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Dr. Bob is Robert Hsiung, MD,
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Posted by SLS on June 13, 2005, at 22:12:41
In reply to Re: Amitriptyline - Therapeutic window or not » SLS, posted by Sarah T. on June 13, 2005, at 21:25:17
> > > > If you try reducing the dosage quickly, you might experience a reboud improvement that lasts a few hours to a few days.> - Scott
>
> Hi Scott.
>
> I have experienced this brief rebound improvement when withdrawing from TCA's. I would like to know why that happens. Do you know?No, but I bet the answer would yield a great clue as to why they work in the first place. I think it might involve forcing the system to establish a new equilibrium in response to a changing environment. Perhaps it takes a few hours to a few days for the receptors to respond to the new conditions after a dosage reduction. In the meantime, the brain tries to maintain a homeostasis built around a dysfunctional state. When it is successful, you relapse. When unsuccessful, you get well. I think this is why a drug like Tianeptine, a serotonin reuptake accelerator can mimick the effects of SSRIs, even though these drugs exert exactly the opposite effect at the synapse. It forces the system to compensate for either condition. Hopefully, when compensation occurs, the system will settle and reregulate itself and establish the dynamics according to the original genetic blueprint. This is just me thinking out loud.
- Scott
Posted by ed_uk on June 14, 2005, at 7:43:21
In reply to Re: Amitriptyline - Therapeutic window or not, posted by SLS on June 13, 2005, at 22:12:41
Hi Scott!
>Hopefully, when compensation occurs, the system will settle and reregulate itself and establish the dynamics according to the original genetic blueprint.
A bit like shocking the heart to terminate an arrhythmia.
~Ed
Posted by ed_uk on June 14, 2005, at 7:54:32
In reply to Amitriptyline - Therapeutic window or not, posted by cliffstone on June 13, 2005, at 18:13:05
Hi cliffstone,
>Now I´m on 300 mg with fairly poor results.
Since you're on a high dose, have you had an ECG for safety reasons?
>I have found various studies and a few posts on this message board concerning a possible therapeutic window of amitriptyline. By further investigating this topic I found that there are quite a lot of contradicting information.
That's very true. Have you had your blood level measured? Are you having any side effects?
In a textbook I've got, the following is suggested........
AMITRIPTYLINE: serum or plasma specimen, trough level ie. >12hrs after the last dose.
Therapeutic: 120-250ng/mL
Toxic: >500ng/mLNORTRIPTYLINE: serum or plasma specimen, trough level ie. >12hrs after the last dose.
Therapeutic: 50-150ng/mL
Toxic: >500ng/mLNortriptyline is a metabolite of amitriptyline.
Kind regards,
Ed.
Posted by cliffstone on June 14, 2005, at 10:27:27
In reply to Re: Amitriptyline - Therapeutic window or not, posted by SLS on June 13, 2005, at 21:17:11
Hi Scott
Thanks ever so much for your input. My official diagnosis is distymia. My own diagnosis is additional mild social phobia and/or avoidant personality with anhedonia and very poor mood reactivity. Depression is worse in the morning. I´ve tried Lexapro, Effexor, Paxil, Anafranil, Nortriptyline together with an antipsychotic, Prozac in combination with Zyprexa, Moclobemide, amisulride, sulpride, Mirapex, Reboxetine, buprenorfine, amatadine, lithium, trazodone, Remeron and some others which I can´t even remember. I have to admit though that not all of the above trials were fair. Sometimes I quit after 2 weeks of nonresponse.
I´ve had a 3 weeks response to the nortrip combo, and a respone to mirapex and amisulpride that lasted a few days. Buprenorfine always works but I don´t like to take opioids. To the Prozac/Zyprexa combo I had a response that lasted a few hours. Basically I´m fairly treatment resistant.
I´ve been taking the amitrip for about 8 weeks and it doesn´t show any effect most of the time but still sometimes it works so I consider myself a partial responder. Since I get quite desperate from time to time I would really appreciate any input concerning alternative treatment options or augmenting strategies.
Looking foreward to hearing from you.
Posted by cliffstone on June 14, 2005, at 10:30:35
In reply to Re: Amitriptyline - Therapeutic window or not » cliffstone, posted by Phillipa on June 13, 2005, at 18:30:18
Hi Philipa,
Yes I´ve done extensive research but since there are contradicting studie I plainly don´t know what to do.
Regards
Posted by cliffstone on June 14, 2005, at 10:42:09
In reply to Re: Amitriptyline - Therapeutic window or not » cliffstone, posted by ed_uk on June 14, 2005, at 7:54:32
> Hi cliffstone,
>
> >Now I´m on 300 mg with fairly poor results.
>
> Since you're on a high dose, have you had an ECG for safety reasons? Not yet, but in case the amtrip works I will.
>
> >I have found various studies and a few posts on this message board concerning a possible therapeutic window of amitriptyline. By further investigating this topic I found that there are quite a lot of contradicting information.
>
> That's very true. Have you had your blood level measured? Are you having any side effects? No, I haven´t had my blood checked yet. Apart from the usual dry mouth and constipation. Initially I had tachycardia but that´s mostly gone.
>
> In a textbook I've got, the following is suggested........
>
> AMITRIPTYLINE: serum or plasma specimen, trough level ie. >12hrs after the last dose.
>
> Therapeutic: 120-250ng/mL
> Toxic: >500ng/mL
>
> NORTRIPTYLINE: serum or plasma specimen, trough level ie. >12hrs after the last dose.
>
> Therapeutic: 50-150ng/mL
> Toxic: >500ng/mL
>
> Nortriptyline is a metabolite of amitriptyline.
>
> Kind regards,
> Ed.
>
Kind regards
Posted by SLS on June 14, 2005, at 11:15:23
In reply to Re: Amitriptyline - Therapeutic window or not, posted by cliffstone on June 14, 2005, at 10:42:09
The term "therapeutic window" actually does not refer to an "efficacy window" as is the case with nortriptyline. A therapeutic window is that range of dosages that produce efficacy while preserving tolerability. The upper range of nortriptyline is an efficacy window while the upper range of amitriptyline is a therapeutic window. If you were to continue raising the dosage of nortriptyline, it would still be tolerable, but ineffective. Were you to continue to raise the dosage of amitriptyline, you would retain efficacy, but the side effects will become intolerable.
Does that make any sense?
I think this is where you find contradiction in your interpretation of the literature.
- Scott
Posted by cliffstone on June 14, 2005, at 11:28:21
In reply to Re: Amitriptyline - Therapeutic window or not » cliffstone, posted by SLS on June 14, 2005, at 11:15:23
Hi Scott
Very interesting - didn´t know that. Do you have any idea how and with what to augment he amtrip. Also I would be very gratful to hear about other tratment options for mt condicion.
Best regards
Posted by ed_uk on June 14, 2005, at 14:21:04
In reply to Re: Amitriptyline - Therapeutic window or not, posted by cliffstone on June 14, 2005, at 10:27:27
Hi Cliffstone,
>My official diagnosis is distymia. My own diagnosis is additional mild social phobia and/or avoidant personality with anhedonia and very poor mood reactivity. Depression is worse in the morning. I´ve tried Lexapro, Effexor, Paxil, Anafranil, Nortriptyline together with an antipsychotic, Prozac in combination with Zyprexa, Moclobemide, amisulride, sulpride, Mirapex, Reboxetine, buprenorfine, amatadine, lithium, trazodone, Remeron and some others which I can´t even remember.
Have you tried phenelzine (Nardil) or tranylcypromine (Parnate)???
~Ed
Posted by cliffstone on June 14, 2005, at 14:55:03
In reply to Re: Amitriptyline - Therapeutic window or not » cliffstone, posted by ed_uk on June 14, 2005, at 14:21:04
Hi Ed
Thanks for your input. I live in Mexico and this has a good side and a bad one. The good thing is that I get everything, but really everything over the counter without prescription. The downside is that both meds are not available in Mexico. So I might have to consider some mailorder service.
Cheers anyway
Posted by SLS on June 14, 2005, at 15:32:07
In reply to Re: Amitriptyline - Therapeutic window or not, posted by cliffstone on June 14, 2005, at 11:28:21
> Hi Scott
>
> Very interesting - didn´t know that. Do you have any idea how and with what to augment he amtrip. Also I would be very gratful to hear about other tratment options for mt condicion.
>
> Best regards
What you experienced with your brief 2-day response to amitriptyline is known as tachyphylaxis. It might be an indicator that you will need a mood-stabilizer. Lithium might be a good place to start. Some people feel better within 3 days of adding it to a TCA. On the other hand, many people don't like the way they feel on lithium. They feel flat and unmotivated. However, it is still worth a try. It is easy enough to do, and you would get your answer quickly. If nothing happens in 7-10 days, it probably won't work. I would recommend a dosage of 600mg. If it helps, you can try lowering the dosage later.Other mood stabilizers that are available in the US include:
Tegretol
Trileptal
Depakote
Lamictal
Keppra
TopamaxNeurontin (unproven)
Gabatril (unproven)
Pregabalin (unproven)Which of these do you have available to you?
Which of the drugs that you have tried did you have a partial response to?
- Scott
Posted by cliffstone on June 14, 2005, at 16:17:39
In reply to Re: Amitriptyline - Therapeutic window or not, posted by SLS on June 14, 2005, at 15:32:07
Hi Scott
Really appreciate your efforts to help. Ive taken Lithium in the past as an augmentor to something I don´t remember. Still got some at home and will give it a shot. Flat and unmotivated, that pretty well describes my current state of mind and I don´t think I could be still flatter and less motivated than I am at the moment.
Lamictal I have tried in the past without any effect or side effect for that matter. Even though that I ramped up the dose pretty fast.
I will check availability of the other mood stabilizers.
Be in touch
Wolf (my real name)
Posted by ed_uk on June 14, 2005, at 17:07:00
In reply to Re: Amitriptyline - Therapeutic window or not, posted by cliffstone on June 14, 2005, at 14:55:03
Hi Wolf,
It is possible to get Nardil and Parnate in Mexico somehow. Tepiaca lives in Mexico and he takes Nardil.
Kind regards,
Ed.
Posted by Tepiaca on June 14, 2005, at 22:00:29
In reply to Calling Tepiaca: we need your help!!! » cliffstone, posted by ed_uk on June 14, 2005, at 17:07:00
> Hi Wolf,
>
> It is possible to get Nardil and Parnate in Mexico somehow. Tepiaca lives in Mexico and he takes Nardil.
>
> Kind regards,
> Ed.Hi Ed! ,
how r you my friend? . I saw your mail. I am here =)Hi Wolf !
wow , it´s not common to find mexican people here.
Maybe you are the second person I have known in psychobabbleWolf, in which city do you live ?? .
As well like you, I have tied a lot of medicines in the past. Nardil has been the best by much.
I have been 2 years on it.If you live in a big city, you may want to look in pharmacies that have US medicines. I sometimes buy Nardil in pharmacies of this kind , unfortunately Nardil is very expensive , it costs 110 US dolars. That is why I rather travel to the frontier of Mexico in Texas, wich is very near from here , and buy the bottle for only 63 US dolars.
Please feel free to make any question. I´ll help you gladlyTEPI =)
Posted by ed_uk on June 15, 2005, at 9:36:22
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED, posted by Tepiaca on June 14, 2005, at 22:00:29
Hi Tepi!
Thanks for helping Wolf :-)
>how r you my friend?
I'm ok thank you :-) I just restarted Celexa for anxiety. How are you? I hope the Nardil is still working well and the side effects are not too bad :-)
Greetings!
Ed.
Posted by cliffstone on June 15, 2005, at 9:58:36
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED, posted by Tepiaca on June 14, 2005, at 22:00:29
Hi Tepi:
Que onda
Actually I´m German but I´ve been living in Mexico City for a few years so I´m some sort of a "chilango aleman". I´ve seen previous posts on this message board from you and I would greatly appreciate some help from your side, if possible.
For my condition which is some sort of dysthymia mixed with generalized anxiety and a mild form of social phobia I have been recommended Parnate on various occasions. Unfortunately I haven´t been able to get it anywhere. So if you could help me out with a source preferably in D.F. that would be absolutely fantastic.
In any case I give you my email which is: [email protected]
Saludos y un abrazo
Wolf
Posted by Tepiaca on June 15, 2005, at 19:18:16
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED, posted by cliffstone on June 15, 2005, at 9:58:36
> Hi Tepi:
>
> Que onda
>
> Actually I´m German but I´ve been living in Mexico City for a few years so I´m some sort of a "chilango aleman". I´ve seen previous posts on this message board from you and I would greatly appreciate some help from your side, if possible.
>
> For my condition which is some sort of dysthymia mixed with generalized anxiety and a mild form of social phobia I have been recommended Parnate on various occasions. Unfortunately I haven´t been able to get it anywhere. So if you could help me out with a source preferably in D.F. that would be absolutely fantastic.
>
> In any case I give you my email which is: [email protected]
>
> Saludos y un abrazo
>
> Wolf
Hi wolf , I have really no idea where you can buy Parnate in Mexico City. I only have been there 3 or 4 times in my life. What you need to do is to find a pharmacie that import US medicament. I am sure there must be a lot of them over there. Look in the "Sección Amarilla", or ask it to some doctors or friends. Parnate must be in 1100 pesos more or less. Try to do this and tell me what was your luck.Suerte Camarada
Tep
Posted by Tepiaca on June 15, 2005, at 19:22:35
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED » Tepiaca, posted by ed_uk on June 15, 2005, at 9:36:22
> Hi Tepi!
>
> Thanks for helping Wolf :-)
>
No problem Ed
>>
How are you? I hope the Nardil is still working well and the side effects are not too bad :-)
>mmm, it is not working as well as in the last week. Something happened, I dont know what it is.
I increased Seroquel to 75mg to see If I can get the same benefit. Hope this can works
Posted by ed_uk on June 15, 2005, at 19:28:14
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED » ed_uk, posted by Tepiaca on June 15, 2005, at 19:22:35
Hi Tepi!
>I increased Seroquel to 75mg to see If I can get the same benefit. Hope this can works
Me too :-)
~Ed
Posted by cliffstone on June 20, 2005, at 10:43:30
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED » cliffstone, posted by Tepiaca on June 15, 2005, at 19:18:16
Hi Tepiaca
Many thanks for your support. As a matter of gfact I have already checked the seccion amarilla but have been unsuccessful so far. An advantage may be that I travel a lot to the north of Mexico, mainly Saltillo and Monterrey. So if you could tell me where in Mexico you get the Parnate I mayby could go there during one of my trips to the nortt. Also it would be interesting to know if I would need a prescription or not. I have a farmacia right around the corner and they are my cuates and sell me everything.
Thanks in advance for your help.
Saludos
Wolf
Posted by cliffstone on June 22, 2005, at 11:02:23
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED, posted by cliffstone on June 20, 2005, at 10:43:30
Hi Tepiaca
It would be great to know where in Mexico you have bought your Nardil and/or Parnate and if you need a prescription to get it. I have done some extensive research, but I couldn´t find a pharmacy selling imported meds.
Saludos
Wolf
Posted by Tepiaca on June 23, 2005, at 21:12:07
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED, posted by cliffstone on June 22, 2005, at 11:02:23
> Hi Tepiaca
>
> It would be great to know where in Mexico you have bought your Nardil and/or Parnate and if you need a prescription to get it. I have done some extensive research, but I couldn´t find a pharmacy selling imported meds.
>
> Saludos
>
> Wolf
Hola Wolf
Here in Monterrey you can buy Nardil or Parnate in "Farmacia las lomas". It is in front of the Hospital San Jose. I don´t know how much you know the city, but it is very easy to locate this pharmacy. Rigth now I don´t have the telephone number, let me ask for it and I´ll let you know it
You don´t need prescription to buy them, nor Nardil nor ParnateCualquier otra cosa que necesites avisame y con gusto te ayudo
SaludosTep
Posted by cliffstone on June 27, 2005, at 10:39:06
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED » cliffstone, posted by Tepiaca on June 23, 2005, at 21:12:07
Hola Tepi
You are marvelous - You don´t know how much I appreciate your help. We have an office in Saltillo and I can make some of my people get the Parnate and send it to D.F.
In any case if you can find out their telephone No. that would be fantastic. Maybe I can pay by credit card and have it sent to me by DHL or someting like that.
Saludos y un abrazo
Wolf
Posted by cliffstone on June 27, 2005, at 11:06:49
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED » cliffstone, posted by Tepiaca on June 23, 2005, at 21:12:07
Hola Tepi
Just got the telephone no. of Farmacia las Lomas from the internet. They do mailorder service in all of Mexico for 150 Pesos. Sounds reasonable to me.
Thanks again Ed and Tepi.
When I come to Mty the next time we ought to have a coffee in the barrio antiguo.
Saludos
Wolf
Posted by Tepiaca on June 28, 2005, at 0:03:13
In reply to Re: Calling Tepiaca: we need your help!!!Wolf-ED, posted by cliffstone on June 27, 2005, at 11:06:49
> Hola Tepi
>
> Just got the telephone no. of Farmacia las Lomas from the internet. They do mailorder service in all of Mexico for 150 Pesos. Sounds reasonable to me.
>
> Thanks again Ed and Tepi.
>>
> Saludos
>
> WolfThat is great Wolf !
So you are starting Parnate ?..... I wish you good luck.> When I come to Mty the next time we ought to have a coffee in the barrio antiguo.
Of course, stay in touch, don´t hesitate to ask for help.
Muchas suerte amigo!
Tep
This is the end of the thread.
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