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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by linkadge on February 12, 2005, at 10:22:07
Seeing psychiatrist soon. Going to push for a TCA trial.
My problems are: Sleep, anxiety, depression, migrane.
But. I would like to avoid amitryptaline if possable since am in university and having enought cognative problems as is.
Can anyone who knows TCA's help me ??
Linkadge
Posted by SLS on February 12, 2005, at 10:57:45
In reply to need TCA advice, posted by linkadge on February 12, 2005, at 10:22:07
> Seeing psychiatrist soon. Going to push for a TCA trial.
>
> My problems are: Sleep, anxiety, depression, migrane.
>
> But. I would like to avoid amitryptaline if possable since am in university and having enought cognative problems as is.
>
> Can anyone who knows TCA's help me ??
>
> Linkadge
>
Perhaps nortriptyline should be your first choice. It might retain the anti-migraine properties of amitripyline while sparing you the antimuscarinic effects (both cognitive and peripheral) and the sedation/somnolence that most often accompanies amitriptyline.If your brain is medication-naive (a virgin) to nortripyline and amitripyline, you might experience sedation or somnolence at the beginning of nortriptyline treatment. This should pass withing a week or so. You might want to start it on a Friday night, and hope that any somnolence that might occur abates by Monday.
Although lower dosages can be used for migraine, I would suggest making your initial target dosage of nortriptyline to be 75mg to treat depression. Wait 10-14 days after attaining this dosage and then test your blood levels. Of the TCAs, nortriptyline has been the most closely studied with regard to blood-levels and antidepressant response; the range being 50-150 ng/ml. You can see that with such a large range, the blood test should be used as a flexible guide rather than an absolute indication. Nortripyline is perhaps the only antidepressant that has a window of efficacy (as opposed to a therapeutic window). If you surpass your optimum dosage range (hopefully, you will have one), you can actually lose the antidepressant response. More is worse, not better. Either stick to the name brand Pamelor, or try to procure a generic for which the manufacturer remains the same when you fill your prescriptions.
- Scott
Posted by SLS on February 12, 2005, at 11:58:20
In reply to Re: need TCA advice » linkadge, posted by SLS on February 12, 2005, at 10:57:45
I forgot to mention to those who are not familiar with tricyclic antidepressants (TCA) that amitripyline is converted to nortriptyline in the body. Nortripyline is an active metabolite of amitriptyline that produces milder side effects while retaining much of the therapeutic benefit of the parent compound.
Drugs like imipramine and amitripyline are considered to be tertiary tricyclics while their metabolites, desipramine and nortriptyline respectively, are labelled secondary. The tertiary compounds exert a stronger anticholinergic side effect profile as well as being more serotonergic than the secondaries. They are sometimes considered to be more potent antidepressants. Tertiary versus secondary describes molecular structure. Most of the TCAs are tertiary. I believe protriptyline is the only other secondary TCA available as a medication. I don't know if it is derived from a tertiary compound and how its side effect profile might compare to one.
- Scott
> > Seeing psychiatrist soon. Going to push for a TCA trial.
> >
> > My problems are: Sleep, anxiety, depression, migrane.
> >
> > But. I would like to avoid amitryptaline if possable since am in university and having enought cognative problems as is.
> >
> > Can anyone who knows TCA's help me ??
> >
> > Linkadge
> >
>
>
> Perhaps nortriptyline should be your first choice. It might retain the anti-migraine properties of amitripyline while sparing you the antimuscarinic effects (both cognitive and peripheral) and the sedation/somnolence that most often accompanies amitriptyline.
>
> If your brain is medication-naive (a virgin) to nortripyline and amitripyline, you might experience sedation or somnolence at the beginning of nortriptyline treatment. This should pass withing a week or so. You might want to start it on a Friday night, and hope that any somnolence that might occur abates by Monday.
>
> Although lower dosages can be used for migraine, I would suggest making your initial target dosage of nortriptyline to be 75mg to treat depression. Wait 10-14 days after attaining this dosage and then test your blood levels. Of the TCAs, nortriptyline has been the most closely studied with regard to blood-levels and antidepressant response; the range being 50-150 ng/ml. You can see that with such a large range, the blood test should be used as a flexible guide rather than an absolute indication. Nortripyline is perhaps the only antidepressant that has a window of efficacy (as opposed to a therapeutic window). If you surpass your optimum dosage range (hopefully, you will have one), you can actually lose the antidepressant response. More is worse, not better. Either stick to the name brand Pamelor, or try to procure a generic for which the manufacturer remains the same when you fill your prescriptions.
>
>
> - Scott
Posted by linkadge on February 12, 2005, at 12:03:08
In reply to Re: need TCA advice, posted by SLS on February 12, 2005, at 11:58:20
Where does clomipramine fit into the picture?
The only reason I am concerned is that if I swich abruptly from a SSRI Zoloft to a NRI, like nortrip, this might be a big change.
Linkadge
Posted by Ritch on February 12, 2005, at 12:50:21
In reply to Re: need TCA advice, posted by linkadge on February 12, 2005, at 12:03:08
> Where does clomipramine fit into the picture?
>
> The only reason I am concerned is that if I swich abruptly from a SSRI Zoloft to a NRI, like nortrip, this might be a big change.
>
> LinkadgeI wouldn't write off amitriptyline too quick since it has the benefits for migraine prophylaxis *and* also has a significant amount of serotonergic activity. It *is* very very sedative though on start up. However, I found doxepin to be more sedative than amitrip. Also, from what I remember .. the last time I was on amitrip. was just 10mg twice daily and I definitely noticed an improvement in focus and attention, but it was slow in coming.. it took nearly a month. The reason I stopped it was oddly enough a lack of impulsive spontaneity that other people commented about.. it definitely didn't seem to make my bipolar worse.. I can see where it would be a good ADD med for some.. if you can tolerate it the start up and it doesn't cause too much postural hyotension, etc. Nort. worked good on ADD sx also, but with less side effects (no postural hypotension and could take it easily in the day).. but the amitrip. seemed a lot more anxiolytic. Never tried clomipramine. Tried imipramine and didn't like it. Tried desipramine, but it *caused* too much anxiety. There are people that take a mix of *both* amitrip. and nortrip. to balance the benefits and s/e's of each one.
Posted by SLS on February 12, 2005, at 12:58:06
In reply to Re: need TCA advice, posted by linkadge on February 12, 2005, at 12:03:08
> Where does clomipramine fit into the picture?
>
> The only reason I am concerned is that if I swich abruptly from a SSRI Zoloft to a NRI, like nortrip, this might be a big change.
>
> LinkadgeZoloft would result in an increase (doubling?) of nortriptyline levels via its inhibition of cytochrome P450 2D6. It might be problematic to taper the Zoloft while simultaneously titrating the nortriptyline. You could probably do it if you take this into account and titrate the nortriptyline more slowly until you finished tapering the Zoloft. Maybe start at 10mg and raise the dosage by 10mg every 5 days as you taper the Zoloft over a period of two weeks (total guestimate). Then move up to 75mg. Clomipramine possesses the most potent antidepressant properties of all the TCAs. I don't know about migraines, though. Clomipramine will produce side effects that seem to be a combination of those of a tertiary TCA and those of a SSRI. Clomipramine is imipramine with a chlorine attached to it.
- Scott
Posted by linkadge on February 12, 2005, at 13:32:22
In reply to Re: need TCA advice, posted by SLS on February 12, 2005, at 12:58:06
I'm really leaning towards clomipramine. Perhaps with a little lithium or depakote.
I just hope this doctor listens and is willing to try a suggestion or two.
Linkadge
Posted by linkadge on February 12, 2005, at 13:37:21
In reply to Re: need TCA advice, posted by linkadge on February 12, 2005, at 13:32:22
What makes you say clomipramine has the most antidepressant activity ??
Linkadge
Posted by SLS on February 12, 2005, at 20:15:44
In reply to Re: need TCA advice, posted by linkadge on February 12, 2005, at 13:37:21
> What makes you say clomipramine has the most antidepressant activity ??
>
> Linkadge
This was the viewpoint of many of the doctors I spoke to before the advent of SSRIs, after which the TCAs were relegated to 3rd or 4th line treatments, and the superiority of clomipramine forgotton.
- Scott
This is the end of the thread.
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