![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 43 to 67 of 121. Go back in thread:
Posted by JadeKelly on January 15, 2009, at 9:17:24
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 15, 2009, at 7:28:03
> Hi.
>
> I'm starting to lose it. Depression is re-ermerging. Some derealization, too. I am still only taking 50% of the dosage of desipramine that I think I'll need. I'm not terribly scared, but I wish I could treat myself with this one. I do respect my doctor's wishing to be cautious and do no harm. I just wish that these were better days. I feel like they are being wasted.
>
> Feeling lonely and old...
>
>
> - ScottHi Scott,
I wish there were something I could do. Depression Sucks. Just remember it will end. How long until you get to 100% desipramine dosage? I haven't taken it so I don't know how long it takes to work. I'm sorry you're lonely but we're here...and I've heard you're not old, so. I hope this goes quickly for you and take good care of yourself. You're a good guy and you deserve to be well. Better days are coming.
;-)
Patient patient, Jade
Posted by JadeKelly on January 15, 2009, at 12:27:28
In reply to Re: I want to switch from nortriptyline to desipramine » SLS, posted by JadeKelly on January 15, 2009, at 9:17:24
Hi Scott,
Hope you're feeling even a little better would be nice, heh? Anyway, I'm looking for a new Doc and came across something interesting. Don't know if you're feeling like lookin at this kinda stuff right now or not but here it is:
My current PDoc lectures at Sheppard Pratt in Baltimore, and this PDoc was giving a lecture there as well, Dr. David Goodman. This was 10 years ago which was interesting to me. You may have already seen it. PDoc Goodman worked (works? I hope) at the Green Spring Station Johns Hopkins out patient Clinic, Psych Dept. I couldn't get the link to email so here it is:
http://www.mdpsych.org./SP99dGoodman.htm.
This was Spring 1999; Vol.No.1.
If you haven't seen this, read to the bottom. I think you'll find it interesting. Let me know if you want more of the lecture, etc.
I'll be calling over there anyway to get an appt with Goodman or his protege I hope.
Maybe you're watching a comedy and having an awesome lunch. I hope so.
~Jade
Posted by JadeKelly on January 15, 2009, at 12:43:16
In reply to Re: I want to switch from nortriptyline to desipramine » JadeKelly, posted by JadeKelly on January 15, 2009, at 12:27:28
Diagnosis and Treatment of Refractory Depression
Sheppard Pratt Psychiatric Lecture Series, February 1999
by Dr. David Goodman[Spring 1999; Vol.26 No. 1]
I had the honor of being invited to present an update on pharmacologic treatment of refractory depression. For this presentation, refractory depression was defined as a patient who has been on adequate dosing trials of at least 6 to 8 antidepressant combinations and failed to adequately respond. For the purpose of diagnosis, it is important to remember that a patient uses the term "depressed" or "anxious" as a descriptor of mood, and not a diagnosis. It is the clinician who needs to enumerate the patient's symptoms in order to substantiate a clinical psychiatric diagnosis. Although we may speak about depression as a clinical diagnosis, in fact, depression is a mood phase which can be seen in major recurrent depression or bipolar disorder. Diagnostic accuracy is essential in determining effective treatment. Many unsuccessful treatments have been started prematurely without an accurate assessment of symptoms and conclusive diagnosis.
Symptoms of clinical depression are well-known amongst physicians and mental health professionals. However, diagnostic confusion arises when patients present with depressed mood accompanied by anxiety and/or agitation. There seems to be increased focus on the treatment of depression with anxiety, as many pharmaceutical companies attempt to establish their antidepressant in this area. However, anxiety with depression is distinctly different from depression with agitation. Anxiety is accompanied by worry, a sense of impending doom, general fearfulness and usually no significant insomnia. In contrast, agitation is characterized by physical restlessness, irritability, an internal sense that the "motor is revved," and significantly decreased sleep. It is important to make this distinction because agitation occurring with depression may reflect an underlying bipolar diathesis. This diagnostic distinction becomes important because bipolar patients in depressed phases are typically less responsive to antidepresants without a mood stabilizing agent when compared to the antidepressant response of major depressed patients.
In a study of 50 inpatients by Ghaemi, et al, it was found that bipolar disorder was severely under-diagnosed. Forty-two percent of the bipolar patients had carried other diagnoses. Of the 42%, 90% of them carried a diagnosis of unipolar depression. Therefore, that which we call refractory depression may in fact be a patient with a bipolar disorder who is only partially responsive to any antidepressants they have been on.
Since mental health professionals are probably most familiar with the selective serotonin re-uptake inhibitors, the five U.S. SSRIs were reviewed. The kinetics and active metabolites of fluoxetine, paroxetine, sertraline, citalopram and fluvoxamine were discussed. Linear kinetics applies only to sertraline and citalopram. The presence of food seems to have no clinical effect on SSRI absorption. The only two SSRIs with clinically active metabolites are fluoxetine and sertraline. Citalopram is the latest SSRI in the U.S. market. Specific kinetic and clinical features were reviewed. Citalopram seems to have the lowest inhibitory effect on the P450 system in in-vitro studies. This has lead clinicians to believe that it probably has fewer possible drug-drug kinetic interactions. In addition, it is the most highly selective serotoninergic antidepressant as judged by the ratio of dopamine re-uptake affinity to serotonin re-uptake receptor affinity.
There are five key clinically relevant psychopharmacologic concepts that are important in the poly psychopharmacologic treatment of refractory patients.
1. Drug-drug interactions: Pharmacokinetics (changes in drug absorption, distribution, metabolism, and excretion) versus pharmacodynamics (when two drugs act at the same or interrelated receptor site). A clinician must decide in which of these two categories a patient's side effects occur because this will determine how drug doses are modified.
2. Genetic polymorphism: There are five isoenzymes which are particularly relevant in psychiatry. Two of these isoenzymes 1A2 and 3A4 have no genetic polymorphism, that is, there is not much variation from 1 patient to another in the metabolism of substrates through these isoenzymes. This is in contrast to 2C19 and 2D6, for which the slow versus fast metabolizers exist. There are ethnic and racial differences. Approximately 20% of the Japanese and 4% of Caucasians are slow metabolizers for 2C19 substrates. Approximately 7% of Caucasians, but only 2% of Asians are slow metabolizers for 2D6 substrates.
3. The clinical onset of drug-drug interactions: The inhibition of drug metabolism and decrease in drug clearance causes an elevation in serum levels. The clinical effect of this elevation is usually seen in 2-5 half-lives of the drug whose metabolism is inhibited. However, when a drug's metabolism is induced and serum levels fall, the clinical effect is not seen for several weeks. Therefore, if you know the temporal relationship between a drug and the onset of side effects, you might be able to deduce whether metabolic inhibition or induction has taken place.
4. The clinical relevance and differences between in-vitro versus in-vivo study results: Isoenzyme inhibition, seen in-vitro, takes into account only a parent drug. The in-vivo studies will take into account inhibitory effects of any metabolites. This was seen when comparing three SSRIs with desipramine blood levels. So although we may be able to extrapolate clinical information from in-vitro data, it should not be presumed as conclusive.
5. Drugs can be metabolized through multiple isoenzymes: It is important to be apprised of the substrate's major pathway when looking at spreadsheets of substrates and isoenzymes. Both imipramine and propranolol run through four isoenzymes. Clozapine runs through three isoenzymes. If you are not familiar with the major metabolic pathway, you may presume clinically relevant drug interactions where none exist and thereby avoid potentially useful drug combinations.
As had been mentioned earlier, diagnostic accuracy is essential in treating depressed patients. Patients who are depressed and bipolar should avoid tricyclic antidepressants because of a tendency to increased cycling frequency and worsen the pharmacologic response of the illness.
With the drive to identify depression in primary care, the issue of diagnostic accuracy in the consideration for bipolar disorder seems to have been lost. Although we might say that SSRIs do not increase cycling frequency, it took 25 years before we determined that tricyclic antidepressants increase cycling frequency. Who is to say what we will decide 20 years from now. Therefore, the prescription of these medications should be used judiciously and with diagnostic accuracy.
Pharmacologic algorithms have suggested that clinicians change from one class of antidepressant to another class of antidepressant if a patient fails to respond. Although this makes sense at face value, it wasn't until recently that we had research in this area. The response rate if you switch from a TCA to a TCA is approximately 22%. Switching from a TCA to an SSRI produces a 45% response rate. Switching from an SSRI to a TCA produces a 62% response rate. However, the question to be answered is, what is the response rate when you switch from one SSRI to another SSRI. Keep in mind that the SSRI structures are completely different. I have often said that what we know about these drugs we can stuff in a thimble and what we don't know about these drugs can fill a library. There is one study by Jaffe, et al, which took a look at response rates when switching from one SSRI to another. In general, he found a 50% response rate when changing from one SSRI to another. Therefore, it is important not to discard the whole class of SSRIs simply because the patient failed to respond to one. It is also well established that patients developing side effects on one SSRI may very well tolerate an alternative SSRI.
I reviewed the typical adjunctive agents used in refractory depression. In Pharmacotherapy, 4th Generation of Progress, there are reviews of response rates for adjunctive agents. Twelve studies of lithium augmentation to TCAs produced a response rate of 56%. Twelve reported T3 potentiation to TCAs showed a response rate of 40%. The addition of fluoxetine to TCAs in two studies showed a response rate of 47%. The addition of MAOIs to TCAs in ten studies produced a response rate of 54%. As you read this, you may notice a very untraditional drug combination, that is MAOIs with TCAs. Yes, there are several papers supporting the use of these agents without severe drug reactions.
Historically, the use of MAOIs has been infrequent, despite the fact that overwhelming research supports their benefit. Years ago, the dietary restrictions seemed to be so severe that clinicians worried that the patient would inadvertantly eat a restricted food, have a severe hypertensive reaction and suffer a stroke or heart attack. However, as the years have gone on, experts have revised and simplified the MAOI dietary restrictions. The current restrictions are very workable for most patients. Many patients who are judged to be refractory have never been on MAOIs. Clinicians who fail to use MAOIs eliminate a very effective class of agents.
To further complicate the treatment, MAOIs can be used with stimulants and TCAs. Although there are severe warnings and contraindications, there is a body of literature supporting their combined use. My clinical experience in about 8 patients, has been fairly rewarding. I stress that no physician should consider these drug combinations before the patient has been tried on the typical and traditional drug combinations. The MAOI combinations should be used by a clinician familiar with the literature and in patients who are trustworthy. It is important that patients monitor blood pressure and pulse as dosages of MAOIs and stimulants or tricyclics change. For those clinicians wishing to gain more experience in this area, I recommend Clinical Advances in Monoamine Oxidase Therapies, edited by Sidney Kennedy, MD, published by American Psychiatric Press, Inc. In this book, there is a report of nine trials with over 1,000 patients on MAOIs-TCA combinations, with no death or severe toxic events. Three open trials and 3 chart reviews showed treatment responses between 65-80%. These are remarkable response rates given the fact that patients have been severely refractory to other agents.
When using MAOIs, it is important to know the recommended wash-out period from other drugs. In general, when going from an MAOI to an SSRI, 4-5 weeks needs to be allotted.
When changing from a TCA, buproprion, SSRI to MAOI, a 2-week wash-out period is recommended. Keep in mind, that if you change from one MAOI to a second MAOI, there is also a 2-week wash-out recommendation. These recommendations are conservative and experienced clinicians have published reports of drug switches with shorter periods of wash-out.
Perhaps the most critical factor in the treatment of depressed patients is the provision of hope. It is important for the clinician to be diagnostically committed and hopeful that a successful treatment alternative will be identified. As noted, there are a number of pharmacologic alternatives beyond traditional recommendations. Those clinicians treating refractory depression should become familiar with the breadth of pharmacologic options. When patients believe that there is something else to be tried, it allows them to better tolerate their depression, demoralization and frustration.
Dr. David Goodman, is an Assistant Professor of Psychiatry at The Johns Hopkins University, School of Medicine, and is in private practice at Greenspring Station in Baltimore County.
Posted by Phillipa on January 15, 2009, at 20:35:25
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 15, 2009, at 7:28:03
Scott so sorry. What's next? Love Phillipa
Posted by sandy404 on January 16, 2009, at 6:17:04
In reply to I want to switch from nortriptyline to desipramine, posted by SLS on January 3, 2009, at 16:30:10
When I was on nortriptyline, I gained 70 pounds. I went from a size 10 to a size 1X. But it was the only med. that worked. I had tried them all. After about 7 years, I went on Zoloft, but the weight didn't fall off. I had to work at it. But it came off.I was pretty good for about 6 years. Now, I don't know what to do. I am so depressed that most days I don't get out of bed, except to check my computer. I'm wondering if I need to go back on nortriptyline.
Posted by SLS on January 16, 2009, at 7:45:20
In reply to Re: I want to switch from nortriptyline to desipramine, posted by sandy404 on January 16, 2009, at 6:17:04
> When I was on nortriptyline, I gained 70 pounds. I went from a size 10 to a size 1X. But it was the only med. that worked. I had tried them all. After about 7 years, I went on Zoloft, but the weight didn't fall off. I had to work at it. But it came off.I was pretty good for about 6 years. Now, I don't know what to do. I am so depressed that most days I don't get out of bed, except to check my computer. I'm wondering if I need to go back on nortriptyline.
It is a hell of a thing to have to choose between obesity and depression. I guess you've already tried desipramine. How did you react to it? Some investigative psychiatrists are now using desipramine to combine with SRI drugs like Zoloft and Effexor.
Parnate, and MAOI, is weight-neutral. Some people even lose weight while taking it.
I'm currently taking:
Parnate 80mg
desipramine 150mg
Lamictal 200mg
Abilify 20mg
I am probably going to need desipramine 300mg to feel really well. I see my doctor today. I am forced to increase the dosage at his cautious and methodical pace rather than the pace I have historically been able to tolerate. It is very frustrating.
- Scott
Posted by SLS on January 16, 2009, at 13:44:56
In reply to Re: I want to switch from nortriptyline to desipramine » sandy404, posted by SLS on January 16, 2009, at 7:45:20
> I'm currently taking:
>
> Parnate 80mg
> desipramine 150mg
> Lamictal 200mg
> Abilify 20mg
>
>
> I am probably going to need desipramine 300mg to feel really well. I see my doctor today. I am forced to increase the dosage at his cautious and methodical pace rather than the pace I have historically been able to tolerate. It is very frustrating.It's official. My doctor will allow me to go up to 200mg of desipramine. But I must stay there for 3 weeks. I would be much better at 300mg for 2 weeks, but I couldn't sell the idea to him. That's ok, I guess. I'm not suffering terribly. If I were in his position, I would be doing exactly the same thing. I can't fault him. He has never seen me on 300mg of desipramine or imipramine, two drugs that I have already demonstrated I need 300mg of.
Oh, well. After two weeks at 200mg, he wants me to get a blood level. This is another smart thing to do, but I know it is unnecessary. Man, this is going to take some self-discipline on my part. I start school next week, and I would have like to have been mentally sharper and have more energy. It will be a push. Dammit. Just like always.
I feel crappy but happy.
- Scott
Posted by Phillipa on January 16, 2009, at 19:36:51
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 16, 2009, at 13:44:56
Scott that's funny crappy and happy. Love Phillipa
Posted by SLS on January 19, 2009, at 11:53:59
In reply to Re: I want to switch from nortriptyline to desipramine » SLS, posted by Phillipa on January 16, 2009, at 19:36:51
I wish I could go right up to 300mg of desipramine. I am continuing to fade here. I still have to wait 10 days and get a blood test for desipramine level. My doctor is understandably cautious. It is the right thing for him to do since he has never seen me on this drug before. I acknowledged to him that I was trying to "sell" him on the 300mg, so he knows where I'm at. I can't wait to feel great, but I guess I'll have to. Time can be a real MF.
Things could be so much worse. For decades, they had been.
- Scott
Posted by Phillipa on January 19, 2009, at 20:27:14
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 19, 2009, at 11:53:59
Scott don't fade call the pdoc. I mean it. Love Phillipa
Posted by SLS on January 23, 2009, at 7:17:16
In reply to Re: I want to switch from nortriptyline to desipramine » SLS, posted by Phillipa on January 19, 2009, at 20:27:14
> Scott don't fade call the pdoc. I mean it. Love Phillipa
I am following doctor's orders.
I am not a happy camper, though.
I have to wait 2 weeks before I see the doctor next. What frustration! He wanted me to be on 200mg for 2 weeks and then get a blood level of desipramine. Meanwhile, I have trouble getting myself to do anything except post repeatedly on this website. I'm going to push myself to go to the gym, even though I know my workouts are going to suck. We'll see.
If I were to pop 2 extra pills today, I would feel great tomorrow. It is taking me a lot of self-discipline not to do so.
I have faded, but I am not feeling awful. I am stable at this point.
Disbelievers, watch out!
- Scott
Posted by desolationrower on January 23, 2009, at 13:04:47
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 23, 2009, at 7:17:16
despite your self-report you seem quite affable.
-d/r
Posted by Phillipa on January 23, 2009, at 20:11:44
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 23, 2009, at 7:17:16
As Nike says Just Do it. Excercise that is know you loved in the past. Phillipa
Posted by bulldog2 on January 24, 2009, at 14:11:29
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 23, 2009, at 7:17:16
> > Scott don't fade call the pdoc. I mean it. Love Phillipa
>
> I am following doctor's orders.
>
> I am not a happy camper, though.
>
> I have to wait 2 weeks before I see the doctor next. What frustration! He wanted me to be on 200mg for 2 weeks and then get a blood level of desipramine. Meanwhile, I have trouble getting myself to do anything except post repeatedly on this website. I'm going to push myself to go to the gym, even though I know my workouts are going to suck. We'll see.
>
> If I were to pop 2 extra pills today, I would feel great tomorrow. It is taking me a lot of self-discipline not to do so.
>
> I have faded, but I am not feeling awful. I am stable at this point.
>
> Disbelievers, watch out!
>
>
> - Scott
>Scott your the man. You have the willpower and discipline to get this done.
Posted by JadeKelly on January 24, 2009, at 18:42:29
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 23, 2009, at 7:17:16
As I was saying....
Posted by JadeKelly on January 24, 2009, at 19:14:02
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 23, 2009, at 7:17:16
Scott,
Glad you are stable and being a patient patient.
Your advice, that you are currently applying to yourself, is paying off for me exponentially :-)
I found a Phychiatrist-Pharm who was combining Parnate, desipramine and stims 15 years ago.
I told him I'd done some research and he gave me the "speech". He pulled my chair over to his and said" I could explain all the neuro-science that will go into the plan I have for you but you need to trust me, okay? I have a plan for you and I need to know that you will not change it AT ALL.
He spoke with me for 1 1/2 hours.
He had me at "I have a plan".
~Jade, be greedy and go for it all, that Jade haha
Posted by Vincent_QC on January 26, 2009, at 7:26:23
In reply to Re: I want to switch from nortriptyline to desipramine, posted by JadeKelly on January 24, 2009, at 19:14:02
> Scott,
>
> Glad you are stable and being a patient patient.
>
> Your advice, that you are currently applying to yourself, is paying off for me exponentially :-)
>
> I found a Phychiatrist-Pharm who was combining Parnate, desipramine and stims 15 years ago.
>
> I told him I'd done some research and he gave me the "speech". He pulled my chair over to his and said" I could explain all the neuro-science that will go into the plan I have for you but you need to trust me, okay? I have a plan for you and I need to know that you will not change it AT ALL.
>
> He spoke with me for 1 1/2 hours.
>
> He had me at "I have a plan".
>
> ~Jade, be greedy and go for it all, that Jade haha
>
>What is the "plan" exactly??? And why i'm not able to find a good Phychiatrist-Pharm in the Quebec province (Canada), like the one you have? lol Mine don't want to add a small dose of Trazodone on my MAOI drug to help me to sleep...so forget about a combo with other stimulant or anything else... That's suck since I change often of Doctors and Psychiatrist and no ones offer to me NEW solutions...I'm always the ones who proposed new drugs or different drugs often use off-label for social anxiety... I wonder why all the Psychiatrists in the Canada, at least in Quebec province, have nothing to offer new when is time to talk about social anxiety...? I thin the Pharmaceutical industry surrounded them too much...since they promote "new" product, more expensive but with no "evidence" and "proof" of a good results on social anxiety...Anyway...
Posted by SLS on January 29, 2009, at 14:32:09
In reply to Re: I want to switch from nortriptyline to desipramine » JadeKelly, posted by Vincent_QC on January 26, 2009, at 7:26:23
Rats.
I spoke to my doctor on the phone today, hoping that he would let me increase the dosage of desipramine. He said no. He said that he wanted to see the results of the blood test for desipramine levels first. Logical. I then asked him if he were worried about cardiac side effects. That didn't seem to be his problem, but he demonstrated to me that he is very afraid of using this drug in combination with Parnate. I now have my doubts that he is going to prescribe the 300mg I need. I have been on that dosage before.
I might have to start planning to see another doctor if mine refuses to increase the dosage of desipramine. I'll either see my old doctor in Princeton or see the doctor at Columbia in NYC that I once had a consultation with. I would place myself on the 300mg before hand.
- Scott
Posted by Jadekelly on January 29, 2009, at 19:02:32
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 29, 2009, at 14:32:09
Scott,
I thought that's what the blood test was for. So you could go up on the desiprimine. That stinks.
Vince, (and Scott) my new PDoc's plan, as unbelievable as it is, is to get me up to 30mg Ritalin with the 70mg Parnate, by tomorrow, see him again in a week, not sure if/ how many more increases. If that doesn't get me to 100% he says he does use....desiprimine. I'll see him every two weeks until ?????
Scott, he's the one at JH that I posted info above a while ago. 10-15 years ago he was using those three drugs together. I start therapy next week as well. To work on my "stuff". I'm ready now.
Good Luck,
Jade
Posted by Phillipa on January 29, 2009, at 20:36:11
In reply to Re: I want to switch from nortriptyline to desipramine, posted by SLS on January 29, 2009, at 14:32:09
Scott you do what you gotta do. Phillipa ps good luck convincing this one but you're not that far away.
Posted by Vincent_QC on January 30, 2009, at 9:38:59
In reply to Re: Scott + Vince » SLS, posted by Jadekelly on January 29, 2009, at 19:02:32
> Scott,
>
> I thought that's what the blood test was for. So you could go up on the desiprimine. That stinks.
>
> Vince, (and Scott) my new PDoc's plan, as unbelievable as it is, is to get me up to 30mg Ritalin with the 70mg Parnate, by tomorrow, see him again in a week, not sure if/ how many more increases. If that doesn't get me to 100% he says he does use....desiprimine. I'll see him every two weeks until ?????
>
> Scott, he's the one at JH that I posted info above a while ago. 10-15 years ago he was using those three drugs together. I start therapy next week as well. To work on my "stuff". I'm ready now.
>
> Good Luck,
>
> Jade
>
>Hi Jade!
Good...I hope the addition of a higher dose of Ritalin will help you ;-) CBT will also help a lot I think, if you have the energy to do it of course... ;-)For now, MY plan is not as positive than you...
I never get an answer from the compagny who promote and sell the Marplan (MAOI)...Validus...They never answer to me, even if I e-mail them 2 times since more than 1 week...I just wanted basic info like the price and how to import it to the Canada...They seem to not be very friendly with that process or they don't care about the Canadian residents or market...Anyway, it's in the schedule F of drugs that I can import (3 months supply) by mail in the Canada...The Canadian Border are not suppose to keep the drugs...since it's permit as an importation here...
For the Emsam or the oral Selegiline, I will not try it...since I read a lot of old threads about the effect of the oral and the patch Selegiline...It will not help a lot for my social phobia and my anxiety....Yeah, I need to have more energy, but I don't want to increase my anxiety...
So for the PLAN...I will ask for the Nardil again, because it's Gaba-energic (or something like this...agonist and not antagonist...I learn my lesson now...I argue with another member of the Babble site about Gaba-B drugs...anyway...), and I will ask maybe just to add a real small dose of oral Selegiline, since it give some energy...I will not be able to get the Ritalin with the Nardil, since my PDoc is really not into combo or cocktail drugs mix...He prefer to work on one thing at the time...SO I guess I will be left only with the Nardil...start it at a very low dose, 15mg week...increase at 30 after 2 weeks...and be able to reach the 90mg just in 3 months...He is also very slow on the increasement of the dosage...I hate that but well I have no choice...
At the same time, I will bring to him the informations I found about the importation of the Marplan in the Canada, he will be able maybe to do all the things for me...we will see before the price of it...I read somewhere that a 10mg Marplan pills is something like 2$...since the effective dosage is 60mg, it will cost 12$ day...for me that's expensive, since with the public insurrance in the Quebec province, we don'T pay for drugs in the approved list ...Nardil is free, oral Selegeline is free also...but we have a limited choice...Ritalin regular is cover but not the SR version...Celexa is free but the Cipralex (Lexapro) is not cover...Effexor-XR is cover, but not the new Cymbalta...
So that's it...for now, I have to wait until next tuesday before I See my Pdoc again, I just sleep all day long, no energy at all, I use the maximum dose of Valium I can (20mg minimum/day) just to be able to calm down a little bit...and at night I need to double my dosage of Seroquel to be able to sleep (so 2 x 25mg)... I have only 2 pills left in my bottle and I can't have a refil of my prescription before the 7 february...I can't call my Family doctor office, since they don't take call...before I Was able to talk to my Doctor at anytime, now I can't...I see him only the 16 february so I will ask at this time to double my dosage of Seroquel..but for now I will have to buy cheap allergy medecine to help to sleep at night...I try some Unisom, the Xtra strenght version, they do nothing on me...Anyway that's another story...
I'm a lot frustrated cause I can't do progress and work on my CBT...I'm not able to find the energy at daytime to go outside the house and make my exposure time in social events...(Shopping center for now)...And i'm also a lot frustrated because I'm left without AD to help me now... That's too bad I Return my box of Nardil to the drugstore 2 months ago...I had a lot of them so it will be a good option to begin it before my appointment with the PDoc next week...but now I have to wait , again...and all the long process it will take to reach the 90mg...it will be very long...
Well that's it...that's a hard time for me...I never felt this way before...I feel not very stable...And my blood pressure never return to the normal after my adventure with the Parnate...strange no??? I'm always at the 140/90 stage... I wonder why...before it was always low...
I will have to investigate for this also...ask for blood test and others things like that...
Well, for now I have to go, but I wish you a good luck with your PLAN...I really hope it will work ok!!! I will think of you ;-)
Take care!
Vincent ;-)
Posted by SLS on February 4, 2009, at 8:14:02
In reply to Re: I want to switch from nortriptyline to desipramine » SLS, posted by Phillipa on January 29, 2009, at 20:36:11
> Scott you do what you gotta do. Phillipa ps good luck convincing this one but you're not that far away.
Still at 200mg of desipramine.
I'm hanging in there. My deterioration has leveled off. Strategic use of caffeine has helped. I am going to try to pick up my lab results today. I don't trust the lab to fax it to my doctor before Friday's appointment. He won't raise the dosage without that lab report.
- Scott
Posted by SLS on February 4, 2009, at 15:34:58
In reply to Re: I want to switch from nortriptyline to desipramine » Phillipa, posted by SLS on February 4, 2009, at 8:14:02
> > Scott you do what you gotta do. Phillipa ps good luck convincing this one but you're not that far away.
>
> Still at 200mg of desipramine.
>
> I'm hanging in there. My deterioration has leveled off. Strategic use of caffeine has helped. I am going to try to pick up my lab results today. I don't trust the lab to fax it to my doctor before Friday's appointment. He won't raise the dosage without that lab report.Got it!
Woohoo!
My desipramine level is low enough to warrant dosage increases.
My desipramine level: 99ng/ml
Reference range: 100-300ng/mlPhew!
- Scott
Posted by Phillipa on February 4, 2009, at 20:16:11
In reply to Re: I want to switch from nortriptyline to desipramine » Phillipa, posted by SLS on February 4, 2009, at 8:14:02
Well how did it come out the blood levels? Love Phillipa
Posted by SLS on February 6, 2009, at 18:10:37
In reply to Re: I want to switch from nortriptyline to desipramine » SLS, posted by Phillipa on February 4, 2009, at 20:16:11
Well, as I expected, my doctor raised my dosage of desipramine from 200mg to 250mg. I know that I need 300mg. However, if I were sitting in his chair, I would probably do exactly the same thing. So...
Now I have to wait another three weeks before he will consider raising the dosage again. I think he will if I need it. At least, that's the impression I got from him today. I will just have to be patient. I am not really suffering all that much. I am grateful for that.
- Scott
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