Psycho-Babble Medication Thread 1060862

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Nardil/phenelzine at 45mg (Lotsa Questions, Sorry)

Posted by dbbs on February 19, 2014, at 12:43:09

Hi there! Long time listener, first time caller. I know some of you guys have a lot of experience with MAOIs, and I had some questions to ask I can't seem to find the answers to elsewhere. Thanks for reading my post, and thanks doubly for any informative answers.

Backstory:

Currently I'm being prescribed Nardil/phenelzine at 45mg/day. My medical provider (a psychiatric nurse practitioner) was the only one at the clinic I go to who was willing to prescribe an MAOI at all, but she's been very cautious about it because even though her age (about 50) I don't think she has prescribed one in many years, if ever. I'm also on Klonopin/clonazepam 5mg/day - yes, a high dose, but I have severe panic attacks & PTSD flashbacks that come and go all day, and clonazepam has been the only thing to calm that down, though I wish it didn't make me so sedated. In addition to the 5mg of clonazepam, for medical reasons I also take 150mg of Dantrium/dantrolene Sodium (for back spasticity), 440mg of Aleve/naproxen Sodium a day (for back inflammation), a Multivitamin (to supplement what's missing in my diet), a B-Complex vitamin (to offset the B6 deficiency caused by Nardil), and Fish Oil (to offset the unhealthy ratio of Omega-6 to Omega-3 fatty acids that I normally get.) I occasionally take Claritin/loratadine for allergies.

Even after just a week plus on Nardil, it has been significant improvement over the 7 or 8 med combo I was taking, though I do miss the Dexedrine spansules/dextroamphetamine extended release capsules for my ADHD. The problem is that Dexedrine doesn't really touch me much when I'm depressed - it just makes me able to focus on video games (not the intended use I'm sure.) Sure, this helps distract me when I'm depressed, but I'd really rather get up and DO things and no be depressed - my doctor actually said I may regret going off the the Dexedrine, but I feel like the depression is a more pressing matter. And in just a week on Nardil I have improved mildly - taken care of yard and patio duties I've left going for years (amazing how so my plants have survived this long with just the rainwater in the desert...) and vacuuming... though my room is almost as cluttered as ever.

I'm not sure if this is me experiencing the so-called "Nardil mania" I've heard others referencing that comes on at the second week or so - I certainly don't feel good and I've asked my family members if I seem manic, and they all say no, just that I seem mildly less depressed. My thought is that if it's not "Nardil mania", then it's possibly the MAOI kicking in faster because I've already been on antidepressants for years and my receptors were prepared for the slight boost in neurotransmitters that's probably already been achieved.

Just so you know, my diagnoses are:

-Major Depressive Disorder (Atypical - hypersomnia, hyperphagia, etc)
-Post Traumatic Stress Disorder
-Attention Deficit Hyperactivity Disorder - Hyperactive-Impulsive Type (though depending on the doctor, it has been listed as inattentive and combined type - but that's my current Dx)
-Panic Disorder
-I also have injuries in my mid & lower back and some disc bulging and degeneration, with some evidence of neuropathic pain developing. I am 30 years old, 6'0"/183cm, 290lbs./131.5kg (severe depression and mostly untreated back issues really don't help with the weight loss), have all my shots (except rabies, grr!) and have a history of ear infections. Blood pressure and heart rate get high when I'm panicked, but otherwise 120/80 BP and 70bpm are normal for me. Don't know why you'd want to know all that, but maybe it helps.


My actual questions:

1.) My doctor is VERY inexperienced with Nardil, especially the dosages involved. She has me set to take 45mg/day for two months. Is it possible that this will have an effect on me? I think because my anxiety disorders she would rather I give Nardil a complete trial first before trying me on Parnate/tranylcypromine, so I can't switch to that, not yet.

1b.)I know the goal is to destroy 80-85% of the MAO in my body to achieve therapeutic efficacy, so even if I can't convince her to raise the dose higher, this should be possible at some point even if I'm stuck with a 45mg/day dose (assuming my body doesn't make MAO faster than phenelzine can react with it), right?

2.) Are there any recently published, publicly available, and scientifically accepted sources I print out to show her that I would benefit more from a 60mg-75mg dosage (what I'm shooting for.)

3.) I know that Nardil as a reasonably nonselective irreversible MAOI will (probably significantly) increase deficient levels of phenethylamine in my brain. I know that phenethylamine deficiency is by some models either a symptom or causative factor in ADHD. In other models it's a lack of norepinephrine and dopamine. All of these are boosted by Nardil. Is there a reasonable chance this may help me with my ADHD?

3b.) If not, can anyone provide me with any publicly available, recently published scientific papers regarding the use of very low dose Dexedrine Spansules/Dextrostat/dextroamphetamine IR or ER (the levoamphetamine in Adderall causes my panic & heart rate levels to skyrocket for some reason - several times in the hospital with them switching my Dexedrine to Adderall XR because of no Dexedrine in stock & several ECGs later, this has been established) - or even papers regarding the use of very low dose Adderall/Adderall XR/dextroamphetamine-amphetamine mixed salts in combination with Nardil? I know this has been used at very low doses with positive effect, but I know if this becomes an issue later I better have some pretty well grounded scientific evidence to back this up to get even a chance at it.

Ritalin/methylphenidate is a no go (anxiety goes through the roof) but Vyvanse/lisdexamfetamine is a possibility, also, I've just never been prescribed it. Also, Provigil/modafinil is a no go, not covered by insurance. Adderall is a no go too, it's just I'm sure papers on Adderall would be proof enough for her to give me a low dose of Dextrostat or Dexedrine.

3c.) Along the same line of medication supplements and changes, if I gain no lasting benefit from Nardil or achieve only an incomplete response (even at a higher dose), would one recommend I ask for a switch to Parnate/tranylcypromine, or is there another medicine that I could supplement the Nardil with? Of the medicines I know are safe, I've taken quite a few of them - but they have almost all had such huge antihistamine effects that I've slept for 24-36+ hours straight after single doses and slept for most of 2-4 weeks to give the medicine a "full trial" before I finally couldn't handle the sleep anymore. I would say the worst culprits were prazosin, amitryptiline, Remeron/mirtazapine, Seroquel/quetiapine, Risperdal/risperidone, and a couple first generation typical antipsychotics they tried me on very briefly at the hospital. I have malignant hypothermia, and I know this can in some cases be comorbid with neuroleptical malignant syndrome, and I'm very leery of taking certain known problematic antipsychotics because of this - but so far I've just had some really negative side effects that didn't kill me, though I did feel quite zombified for months after taking each one for a duration. One dose of haloperidol did turn me into a snarling, loud, angry, and quite terrible feeling monster, so it's possible that one could have triggered neuroleptical malignant syndrome if continued, but I didn't want to test that theory out.

The only antipsychotic that worked positively without side effect for me was Abilify/aripiprazole, but getting that covered here by my insurance requires I go through a trial of several different antipsychotics, even those unapproved as adjunctive treatment in MDD, Whle I have tried several antipsychotics in the past; most of the ones I was on before were paid through private insurance when I was employed. Unfortunately, they want me to re-test me on several of them I've already been on - through my public insurance as part of 'step-up' therapy. This is minly because Abilify is so expensive, of course. I'm not willing to put up with several months of antipsychotic hell again just for the chance of them approving Abilify.

I was thinking maybe nortripytline, but even that is a potent antihistamine, and I'd like to avoid those, unless the antihistamine sleep effect wears off by morning? Any experience with that? I can't wait till Abilify goes generic; I'll be asking for it the very next day, even if Nardil is working great. That stuff really helped me get out of a suicidal slump when I was in the hospital. I really have no idea if the Nardil will work for me as is or not, I just like to have a "game plan" so I can be prepared for suggestions if this doesn't work right (an unfortunate side effect of no antidepressant or adjunctive therapy aside from Abilify ever working properly on me.)

Please note:

I cannot switch doctors (aside from within the clinic) and my experience with the other medical practitioners in the clinic has been BAD. I am stuck in the public mental health system in Arizona because I'm out of work, have SMI status, and am on AHCCCS - Arizona's Medicaid system. In its defense, it's really it's not bad - I've had friends in the UK on the NHS get much worse and far less prompt and appropriate responses than I have here.

The good news is I am receiving medicine, receiving therapy, taking an active role in my treatment and being given an opportunity to play that role, and on top of that if I feel there is a problem with my medication I can go in during the morning Monday-Friday and see my doctor without an appointment if I feel my meds are really wrong. I have no complaints about my medical provider, in fact, I feel quite lucky as she has listened to me and has been willing to hear me out and usually gives me what I ask to try if it's reasonable.

But, reasonable includes medicines she's familiar wit, and I completely understand that. She's willing to work with me, but I know she's extremely cautious with the MAOI (as evidenced by the fact that her appointments have gone from every 2-3 months to every week while being inducted on the MAOI.)

Any thoughts/suggestions regarding my questions or additional information? Keep in mind, switching doctors is not an option here. Neither is ordering from the internet to supplement (I'm so poor it took me a week to get money together to buy some new pens, and that's not because I've spent my money on other things!) I have to work within the constraints allotted.

*** Keep in mind, even though I used the phrase "Nardil mania" up there, I am only using it because I have heard people use that phrase used to describe a portion of the induction phase of Nardil. I have never once been diagnosed with Bipolar I or II and have never once experienced a truly manic, hypomanic, or mixed state naturally or induced from medicine. The fact that I did one or two hours of yard work a day for 2 days I am 100% sure does not qualify me as manic by any definition of the word, it just qualifies me as less depressed and more motivated than normal. So, any suggestion that I am in self denial of a bipolar diagnosis or should push for a bipolar diagnosis - and/or that I may be on the wrong med (trust me, I've even tried some of the bipolar meds off-label for depression) - will be ignored; that is, unless I actually go into one of those states naturally and not because of medication. Sorry for being blunt here, I just want this understood. ***

Thank you so very much again! I appreciate it.

 

Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry)

Posted by Tomatheus on February 20, 2014, at 0:10:09

In reply to Nardil/phenelzine at 45mg (Lotsa Questions, Sorry), posted by dbbs on February 19, 2014, at 12:43:09

dbbs,

Hello, and welcome to Psycho-Babble. Thank you for writing all that you did and for posing all of the questions that you posed. My ability to concentrate on reading is only so-so at present (and is better right now than it was earlier today), so I read through your message in parts, and I think that I understand some of the things that you're trying to ask. I don't have answers to all of your questions, but I'll try to address those that I can at least partially answer.

As to whether or not 45 mg of Nardil could have an effect on you therapeutically in the long run, yes, I do think it's possible, but I think that your chances of benefiting from the medication would be stronger at a higher dose. I looked through some of the Nardil-related studies that I have in my possession, and even though none of them have been published recently, I did come across one that found 90 mg of phenelzine to be superior to 45 mg of the medication. Here's a link to the article's abstract:

http://www.ncbi.nlm.nih.gov/pubmed/6992903

Here's what was reported in the "results" section of the article concerning the dose of phenelzine that was used in relation to therapeutic efficacy:

"Patients taking the high dosage of phenelzine (90 mg daily) showed significantly greater improvement on the Hamilton ratings than those taking lower dosage (45 mg/day) (P <0.02) (Table III). A similar result was found with the results of the patients' self-ratings. Differences in improvement between the dosage schedules started to show after two weeks (i.e. after only one week's treatment with the higher dose) and increased in the succeeding weeks of treatment (Figure) although these differences did not reach statistical significance (F = 1.35, df 3 and 174)."

Concerning whether or not Nardil might help with your ADHD, I think it's conceivable that it might, given its effects on dopamine and phenylethylamine (which you mentioned), but I'm not aware of any scientific evidence that would specifically support the notion that Nardil might be an effective ADHD treatment. I think that it would be best to see how Nardil will affect you in the longer run and then to discuss augmentation strategies with your nurse practitioner if the Nardil doesn't seem to help. Unfortunately, I'm not too well versed on what medications (including stimulants and other ADHD medications) can be safely combined with Nardil, both others here on this board might be.

Well, I'm sorry if I couldn't be of more help, but I figured that I'd chime in and try to answer at least a little bit of what you've asked. I do hope that your Nardil trial will continue to work out well. Feel free to let me know if there's anything more that you'd like for me to explain.

Tomatheus

 

Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry)

Posted by dbbs on February 20, 2014, at 10:36:35

In reply to Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry), posted by Tomatheus on February 20, 2014, at 0:10:09

Thank you very much for the information you provided. An older article is appreciated, too! I ideally would like the newest information available, but I also understand that there was a good 20 or so year period where SSRIs and SNRIs and AAPs like Seroquel/quetiapine were the big thing in (published) biopsychiatric studies on depression. I imagine that's probably because that's where the money is - who wants to prove that a drug class that's been available in generic for 50 years is possibly more effective and far less risky than previously suggested.

I've printed the information out for my next appointment (tomorrow.)

I will definitely give the medicine an adequate trial before suggesting augmentation; I just have this fear of losing my momentum and therefore my chance at being prepared as far in advance as possible. Losing momentum and sinking into my usual pit of do-little-to-nothing is something that has happened many times in the past; I know this is one of my own major weaknesses. Therefore, I try to get all the information I have both printed, read, and available so I'm prepared for all eventualities.

Thank you again for all you have provided. The reassurance alone was helpful, and the information good too. Thanks!

 

Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry)

Posted by kirkglen on March 20, 2014, at 12:35:41

In reply to Nardil/phenelzine at 45mg (Lotsa Questions, Sorry), posted by dbbs on February 19, 2014, at 12:43:09

First, you are taking the best AD on the market. In the past Parke Davis recommended going to 90 mg at a rapid pace. Once the AD effects kicked in, start reducing the dose until you reach a maint. level. Some patients responded to 15 mg. every other day. As to the safety of a MAOI I feel it was totally overblown back when it was first introduced. My understanding is many med schools still teach to avoid them.

I took Nardil for 30 years at 60mg every morning. I had been through every other treatment known at that time. It took the Nardil @ 6 weeks to start working. When it did "oh my God" this is how everyone else feels everyday. I was very fortunate as I raised and educated my children before Nardil decreased it's effect.

Unfortunately even pharms need to profit. 2003 Parke Davis was bought out and the additives were changed . Nardil was developed to be absorbed within the small intestine which has a more alkaline PH. That design is still there but the pill isn't being supplied correctly.

If possible try to get your Pdoc to mandate your med is supplied in a sealed bottle with 60 pills.
This manufacturer Greenstone supplies it in that manner with a dessicant inserted. Without that dessicant H2O will attack the coating reducing the likelihood of the Nardil making it to the small intestine.
Today I still take Nardil but do not get near the bang. I supplement with 1mg Klonopin.
By the way don't worry about the mania.....I think it's just going from feeling so poor to having that "oh my God" switch turned on.

 

Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry)

Posted by rose45 on March 21, 2014, at 15:41:15

In reply to Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry), posted by kirkglen on March 20, 2014, at 12:35:41

Hi,

MAOIs are the only anti depressants that work for me. I was on phenelzine from 1992- 2012, when unfortunately, it stopped working for me. I would increaase slowly from 15 mg - 60 mg. The higher dose felt very uncomfortable, but I would stay on it for approx. 4 weeks, and then gradually reduce. My maintenance dose was 45 mg. This was done at the Maudsely Hospital in London, which is a very well respected institution, and they are always consulted by other psychiatrists here in London.

If you want to quote some other research, you could look at:

http://www.psychotropical.com
which is the website of Dr. Ken Gillman, who is specialised in MAOIs and because he is now retired, seems to have the time to chat on skype, if you would like to talk to him.

Re. the mania you mention, I doubt that you would have it already. In my case, I felt very bad for the first 6 weeks on Nardil, but then after 7-8 weeks , there would be a magical change. I did get manic, spending far too much money, and talking too much, and getting very speedy, so you do need to watch out for those things.

I am now on Parnate, as the Nardil stopped working one year ago. Parnate is very different. For me, the depression went away, but I never got the 'high' or the feeling of energy and sociability that I got on Nardil.

However, Im grateful not to be feeling the way I do when I am not on medication - which is totally suicidal. I have been told that I will probably have to be on antidepressants for the rest of my life. I only hope the parnate doesnt stop working.

Good luck with the nardil. When it works, it is totally magical. You do have to have patience with it though.

 

Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry) » rose45

Posted by SLS on March 22, 2014, at 6:59:55

In reply to Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry), posted by rose45 on March 21, 2014, at 15:41:15

Not many people with more severe depressions can be maintained on 45 mg/day. The range for maintenance dosage is the same as that of acute treatment: 60 - 90 mg/day. One can still relapse at 90 mg/day, but it is much more likely to occur at 45 mg/day.

The ancient package label is wrong.


- Scott

 

Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry)

Posted by rose45 on March 22, 2014, at 15:19:20

In reply to Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry) » rose45, posted by SLS on March 22, 2014, at 6:59:55

Well, all I can say is, that I was so severely depressed, that all I could think about was suicide. Couldnt function at all. And for me, nardil was a miracle. I maintained a dose of 45 mg for over 20 years, feeling totally fine. For me, 60 mg was just too much, and made me feel really weird and bad. I think we are all different, and all react differently to drugs.

 

Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry)

Posted by greg rizzo on January 15, 2020, at 8:25:13

In reply to Re: Nardil/phenelzine at 45mg (Lotsa Questions, Sorry), posted by kirkglen on March 20, 2014, at 12:35:41

Dr. Bob-From the descriptions of others, research and my own experiences, I believe there are two problems with the new nardil as compared to the old:
1) new nardil is absorbed before it reaches the new intestine
2) even if new nardil does reach the new intestine, the absorbtion *rate* is off balance
That's why placing nardil in plasmin plus enteric tabs were only partially effective. yes, more phenelzine would likely survive the trip through the stomach, but once the enteric tab dissolved, the nardil itself won't be absorbed to the maximum level without an excipient to aid it.
The best excipients to aid absorption into the small intestine are bioperine,sugar invert (a.k.a. honey) an antacid, and ethanol (alcohol). Sugar is quite good, but the absorbtion rate, though high, is relatively slow.
As far as absorption into the small intestine, NOTHING beats alcohol. It's rate and level of absorption by the small intestine is extremely high. Obviously, I don't mean kick back shots of tequila, I'm talking mere drops of the substance.
Therefore mixing nardil with either honey or alcohol has been much more effective. I also take Bydureon, which slows digestion (long acting Byetta similar to Victoza, a GLP1 agonist) and which I suspect may be having some impact on how I absorb Nardil (even though I try to always take on an empty stomach).
Been trying this for 2 1/2 weeks and seems to be working. Haven't had a down day in those 2 1/2 weeks.


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