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Dr. Bob is Robert Hsiung, MD,
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Posted by Phillipa on October 30, 2011, at 20:54:05
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 30, 2011, at 19:25:50
Thanks for answering. We get concerned when someone doesn't repost after being so ill. Things any better now? What is your docs plan for meds for you? Phillipa
Posted by creepy on October 30, 2011, at 22:09:00
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by jono_in_adelaide on October 30, 2011, at 6:40:38
Lots of interactions with these two classes of medication. Its important to know since it gets missed. Especially nowadays with docs squeezing patients with multiple meds into 10minute windows. Its no wonder theres so much concern over liability =(
Heres the study on sertraline + desipramine if anyones interested
http://www.ncbi.nlm.nih.gov/pubmed/9241008
Posted by creepy on October 30, 2011, at 22:10:53
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft » jono_in_adelaide, posted by SLS on October 30, 2011, at 7:32:17
I could see desipramine with an MAOI.. but not a serotinergic one like imipramine. Im guessing you were experimenting since other options didnt work out?
Posted by Abaigeal on October 31, 2011, at 6:14:55
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft » Abaigeal, posted by Phillipa on October 30, 2011, at 20:54:05
things are...okay right now. I get extremely sick at least once a day where I can't do anything, just lay on the couch, chest pains, nausea, angry all the time, I've had a headache for at least a month... I have no idea what to do! The doctors don't know sh*t yet.
Posted by jono_in_adelaide on October 31, 2011, at 6:47:35
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 31, 2011, at 6:14:55
"Thus, when coadministered with 50 mg/day desipramine, sertraline had significantly less pharmacokinetic interaction than paroxetine with desipramine at the recommended starting dosages of 50 mg/day and 20 mg/day, respectively."
I dont think that suggests there are significant interactions between sertraline and desipramine.
Posted by Abaigeal on October 31, 2011, at 10:36:11
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by jono_in_adelaide on October 31, 2011, at 6:47:35
amitriptyline is a totally different drug, it's old as f*ck. I'm getting extremely agitated, and I don't know what to do. I can't sleep for more than 2 hours.. ugh
Posted by jono_in_adelaide on October 31, 2011, at 17:35:00
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 31, 2011, at 10:36:11
OK, have you tried a mild sleeping pill, such as ambien?
Have you considered that the symptoms you are getting are because of the condition that led you to a psychiatrist, rather than your misadventure with meds?
Try and not get into the victim trap of blaming everything wrong in your life on that one misadventure.
I'd ask your doc for a mild sleeping pill, take a simple analgesic for the headaches (for example Exedrin) and perhaps go back on another antidepressant, such as mirtazapine (Remeron)
Posted by dove on October 31, 2011, at 17:39:08
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 31, 2011, at 10:36:11
Do sleep meds like Ambien or Lunesta trigger serotonin effects? Could she take something like that to help with sleep, or something along the lines of Gabapentin or Lyrica?
Posted by Abaigeal on October 31, 2011, at 18:19:07
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by jono_in_adelaide on October 31, 2011, at 17:35:00
Okay, right now, I have no idea what is going on with my brain. I'm trying to get some ideas of what to tell the psychiatrist tomorrow. I keep going from being happy to angry, to anxious, panic attacks, sad, hopeless. And not sleeping well, with a headache all the time, does not help. I've never been like this before. Is it possible amitriptyline has been covering up the onset symptoms of maybe bipolar disorder?
Posted by Phillipa on October 31, 2011, at 18:59:03
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 31, 2011, at 18:19:07
I feel anything is possible. You do need sleep though. Will you post what your doc says? Maybe call? Phillipa
Posted by dove on October 31, 2011, at 19:06:30
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 31, 2011, at 18:19:07
Bipolar is treated with mood stabilizers and "usually" more extreme with more definitive highs and lows. Not saying a mood stabilizer would be of no use but remember that you are coming off of 2 years of amitriptyline use cold turkey. There are going to be some rough edges for a while (particularly when losing both the zoloft and ami). I had lots of mood changes and volatility when I quit taking ami.
Tell the p-doc what you are feeling, you don't need a "label" to receive help, they need to treat the symptoms you are currently feeling if possible, help ease the withdrawal. Write a list, have something in hardcopy to read so you don't get flustered and forget the important things that are seriously disabling you.
Hopefully the doc has experience treating patients who have had serotonin syndrome. There are other classes of meds that should help ease some of the symptoms or at least make them somewhat manageable.
Posted by dove on October 31, 2011, at 19:20:56
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by jono_in_adelaide on October 31, 2011, at 17:35:00
Mirtazapine is contra-indicated after severe serotonin syndrome I thought? Could she utilize a straight NRI? Like Reboxetine (panic and depression)? Or even Bupropion (depression)? Not sure what affinity bupropion has for serotonin receptors anymore... Use ambien or lunesta or something for sleep help.
Migraine help is most likely not going to some from exedrin (at least that didn't help mine which was why I was started on amitriptyline originally). Gabapentin or calcium channel blocker for migraine, I don't know.
Posted by jono_in_adelaide on October 31, 2011, at 19:31:28
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 31, 2011, at 18:19:07
amitrioptyline is more likely to trigger bipolar than cover it up, it has probably masked the headaches and depression though.
I'd ask for a sleeping pill for a while (Ambien for example) and discuss the possability of taking an antidepressant like nortriptyline, this will help the headaches, help with your sleep, and help with anxiety/depression.
Usual dose would be 75mg at night. An alternative would be remeron, this would be better for anxiety, about the same for depression, perhaops not so strong against headache.
Posted by Abaigeal on October 31, 2011, at 19:50:33
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by jono_in_adelaide on October 31, 2011, at 19:31:28
I've been on remeron twice before, the first time I got really bad RLS, second time it made my anxiety go crazy. I will ask for a sleeping aid. I was reading that amitriptyline is sometimes used for people with bipolar. And I don't know a thing about nortriptyline.
Posted by Abaigeal on October 31, 2011, at 20:04:31
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 31, 2011, at 19:50:33
"Nortriptyline is the active metabolite of amitriptyline that is demethylated in the liver. It inhibits the reuptake of norepinephrine (noradrenaline) and, to a lesser extent, serotonin with negligible effects on dopamine reuptake. Nortriptyline also has antagonistic effects at a variety of receptors"
It effects serotonin, I'm not supposed to ever take anything that affects serotonin??
Posted by jono_in_adelaide on October 31, 2011, at 20:17:28
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on October 31, 2011, at 20:04:31
Nortriptyline is very safe, it is highly selective for noradrenalin, I dont think it has ever been associated with seretonin syndrome, it is commonly used in combination with SSRI's
Taking it by it self without an SSRI there would be no risk at all.
Ask your doctor and see what he says, the worst he can say is no.
I'd ask about taking nortriptyline 75mg at bedtime, and 10mg ao Ambien at bedtime if needed/when needed
Posted by Abaigeal on November 1, 2011, at 7:01:47
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by jono_in_adelaide on October 31, 2011, at 20:17:28
So I went to bed around 12, woke up at 3, was drawing and listening to music til like 5.. then I got really sick, started hyperventilating, took my ativan, but then I started hallucinating again, just latices and uncontrollable shakes. I do not understand what is going on. Was it just from the hyperventilating? Lack of oxygen? The ativan is finally kicking in. I just want to sleep and not have this headache!
Posted by hyperfocus on November 2, 2011, at 18:33:24
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on November 1, 2011, at 7:01:47
I think what you should immediately do is have your amitriptyline blood levels checked. TCA blood levels can vary wildly in people. Some people can have extraordinary high levels of amitrip in their system than others at the same dose because of reduced clearance by their bodies. This reduced clearance can just be due to an individual's metabolism or because of concurrently taking another drug that inhibits the metabolism of the amitrip. I know for sure fluoxetine inhibits CYP450 2D6, the liver enzyme responsible for metabolizing amitrip, and combining these 2 is dangerous and not recommended. According to this article, sertaline is 4th on the list of SSRIs with this liver enzyme interaction:
http://cat.inist.fr/?aModele=afficheN&cpsidt=2889071
The selective serotonin reuptake inhibitors (SSRIs) and venlafaxine display the following rank order of in vitro potency against the cytochrome P450 (CYP) isoenzyme CYP2D6 as measured by their inhibition of sparteine and/or dextromethorphan metabolism : paroxetine > fluoxetine = norfluoxetine > sertraline ≥ fluvoxamine > venlafaxine. On this basis, paroxetine would appear to have the greatest and fluvoxamine and venlafaxine the least potential for drug interactions with CYP2D6-dependent drugs. In vivo, inhibitory potency is affected by the plasma concentration of the free (unbound) drug, a potentially important consideration since many CYP2D6-metabolised drugs exhibit nonlinear (saturable) kinetics, and by the presence of metabolites, which might accumulate and interact with the CYP system. Under steady-state conditions, paroxetine and fluoxetine are approximately clinically equipotent inhibitors of CYP2D6 in vivo (as determined through their effects on desipramine metabolism) ; sertraline, in contrast, shows lower steady-state plasma concentrations than fluoxetine and, hence, a less pronounced inhibition of CYP2D6. Of the drugs that are metabolised by CYP2D6, secondary amine tricyclic antidepressants, antipsychotics (e.g. phenothiazines and risperidone), codeine, some antiarrhythmics (e.g. flecainide) and β-blockers form the focus of clinical attention with regard to their potential interactions with the SSRIs. Coadministration of desipramine and fluoxetine (20 mg/day) at steady-state produced an 4-fold elevation in peak plasma desipramine concentrations, while the long half-life of the active metabolite norfluoxetine was responsible for a significant and long lasting ( 3 weeks) elevation of plasma desipramine concentrations after discontinuation of fluoxetine. Similarly, coadministration of desipramine with paroxetine produced an 3-fold increase in plasma desipramine concentrations. In contrast, coadministration of desipramine and sertraline (50 mg/day) for 4 weeks resulted in a considerably more modest ( 30%) elevation in plasma desipramine concentrations. Coadministration of fluoxetine (60 mg/day, as a loading dose) [equivalent to serum concentrations obtained with 20 mg/day at steady-state] with imipramine or desipramime resulted in 3- to 4-fold increases in plasma area under the curve (AUC) values for both imipramine and desipramine (illustrating a significant drug interaction potential at multiple isoenzymes). Consistent with its minimal in vitro effect on CYP2D6, fluvoxamine shows minimal in vivo pharmacokinetic interaction with desipramine, but does interact with imipramine ( 3- to 4-fold increase in AUC) through inhibition of CYP3A3/4, CYP1A2, and CYP2C19. Thus, the extent of the in vivo interaction between the SSRIs and tricyclic antidepressants mirrors to a large extent their in vitro inhibitory potencies against CYP2D6 and other isoenzyme systems, especially if one takes into account pharmacokinetic factors.The symptoms you describe could be as a result of TCA toxicity instead of or in addition to serotonin syndrome. Amitriptyline is a Alpha-1 adrenergic receptor blocker and a fast sodium channel blocker, which is bad news for your heart. Levels of amitrip that are too high put you at risk for sudden death due to cardiotoxicity. I urge you to get your amitrip blood levels checked ASAP and DON'T increase the amitrip dose. Your story sounds a bit too close to comfort to this case:
http://www.preskorn.com/columns/0211.html"The patient denied any problems with anticholinergic side effects such as dry mouth, constipation, or urinary retention. Given that fact and the inadequate response, the amitriptyline dose was increased to 250 mg/day.
After 8 days, the patient complained of generalized anxiety, a panic episode, recurrent bouts of palpitations, and headaches. The psychiatrist concluded that the depressive episode was worsening with the development of more prominent anxiety symptoms. Given this assessment and no complaints of anticholinergic side effects, the amitriptyline dose was increased to 300 mg/day and the following medications were added: propranolol, 20 mg three times a day, diazepam, 5 mg four times a day, and flurazepam, 30 mg at night.
After 2 weeks, the patient was more listless, disinterested and confused. The assessment was worsening of the depressive episode. Given this assessment and no complaints of anticholinergic side effects, the amitriptyline dose was increased to 350 mg/day. Three days later, the patient complained of intermittent chest pain and swelling of his feet. Furosemide (Lasix) was added to treat these complaints."
The patient eventually died. I had a bit of amitrip overdose this month too btw: http://www.dr-bob.org/babble/20111016/msgs/999903.html and it was pretty scary.
Posted by Abaigeal on November 2, 2011, at 19:44:28
In reply to Re: TCA toxicity, important! » Abaigeal, posted by hyperfocus on November 2, 2011, at 18:33:24
did I mention I was hospitalized for 3 days? lol.. they checked my tca blood levels 3 times a day just to be sure.
On another note - The doc appointment was not a doctors appointment by they way. I guess the mental health place had to cut back spending.. so I had to see a social worker.. total bs. I see the pain doctor tomorrow for the nonstop migraine. I'm having less panic attacks, chest pains, only taken 1 ativan today. Insomnia is terrible though. I went 25 hours. Haven't done that since before amitriptyline. Just wanted to update you guys.
Posted by JONO_IN_ADELAIDE on November 2, 2011, at 19:47:27
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on November 1, 2011, at 7:01:47
Try taking your Ativan along with two Advil-PM about an hour before you want to go to sleep. This should relieve your headache and give you a good nights sleep.
During the day, plain Advil should help the headache.
It might be time to ask for a referal to a neurologist for a checkup.
Can you list the meds that you are currently taking right now?
Posted by Abaigeal on November 2, 2011, at 19:53:11
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by JONO_IN_ADELAIDE on November 2, 2011, at 19:47:27
I see a neurologist on the 11th :) and a real psych on the 8th. The hospital I was at was extremely thorough and helpful.. I don't think I could have been in better hands. I keep trying to take excedrin with the ativan. I'm probably going to try the botox injections.. or calcium channel blockers. I'm telling you.. nothing helps this headache. The only meds I am taking are ativan, magnesium, b12, multivitamins, occasionally melatonin, loratadine, and omeprazole. The only prescription I have is ativan and omeprazole.
Posted by Phillipa on November 2, 2011, at 20:57:52
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on November 2, 2011, at 19:53:11
Headache of concern have you had an MRI of the head? Phillipa
Posted by Abaigeal on November 2, 2011, at 20:58:27
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft » Abaigeal, posted by Phillipa on November 2, 2011, at 20:57:52
I've had a CT scan, no MRI
Posted by dove on November 2, 2011, at 21:07:51
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on November 2, 2011, at 20:58:27
Severe migraines (with aura, without aura and some sort of mini-stroke kind) run in our family.
Posted by Phillipa on November 3, 2011, at 18:35:50
In reply to Re: Serotonin syndrome. Amitriptyline+zoloft, posted by Abaigeal on November 2, 2011, at 20:58:27
Results normal? So what now? Phillipa
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