![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 65 to 89 of 114. Go back in thread:
Posted by ed_uk on May 13, 2005, at 11:30:32
In reply to Re: On the ketamine note ... » ed_uk, posted by franco neuro on May 13, 2005, at 11:01:24
Hi Franco,
What type of pain do you suffer from? I think you mentioned that you used to take amitriptyline but it was too sedating. Have you tried desipramine or nortriptyline?
Ed.
Posted by ed_uk on May 13, 2005, at 11:35:49
In reply to Re: On the ketamine note ..., posted by franco neuro on May 13, 2005, at 11:24:17
Desipramine, a TCA which acts as a relatively selective norepinephrine reuptake inhibitor, can be useful in neuropathic pain.............
Efficacy of desipramine in painful diabetic neuropathy: a placebo-controlled trial.
Max MB, Kishore-Kumar R, Schafer SC, Meister B, Gracely RH, Smoller B, Dubner R.
Neurobiology and Anesthesiology Branch, National Institute of Dental Research, National Institutes of Health, Bethesda, MD 20892.
Although amitriptyline relieves pain in many patients with painful diabetic neuropathy, side effects often preclude effective treatment. Desipramine has the least anticholinergic and sedative effects of the first generation tricyclic antidepressants. We compared a 6 week course of desipramine (mean dose, 201 mg/day) to active placebo in 20 patients with painful diabetic neuropathy in a double-blind crossover trial. Pain relief with desipramine was statistically significant in weeks 5 and 6. Eleven patients reported at least moderate relief with desipramine, compared to 2 with placebo. Pain relief tended to be greater in depressed patients, but relief was also observed in patients who did not show an antidepressant effect. We conclude that desipramine relieves pain in many patients with painful diabetic neuropathy, offering an alternative for patients unable to tolerate amitriptyline. Blockade of norepinephrine reuptake, an action shared by desipramine, amitriptyline, and other antidepressants proven effective in neuropathic pain, may mediate this analgesic effect.
Clin Pharmacol Ther. 1990 Mar;47(3):305-12. RDesipramine relieves postherpetic neuralgia.
Kishore-Kumar R, Max MB, Schafer SC, Gaughan AM, Smoller B, Gracely RH, Dubner R.
Neurobiology and Anesthesiology Branch, National Institute of Dental Research, National Institute of Health, Bethesda, MD 20892.
Desipramine has the least anticholinergic and sedative effects of the first generation tricyclic antidepressant agents, but its pain-relieving potential has received little study. Other antidepressant agents--notably amitriptyline--are known to ameliorate postherpetic neuralgia, but those agents are often toxic. In a randomized double-blind crossover design, we gave 26 postherpetic neuralgia patients 6 weeks of treatment with desipramine (mean dose, 167 mg/day) and placebo. Nineteen patients completed both treatments; 12 reported at least moderate relief with desipramine and two reported relief with placebo. Pain relief with desipramine was statistically significant from weeks 3 to 6. Psychiatric interview at entry into the study produced a diagnosis of depression for 4 patients; pain relief was similar in depressed and nondepressed patients and was statistically significant in the nondepressed group alone. We conclude that desipramine administration relieves postherpetic neuralgia and that pain relief is not mediated by mood elevation. Blockade of norepinephrine reuptake, an action shared by desipramine, amitriptyline, and other antidepressant agents that have relieved neuropathic pain, may be involved in relief of postherpetic neuralgia.
Posted by franco neuro on May 13, 2005, at 21:43:19
In reply to Re: On the ketamine note ... » franco neuro, posted by ed_uk on May 13, 2005, at 11:30:32
Hi Ed,
> What type of pain do you suffer from? I think you mentioned that you used to take amitriptyline but it was too sedating. Have you tried desipramine or nortriptyline?
I suffer from neuropathic pain. It's mostly on my left side. Nerve pain and weekness in my left leg and foot and visceral and pelvic pain. I wish I had taken desipramine instead of amitriptyline. It's a much "cleaner" med. All the time I was taking it I thought it was it's antihistamine action that was putting me to sleep. But I've come to realize it wasn't. I've tested various antihistamines and I don't find them sedating at all. They are somewhat analgesic as far as the visceral pain goes. I had to keep upping the dose of amitriptyline over the course of the three and a half years I was on it. I must have really been propping up my NE levels because when I stopped it I really went down hill fast. It was like the bottom dropped out. I felt like my muscles were melting away. It was pretty horrible. I still haven't recovered over two years later. Right now I'm trying to find the right cocktail. Neurontin has helped a lot with the peripheral pain. And the first day I took bupropion SR I felt a sense of relief all over the left side of my chest and torso. There was just a feeling like it was filling up this painful hollowness (if that makes any sense) on my left side. Ufortunately, it started to knock me out. I know there is a large NE componant to my problems. But I'm trying to pinpoint exactly which NE receptors. I'd like to give Clonidine a shot. It's stimulates the alpha-2 receptor and has some other interesting properties.
Posted by franco neuro on May 13, 2005, at 22:46:42
In reply to Desipramine in neuropathic pain » franco neuro, posted by ed_uk on May 13, 2005, at 11:35:49
Yes, I like the fact that it's not particularly anticholinergic. I want to dull the pain, not my intellect. I'm really trying to get at the heart of how this all happened. No one has explained it better that Jay Goldstein in "Tuning the Brain". I read that book and it was as though he was describing my life. Here are some excerpts:
"If an individual is temperamentally, developmentally, and/or environmentally predisposed to interpret too many stimuli as possibly threatening, then attentional resources, which require increased secretion of neurotransmitters norepinephrine (NE) and dopamine (DA) (among others), will be consumed locally at too rapid a rate, and the brain will develop a deficit in them sooner or later. Then, an overt neurosomatic disorder will occur."
"It has taken me twenty years of thinking to succinctly synthesize what is described here, i.e., improper selection of salience produces overuse of the 'attentional spotlight,' which raises signal-to-noise ratio by overly frequent secretion of dopamine and norepinephrine. At some time during a person's life, a neural network orchestrated by the prefrontal cortex may be unable to induce sufficient production of these transmitter substances. This inability may be sporadic or virtually constant, but the result will be neurosomatic symptoms."
"A postulate to which I shall continually refer in this book is that patients with neurosomatic disorders have overly learned and overly generalized associative responses and that the primary molecular basis of this memory dysfunction involves the NMDA receptor."
Me again. Basically, an oversensitized NMDA receptor for glutamate and/or an over secretion of glutamate causes the brain to be in a state of overexcitability or hypervigilance (i.e. overactive fight or flight response, increased startle response, anxiety, poor response to stress, perceiving non-threatening situations as threatening, etc., etc.) This state of perpetually being stressed out ultimately leads to a depletion of DA and NE.
"Inhibiting the NMDA receptor, the presynaptic release of glutamate, and facilitating NE and DA secretion should be effective ways of treating neurosomatic disorders."
That's it in a nutshell. The man is a genius. I love this book. He has a whole list of his favorite medications. But what he considered the best treatments and also the best tools for predicting which medications would work best for his patients, are IV ketamine (NMDA antagonist) and IV lidocaine (primarily suppresses glutamate release). Now all of this makes perfect sense to me. But I can't seem to find a doctor who knows his *ss from his elbow, let alone what the function of the NMDA receptor is!
Posted by ed_uk on May 14, 2005, at 9:42:17
In reply to Re: Desipramine in neuropathic pain » ed_uk, posted by franco neuro on May 13, 2005, at 22:46:42
Hi Franco,
>Nerve pain and weekness in my left leg and foot and visceral and pelvic pain.
I hope you don't mind me asking. What is the cause of your pain?
>I wish I had taken desipramine instead of amitriptyline.
Why don't you try desipramine now?
I've taken lofepramine, a similar drug to desipramine, it didn't cause any cognitive impairment.>IV ketamine (NMDA antagonist) and IV lidocaine...........
But these treatments are not easy to 'get hold of'. Why don't you try the more usual treatments first? You could try desipramine next. Being interested in the NMDA receptor, I expect you've already tried dextromethorphan. Perhaps you could consider oral amantadine, IV amantadine has also been used.
'Dextromethorphan is effective in a dose-related fashion in selected patients with diabetic neuropathy. This was not true of postherpetic neuralgia, suggesting a difference in pain mechanisms. Selective approaches to pain-relevant N-methyl-d-aspartate receptors are warranted.'
Diabet Med. 2003 Feb;20(2):114-8.
A pilot study of the beneficial effects of amantadine in the treatment of painful diabetic peripheral neuropathy.Amin P, Sturrock ND.
Department of Diabetes and Endocrinology, Nottingham City Hospital, Nottingham, UK.
BACKGROUND: Current symptomatic treatments for painful peripheral neuropathy in diabetes have variable efficacy in individual patients. Amongst other chemical transmitters involved in pain reception, the N-methyl-D-aspartate (NMDA) subtype of excitatory amino acid receptor is involved in nociception. Amantadine was recently shown to act as a non-competitive antagonist of NMDA and may be effective in the treatment of neuropathic pain in patients with cancer. We have looked at the benefit of amantadine infusion in diabetic patients with painful peripheral neuropathy. METHODS: Seventeen patients with diabetes (nine men) completed this double-blind randomized crossover placebo-controlled trial of intravenous amantadine. The average age was 58.4 (sd 11) years, with duration of diabetes of 21.1 (8.7) years and duration of painful peripheral neuropathy symptoms of 29.1 (24) months. All analgesics except paracetamol were stopped for 4 weeks prior to the study. Infusions were carried out on a weekly basis with amantadine being administered intravenously as a single 200-mg infusion. The Neuropathy Symptom Score (NSS), together with visual analogue scales, were used to assess current pain intensity (VAS-P) pre-therapy and 1 week later VAS-P was repeated together with a visual analogue scale used to assess relief in pain (VAS-R) and the Physicians Global Evaluation (PGE) score used to assess response to therapy. RESULTS: Pre-therapy, the NSS was 6.8 (6.3-7.4) at baseline, remaining unchanged at 6.6 (5.8-7.4) after placebo (P = 0.33), but fell to 4.6 (3.4-5.8) after amantadine (P = 0.003 vs. baseline and P = 0.02 vs. placebo). The baseline perception of pain was scored as 7.8 cm (7.3-8.3), with no difference following placebo, at 8.2 cm (7.7-8.6) (P = 0.34), but following amantadine it fell to 6.2 cm (4.9-7.8) (P = 0.01 compared with pre-therapy, P = 0.003 compared with placebo). The perception of relief from pain following placebo was only 0.2 (-0.2 to +0.6) but following amantadine was 10-fold better at 1.9 (0.8-3.1) (P = 0.016). The PGE assessment of pain relief was -0.3 (-0.5 to 0) for placebo and following amantadine was 0.8 (0.1-1.5) (P = 0.006). CONCLUSIONS: Our study has shown that intravenous amantadine is beneficial in reducing the pain of painful peripheral neuropathy, with an effect sustained for at least 1 week after an infusion.
Can patients with chronic neuropathic pain be cured by acute administration of the NMDA receptor antagonist amantadine?Eisenberg E, Pud D.
Pain Relief Unit, Rambam Medical Center, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa.
The treatment of neuropathic pain remains a challenge as it rarely leads to long-term relief of symptoms. We report three patients with chronic neuropathic pain, in whom acute administration of the N-methyl-D-aspartate (NMDA) receptor antagonist amantadine resulted in complete resolution of symptoms, presumably due to termination the central 'wind-up' phenomenon.
Pain. 1998 Apr;75(2-3):349-54.
The NMDA receptor antagonist amantadine reduces surgical neuropathic pain in cancer patients: a double blind, randomized, placebo controlled trial.
Pud D, Eisenberg E, Spitzer A, Adler R, Fried G, Yarnitsky D.
Pain Relief Unit, Rambam Medical Center, Haifa, Israel.
Neuropathic pain is often severe, persistent, and responds poorly to analgesic medications. Recent evidence suggests that N-methyl-D-aspartate (NMDA) receptor antagonists may be effective in the treatment of neuropathic pain. The present trial was designed to test the efficacy of acute administration of the NMDA receptor antagonist amantadine in relieving surgical neuropathic pain in patients with cancer. The study sample consisted of 15 cancer patients with the diagnosis of surgical neuropathic pain. Two 500 ml infusions of either 200 mg amantadine or placebo were administered over a 3 h period, in a randomized order, 1 week apart from each other. Spontaneous and evoked pain were measured for 48 h before treatment, during treatment, and for 48 h following treatment. An average pain reduction of 85% was recorded at the end of amantadine infusion vs. 45% following placebo administration. The difference in pain relief between the two treatments was statistically significant (P = 0.009). Mean pain intensity remained significantly lower during the 48 h following amantadine treatment as compared with the 48 h prior to treatment (31% reduction; P = 0.006), whereas no such effect was found with the placebo (6% reduction; P = 0.40). Amantadine, but not the placebo, also reduced 'wind up' like pain (caused by repeated pinpricking) in four patients. We conclude that amantadine infusion is a safe and effective acute treatment for surgical neuropathic pain in cancer patients. Further trials with long-term oral or parenteral amantadine treatment should be conducted.
Posted by ed_uk on May 14, 2005, at 18:17:59
In reply to Re: Desipramine in neuropathic pain » ed_uk, posted by franco neuro on May 13, 2005, at 22:46:42
PS. You mentioned antihistamines. Have you tried diphenhydramine (Benadryl)? Did it reduce your pain?
Ed.
Posted by franco neuro on May 14, 2005, at 22:09:37
In reply to Re: Desipramine in neuropathic pain » franco neuro, posted by ed_uk on May 14, 2005, at 9:42:17
Hi Ed,
Thanks for the useful information.
> I hope you don't mind me asking. What is the cause of your pain?
That is the million dollar question. I've had numerous opinions, but no doctor has been able to give me a real answer. Nothing showed up on MRI and basic blood work was always pretty normal. That is until the past year or so. My sedimentation rate went from 1 to 24. No doubt due to neurogenic inflammation. Cholesterol and homocysteine have shot up and testosterone has dropped (no doubt coinciding with plummeting dopamine levels).
I've been to psychologists. While it's always good to get stuff off of ones chest, it certainly didn't help me physically. I think Dr. Goldstein has really given me the answer. As explained in my previous post. Genetic predisposition, severe childhood stress, injuries (twice broken right arm), etc. Even though the causative factors may be long gone, the changes to the neural networks, receptors, synapses, etc., remain.
I started to feel something was physically amiss quite early on. But it really didn't start to impact my life until about 7 years ago. I went through a period of high stress (bad relationship, stressful work environment, stressful living situation, etc.) that I think started the downward spiral. I started having severe insomnia and started noticing strange sensations in my legs and weakness in my left foot. I've been on the medical merry-go-round ever since.
> But these treatments are not easy to 'get hold of'. Why don't you try the more usual treatments first? You could try desipramine next. Being interested in the NMDA receptor, I expect you've already tried dextromethorphan. Perhaps you could consider oral amantadine, IV amantadine has also been used.
All true. I think I can get the IV lidocaine. I've only located one doctor who does the IV ketamine. He's located about 4 hours drive from me. IV amantadine was Dr. Goldstein's third most effective treatment behind IV ketamine and IV lidocaine. I would like to try oral amantadine since it is an NMDA antagonist and a dopamine agonist. Desiprimine is on my list. I'm sure it will help with pain, but I still think I need to address the NMDA/glutamate issue. Desiprimine is also cheap. As is dextromethorphan. I haven't tried it yet. I want to. I've found out recently that Benedryl does indeed help with my visceral nerve pain. I just took one. Histamine is an NMDA agonist, so antihistamines are in effect indirect NMDA antagonists.
My biggest problem after all of these years is still trying to find a doctor who will work with me on getting to the bottom of this.
Posted by ed_uk on May 15, 2005, at 7:40:19
In reply to Re: Desipramine in neuropathic pain » ed_uk, posted by franco neuro on May 14, 2005, at 22:09:37
Hi Franco!
>I think I can get the IV lidocaine.
Perhaps you could try dextromethorphan first. You can get it without a prescription in the UK, I'm not sure about anywhere else though.
Kind regards,
Ed.
Posted by franco neuro on May 15, 2005, at 11:27:04
In reply to Re: Desipramine in neuropathic pain » franco neuro, posted by ed_uk on May 15, 2005, at 7:40:19
Hi Ed,
That's not a bad idea. To tell you the truth I'm not sure if it's available without a prescription here. It may well be. I still would like to try the IV's though. I've read of people having gotten long term relief from just one three or for hour IV of lidocaine or ketamine. Sometimes lasting up to three years! Dr. Goldstein refers to it as "instantaneous neural network reconfiguration." Though I'm sure it's rare, it's worth a try. Tomorrow's I'll make an appointment with the (probable) IV lidocaine doc. I can pick up a script for more gabapentin while I'm there and ask about dextromethorphan.
Posted by ed_uk on May 15, 2005, at 13:04:03
In reply to Re: Desipramine in neuropathic pain » ed_uk, posted by franco neuro on May 15, 2005, at 11:27:04
Hi,
Have a look for dextromethorphan (DXM HBr)here.......
Althought you're not going to be taking dextromethorphan recreationally, erowid provides some useful information as usual.....
http://www.erowid.org/chemicals/dxm/dxm_info2.shtml
http://www.erowid.org/chemicals/dxm/dxm.shtml
>Tomorrow's I'll make an appointment with the (probable) IV lidocaine doc.
I hope it goes well :-)
Kind regards,
Ed.
Posted by franco neuro on May 15, 2005, at 19:02:58
In reply to Re: Desipramine in neuropathic pain » franco neuro, posted by ed_uk on May 15, 2005, at 13:04:03
Thanks Ed,
I'd like to try and get some plain old dextromethorphan. I really don't feel like chugging cough syrup right now. :-)
Posted by ed_uk on May 16, 2005, at 10:16:57
In reply to Re: Desipramine in neuropathic pain » ed_uk, posted by franco neuro on May 15, 2005, at 19:02:58
Hi,
I think you used to be able to get it from chemical suppliers. I'm not sure if this is possible anymore due to the reports of misuse.
Ed.
Posted by gromit on May 17, 2005, at 0:17:27
In reply to Re: Desipramine in neuropathic pain » ed_uk, posted by franco neuro on May 15, 2005, at 19:02:58
> Thanks Ed,
>
> I'd like to try and get some plain old dextromethorphan. I really don't feel like chugging cough syrup right now. :-)If you follow the link Ed posted http://www.erowid.org/chemicals/dxm/dxm_info2.shtml there are several brands of DXM gelcaps listed.
Posted by franco neuro on May 17, 2005, at 10:39:09
In reply to Re: Desipramine in neuropathic pain » franco neuro, posted by gromit on May 17, 2005, at 0:17:27
Hi,
I took another look and there is a prodcut that's called DexAlone. It comes in a gelcap and is available without a prescription. May be worth a try.
Thanks,
Franco
Posted by ed_uk on May 17, 2005, at 14:10:17
In reply to Re: Dextromethorphan, posted by franco neuro on May 17, 2005, at 10:39:09
I hope it helps!
Ed.
Posted by stephano on June 16, 2005, at 2:24:46
In reply to Anyone TIRED on Wellbutrin XL?, posted by islandangel on March 19, 2005, at 22:29:23
Hi all,
I'm new to the forum- just stumbled across some of the posts in this thread which I found particularly interesting. NeuroFranco- I too have CFS (have been ill for around a decade now) and have followed the work of Goldstein. I am in Australia but was saving up to go and see him when I found he had retired. I have little doubt that (my version of) CFS is exactly what he talks about with his lymbic hypothesis. A big "Yes" to chemical smells/sensitivity too for me!Until recently, I had never found any medication that helped me. SSRIs and anything else that focussed on boosting serotonin did nothing and often made me worse.
It was when I CAME OFF a drug (effexor) that I finally had a good drug response. (This happened in the second year of my illness but nobody could ever tell me why it might have happened or how to recreate it). I had been on it for around 5 months (225mg), realised it wasn't doing anything good, so decided to come off it and worked down to zero over the course of a couple of weeks (which is obviously faster than is recommended). I then had a period of maybe 10-12 days where I felt (miraculously) pretty close to normal. Interesting considering many people talk of negative experiences when withdrawing from venlafaxine. It actually helped me. I had a similar response when I ceased Zoloft.
That was many years ago, and I then went through a full range of expensive, time-wasting alternative therapies. Nothing helped and I was still very ill with a range of symptoms, including moderate to severe endogenous mood disturbance (depression+ anxiety)
At the start of this year I thought again about the 'coming off effexor' phenomenon, as it was the only time over the past decade that I had felt better.
I came to the conclusion that dopamine might be involved.(Too long to explain how I came to this conclusion!) Although there are no antidepressants that specifically target dopamine here in Australia (Wellbutrin is only here as 'Zyban' for quitting smoking and is very expensive) a pharmacologist I spoke to reckoned that the noradrenaline reuptake inhibitor Edronax (reboxetine) also had some effect on dopamine. I was sceptical, but this drug did indeed help. (I think you have a different snri in the U.S...Cymbalta maybe???)
I can relate to the counter-intuitive experience of being rendered sleepy/exhausted by a stimulant, because edronax does that to me sometimes. It waxes and wanes..sometimes it helps quite a lot, sometimes it puts me to sleep, sometimes it helps with physical symptoms but not mood. (Although anxiety has been pretty well reduced)
One of the stranger symptoms I have had with this illness is very flaccid muscle tone. It happened suddenly at the start of the condition, not as a result of deconditioning or anything. The edronax works to improve that significantly, and improves muscle tone back up to near what it should be in a 30 year old. (my age) No idea why, although I had previously found that pseudophedrine in big enough doses improved muscle tone too. (So suspect it's something to do with CNS stimulation)
Anyway, the point of this post is to say that Edronax has, overall, made me more functional, but things like mood and libido are still not too good. Am going to bite the bullet and borrow money to try Wellbutrin (called 'Zyban' here, but it's the same drug, Bupropion)
I must admit that life has been a veritable nightmare since I was twenty, but I am finally seeing the tiniest hint of a light at the end of the tunnel.
Anyway- I hope the wellbutrin helps...if not, I may have to revert to the edronax and work out how to boost dopamine with a separate agent. Has anyone ever used any of the Parkinson's drugs off-label for this purpose?
Any input about anything most appreciated. Best wishes all....this is a great forum.
Posted by 4WD on June 17, 2005, at 21:49:45
In reply to Re: Anyone TIRED on Wellbutrin XL?, posted by stephano on June 16, 2005, at 2:24:46
Hi Stephano,
When I took Wellbutrin I had more physical energy but I had no inner motivation or enjoyment of it. I just needed to be active, moving around, working off nervous energy. It wasn't particularly pleasant. I also got insomnia. I could fall asleep okay but I would wake up half a dozen times and wouldn't be able to sleep long enough. OTOH I think I might have too much dopamine because zyprexa makes me feel much better (except I can't take it because I have an eating disorder that it wakes up).
Hope this helps.
Posted by SLS on June 18, 2005, at 7:48:06
In reply to Re: Anyone TIRED on Wellbutrin XL? » stephano, posted by 4WD on June 17, 2005, at 21:49:45
Hi.
> When I took Wellbutrin I had more physical energy but I had no inner motivation or enjoyment of it.
This is a common description of the nature of response to Wellbutrin. People who react this way to Wellbutrin often gain the motivation and enjoyment when a serotonergic is added to it (SSRIs, Effexor, Cymbalta). For a friend of mine, the addition of Effexor did the trick. The improvement in her depression and the attendant increases in functionality and enjoyment of life was marvelous to watch. She had spent most of her life in a state of moderate depression; fighting every day just to maintain a job and take out the garbage. She later switched the Effexor to Lexapro and now feels even better. I think the switch helped clear her mind, which had been left a bit foggy by the Effexor.Wellbutrin + SRI are complementary. That which one lacks, the other has and vice-versa. In addition, the Wellbutrin can act to reverse the apathy and sexual side effects of the SRI.
- Scott
Posted by TamaraJ on June 18, 2005, at 9:23:52
In reply to Re: Anyone TIRED on Wellbutrin XL?, posted by SLS on June 18, 2005, at 7:48:06
Scott,
I started Wellbutrin SR about 3 weeks ago, to augment the 75mg of nortrityline I have been taking. Would I be better off changing the nort for a SSRI like Lexapro, or does the Wellbutrin/nort combo have the potential to be a good one? It seems to be ok so far, and I am only at 100mg of Wellbutrin (which, I know, is not the therapeutic does). I went up to 150mg for 5 or 6 days, but ended up with really bad heads (almost migraine-like). I am going to try 100mg a.m. and 100mg p.m. (early afternoon) to see if that is more tolerable. The 150mg all at once seems to affect me badly for some reason :-(
Thanks.
Tamara
Posted by SLS on June 18, 2005, at 9:53:46
In reply to Re: Anyone TIRED on Wellbutrin XL? - ? for Scott » SLS, posted by TamaraJ on June 18, 2005, at 9:23:52
Hi Tamara.
How are you feeling right now?
> I started Wellbutrin SR about 3 weeks ago, to augment the 75mg of nortrityline I have been taking.
You might want to try moving up the dosage of nortriptyline to 100mg.
> Would I be better off changing the nort for a SSRI like Lexapro, or does the Wellbutrin/nort combo have the potential to be a good one?
Hmm. I wish I could answer this question for you. I know how much easier your decision-making process would be by having a definitive answer.
Do you think the Wellbutrin has helped at all?
> It seems to be ok so far, and I am only at 100mg of Wellbutrin (which, I know, is not the therapeutic does). I went up to 150mg for 5 or 6 days, but ended up with really bad heads (almost migraine-like). I am going to try 100mg a.m. and 100mg p.m. (early afternoon) to see if that is more tolerable. The 150mg all at once seems to affect me badly for some reason
:-(
I'm not a real big advocate of the XL once-a-day prescription. If I were taking Wellbutrin, I would take the SR version twice a day morning and evening.
Perhaps someone can provide some input as to the possibility that it is the nortriptyine that is acting as a catalyst to produce the headaches you get when you try to increase the dosage of Wellbutrin. It is conceiveable that you can take larger dosages of Wellbutrin in the absence of nortriptyline. I think I would proceed in the following sequence if I wanted to build a treatment around Wellbutrin:
1. Increase nortriptyline to 100mg; return to 75mg only if depression gets worse.
2. Switch to twice a day schedule of Wellbutrin of SR or XL: morning and evening.
3. Increase dosage of Wellbutrin gradually to 300mg.
4. If you cannot tolerate the higher dosages of Wellbutrin, discontinue nortriptyline. If tolerated, continue with the nortriptyline.
5. Attempt to increase the dosage of Wellbutrin to 300mg
6. Add to the Wellbutrin the SRI that you had the best response to in the past. These would include the SSRIs, Effexor, and Cymbalta. You can continue taking the nortriptyline.
If you prefer to stay with nortriptyline or cannot tolerate a higher dosage of Wellbutrin in its absence, you can discontinue the Wellbutrin, restart the nortriptyline if necessary and add Parnate, Effexor, or Cymbalta.
- Scott
Posted by TamaraJ on June 18, 2005, at 10:20:59
In reply to Re: Anyone TIRED on Wellbutrin XL? - ? for Scott » TamaraJ, posted by SLS on June 18, 2005, at 9:53:46
> Hi Tamara.
>
> How are you feeling right now?
>
-- I am feeling not too bad, not too bad at all. I think I am almost there actually, which is a nice feeling.
>
> You might want to try moving up the dosage of nortriptyline to 100mg.
>
-- I tried to up the nort to 100mg a number of weeks ago, and it left me really sluggish and slow the next day. I tried the 100mg for a number of days, but it seemed to actually make me feel worse. Must be that therapeutic window thing. So, I went back to 75mg, and I was fine, but still lacking energy and motivation (I am, by nature, a somewhat hyper, high energy person, so my expectations may be too high really).
>
> Hmm. I wish I could answer this question for you. I know how much easier your decision-making process would be by having a definitive answer.
>
-- I know, it is so much a case of trial and error. I don't have any significant adverse effects with the Wellbutrin/nort combo, so I will stick with it for a while. Plus, my understanding is that nort works on serotonin as well, so I assume it is much like a SNRI?
>
> Do you think the Wellbutrin has helped at all?
>
-- Oh, yes, I have noticed a difference in my mood, my energy levels and my motivation, even at 100mg. Not an enormous difference, but enough that I am encouraged. So, I am going to try hard to tolerate a higher dose to get me over the last of the hump.
>
> I'm not a real big advocate of the XL once-a-day prescription. If I were taking Wellbutrin, I would take the SR version twice a day morning and evening.
>
-- I have heard negative things about the XL version. I am going to stick with the SR version. I think Minnie was saying that she also had a negative reaction to the 150mg tab, but when she takes 2, 100mg tabs, no negative reaction. Weird.
>
> Perhaps someone can provide some input as to the possibility that it is the nortriptyine that is acting as a catalyst to produce the headaches you get when you try to increase the dosage of Wellbutrin. It is conceiveable that you can take larger dosages of Wellbutrin in the absence of nortriptyline.-- I am wondering if the headaches were caused by my smoking. I have been trying to quit, and have cut down significantly since starting the Wellbutrin, but still have about 10 smokes a day. I wonder if the increased dose of Wellbutrin, combined with smoking, was producing migraine-like headaches. For some reason, that would make sense to me, and it was something that dawned on me this morning.
>
I think I would proceed in the following sequence if I wanted to build a treatment around Wellbutrin:
>
> 2. Switch to twice a day schedule of Wellbutrin of SR or XL: morning and evening.
>
-- I think you are right on here. I am going to try this, starting tomorrow, to see how I respond. Hopefully, there will be no problems. Actually, I have been quite fortunate with both the nort and the Wellbutrin. With the exception of some start-up side effects the first couple of weeks, I have not been troubled by much in terms of continuing side effects (knock on wood :-)).
>
> 3. Increase dosage of Wellbutrin gradually to 300mg.
>
-- Yes, depending on how I respond to the 200mg (in two doses), I would go up to 300mg if more antidepressant effect is needed. I am hoping that 200mg will do it for, since I really am almost there (yipes, I hope I have jinxed myself now).
>
> If you prefer to stay with nortriptyline or cannot tolerate a higher dosage of Wellbutrin in its absence, you can discontinue the Wellbutrin, restart the nortriptyline if necessary and add Parnate, Effexor, or Cymbalta.
>
-- I am a bit nervous of MAOIs, but I would certainly consider one if the nort/wellbutrin combo ends up proving disappointing. I have tried Effexor, and it was not good for me (had some continuing side effect problems that ended up causing even bigger problems). And, unfortunately, Cymbalta is not available in Canada yet :-(Thanks so much, Scott, for taking the time to respond to my questions. I really appreciate it. I was just curious to know if one of the newer ADs might work better with the Wellbutrin than the nort, but I am optimistic about the combo on am on now. So I hope things just continue to get better.
All the best, and take good care of yourself.
Tamara
Posted by ed_uk on June 18, 2005, at 10:38:58
In reply to Re: Anyone TIRED on Wellbutrin XL? - ? for Scott » SLS, posted by TamaraJ on June 18, 2005, at 10:20:59
Hi T!
>Wellbutrin
Perhaps you won't need to increase your Well dose any further. Maybe, after a couple more weeks on your current dose, you'll be feeling much better...
Ed xx
Posted by TamaraJ on June 18, 2005, at 12:42:56
In reply to Re: Anyone TIRED on Wellbutrin XL? - ? for Scott » TamaraJ, posted by ed_uk on June 18, 2005, at 10:38:58
> Hi T!
>
> >Wellbutrin
>
> Perhaps you won't need to increase your Well dose any further. Maybe, after a couple more weeks on your current dose, you'll be feeling much better...
>
-- I wonder. Oh, no, decisions, decisions. I think I am going to try 200mg (in two doses) tomorrow or Monday just to see if I can tolerate it and to see if it makes me feel even better. What the heck, it's still not a high dose. I have also been taking Pregnenolone and DHEA (in very small doses) for a couple of weeks. I think they have helped in some way as well. My hormones were totally screwed up from the Depo months ago, so perhaps the Pregnenolone and DHEA are helping to bring them back into balance. Who knows. All I know is that I want to be me again, and I think (and hope and pray) that I am almost there.
Tamara
xoxo
Posted by ed_uk on June 18, 2005, at 14:27:30
In reply to Re: Anyone TIRED on Wellbutrin XL? - ? for Scott » ed_uk, posted by TamaraJ on June 18, 2005, at 12:42:56
Hi T!
>I think I am going to try 200mg (in two doses) tomorrow or Monday just to see if I can tolerate it and to see if it makes me feel even better.
I hope it helps :-) .......and it doesn't make you irritable :-O
Ed xxx
Posted by 4WD on June 18, 2005, at 15:45:19
In reply to Re: Anyone TIRED on Wellbutrin XL?, posted by SLS on June 18, 2005, at 7:48:06
> Hi.
>
> > When I took Wellbutrin I had more physical energy but I had no inner motivation or enjoyment of it.
>
>
> This is a common description of the nature of response to Wellbutrin. People who react this way to Wellbutrin often gain the motivation and enjoyment when a serotonergic is added to it (SSRIs, Effexor, Cymbalta). For a friend of mine, the addition of Effexor did the trick. The improvement in her depression and the attendant increases in functionality and enjoyment of life was marvelous to watch. She had spent most of her life in a state of moderate depression; fighting every day just to maintain a job and take out the garbage. She later switched the Effexor to Lexapro and now feels even better. I think the switch helped clear her mind, which had been left a bit foggy by the Effexor.
>
> Wellbutrin + SRI are complementary. That which one lacks, the other has and vice-versa. In addition, the Wellbutrin can act to reverse the apathy and sexual side effects of the SRI.
>
>
> - Scott
>Unfortunately the Wellbutrin also increased anxiety for me. And the insomnia was a big problem. I know I could add more Klonopin to counteract the anxiety and a sleeping med to counteract the insomnia but I get to the point of thinking okay I'm taking one med for this and another to counteract the effects of the first med and so on. I remember your post about if you want to play you've gotta pay but I guess I'm just stubborn and not quite miserable enough to be willing to put up with four sets of side effects.
In my heart I want to be med free or conquer this with a minimum of medication plus supplements and exercise. I don't know if this will work but I've never tried it before so I might as well give it at least as long of a shot as I have given specific meds. And I keep hoping that my former abuse of pain meds was a large part of the cause of my depression and that now that I'm free of that, I can get better depression wise (with time).
Marsha
>
Go forward in thread:
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
[email protected]
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.