Psycho-Babble Medication Thread 1104810

Shown: posts 1 to 17 of 17. This is the beginning of the thread.

 

Why do people not like Amitriptyline + Mirtazapine

Posted by mtom on June 9, 2019, at 19:47:02

Posted this to Alternative in error so reposting to Medications:

I know when SSRI's were introduced, TCA'S lost popularity. Is this because SSRI's are truly better, or was it marketing?

A 2018 Review of 21 AD's published in Lancet found Amitriptyline highest for efficacy, but among lowest for acceptability. I know weight gain and sedation are problems - what else?

And Mirtazapiine (Remeron) ranked 2nd highest for efficacy, but in the middle for acceptability - and it also has same issues with somnolence and weight gain.

Despite their finding of both having higher antidepressant efficacy than other AD's, I can't find a lot of discussion from users supporting this for either. Lancet review included 522 trials, although there was a lot more data for some than others (e.g. Remeron seemed fairly low), some compared 2 (or more) AD's head-to head, some against placebo, studies from Pharma companies seem to be included, and they noted there was risk of bias and certainty of evidence was moderate to very low.

Still, it seems to be the largest study done to date.

Comments re Amitriptyline? And any others including Mirtazapine for efficacy and side effects? (e.g. why large drop outs for both).

Note: I've tried citalopram (Celexa) - huge anxiety/agitation and other SE's, then escitalopram (Lexapro, Cipralex) - similar SE's although slightly less intense. No efficacy from either, although Lexapro is often cited as one of most effective with least side effects.

Tried Amitryptiline many years ago and did have somnolence and weight gain issues. Not sure if it was effective for depression and anxiety, I did feel better but also had resolved some situational stresses in my life at the same time.

Right now weight gain issue is OK as I've lost a lot of weight. But sleep isn't a problem for me (in fact fatigue is) and somnolence SE is worriesome. And I've read anxiety can be an issue with effective doses of Mirtazapine (even though also prescribed off label for anxiety) - apparently the Norepinephrine effect kicks in at higher doses. Concerned about this as I get anxiety on other AD's. Have read at lower doses Remeron is mostly sedating and AD effect doesn't kick in until higher doses (which may then trigger anxiety).

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by Christ_empowered on June 10, 2019, at 8:23:10

In reply to Why do people not like Amitriptyline + Mirtazapine, posted by mtom on June 9, 2019, at 19:47:02

hi. in the US, remeron is often used with other Rx drugs. wellbutrin+remeron, an ssri+remeron, effexor+remeron (that's "california rocket fuel," apparently...), etc. in the US, the tendency is to use somewhat lower doses than are (were?) popular in the EU, for whatever reason(s).

If you and your doctor(s) opt for a tca, are you sure you want to settle on Elavil? Tofranil, vivactil, even...surmontil...there are plenty of tca drugs still on the market, and I think the adverse effect profile of some of them might be better in your situation than good ole elavil. but i could be wrong, obviously.

one treatment I saw...was using a sustained release stimulant in combination with remeron. never known anyone on that combination, but the idea was to enhance the ad action (and help sedation and fatigue) with a stimulant and then improve sleep and anxiety with the remeron. wellbutrin+remeron might be somewhat similar (?).

have you been prescribed modafanil or anything to help w/ fatigue? i dont think its addictive or anything, its just...an option some people seem to benefit from, so i thought id mention it.

hope things get better for you.

 

Re: Why do people not like Amitriptyline + Mirtazapine » Christ_empowered

Posted by mtom on June 10, 2019, at 11:54:52

In reply to Re: Why do people not like Amitriptyline + Mirtazapine, posted by Christ_empowered on June 10, 2019, at 8:23:10

My doc is thinking of adding low dose Remeron to my currently low dose escitalopram (lexapro).

I thought of Amitriptyline because a recent Lancet review found it most effective of 21 AD's, although 6th for acceptability.

She avoided Wellbutrin with me because some people report over-stimulation, and this is a problem for me for other AD's. In addition, a Genetic Report I did last year indicated one of my P450 enzyme alleles correlates to an increased response to Bupropion (Welbutrin).

With my anxiety, I need to avoid anything stimulating (I even drink decaf coffee & tea now).

Some people report increased anxiety with Remeron. Also there is the problem with somnolence (and possibly too much weight gain). I don't see that many reports of efficacy for depression, although that study rated it #2 for this (but actual data they based this on seems limited).

None of the other TCA's you mentioned were included in the 21 meds reviewed in the large Lancet study I've referred to in other posts.(?). The only other TCA in that study was clomipramine, and it was at the bottom for acceptability (i.e. the worst).


> hi. in the US, remeron is often used with other Rx drugs. wellbutrin+remeron, an ssri+remeron, effexor+remeron (that's "california rocket fuel," apparently...), etc. in the US, the tendency is to use somewhat lower doses than are (were?) popular in the EU, for whatever reason(s).
>
> If you and your doctor(s) opt for a tca, are you sure you want to settle on Elavil? Tofranil, vivactil, even...surmontil...there are plenty of tca drugs still on the market, and I think the adverse effect profile of some of them might be better in your situation than good ole elavil. but i could be wrong, obviously.
>
> one treatment I saw...was using a sustained release stimulant in combination with remeron. never known anyone on that combination, but the idea was to enhance the ad action (and help sedation and fatigue) with a stimulant and then improve sleep and anxiety with the remeron. wellbutrin+remeron might be somewhat similar (?).
>
> have you been prescribed modafanil or anything to help w/ fatigue? i dont think its addictive or anything, its just...an option some people seem to benefit from, so i thought id mention it.
>
> hope things get better for you.

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by Christ_empowered on June 10, 2019, at 12:23:28

In reply to Re: Why do people not like Amitriptyline + Mirtazapine » Christ_empowered, posted by mtom on June 10, 2019, at 11:54:52

hi. i wasn't trying to play MD or know it all, just...thought I'd try to be helpful, that's all. anyway...

elavil was, once, a fairly popular drug. there were (are?) 2 combo pills of it, one w/ librium and one w/ perphenazine. i don't know how people tolerated those drugs, but...there you go.

have you ever been prescribed buspirone (buspar in the US) ? its non-sedating...i vaguely seem to recall reading that the drug company initially thought they had a new neuroleptic on their hands, but that didn't pan out...

but anyway: it is sometimes used w/ antidepressants, to calm people down and boost overall response. i think it requires 2-3x daily dosing, non-addictive, i dont know if there's a known discontinuation syndrome.

can you take gaba-ergic drugs? gabapentin, lyrica...or not so much?

sorry you're going thru it. :-(

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by linkadge on June 10, 2019, at 14:54:28

In reply to Why do people not like Amitriptyline + Mirtazapine, posted by mtom on June 9, 2019, at 19:47:02

I never found that mirtazapine increased anxiety (took it as high as 30mg). On the contrary, SSRIs did increase anxiety.

If sleep is not your core issue, then mirtazapine or amitriptyline may not be the best choices. Nortriptyline (related to amitriptyline) tends to cause less sedation and may improve energy more.

I think amitriptyline is so effective because, it hits so many targets. As mentioned, it is not well tolerated, but it has several complimentary antidepressant mechanisms.

serotonin / norepinephrine reuptake inhibition
antihistamine effect (reduces anxiety)
anticholinergic (antidepressant effect)
calcium channel inhibition (reduce pain, anxiety)
anti-serotonin (blocks certain receptors which can increase anxiety)

Linkadge

 

Re: Why do people not like Amitriptyline + Mirtazapine » Christ_empowered

Posted by mtom on June 10, 2019, at 19:32:09

In reply to Re: Why do people not like Amitriptyline + Mirtazapine, posted by Christ_empowered on June 10, 2019, at 12:23:28

No I didn't think you were doing that at all. Sorry if my response seemed abrupt, after I started writing I realized I was running late for an appointment and rushed it.

I think years ago I took one of the other meds you mentioned but didn't find it did anything. My current doctor hasn't suggested them (at least not recently, I think at one point she considered an antiepileptic like Lyrica, but we tossed it out as an option for reasons I don't remember). She doesn't seem to want to consider amitryptyline either, we haven't discussed why.

I saw one Pdoc last fall who was useless (and was with a major Teaching Hospital!). I knew more about meds and published research than he did. But getting referred to another, we'll see how that goes.

Going to try very low dose Remeron to start augmenting my low dose Escitalopram. I've been tapering Escitalopram for a while, may be part of the reason I've been feeling worse.

Thanks for your thoughts....

> hi. i wasn't trying to play MD or know it all, just...thought I'd try to be helpful, that's all. anyway...
>
> elavil was, once, a fairly popular drug. there were (are?) 2 combo pills of it, one w/ librium and one w/ perphenazine. i don't know how people tolerated those drugs, but...there you go.
>
> have you ever been prescribed buspirone (buspar in the US) ? its non-sedating...i vaguely seem to recall reading that the drug company initially thought they had a new neuroleptic on their hands, but that didn't pan out...
>
> but anyway: it is sometimes used w/ antidepressants, to calm people down and boost overall response. i think it requires 2-3x daily dosing, non-addictive, i dont know if there's a known discontinuation syndrome.
>
> can you take gaba-ergic drugs? gabapentin, lyrica...or not so much?
>
> sorry you're going thru it. :-(

 

Re: Why do people not like Amitriptyline + Mirtazapine » linkadge

Posted by mtom on June 10, 2019, at 19:42:57

In reply to Re: Why do people not like Amitriptyline + Mirtazapine, posted by linkadge on June 10, 2019, at 14:54:28

For some reason Mirtazapine seems to be frequently recommended as an add-on to SSRI's. SSRI's do increase my anxiety. Now taking a very low dose, have been reducing gradually (escitalopram). Going to try a low dose Remeron as an add on and see how it goes. Many say it helps anxiety (although some don't) and may boost effectiveness of SSRI's.

Why is amitriptyline not well tolerated? I know about the weight and somnolence issues, but Mirtazapine has these too. Are there other issues with amitriptyline?

> I never found that mirtazapine increased anxiety (took it as high as 30mg). On the contrary, SSRIs did increase anxiety.
>
> If sleep is not your core issue, then mirtazapine or amitriptyline may not be the best choices. Nortriptyline (related to amitriptyline) tends to cause less sedation and may improve energy more.
>
> I think amitriptyline is so effective because, it hits so many targets. As mentioned, it is not well tolerated, but it has several complimentary antidepressant mechanisms.
>
> serotonin / norepinephrine reuptake inhibition
> antihistamine effect (reduces anxiety)
> anticholinergic (antidepressant effect)
> calcium channel inhibition (reduce pain, anxiety)
> anti-serotonin (blocks certain receptors which can increase anxiety)
>
> Linkadge

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by Lamdage22 on June 11, 2019, at 14:26:47

In reply to Re: Why do people not like Amitriptyline + Mirtazapine » linkadge, posted by mtom on June 10, 2019, at 19:42:57

Yep there is a chance you will have anorgasmia and ED.

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by Hordak on July 1, 2019, at 15:04:13

In reply to Why do people not like Amitriptyline + Mirtazapine, posted by mtom on June 9, 2019, at 19:47:02

There is no logic in combining Amitriptyline and Mirtazapine: Both are strong antihistamines and strong 5HT2 antagonists... so why take them both?

Better:
Amitriptyline + Pregabalin
Mirtazapine + SSRI / SSRNRI

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by Hordak on July 1, 2019, at 15:10:11

In reply to Why do people not like Amitriptyline + Mirtazapine, posted by mtom on June 9, 2019, at 19:47:02

Garbage in, Garbage out.

https://psychotropical.com/lancet-21-antidepressants-meta-analysis/

https://psychotropical.com/mirtazapine-a-paradigm-of-mediocre-science/

https://psychotropical.com/mirtazapine-dubious-evidence/

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by Hordak on July 1, 2019, at 15:34:12

In reply to Why do people not like Amitriptyline + Mirtazapine, posted by mtom on June 9, 2019, at 19:47:02

Amitriptyline is a powerful drug, is definitely more potent than Mirtazapine (in addition to antihistamine and 5HT2 antagonism it offers SRI / NRI properties + anticholinergic etc.)

 

Re: Why do people not like Amitriptyline + Mirtazapine » Hordak

Posted by mtom on July 1, 2019, at 15:37:05

In reply to Re: Why do people not like Amitriptyline + Mirtazapine, posted by Hordak on July 1, 2019, at 15:04:13

I meant Amitriptyline "and" Mirtazapine (separately) but when I put the & symbol in, it changed to + after I posted. Wanted to compare the 2, not take together.

> There is no logic in combining Amitriptyline and Mirtazapine: Both are strong antihistamines and strong 5HT2 antagonists... so why take them both?
>
> Better:
> Amitriptyline + Pregabalin
> Mirtazapine + SSRI / SSRNRI
>

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by Hordak on July 1, 2019, at 19:06:43

In reply to Re: Why do people not like Amitriptyline + Mirtazapine » Hordak, posted by mtom on July 1, 2019, at 15:37:05

Yes, I've noticed afterwards :=D

> I meant Amitriptyline "and" Mirtazapine (separately) but when I put the & symbol in, it changed to + after I posted. Wanted to compare the 2, not take together.
>
> > There is no logic in combining Amitriptyline and Mirtazapine: Both are strong antihistamines and strong 5HT2 antagonists... so why take them both?
> >
> > Better:
> > Amitriptyline + Pregabalin
> > Mirtazapine + SSRI / SSRNRI
> >
>
>

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by SLS on July 2, 2019, at 12:03:10

In reply to Re: Why do people not like Amitriptyline + Mirtazapine, posted by Hordak on July 1, 2019, at 15:04:13

> There is no logic in combining Amitriptyline and Mirtazapine: Both are strong antihistamines and strong 5HT2 antagonists... so why take them both?

Perhaps there is some logic. Amitriptyline is a reuptake inhibitor, primarily of norepinephrine. It also inhibits the reuputake of serotonin to some extent. Mirtazapine does neither of these things. I guess it is possible that that the NE reuptake inhibition of amitriptyline will work synergistically with the NE alpha2 antagonism of mirtazapine. I don't think I have seen these two drugs combined, though. I would think that using nortriptyline would be a better choice to combine with mirtazapine because it is not antihistaminic. I haven't seen this combination used, either.


- Scott
>

 

Clarifying: meant Amitriptyline or Mirtazapine

Posted by mtom on July 2, 2019, at 14:51:40

In reply to Re: Why do people not like Amitriptyline + Mirtazapine, posted by SLS on July 2, 2019, at 12:03:10

As mentioned somewhere in the thread, I put a & symbol for "and" in the original title (meaning either or), but when it posted it changed that to the + symbol.

 

Re: Clarifying: meant Amitriptyline or Mirtazapine

Posted by SLS on July 4, 2019, at 18:27:38

In reply to Clarifying: meant Amitriptyline or Mirtazapine, posted by mtom on July 2, 2019, at 14:51:40

> As mentioned somewhere in the thread, I put a & symbol for "and" in the original title (meaning either or), but when it posted it changed that to the + symbol.

It is good that I misunderstood your question. It would be nice to hear from people who have combined a tricyclic with mirtazapine.


- Scott

 

Re: Why do people not like Amitriptyline + Mirtazapine

Posted by Hordak on July 27, 2019, at 16:01:56

In reply to Re: Why do people not like Amitriptyline + Mirtazapine, posted by SLS on July 2, 2019, at 12:03:10

> > There is no logic in combining Amitriptyline and Mirtazapine: Both are strong antihistamines and strong 5HT2 antagonists... so why take them both?
>
> Perhaps there is some logic. Amitriptyline is a reuptake inhibitor, primarily of norepinephrine. It also inhibits the reuputake of serotonin to some extent. Mirtazapine does neither of these things. I guess it is possible that that the NE reuptake inhibition of amitriptyline will work synergistically with the NE alpha2 antagonism of mirtazapine. I don't think I have seen these two drugs combined, though. I would think that using nortriptyline would be a better choice to combine with mirtazapine because it is not antihistaminic. I haven't seen this combination used, either.
>
>
> - Scott
> >
>
>

Yes, Nortriptyline would be preferable... less side effects.


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