
>
>
> > If you have had any positive response to Parnate at all, then I might suggest seeing if you can stick with it while titrating your dosage upward. The 60 mg maximum dosage... I'm not really sure where they got that from. From my readings about Parnate, the therapeutic dosage is something along the lines of 1 mg per 1.5 kg of the patient's weight. For me at 175 lbs, that means I should be taking anything up to around 120 mg as a therapeutic dose (or possibly more).
> >
> > Parnate is a very safe medication, provided you avoid anything that's contraindicated. Many people on this board have had success with "high" doses of Parnate and even report that many of the adverse side-effects disappear once they get above 60 mg.
> >
> > Anyway, sorry this was so long. I just wanted to pass that thought along as a suggest for you to consider. I wish you the best.
> >
> > Shannon
>
>Hi FB,
I've been considering asking for Provigil, since it's schedule IV rather than II, one imagines it might not be a Herculean labor to get it. I feel like it is a shame to fall back on it, when there are plenty of potent options out there, but then again I've never tried it. I've heard that if you aren't new to PStims, though, it will feel like glorified caffeine. Probably cheaper than my current energy drink/coffee habit, though.
Posted by dragonblack on July 26, 2011, at 11:06:19
In reply to Re: Giving up on Parnate: what's next before ECT?, posted by g_g_g_unit on July 26, 2011, at 8:14:47
> Are you in Adelaide, Australia? I lived in New Zealand for a while, where the prescribed ceiling dose for Parnate was 30mg, which seemed unusually low in comparison to the US. I was just wondering if the same thing applied here (I'm currently in Melbourne) ..
>
> > I guess you *could* go to a walkin clinic and get a script for nortriptyline, I'm pretty sure you'd get one fairly easily, it isnt a drug of abuse or anything.
> >
> > The usual way of taking it with Parnate is to stop the parnate, and wait a week, then start taking Parnate 10mg and Nortriptyline 25mg, and slowly incrase to nortriptyline 100mg per day and Parnate xxxmg/day over a couple of weeks.
> >
> > I'm nor advising you to do this, or saying it would be wise, just pointing out a slightly dishonest option
>
>No, good old U.S. The reason I can't go above 60 is that I get Parnate for free through GSK's Patient Assistance Program. I called to ask if they would fill it if I sent in a prescription for higher than 60, suspecting that they wouldn't. At first I was told the limit was 30, and I thought, oh great, I just alerted them to the fact that I'm already on 60, watch them drop me down (it did take 4 prescriptions and months to get 60 mg filled), then a supervisor said that the strict limit was 60. So, there I go. Beggars can't be choosers.
Posted by dragonblack on July 26, 2011, at 11:21:02
In reply to Re: Giving up on Parnate: what's next before ECT? » dragonblack, posted by floatingbridge on July 26, 2011, at 10:01:48
> DB, I misread your post. I am truly sorry about that. (my excuse was being up almost all night. But still...:-/)
>
> So you are on abilify. 2mg. For how long? And will you take it to 5mg? Or 10mg? Do you feel anything from it yet for better or worse?
>
> It could help if you are finding your thoughts moving toward ECT. But I still think an alerting agent still sounds indicated. Is you chief worst symptom of the depression your fatigue?
> I thought provigil/nuvigil was easier to come by than aderall or amphetamine stimulant..
>
> I know someone who did reasonably well on parnate, provigil, and let me think what tea it was. Didn't take much tca. Let me see if I can find out. (But those tca's seems so idyosyncratic and particular person to person.)
>
> Still wishing you the best.
>
>Hey,
No worries. Not to bore you with my Abilify tale, but it sorta happened in backwards fashion. It was on my list of possible Parnate augments, particularly if I couldn't get a stimulant prescribed, which I can't (they told me it was illegal to prescribe a schedule II stimulant in OH. Pretty sure untrue). I had to go off of lithium, and just assumed that I was to switch to another mood stabilizer, but once Abilify was in the picture my NP said I could just do that since it's indicated for Bipolar. I only wanted to try Abilify at a low dose, as an augment, and didn't want to use it as an AP per se, but it was attractive to me to just start one med instead of two, and see how Abilify does first. I was surprised they were fine with me just going off lithium without replacing it, frankly. So, I've been on 2 mg for about 3 weeks, and it's been helpful, overall, I seem a little more active and the sexual sides of Parnate diminished, libido started to return. I do plan on going up on Abilify, just because I don't have a mood stabilizer in place, but I'll be pretty cautious in doing so. I'm going to ask to go to 5 mg for the time being. It's particularly enervating for me, and it certainly hasn't touched the Parnate fatigue, so I'm not big on the idea of sitting tight on Parnate while I titrate up on Abilify. I like to go slow, and these med trials take so long anyway, if I have to leave everything else untouched while I adjust each med I really will lose it. Without being able to go up on Parnate, if I can't augment it with a stim or tca I want to just move on.
Posted by dragonblack on July 26, 2011, at 11:24:44
In reply to Abilified, and other semantic cruelties, posted by dragonblack on July 26, 2011, at 11:21:02
I meant it ISN'T particularly enervating.
Posted by floatingbridge on July 26, 2011, at 12:36:36
In reply to Abilified, and other semantic cruelties, posted by dragonblack on July 26, 2011, at 11:21:02
Hey DB,
Sorry for all the constraints you havebto deal with regarding medications :-/
Abilify changed it's effect as the dose went up. What's that phrase folks use? Sweet spot? My doc pushed the dose up and up past efficacy.....
Posted by utopizen on July 26, 2011, at 18:49:07
In reply to Giving up on Parnate: what's next before ECT?, posted by dragonblack on July 24, 2011, at 17:04:46
what's wrong with ECT?
I know folks who've done it, and it's changed their lives for the better... and far fewer side effects than Parnate.
All the cheese you can eat, too. Honestly, what's the hesitation?
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Dr. Bob is Robert Hsiung, MD,
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