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Dr. Bob is Robert Hsiung, MD,
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Posted by Phillipa on December 30, 2009, at 10:53:18
In reply to Re: Trying a different tack » mtdewcmu, posted by SLS on December 30, 2009, at 8:57:18
I wish you luck why did you decide this? Just curious. Phillipa
Posted by mtdewcmu on December 30, 2009, at 22:21:57
In reply to Re: Trying a different tack, posted by Phillipa on December 30, 2009, at 10:53:18
> I wish you luck why did you decide this? Just curious. Phillipa
I have been on Prozac for three weeks, and I started taking 40mg a few days ago, and I am feeling no better now than I was three weeks ago. I know that you're supposed to wait longer than 3 weeks for meds to work, but I have run out of patience with this process. Also, I read a study that showed that if you don't see improvement after 2 weeks on a med, your odds of ever seeing any improvement are slim.
I am thinking that the Remeron and Prozac are canceling each other out. Part of the way Remeron works is to block serotonin receptors, and Prozac increases extracellular serotonin, so it seems like I'm forfeiting the benefit of blocking 5-HT2 by taking Prozac. I want to see what Remeron is like by itself. I have actually felt better each time I have increased the Remeron.
Moreover, I am looking ahead to what other meds I might try. I have just about given up on SSRIs. If Remeron by itself if not sufficient (along with WB, possibly), then I would like to maybe try some nortriptyline and/or lithium. I'll see if my pdoc has any suggestions.
Posted by floatingbridge on December 30, 2009, at 22:30:02
In reply to Re: Trying a different tack, posted by mtdewcmu on December 30, 2009, at 22:21:57
I wish you the best. There is something to be said for patience, (waiting out a few more weeks--any side effects?), and conversely, trusting intuition. I advocate neither here--just wishing you success.
fb
do you keep a med journal?
Posted by mtdewcmu on December 30, 2009, at 22:31:09
In reply to Re: Trying a different tack » mtdewcmu, posted by SLS on December 30, 2009, at 8:57:18
> > I am suspicious that Prozac is doing more harm than good, so I am going to try simplifying my regimen to Wellbutrin (300mg, XL) and Remeron (45mg). Wish me luck.
>
> Good luck!!!
>
> :-)
>
> If you decide to return to an SRI, I would recommend using either Effexor or Lexapro to go along with the other drugs you are taking. You could perhaps add Geodon if your response to these treatments is incomplete.
>
>
> - ScottUnfortunately, I am paying out of pocket for my meds, and Lexapro and Effexor are both very expensive. The instant release form of Effexor is not, but I don't want to take it 2-3 times a day.
Geodon is also expensive. Do you think there is a point in trying Geodon if Abilify has not helped? I also had unpleasant side effects from Abilify, like heart palpitations (which I attribute to the adrenergic blocking effect), and orthostatic hypotension. Is Geodon any better in this respect?
I am thinking of moving on from the SSRIs (and Effexor is very similar to an SSRI) and trying nortriptyline if necessary. I liked the way amitriptyline felt. The only problem with amitriptyline was the tachycardia, but nortriptyline is supposed to be better.
Posted by mtdewcmu on December 30, 2009, at 22:38:10
In reply to Re: Trying a different tack » mtdewcmu, posted by floatingbridge on December 30, 2009, at 22:30:02
> I wish you the best. There is something to be said for patience, (waiting out a few more weeks--any side effects?), and conversely, trusting intuition. I advocate neither here--just wishing you success.
Yes, I wish I had more patience. But I have been trying to fix my meds since July and my patience has run out. I am putting my trust in intuition (with reasons, too).
>
> fb
>
> do you keep a med journal?No. But I have a pretty good memory for these things.
Posted by SLS on December 31, 2009, at 2:20:37
In reply to Re: Trying a different tack, posted by mtdewcmu on December 30, 2009, at 22:31:09
> > > I am suspicious that Prozac is doing more harm than good, so I am going to try simplifying my regimen to Wellbutrin (300mg, XL) and Remeron (45mg). Wish me luck.
> > Good luck!!!
> >
> > :-)
> >
> > If you decide to return to an SRI, I would recommend using either Effexor or Lexapro to go along with the other drugs you are taking. You could perhaps add Geodon if your response to these treatments is incomplete.> Unfortunately, I am paying out of pocket for my meds, and Lexapro and Effexor are both very expensive. The instant release form of Effexor is not, but I don't want to take it 2-3 times a day.
>
> Geodon is also expensive. Do you think there is a point in trying Geodon if Abilify has not helped?I wish I could say for sure. I haven't kept track of anyone who has taken both drugs in this order to be able to come to any conclusions. I would say that the drugs are different enough to entertain the idea.
> I also had unpleasant side effects from Abilify, like heart palpitations (which I attribute to the adrenergic blocking effect)...
I'm drawing a blank. What adrenergic blocking effect are you referring to?
> ...and orthostatic hypotension. Is Geodon any better in this respect?
I know that I am not being a lot of help here, but I would again have to say that I don't know, primarily because I haven't heard of hypotension being a problem with Abilify. Geodon would probably be worse as it is a more potent antagonist at NE alpha1 receptors. However, I had no such problem with Geodon at a dosage of 80mg.
> I am thinking of moving on from the SSRIs (and Effexor is very similar to an SSRI) and trying nortriptyline if necessary. I liked the way amitriptyline felt. The only problem with amitriptyline was the tachycardia, but nortriptyline is supposed to be better.
Nortriptyline is better because it has a much reduced potency as an anticholinergic. I think it is a reasonable choice. You can always augment it if it does not produce adequate results as monotherapy.
- Scott
Posted by mtdewcmu on December 31, 2009, at 11:16:32
In reply to Re: Trying a different tack » mtdewcmu, posted by SLS on December 31, 2009, at 2:20:37
> > > > I am suspicious that Prozac is doing more harm than good, so I am going to try simplifying my regimen to Wellbutrin (300mg, XL) and Remeron (45mg). Wish me luck.
>
> > > Good luck!!!
> > >
> > > :-)
> > >
> > > If you decide to return to an SRI, I would recommend using either Effexor or Lexapro to go along with the other drugs you are taking. You could perhaps add Geodon if your response to these treatments is incomplete.
>
> > Unfortunately, I am paying out of pocket for my meds, and Lexapro and Effexor are both very expensive. The instant release form of Effexor is not, but I don't want to take it 2-3 times a day.
> >
> > Geodon is also expensive. Do you think there is a point in trying Geodon if Abilify has not helped?
>
> I wish I could say for sure. I haven't kept track of anyone who has taken both drugs in this order to be able to come to any conclusions. I would say that the drugs are different enough to entertain the idea.
>
> > I also had unpleasant side effects from Abilify, like heart palpitations (which I attribute to the adrenergic blocking effect)...
>
> I'm drawing a blank. What adrenergic blocking effect are you referring to?
>It was harder than I expected to find a reference for this.
"Similar to the anticholinergic effects of these medications, alpha blockade and postural hypotension may result in reflex tachycardia." from http://emedicine.medscape.com/article/815881-overview
Basically, I think the alpha blockade dilates peripheral blood vessels, forcing the heart to beat faster to compensate for the resulting drop in blood pressure. I am tall, so that may make me especially sensitive to the hypotensive effects.
> > ...and orthostatic hypotension. Is Geodon any better in this respect?
>
> I know that I am not being a lot of help here, but I would again have to say that I don't know, primarily because I haven't heard of hypotension being a problem with Abilify. Geodon would probably be worse as it is a more potent antagonist at NE alpha1 receptors. However, I had no such problem with Geodon at a dosage of 80mg.
>The new drug Saphris is a highly specific 5-HT2 inhibitor. I wonder how effective it would be as an antidepressant or an adjunct.
> > I am thinking of moving on from the SSRIs (and Effexor is very similar to an SSRI) and trying nortriptyline if necessary. I liked the way amitriptyline felt. The only problem with amitriptyline was the tachycardia, but nortriptyline is supposed to be better.
>
> Nortriptyline is better because it has a much reduced potency as an anticholinergic. I think it is a reasonable choice. You can always augment it if it does not produce adequate results as monotherapy.
>
>
> - ScottIt is high on my list of things to try if I can ever get most of the SSRIs washed out of my system. I had to take a Prozac yesterday due to withdrawal. I didn't expect Prozac withdrawal already on the first day without taking it.
Posted by Phillipa on December 31, 2009, at 19:04:26
In reply to Re: Trying a different tack, posted by mtdewcmu on December 31, 2009, at 11:16:32
That does sound odd the early withdrawal with such a long halflife. Could it be it was really working? Phillipa
Posted by mtdewcmu on December 31, 2009, at 19:33:24
In reply to Trying a different tack, posted by mtdewcmu on December 30, 2009, at 8:43:21
I took some Paxil this morning, and I was surprised -- shocked, even -- to find that it caused no gastrointestinal problems, and I felt good! The Remeron seems to be highly effective at blocking the side effects of Paxil. My fears that SSRIs and Remeron cancel out appear to be unfounded. Here's what I'm going to take from now on:
Paxil 20mg
Remeron 30-45mg
Budeprion XL 150mg
Prozac in small doses as needed for withdrawalI think I may have finally hit on the right cocktail -- my mood is light, and almost cheerful, even.
Please, God -- even though I don't believe in you -- let this be the answer!
Posted by floatingbridge on December 31, 2009, at 19:43:45
In reply to Remeron + Paxil: so far, so good!, posted by mtdewcmu on December 31, 2009, at 19:33:24
I'm hoping for you, too!
fb
Posted by mtdewcmu on December 31, 2009, at 20:01:48
In reply to Re: Remeron + Paxil: so far, so good! » mtdewcmu, posted by floatingbridge on December 31, 2009, at 19:43:45
Posted by mtdewcmu on January 1, 2010, at 7:49:09
In reply to Remeron + Paxil: so far, so good!, posted by mtdewcmu on December 31, 2009, at 19:33:24
Well, I took 30mg of Paxil about half an hour ago and I have already had a laxative effect. So, the GI s/e may not be entirely gone. I wonder if Paxil CR might be better?
Posted by floatingbridge on January 1, 2010, at 11:03:33
In reply to Re: Remeron + Paxil: so far, so good!, posted by mtdewcmu on January 1, 2010, at 7:49:09
> Well, I took 30mg of Paxil about half an hour ago and I have already had a laxative effect. So, the GI s/e may not be entirely gone. I wonder if Paxil CR might be better?
Maybe laxative effect is due to the increased dose? Could 20 be a therapeutic dose for you?
Don't know about CR....
fb
Posted by mtdewcmu on January 1, 2010, at 22:58:14
In reply to Re: Remeron + Paxil: so far, so good!, posted by floatingbridge on January 1, 2010, at 11:03:33
Well I had a pretty good day at work today. The GI side effects wore off for the most part. I felt some edginess in the first part of the day when the Paxil and Wellbutrin were kicking in hard. Later on, the feeling mellowed out for a brief interval, then around sunset my mood dropped again. Although it was not as bad as it has been. So it seemed that I was on too much ADs in the morning, and not enough in the evening. It has occurred to me that the feeling of dropping off a cliff moodwise could be due to the Wellbutrin wearing off (I don't put much faith in Budeprion's 24-hour time release). I think over the longer term I'd like to drop WB and possibly replace it with nortriptyline. In the short term, I may decrease the Wellbutrin, and I think I'll divide the Paxil into two doses to simulate a time release. I think I also need to decrease the Remeron, because Paxil is a potent CYP 2D6 inhibitor and Remeron is metabolized by CYP 2D6. I wonder if it would be worth paying a lot to get Paxil CR in the future. Another thing I am wondering is whether a mood stabilizer might smooth out the up and down that I get through the day. If so, what would be a good choice? In the past, Lamictal made it hard to drive safely. Or maybe this nighttime crashing is just a symptom of depression and I should wait it out...?
Posted by mtdewcmu on January 2, 2010, at 22:19:46
In reply to Re: Remeron + Paxil: so far, so good!, posted by mtdewcmu on January 1, 2010, at 22:58:14
Well, my mood is improving, but my bowels are tied in a knot again. So much for Remeron and its 5-HT3 inhibition...
Posted by RocketMan on January 2, 2010, at 23:07:35
In reply to Re: Remeron + Paxil: so far, so good... or is it?, posted by mtdewcmu on January 2, 2010, at 22:19:46
> Well, my mood is improving, but my bowels are tied in a knot again. So much for Remeron and its 5-HT3 inhibition...
Drink lots of water and eat niblet corn..... helps me :-)
Posted by mtdewcmu on January 2, 2010, at 23:12:29
In reply to Re: Remeron + Paxil: so far, so good... or is it? » mtdewcmu, posted by RocketMan on January 2, 2010, at 23:07:35
> > Well, my mood is improving, but my bowels are tied in a knot again. So much for Remeron and its 5-HT3 inhibition...
>
> Drink lots of water and eat niblet corn..... helps me :-)
>
>Actually, I took my nightly Remeron already and it rapidly helped to untie them from their knot. So I guess there is something to the 5-HT3 theory. I think I will take the Paxil and Remeron at the same time from now on, so they cancel out better.
Posted by SLS on January 3, 2010, at 7:11:17
In reply to Re: Remeron + Paxil: so far, so good... or is it?, posted by mtdewcmu on January 2, 2010, at 22:19:46
> Well, my mood is improving, but my bowels are tied in a knot again. So much for Remeron and its 5-HT3 inhibition...
I hadn't heard of this theory. What is it all about?
- Scott
Posted by mtdewcmu on January 3, 2010, at 7:28:21
In reply to Re: Remeron + Paxil: so far, so good... or is it? » mtdewcmu, posted by SLS on January 3, 2010, at 7:11:17
> > Well, my mood is improving, but my bowels are tied in a knot again. So much for Remeron and its 5-HT3 inhibition...
>
> I hadn't heard of this theory. What is it all about?
>
>
> - ScottThere are 5-HT3 receptors in the gut, and apparently they are responsible for a lot of the GI side effects of SSRIs. Remeron blocks them.
Posted by SLS on January 3, 2010, at 7:45:42
In reply to Re: Remeron + Paxil: so far, so good... or is it?, posted by mtdewcmu on January 3, 2010, at 7:28:21
> > > Well, my mood is improving, but my bowels are tied in a knot again. So much for Remeron and its 5-HT3 inhibition...
> >
> > I hadn't heard of this theory. What is it all about?
> >
> >
> > - Scott
>
> There are 5-HT3 receptors in the gut, and apparently they are responsible for a lot of the GI side effects of SSRIs. Remeron blocks them.
Does that include peristalsis? I know that ondansetron has no such effect.What did you mean when you described yourself as being tied in knots?
Thanks.
- Scott
Posted by mtdewcmu on January 3, 2010, at 8:57:01
In reply to Re: Remeron + Paxil: so far, so good... or is it? » mtdewcmu, posted by SLS on January 3, 2010, at 7:45:42
> > > > Well, my mood is improving, but my bowels are tied in a knot again. So much for Remeron and its 5-HT3 inhibition...
> > >
> > > I hadn't heard of this theory. What is it all about?
> > >
> > >
> > > - Scott
> >
> > There are 5-HT3 receptors in the gut, and apparently they are responsible for a lot of the GI side effects of SSRIs. Remeron blocks them.
>
>
> Does that include peristalsis? I know that ondansetron has no such effect.
>Here is a bit from Goodman & Gilman (I hope I'm not violating the copyright):
"Motility of gastric and intestinal smooth muscle may be either enhanced or inhibited via at least 6 subtypes of 5-HT receptors (Table 112). The stimulatory response occurs at nerve endings on longitudinal and circular enteric muscle (5-HT4), at postsynaptic cells of the enteric ganglia (5-HT3 and 5-HT1P), and by direct effects of 5-HT on the smooth-muscle cells (5-HT2A in intestine and 5-HT2B in stomach fundus)."
So 5-HT3 has a stimulatory effect. I may have remembered the table slightly incorrectly; it says that 5-HT3 causes release of 5-HT from enterochromaffin cells in the GI mucosa and it causes fast depolarization of enteric ganglion cells; 5-HT2A is listed as causing contraction of intestinal smooth muscle. 5-HT2B and 5-HT4 are listed as causing contraction of the stomach fundus and esophagus, respectively. So that would explain why mirtazapine has a greater relaxing effect on the bowel than ondansetron.
Thanks for getting me to look that up and correct my memory.
> What did you mean when you described yourself as being tied in knots?
>It's just my bowel that feels that way, not my whole body. I have a sensation in my lower abdomen that feels like a cramp due to sustained contraction of the bowel, and apparently that's exactly what it is.
> Thanks.
>
>
> - Scott
Posted by mtdewcmu on January 3, 2010, at 9:05:40
In reply to Re: Remeron + Paxil: so far, so good... or is it? » mtdewcmu, posted by SLS on January 3, 2010, at 7:45:42
I'm curious to get your reaction to my observations about the relationship between serotonin preference and effectiveness in SNRIs. Take a look: http://www.dr-bob.org/babble/20091227/msgs/932139.html
Posted by SLS on January 3, 2010, at 11:25:03
In reply to Re: Remeron + Paxil: so far, so good... or is it? » SLS, posted by mtdewcmu on January 3, 2010, at 9:05:40
> I'm curious to get your reaction to my observations about the relationship between serotonin preference and effectiveness in SNRIs. Take a look: http://www.dr-bob.org/babble/20091227/msgs/932139.html
I found it interesting. Perhaps one could mix an SSRI with a relatively small dose of a noradrenergic TCA and obtain a response similar to Effexor.
I was under the impression that Cymbalta was relatively more serotonergic that Savella.
- Scott
Posted by SLS on January 3, 2010, at 11:30:39
In reply to Re: Remeron + Paxil: so far, so good... or is it?, posted by mtdewcmu on January 3, 2010, at 8:57:01
> So 5-HT3 has a stimulatory effect. I may have remembered the table slightly incorrectly; it says that 5-HT3 causes release of 5-HT from enterochromaffin cells in the GI mucosa and it causes fast depolarization of enteric ganglion cells; 5-HT2A is listed as causing contraction of intestinal smooth muscle. 5-HT2B and 5-HT4 are listed as causing contraction of the stomach fundus and esophagus, respectively. So that would explain why mirtazapine has a greater relaxing effect on the bowel than ondansetron.
>
> Thanks for getting me to look that up and correct my memory.Thanks for checking into it and reminding me that my memory is far from infallable.
- Scott
Posted by mtdewcmu on January 3, 2010, at 13:15:50
In reply to Re: Remeron + Paxil: so far, so good... or is it? » mtdewcmu, posted by SLS on January 3, 2010, at 11:25:03
> > I'm curious to get your reaction to my observations about the relationship between serotonin preference and effectiveness in SNRIs. Take a look: http://www.dr-bob.org/babble/20091227/msgs/932139.html
>
> I found it interesting. Perhaps one could mix an SSRI with a relatively small dose of a noradrenergic TCA and obtain a response similar to Effexor.
>
> I was under the impression that Cymbalta was relatively more serotonergic that Savella.
>
>
> - ScottThey are virtually identical.
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