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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by Jaxter99 on February 28, 2018, at 21:50:50
Hi. I'm on a few meds for agoraphobia (risperidone (which is amazing!), paroxetine and clonazepam). I'm also on amitriptyline 25mg for a chronic pain problem I've had for years. (I get bladder pain). The amitrip stopped working a couple of years ago - I think it pooped out after 8 years. The bladder pain came back and I've been battling it for the last couple of years. At the time we tried doubling the dose to 50mg but it seemed to make no difference. I'm now wondering if a switch to noritriptyline could be a possible strategy as it's also for pain at lower doses. But I'm wondering if it's too similar to amitrip and just won't work either. Any thoughts? I'm going to be seeing my uro in a month, but I don't think she'll be very au fait with drug poop out and switching meds (like a psych would).
Thanks
Jaxter
Posted by ed_uk2010 on March 1, 2018, at 13:53:19
In reply to Switch from amitrip to noritrip due to poop out?, posted by Jaxter99 on February 28, 2018, at 21:50:50
Hi,
Glad to hear that a low dose of risperidone is helping so much for anxiety/panic.
Nortriptyline is one of the metabolites of amitriptyline. This means that nortriptyline is produced in the liver when people take amitriptyline. Overall, amitriptyline has been studied more widely for pain than its derivative nortriptyline... but nortriptyline remains an alternative option.
The usual reason for switching from amitriptyline to nortriptyline in chronic pain is because amitriptyline is causing too much drowsiness or certain other side effects. In many cases, people find nortriptyline less sedating. The effectiveness of the two meds for pain is probably fairly similar overall, but some people prefer one to the other.
In your case, you've tried a higher dose of amitriptyline and it doesn't sound like it helped. This suggests that it might be worth asking for a different type of treatment/medication from your urologist, rather than switching from amitriptyline to a similar drug. What do you think?
If you do switch from amitriptyline to something else, bear in mind that after long-term treatment, gradual withdrawal of amitriptyline is recommended to avoid causing symptoms eg. difficulty sleeping etc.
Posted by SLS on March 1, 2018, at 20:53:25
In reply to Re: Switch from amitrip to noritrip due to poop out? » Jaxter99, posted by ed_uk2010 on March 1, 2018, at 13:53:19
Would Cymbalta (duloxetine) be of any value?
- Scott
Posted by ed_uk2010 on March 1, 2018, at 21:51:44
In reply to Re: Switch from amitrip to noritrip due to poop out? » ed_uk2010, posted by SLS on March 1, 2018, at 20:53:25
> Would Cymbalta (duloxetine) be of any value?
I think that's a really interesting idea, but it does bring up some potential issues:
1. I don't think duloxetine has been studied much in chronic bladder pain. I did find an abstract from an observational study, but it didn't appear to be effective or well tolerated.
2. Duloxetine can be useful for stress incontinence, but AFAIK, urgency and frequency are much more common in interstitial cystitis.
Anticholinergics, rather than duloxetine, are often useful for urgency/frequency - which could be part of the reason why amitriptyline sometimes reduces these symptoms.
3. I'd wonder whether a therapeutic dose of duloxetine would be an issue while taking paroxetine. Mainly in terms of serotonergic adverse effects.
Just some thoughts really.
Posted by Jaxter99 on March 2, 2018, at 2:01:14
In reply to Re: Switch from amitrip to noritrip due to poop out? » Jaxter99, posted by ed_uk2010 on March 1, 2018, at 13:53:19
> Hi,
>
> Glad to hear that a low dose of risperidone is helping so much for anxiety/panic.
>
> Nortriptyline is one of the metabolites of amitriptyline. This means that nortriptyline is produced in the liver when people take amitriptyline. Overall, amitriptyline has been studied more widely for pain than its derivative nortriptyline... but nortriptyline remains an alternative option.
>
> The usual reason for switching from amitriptyline to nortriptyline in chronic pain is because amitriptyline is causing too much drowsiness or certain other side effects. In many cases, people find nortriptyline less sedating. The effectiveness of the two meds for pain is probably fairly similar overall, but some people prefer one to the other.
>
> In your case, you've tried a higher dose of amitriptyline and it doesn't sound like it helped. This suggests that it might be worth asking for a different type of treatment/medication from your urologist, rather than switching from amitriptyline to a similar drug. What do you think?
>
> If you do switch from amitriptyline to something else, bear in mind that after long-term treatment, gradual withdrawal of amitriptyline is recommended to avoid causing symptoms eg. difficulty sleeping etc.
>
>
>I am on something else for my bladder (Elmiron) but I've been on it for 7 months now (takes 3-6 months to work) and it doesn't seem to be working. The other medications they recommend I'm either already on (SSRI) or would cause even more drowsiness than I'm already experiencing. (The risperidone really does a number on me that way but there's no way I'm giving that up!)
I must admit after your post I'm wondering if it's even worth trying nortriptyline - if it's so similar to amitriptyline I can't imagine it's going to work where amitrip didn't. I'm only on 25mg - would you not be able to do a straight switch at that dosage?
>
Posted by ed_uk2010 on March 2, 2018, at 4:14:25
In reply to Re: Switch from amitrip to noritrip due to poop out? » ed_uk2010, posted by Jaxter99 on March 2, 2018, at 2:01:14
Hi,
>I am on something else for my bladder (Elmiron) but I've been on it for 7 months now (takes 3-6 months to work) and it doesn't seem to be working.
I'm sorry to hear that.
>The other medications they recommend I'm either already on (SSRI) or would cause even more drowsiness than I'm already experiencing.
Which other medications have they suggested? Amitriptyline often causes more drowsiness than other pain treatments, so if amitriptyline was stopped, you might be able to tolerate something else.
>I'm only on 25mg - would you not be able to do a straight switch at that dosage?
Yes you could. I was meaning to reduce slowly if you were stopping tricylics, not switching to nortriptyline.
Because paroxetine increases the level of tricylics in the body, you aren't likely to need a high dose of either amitriptyline or nortriptyline. And, for safety reasons, it wouldn't be recommended. It sounds like you've been OK on 25mg in terms of side effects though(?) It's common to do an ECG/EKG if someone takes amitriptyline (or nortriptyline) with an interacting drug, but it's not universal.
I suppose the advantage of trying nortriptyline is that it's a fairly simple treatment option.
Posted by Jaxter99 on March 4, 2018, at 1:33:39
In reply to Re: Switch from amitrip to noritrip due to poop out? » Jaxter99, posted by ed_uk2010 on March 2, 2018, at 4:14:25
Which other medications have they suggested? Amitriptyline often causes more drowsiness than other pain treatments, so if amitriptyline was stopped, you might be able to tolerate something else.
Other meds used in treatment are:
Anithistamines -Hydroxyzine pamoate (Vistaril)
Hydroxyzine hydrochloride (Atarax)
Which cause drowsiness but I guess I could take if I stopped the amitriptylineI've heard of Gabapentin as well - but I read something about that it could cause depression which would be terrible for me?
And botox! But obviously that's injected :)
Posted by ed_uk2010 on March 4, 2018, at 2:32:05
In reply to Re: Switch from amitrip to noritrip due to poop out? » ed_uk2010, posted by Jaxter99 on March 4, 2018, at 1:33:39
>Hydroxyzine hydrochloride (Atarax)
>Which cause drowsiness but I guess I could take if I stopped the amitriptyline.True, a few antihistamines have been tried in IC, but mainly hydroxyzine. Also, among its many other actions in the body, amitriptyline is an antihistamine. Amitriptyline does a lot of different things!
Would you rather stop amitriptyline or take something alongside it?
It is (now) not recommended to take hydroxyzine with amitriptyline due to occasional effects on the heart rhythm (if the QT interval is prolonged), so it would be something to take instead rather than together. I think that's particularly relevant to you because you already take a medication which can increase amitriptyline levels (paroxetine).
In general, if someone has become used to taking one drug with a sedative antihistamine effect, like amitriptyline, other potentially sedating antihistamine such as hydroxyzine do not cause much drowsiness. This is because the brain adapts to the effects of histamine receptors being blocked. Because amitriptyline can causes drowsiness through multiple mechanisms, rather than just blocking histamine, I would expect hydroxyzine to cause you milder drowsiness than amitriptyline.
One thing you could take in combination with amitriptyline is a non-sedating antihistamine. Cetirizine (eg. Zyrtec) was suggested in an article I looked at.
Treatment Approaches for Interstitial Cystitis: Multimodality Therapy
Robert J Evans, MD'In patients who cannot tolerate a sedating antihistamine, cetirizine hydrochloride may be a reasonable alternative.'
Cetirizine was discovered because it is the main metabolite of hydroxyzine (ie. hydroxyzine is converted to cetirizine by the liver). In contrast to hydroxyzine, cetirizine causes much less drowsiness and does not affect the heart. As a result of its improved safety, cetirizine is available as a non-prescription medication in most countries, for allergies etc.
>I've heard of Gabapentin as well - but I read something about that it could cause depression which would be terrible for me?
Like other epilepsy medications, gabapentin comes with a depression warning. I would not say it's a common side effect though.
When used to treat chronic pain, gabapentin can be used with or without amitriptyline. There isn't any specific interaction, but taking them together may cause more drowsiness than alone.
Gabapentin has also been used as a treatment for anxiety, for which it is something effective.
If it's necessary to stop treatment with gabapentin, it should be done gradually to avoid unpleasant symptoms.
>
> I've heard of Gabapentin as well - but I read something about that it could cause depression which would be terrible for me?
>
> And botox! But obviously that's injected :)
>
>
>
>
>
Posted by Jaxter99 on March 5, 2018, at 1:38:05
In reply to Re: Switch from amitrip to noritrip due to poop out? » Jaxter99, posted by ed_uk2010 on March 4, 2018, at 2:32:05
> Would you rather stop amitriptyline or take something alongside it?
>
I'd rather stop it if it isn't working and it seems like it would interfere with other possible meds for IC. Plus I'm on a LOT of meds at the moment, it would be nice not to add to the total.> It is (now) not recommended to take hydroxyzine with amitriptyline due to occasional effects on the heart rhythm (if the QT interval is prolonged), so it would be something to take instead rather than together. I think that's particularly relevant to you because you already take a medication which can increase amitriptyline levels (paroxetine).
>
> In general, if someone has become used to taking one drug with a sedative antihistamine effect, like amitriptyline, other potentially sedating antihistamine such as hydroxyzine do not cause much drowsiness. This is because the brain adapts to the effects of histamine receptors being blocked. Because amitriptyline can causes drowsiness through multiple mechanisms, rather than just blocking histamine, I would expect hydroxyzine to cause you milder drowsiness than amitriptyline.
>
> One thing you could take in combination with amitriptyline is a non-sedating antihistamine. Cetirizine (eg. Zyrtec) was suggested in an article I looked at.
>
> Treatment Approaches for Interstitial Cystitis: Multimodality Therapy
> Robert J Evans, MD
>
> 'In patients who cannot tolerate a sedating antihistamine, cetirizine hydrochloride may be a reasonable alternative.'
>
> Cetirizine was discovered because it is the main metabolite of hydroxyzine (ie. hydroxyzine is converted to cetirizine by the liver). In contrast to hydroxyzine, cetirizine causes much less drowsiness and does not affect the heart. As a result of its improved safety, cetirizine is available as a non-prescription medication in most countries, for allergies etc.Wow - thank you for looking that up for me. I have tried another OTC anti-histamine (Loratidine) which didn't do much, do you think it's worth trying a different OTC anti-histamine? I thought hydroxyzine might be different because you need a prescription for it.
>
> >I've heard of Gabapentin as well - but I read something about that it could cause depression which would be terrible for me?
>
> Like other epilepsy medications, gabapentin comes with a depression warning. I would not say it's a common side effect though.
>
> When used to treat chronic pain, gabapentin can be used with or without amitriptyline. There isn't any specific interaction, but taking them together may cause more drowsiness than alone.
>
> Gabapentin has also been used as a treatment for anxiety, for which it is something effective.
>
> If it's necessary to stop treatment with gabapentin, it should be done gradually to avoid unpleasant symptoms.
>
>
> >
> > I've heard of Gabapentin as well - but I read something about that it could cause depression which would be terrible for me?
> >
> > And botox! But obviously that's injected :)
> >
> >Thank you so much for your advice and knowledge! How do you know so much about meds? Are you a pharmacist?
Jaxter
Posted by ed_uk2010 on March 5, 2018, at 17:35:10
In reply to Re: Switch from amitrip to noritrip due to poop out? » ed_uk2010, posted by Jaxter99 on March 5, 2018, at 1:38:05
Hi,
Glad you found the information helpful!
>I'd rather stop it if it isn't working and it seems like it would interfere with other possible meds for IC.
In that case, if your doctor agrees, you can see how you feel when you reduce, say to 10mg amitriptyline. If you have increased IC symptoms, you might decide that it was helping a bit. If not, you could gradually stop and try something else. You might feel less tired on a lower dose or after stopping.
>I have tried another OTC anti-histamine (Loratidine) which didn't do much, do you think it's worth trying a different OTC anti-histamine? I thought hydroxyzine might be different because you need a prescription for it.
Having tried other antihistamines already, cetirizine probably doesn't have the highest chance of helping. On the other hand, it could help - and it's a very low risk choice which is easy to obtain. Cetirizine is a stronger antihistamine than loratadine (which isn't always appreciated).
>I thought hydroxyzine might be different because you need a prescription for it.
It's both similar and different to cetirizine. The antihistamine and anti-allergic effect is very similar. The main difference is the hydroxyzine is much more likely to cause drowsiness. Some people find that hydroxyzine has a mild calming effect, which may help to relieve symptoms.
Gabapentin is the choice which is completely different to anything you're on. Is this something your urologist would try, or probably not?
Posted by Jaxter99 on March 6, 2018, at 2:33:03
In reply to Re: Switch from amitrip to noritrip due to poop out? » Jaxter99, posted by ed_uk2010 on March 5, 2018, at 17:35:10
> In that case, if your doctor agrees, you can see how you feel when you reduce, say to 10mg amitriptyline. If you have increased IC symptoms, you might decide that it was helping a bit. If not, you could gradually stop and try something else. You might feel less tired on a lower dose or after stopping.That's a really good idea - I'll talk with my Uro about it.
>> Having tried other antihistamines already, cetirizine probably doesn't have the highest chance of helping. On the other hand, it could help - and it's a very low risk choice which is easy to obtain. Cetirizine is a stronger antihistamine than loratadine (which isn't always appreciated).
Have bought the Cetirizone (Zyrtec) today to trial - figure I may as well try the OTC stuff first. Will give it a month.
> Gabapentin is the choice which is completely different to anything you're on. Is this something your urologist would try, or probably not?
>I think Gabapentin is def a possibility. I've made a spreadsheet of all the possible choices that I'm going to take to my Uro next month. :)
Thank you for your advice! I hope the 'beast from the east' isn't causing too much chaos for you over there in the UK. My brother lives in London and he keeps sending me pics of all the snow there.
Posted by ed_uk2010 on March 6, 2018, at 17:55:17
In reply to Re: Switch from amitrip to noritrip due to poop out? » ed_uk2010, posted by Jaxter99 on March 6, 2018, at 2:33:03
Hi,
>That's a really good idea - I'll talk with my Uro about it.The thing is, after long-term treatment, you don't always know what a particular med is doing until you reduce it. There is a possibility of symptoms such as temporary sleep disturbances on reducing amitriptyline (in anyone), but if you have increased pain or urinary urgency, you might decide that it actually was helping a little. In that case, you might want to stay on a small dose and add something else. If your symptoms stay the same, you may decide to stop (gradually) and try something entirely different.
>Have bought the Cetirizone (Zyrtec) today to trial - figure I may as well try the OTC stuff first. Will give it a month.
That makes sense. There is nothing to lose by trying it. It doesn't usually cause side effects. If it helps, that's great. If not, you can just stop it without a problem.
>I think Gabapentin is def a possibility. I've made a spreadsheet of all the possible choices that I'm going to take to my Uro next month. :)
Gabapentin is essentially a treatment for chronic pain. Although it's mainly used for nerve pain/neuropathic pain, it is something tried for other types of chronic pain. It might be an option if pain is the main issue. Gabapentin does not interact with many other medications, so can be used alongside most common meds if necessary.
>I hope the 'beast from the east' isn't causing too much chaos for you over there in the UK.
It's actually OK here since yesterday. Most of the snow has melted!
Posted by bleauberry on March 9, 2018, at 13:46:19
In reply to Re: Switch from amitrip to noritrip due to poop out? » ed_uk2010, posted by SLS on March 1, 2018, at 20:53:25
> Would Cymbalta (duloxetine) be of any value?
>
>
> - ScottNot likely. In my opinion. Cymbalta is not praised by many patients, if any at all. In the decades I have been following depression patients at chat rooms and blogs, I have never seen Cymbalta deliver remission to anybody. Remission is the goal. The sooner the better, is the goal.
I think for people dabbling in tricyclics, they get better faster results by going with Ritalin or Adderall or Modafinil combinations with other antidepressants rather than straight antidepressants. I think too often we mess around with things that take forever to work, if they work at all, you never know, but we ignore the things that work in mere hours or days.
If you ask me, any SSRI (but Prozac is the best) combined with a stimulant is likely to blow any tricyclic or Cymbalta in the weeds and it is likely to do so within just days or a couple weeks.
Posted by Lamdage22 on March 11, 2018, at 7:02:46
In reply to Re: Switch from amitrip to noritrip due to poop out?, posted by bleauberry on March 9, 2018, at 13:46:19
> If you ask me, any SSRI (but Prozac is the best) combined with a stimulant is likely to blow any tricyclic or Cymbalta in the weeds and it is likely to do so within just days or a couple weeks.
And yet most of them ruin sex. I always hear people saying that SSRI XY does not have side effects for them. I wonder if they do have that side effect but dont notice it. Obviously, i dont ask;)
Posted by bleauberry on March 12, 2018, at 16:10:51
In reply to Re: Switch from amitrip to noritrip due to poop out?, posted by Lamdage22 on March 11, 2018, at 7:02:46
Viagra does wonders. Especially when combined with Horny Goat Weed and L-Arginine. That gives all the coverage for desire, ability and pleasure.
I mentioned prozac because in my experience and study it has the least side effects of any of the SSRIs.
> > If you ask me, any SSRI (but Prozac is the best) combined with a stimulant is likely to blow any tricyclic or Cymbalta in the weeds and it is likely to do so within just days or a couple weeks.
>
> And yet most of them ruin sex. I always hear people saying that SSRI XY does not have side effects for them. I wonder if they do have that side effect but dont notice it. Obviously, i dont ask;)
>
>
Posted by Lamdage22 on March 13, 2018, at 9:39:40
In reply to Re: Switch from amitrip to noritrip due to poop out? » Lamdage22, posted by bleauberry on March 12, 2018, at 16:10:51
anorgasmia is usually the problem. I have not come accross anything that helps.
This is the end of the thread.
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