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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by enndub on March 28, 2014, at 13:51:41
Hello friends,
Some of you may remember me from a couple years ago when I made a lot of posts regarding my rocky start with Nardil. I'm happy to report that my depression and anxiety are in full remission and I am stable on 75 mg/day of Nardil.
I recently decided to go back to school at UC Berkeley to finish my electrical engineering degree (dropped out after my 3rd semester due to extreme depression and weight loss). I have ADD and a working memory disorder and am finding it extremely difficult to keep up with a full course load.
I was wondering what are my options for treating this while on Nardil? In the past, Vyvanse has been the best drug for my ADD but I doubt I will be able to convince my psych to prescribe that in addition to Nardil.
Are there any safe options for treating ADD while on Nardil?
I've heard Parnate is more stimulating, could switching to Parnate potentially help? I would be hesitant to go this route because I don't want to give up the only drug that has ever successfully treated my depression. Also, I can't afford a washout and re-taper right now, as I am in the thick of school.
Does anyone have any resources that I could show my doctor on the safety of combining stimulants with MAOIs?
Thanks for any help,
Nick
Posted by ed_uk2010 on March 28, 2014, at 14:00:42
In reply to Options for ADD while on Nardil, posted by enndub on March 28, 2014, at 13:51:41
Hi Nick,
Have you considered desipramine?
Posted by enndub on March 28, 2014, at 14:04:37
In reply to Re: Options for ADD while on Nardil, posted by ed_uk2010 on March 28, 2014, at 14:00:42
Hello Ed,
I generally steer clear of the TCAs because I am extremely sensitive to anticholinergics. Even very low doses give me auditory hallucinations and akathisia.
I have tried Strattera in the past, which is an NRI like desiprimine, but did not find it particularly helpful for my ADD. I suppose it could be worth another try now that my depression is in remission.
Posted by Christ_empowered on March 28, 2014, at 20:52:37
In reply to Re: Options for ADD while on Nardil, posted by enndub on March 28, 2014, at 14:04:37
maybe a low(ish) dose of desoxyn? kinda a long shot, but I seem to recall desoxyn being the preferred stimulant for some patients on MAOI drugs.
Posted by SLS on March 28, 2014, at 21:34:12
In reply to Re: Options for ADD while on Nardil, posted by Christ_empowered on March 28, 2014, at 20:52:37
> maybe a low(ish) dose of desoxyn? kinda a long shot, but I seem to recall desoxyn being the preferred stimulant for some patients on MAOI drugs.
Serotonin syndrome?
- Scott
Posted by tom2228 on March 29, 2014, at 14:38:56
In reply to Re: Options for ADD while on Nardil, posted by SLS on March 28, 2014, at 21:34:12
> > maybe a low(ish) dose of desoxyn? kinda a long shot, but I seem to recall desoxyn being the preferred stimulant for some patients on MAOI drugs.
>
> Serotonin syndrome?
>
>
> - Scottnot that anecdotes are much to say about safey but I haven't had any problems with SS while on Desoxyn + MAOIs for 3.5 years. I also (unfortunately; am in my right mind now and I do not recommend) used street m-AMP on a binge basis on up to 40mg Marplan without complications (besides severe mania/ psychosis).
Have you ever tried Desoxyn, Scott? Been meaning to ask you. It's a pretty good option IMO to augment other ADs for depression/ anxiety/ energy, especially if you've tried everything else and other stims. Qualitatively different from other stimulants.
Posted by tom2228 on March 29, 2014, at 14:40:22
In reply to Re: Options for ADD while on Nardil, posted by tom2228 on March 29, 2014, at 14:38:56
> > > maybe a low(ish) dose of desoxyn? kinda a long shot, but I seem to recall desoxyn being the preferred stimulant for some patients on MAOI drugs.
> >
> > Serotonin syndrome?
> >
> >
> > - Scott
>
> not that anecdotes are much to say about safey but I haven't had any problems with SS while on Desoxyn + MAOIs for 3.5 years. I also (unfortunately; am in my right mind now and I do not recommend) used street m-AMP on a binge basis on up to 40mg Marplan without complications (besides severe mania/ psychosis).
>
> Have you ever tried Desoxyn, Scott? Been meaning to ask you. It's a pretty good option IMO to augment other ADs for depression/ anxiety/ energy, especially if you've tried everything else and other stims. Qualitatively different from other stimulants.I would like to add that although I am on 5-HT2a blockers (AAPs and soon nortriptyline) that I didn't have problems with serotonin syndome with that combination before I was on the 5-HT2a antagonists.
Posted by SLS on March 29, 2014, at 14:49:26
In reply to Re: Options for ADD while on Nardil, posted by tom2228 on March 29, 2014, at 14:40:22
> > > > maybe a low(ish) dose of desoxyn? kinda a long shot, but I seem to recall desoxyn being the preferred stimulant for some patients on MAOI drugs.
> > >
> > > Serotonin syndrome?
> > >
> > >
> > > - Scott
> >
> > not that anecdotes are much to say about safey but I haven't had any problems with SS while on Desoxyn + MAOIs for 3.5 years. I also (unfortunately; am in my right mind now and I do not recommend) used street m-AMP on a binge basis on up to 40mg Marplan without complications (besides severe mania/ psychosis).
> >
> > Have you ever tried Desoxyn, Scott? Been meaning to ask you. It's a pretty good option IMO to augment other ADs for depression/ anxiety/ energy, especially if you've tried everything else and other stims. Qualitatively different from other stimulants.
>
> I would like to add that although I am on 5-HT2a blockers (AAPs and soon nortriptyline) that I didn't have problems with serotonin syndome with that combination before I was on the 5-HT2a antagonists.Thanks for sharing your anecdote. Very interesting. I have never thought to use Desoxyn. Thanks for the idea. I don't think I would broach the subject with my doctor until I am off of Parnate.
I hope you continue to feel better and better.
- Scott
Posted by tom2228 on March 30, 2014, at 20:41:15
In reply to Re: Options for ADD while on Nardil » tom2228, posted by SLS on March 29, 2014, at 14:49:26
> > > > > maybe a low(ish) dose of desoxyn? kinda a long shot, but I seem to recall desoxyn being the preferred stimulant for some patients on MAOI drugs.
> > > >
> > > > Serotonin syndrome?
> > > >
> > > >
> > > > - Scott
> > >
> > > not that anecdotes are much to say about safey but I haven't had any problems with SS while on Desoxyn + MAOIs for 3.5 years. I also (unfortunately; am in my right mind now and I do not recommend) used street m-AMP on a binge basis on up to 40mg Marplan without complications (besides severe mania/ psychosis).
> > >
> > > Have you ever tried Desoxyn, Scott? Been meaning to ask you. It's a pretty good option IMO to augment other ADs for depression/ anxiety/ energy, especially if you've tried everything else and other stims. Qualitatively different from other stimulants.
> >
> > I would like to add that although I am on 5-HT2a blockers (AAPs and soon nortriptyline) that I didn't have problems with serotonin syndome with that combination before I was on the 5-HT2a antagonists.
>
> Thanks for sharing your anecdote. Very interesting. I have never thought to use Desoxyn. Thanks for the idea.Glad I could give you another option to think about. Just when you think you've tried everything...
> I don't think I would broach the subject with my doctor until I am off of Parnate.
Are you planning to come off Parnate?
I'm not sure that would be necessary since you are taking Abilify and Nortrip, which both have 5-HT2a antagonism. As you may know, cyproheptadine, a 5-HT2a antagonist, is often used to treat SS.
from Dr. Bob's psychopharm tips "MAOIs in high doses and with stimulants":
Dr. Caldwell:
"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."I've seen you say you tend to get a premonitory "feel" for new meds in the earliest of stage. So I must say, if you should try it, Desoxyn is unlike other stims in that it takes 2 weeks for the actual effect to show. You would have to give it time and may be disappointed if you qualify the effect before then or solely on an acute usage basis. And I would caution to start low and go slow rather than starting higher because you can tolerate it: (1) Avoiding tolerance once the correct dose is found is important with this med, and (2) I notice that anything over my "sweet spot" and I tend to feel worse, perhaps more depressed.
>
> I hope you continue to feel better and better.
>
Thank you, I wish you the same and best of luck.
>
> - Scott
Posted by tom2228 on March 30, 2014, at 20:44:06
In reply to Re: Options for ADD while on Nardil » tom2228, posted by SLS on March 29, 2014, at 14:49:26
Scott have you tried Deplin or pramipexole/ ropinirole?
Posted by SLS on March 31, 2014, at 0:22:42
In reply to Re: Options for ADD while on Nardil » SLS, posted by tom2228 on March 30, 2014, at 20:44:06
Hi Tom.
Thanks for all of your input. Desoxyn sounds interesting. I might discontinue taking Parnate in order to try Brintellix (vortioxetine). I could add it then. I would feel more comfortable adding Desoxyn while not taking a MAOI. I am quite amazed that you were able to combine these drugs without suffering serotonin syndrome.
> Scott have you tried Deplin or pramipexole/ ropinirole?
I tried Deplin while taking Nardil and nortriptyline. It was mildly effective at first, but it pretty much pooped-out within a month. The only DA agonist I tried was bromocriptine in combination with Parnate and desipramine. I felt somewhat better for about 3 days. Right now, I am pushing my dosage of prazosin from 25 mg/day to 30 mg/day. One can go as high as 40 mg/day, but I may have to lobby my doctor to allow me to do this.
- Scott
Posted by tom2228 on March 31, 2014, at 14:46:23
In reply to Re: Options for ADD while on Nardil » tom2228, posted by SLS on March 31, 2014, at 0:22:42
> Hi Tom.
>
> Thanks for all of your input. Desoxyn sounds interesting. I might discontinue taking Parnate in order to try Brintellix (vortioxetine). I could add it then. I would feel more comfortable adding Desoxyn while not taking a MAOI. I am quite amazed that you were able to combine these drugs without suffering serotonin syndrome.
>
You are brave! I am currently on a washout from Marplan and starting nortriptyline tonight as my new pdoc didn't have the guts to combine to two (as well as halving Mirapex). The Abilify feels stronger (in a bad way) and the Desoxyn seems not to work as well, even a slightly higher dose. I think there is something about the mechanism of Desoxyn that becomes altered as dose increases that puts me on the other side of the inverted-U curve if the dose is too high. The MAOI seems to allow for a smaller yet a more efficacious mechanistic action to be potentiated.I believe that SS is a dose-dependent response. Remember unmethylated amphetamines also are serotonergic, too; Desoxyn is just "more" serotonergic. Likewise nortriptyline, although not as significantly as say clomipramine, has SRI properties -- I would reckon that an overdose of nortriptyline would cause SS in a patient on an MAOI. That being said I perhaps had mild symptoms of SS only when using high doses of mAMP (>500-2000mg) over days with 40mg Marplan. None at therapeutic doses; my total daily dose is 17.5mg.
If you try Brintellix, I would wait to try Desoxyn until you have a clear assessment of what Brintellix can do for you on its own. Aside from the 2-week washout, it takes a while for the effects of Parnate at the receptor level to reset, and similarly long for the Brintellix to show its true colors even if it may show efficacy earlier than other ADs.And If you do d/c Parnate, pay close attention to your judgement during the washout. I too am on many psych meds -- 7. Have you considered that although each additional medication provides greater control in specific symptom areas, being on so much medication may perhaps be adverse to your depressive condition? While I still would prefer to add nortrip rather than go off Marplan, taking MAOIs with other stimulating meds (stims, TCAs) is a heavy combination that I'm only realizing now that I am washing out. I still struggle with depression but my brain feels exhausted and partly relieved of a burden of some sorts. While considering possible withdrawal effects I am trying to listen to my heart, knowledge of psychiatry, and my symptoms to consider that I may be improving or worsening, or both, depending on the light in which I look at my condition.
I say this because, while I acknowledge that depression is the "natural" state for many with TRD, perhaps getting back to a more "natural" ebb and flow of life can help the spirit and depression from a humanist perspective. I am trying to determine whether I have assumed depression to be be my natural state, or whether this thinking as I wash out is a return to the complacency with my symptoms that I have nearly drowned over the years and which warrants further aggressive treatment. Unless the worst of discontinuing the MAOI is soon to hit me (only been 1 week).. I may be able to continue somewhat okay without even starting nortriptyline.. but it all comes down to quality of life.
> > Scott have you tried Deplin or pramipexole/ ropinirole?
>
> I tried Deplin while taking Nardil and nortriptyline. It was mildly effective at first, but it pretty much pooped-out within a month. The only DA agonist I tried was bromocriptine in combination with Parnate and desipramine. I felt somewhat better for about 3 days. Right now, I am pushing my dosage of prazosin from 25 mg/day to 30 mg/day. One can go as high as 40 mg/day, but I may have to lobby my doctor to allow me to do this.
>
>
> - Scott
What was your dose of Deplin?
I have heard often, including from the manufacturer's data, that Deplin can take up to 2 months for the proper effect.Bromocriptine is supposedly a very dirty-feeling DA agonist. How long did you give it a chance? Supposedly DA agonists may behave somewhat like an antipsychotic in that the presynaptic receptors do not downregulate fully until at least 2 weeks.
I am also curious about how high a dose you started at. That and I have noticed a substantial difference in effect from 0.375mg ER of pramipexole and 0.75mg; the higher dose is actually too intense for me. Thus I would caution against starting at the average effective dose and to "start low, go slow" in any case. I am discontinuing Mirapex, but I stayed at 0.375 for about 2 months before I went up. Otherwise I am sure I would have found the med completely intolerable if I started higher and may have missed the AD effect that I became familiar with at the lower dose before the sides took over.
Posted by tom2228 on April 2, 2014, at 22:17:23
In reply to Re: Options for ADD while on Nardil » SLS, posted by tom2228 on March 31, 2014, at 14:46:23
Sorry Scott, I hope I wasn't offensive, too personal, or projecting too much. I am feeling really off lately since going off Marplan.
It's been only 2 days on 25mg nortriptyline but I need my MAOI!! The doc will have me up to 75mg by the time I see her Monday but my social issues have become terrible and I feel I am drifting away from how I know, see, and relate to myself. The world I know seems to be shriveling up and dying.
I am starting back on 10mg of Marplan tmrw morning and have enough to continue with that for 8 months, 4 at 20mg.
Posted by SLS on April 3, 2014, at 5:56:06
In reply to Sorry Scott, posted by tom2228 on April 2, 2014, at 22:17:23
> Sorry Scott, I hope I wasn't offensive, too personal, or projecting too much.
Don't be silly. I haven't been posting that often recently. Not replying to your kind and carefully written post was an oversight on my part. Your knowledge and insights are impressive, and very much welcomed.
> I am feeling really off lately since going off Marplan.
That's understandable. I hope things don't drop off too much more for you.
> It's been only 2 days on 25mg nortriptyline but I need my MAOI!! The doc will have me up to 75mg by the time I see her Monday but my social issues have become terrible and I feel I am drifting away from how I know, see, and relate to myself. The world I know seems to be shriveling up and dying.
I understand completely. Unfortunately, this is something that I have experienced too many times myself. You describe it very well.
> I am starting back on 10mg of Marplan tmrw morning and have enough to continue with that for 8 months, 4 at 20mg.Shouldn't you be using a minimum of 40 mg/day of Marplan, even with a TCA?
Most of the literature extant regarding the combination of TCA with MAOI was written before the advent of Prozac and the SSRIs. Here is one from 1995 that you might be able to use a leverage:
---------------------------------------------
http://www.ncbi.nlm.nih.gov/pubmed/7560546
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 C1, Ortega-Soto HA.
Author information
AbstractTreatment-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.
PMID:
7560546
[PubMed - indexed for MEDLINE]-------------------------------------------------------
- Scott
Posted by tom2228 on April 4, 2014, at 11:32:01
In reply to Re: Sorry Scott » tom2228, posted by SLS on April 3, 2014, at 5:56:06
> > Sorry Scott, I hope I wasn't offensive, too personal, or projecting too much.
>
> Don't be silly. I haven't been posting that often recently. Not replying to your kind and carefully written post was an oversight on my part. Your knowledge and insights are impressive, and very much welcomed.Thank you :) I actually want to be a psychiatrist if I can get past my own mental illness enough to get to that point. And okay, I'm glad I didn't make you question your sanity as I have been with this "wash out" bulls**t.
>
> > I am feeling really off lately since going off Marplan.
>
> That's understandable. I hope things don't drop off too much more for you.
>
> > It's been only 2 days on 25mg nortriptyline but I need my MAOI!! The doc will have me up to 75mg by the time I see her Monday but my social issues have become terrible and I feel I am drifting away from how I know, see, and relate to myself. The world I know seems to be shriveling up and dying.
>
> I understand completely. Unfortunately, this is something that I have experienced too many times myself. You describe it very well.
>
> > I am starting back on 10mg of Marplan tmrw morning and have enough to continue with that for 8 months, 4 at 20mg.
>
> Shouldn't you be using a minimum of 40 mg/day of Marplan, even with a TCA?
>
> Most of the literature extant regarding the combination of TCA with MAOI was written before the advent of Prozac and the SSRIs. Here is one from 1995 that you might be able to use a leverage:
>
> ---------------------------------------------
>
> http://www.ncbi.nlm.nih.gov/pubmed/7560546
>
> 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 C1, Ortega-Soto HA.
> Author information
> Abstract
>
> 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.
>
> PMID:
> 7560546
> [PubMed - indexed for MEDLINE]
>
> -------------------------------------------------------
>
>
> - ScottI *should* be on more Marplan, in my opinion, but my new doctor is conserative (old one went on surprise leave) is not okay with the TCA+ MAOI combo.. or the MAOI + stimulant which I've been on nearly 4 years. Even if the plan was to say on just Marplan and/or increase it, she was going to balance out her worries by decreasing Desoxyn to make it "safer" somehow. *ss-backwards if you ask me. Her goal was to get me off one of them so there was no formal contraindication.
So I chose to wash out from Marplan so she wouldn't mess with my ADHD meds, and was willing to give notriptyline monotherapy a shot until the benefits of the MAOI started disappearing. Now I have added back 10mg Marplan and today 20mg in desperation.
I have enough Marplan to continue like this for about 4 months then I'm screwed, unless I can fill Marplan at separate pharmacies without them calling the doc about the contraindication.
In the mean time waiting for old doc to come back, and trying to find someone better. But as far as finding a doc okay with MAOI + TCA + stim? I don't even know where to start.
This is a tough game I am trying to play. For me it's not about returning to a life a I had but more so relieving the depression so I can find what happiness is an create something that will sustain it. That's a tough biochemical task.
And thank you for the study, I brought in a lot of literature to the first appointment but she wasn't phased.
Posted by uncouth on April 12, 2014, at 14:33:42
In reply to Options for ADD while on Nardil, posted by enndub on March 28, 2014, at 13:51:41
enndub,
i am in a very similar situation as you. i just started nardil (have been on MAOIs in the past) and washed out of 40mg vyvanse which had been the only thing that helped me with my inattentive ADD and working memory issues (i am an engineer/entrepreneur too, i feel your pain).let me know what you find. there is another interesting post here about aspartame in diet sodas helping when on MAOIs--which I added a reply to. I truly think there is a real phenomenon there, as aspartame converts to phenylalanine which is a dopamine precurser. Try diet coke on an empty stomach...you never know...
In other news, I have heard vyvanse is possible to dump out into a glass of water, stirr around a bit, and titrate dose carefully. obviously as your doctor, but stimulants and MAOIs can be used judiciously. i haven't tried this yet for my own nardil trial, but i plan to once i get enough nardil in my system. i'm seeing some minor improvements as i increase the dose in terms of ADD, but it's not enough. i use nicotine lozanges with nardil which really seem to help for these issues.
my doc is also thinking about trying disulfiram plus MAOI though he said it's very very untested...theoretically though it should increase dopamine in a different way and have less of a risk as an amphetamine.
let me know how it goes.
This is the end of the thread.
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