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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by NKP on July 10, 2020, at 8:38:43
I am currently on the following psychiatric medicines (I feel bad for taking three different medicines):
* Zoloft 50 mg / day (since April)
* Fluanxol 0.5 mg / day (since April)
* Strattera 25 mg / day (since May)I have a few questions:
1. Can the Fluanxol interfere with the action of the Strattera? Fluanxol is a dopamine antagonist (although I am under the impression that it actually acts as a dopamine agonist at low doses?). Strattera is classed as a norepinephrine reuptake inhibitor, but to my knowledge, it also increases dopamine in some parts of the brain.
2. Does it even make sense to take such a low dose of Strattera? Has anyone else found benefit from such a low dose? I've seen literature that suggests that Strattera doses lower than the target dose of 80 mg / day may still be effective. There are also anecdotes on YouTube and Reddit of folks who seem to have done well on such lower doses. I can't say that I've experienced a dramatic effect from the Strattera, but then, it is said that Strattera is a medicine that is "compared", not "felt", in the sense that you don't "feel" it from day to day, but rather, you notice its effects when you "compare" your functioning, say, six months into treatment, to how you were before treatment.
3. Is there such a thing as a "second wave" of side-effects from Strattera? There are many anecdotes on YouTube and Reddit from folks who say that Strattera took months to start working. I'm wondering if it can also happen, months into the treatment, that one suddenly experiences new side-effects? I ask because this last week I am suddenly experiencing headaches every day, a problem that I never had before.
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To give some context, I was never formally diagnosed as having ADHD. In the past I had a few episodes of depression, for which I was treated by a psychiatrist, and used the following combinations of medicines during different episodes, listed in decreasing order of effectiveness:
* Zoloft + Fluanxol
* Zoloft alone
* Cymbalta
* WellbutrinIn April I went to my family doctor to ask that I be put back on Zoloft and Fluanxol, because even though I didn't feel sad as such, I kept having thoughts about killing myself. He acquiesced. As I described some of my symptoms to him (e.g. forgetfulness, distractability, and procrastination), he said that it sounded a bit like ADHD and suggested that I try Strattera. But the "diagnosis" was very casual and superficial.
So I'm not even sure if I have ADHD. When I read the Wikipedia article on ADHD, I concluded that I did not have the condition. My wife however came to the conclusion, after having read the same article, that I do have ADHD. I also watched YouTube videos by folks with ADHD and I could identify with much of it, hence why I decided to give the Strattera a try a month after my family doctor first suggested it.
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I'm also uncomfortable using the Fluanxol for fear of getting metabolic problems, tardive dyskinesia, or gynecomastia. However, the Fluanxol "quietens" my mind (almost like cutting out the background static) in a way that makes it easier for me to concentrate on things, and it also makes me calmer (I'm a naturally irritable person and I have a short temper to the extent of it almost causing problems at work).
Posted by undopaminergic on July 10, 2020, at 12:11:32
In reply to Questions about Strattera (and Fluanxol), posted by NKP on July 10, 2020, at 8:38:43
>
> I'm also uncomfortable using the Fluanxol for fear of getting metabolic problems, tardive dyskinesia, or gynecomastia.
>That is scarcely a problem with such a low dose as 0.5 mg/day.
> However, the Fluanxol "quietens" my mind (almost like cutting out the background > static)
Wow! That's like an amphetamine!
> in a way that makes it easier for me to concentrate on things, and it also makes me calmer (I'm a naturally irritable person and I have a short temper to the extent of it almost causing problems at work).
>Nice. I'm sorry that it did not help me much, if at all.
-undopaminergic
Posted by linkadge on July 11, 2020, at 8:02:28
In reply to Questions about Strattera (and Fluanxol), posted by NKP on July 10, 2020, at 8:38:43
Hi there,
I'm in a similar situation. I have been diagnosed with ADD, but the diagnosis doesn't fit 100%. I'm also not sure if the attention problems are more a result of other medications. That being said, straterra does help with a number of symptoms. Like yourself, I only take 25mg. I have no plans to increase because this dose is working.
Straterra is a norepinephrine reuptake inhibitor. This means in primarily increases the level of norepinephrine in the brain. Norepinephrine levels are linked to things like energy, motivation, attention, working memory etc. While it is approved only for ADD/ADHD it has been used off label alongside SSRIs for secondary symptoms like energy levels, concentration etc. SSRIs like zoloft, can make attention worse for some people.
In terms of whether Fluanxol will cancel out the straterra, it is a bit complex, but the short answer is no. Although atomoxetine is a norepinephrine reuptake inhibitor, it can also increase dopamine levels in certain brain regions (i.e. the prefrontal cortex). The reason for this is that, in the prefrontal cortex, dopamine is cleared out (to an extent) by the norepinephrine transporter. Increasing dopamine in the prefrontal cortex can help concentration, motivation etc. Now, I'm not sure what symptoms you are taking the Fluanxol for. However, you are taking it in the lower dose range (perhaps more as a sedative)? As you mention, low doses may activate dopamine in certain brain regions. If it does block dopamine to some extent, the atomoxetine will counteract this. Also, the Fluanxol doesn't block norepinephrine.
As far as side effects and action, straterra can take some time to reach its full therapeutic effect. I noticed improvement in the first week and continued improvement into the 2nd and third weeks. Side effects however, typically appear early in treatment. So, if you don't have a side effect now, chances are low that one will suddenly appear (although anything is possible). The main thing to watch with straterra is your blood pressure and pulse. In terms of dose, my doctor said it can vary quite a bit from person to person. I've read this online too. Yes, 80mg may be required for bad ADHD, just as 3-6mg of Fluanxol may be required for schizophrenia.
Linkadge
Posted by linkadge on July 11, 2020, at 8:06:11
In reply to Questions about Strattera (and Fluanxol), posted by NKP on July 10, 2020, at 8:38:43
Just to add, if you don't have schizophrenia, there are alternatives to Fluanxol. Have you tried trazodone?
An alternative to Fluanxol would be seroquel. Although it too is an antipsychotic, it actually metabolizes to norquetiapine (a norepinephrine reuptake inhibitor, like atomoxetine).
If you are using Fluanxol for anxiety, there are alternatives.
Linkadge
Posted by undopaminergic on July 11, 2020, at 12:03:46
In reply to Re: Questions about Strattera (and Fluanxol) » NKP, posted by linkadge on July 11, 2020, at 8:06:11
> Just to add, if you don't have schizophrenia, there are alternatives to Fluanxol. Have you tried trazodone?
>
> An alternative to Fluanxol would be seroquel. Although it too is an antipsychotic, it actually metabolizes to norquetiapine (a norepinephrine reuptake inhibitor, like atomoxetine).
>
> If you are using Fluanxol for anxiety, there are alternatives.
>
> LinkadgeI just wanted to point out that Fluanxol seems to have little sedative potential. It is an anti-histamine, but I never noticed I got tired or apathetic from it, which is unlike trimipramine and clozapine.
Fluanxol has antidepressant effects, but the mechanism of action in this respect is unknown. For what it's worth, I didn't notice an an antidressant effect myself.
I've used doses of 4+ mg, and for several months, so I'm pretty familiar with this drug.
Seroquel is more sedative than Fluanxol, and probably a lot less effective for psychosis. It has little anti-dopaminergic action at typical doses. Then again, so does clozapine, which is regarded as a kind of gold standard for antipsychotics.
-undopaminergic
Posted by NKP on July 12, 2020, at 15:06:05
In reply to Re: Questions about Strattera (and Fluanxol), posted by undopaminergic on July 10, 2020, at 12:11:32
> >
> > I'm also uncomfortable using the Fluanxol for fear of getting metabolic problems, tardive dyskinesia, or gynecomastia.
> >
>
> That is scarcely a problem with such a low dose as 0.5 mg/day.I hope so. I'm on quite a few medicines which influence blood sugar:
(i) I'm on high doses of thyroid medicine (both levothyroxine and liothyronine) and this increases blood sugar.
(ii) To my knowledge, SSRIs increase insulin, which over time contributes to insulin resistance and eventually diabetes. I'm on Zoloft.
(iii) Anti-psychotics, even typicals, can raise blood sugar and contribute to the onset of diabetes. I'm on Fluanxol.
(iv) I don't know what effect Strattera has on blood sugar, but I suspect that it, acting on norepinephrine, probably also increases blood sugar.I recently had fasting blood sugar, HbA1c, and fasting insulin, tests. Each of these numbers in isolation was within the acceptable range, but the three numbers in combination painted a picture of early insulin resistance.
In the past, 1 mg / day of Fluanxol caused significant weight gain over a period of about two years.
Posted by NKP on July 12, 2020, at 15:08:17
In reply to Re: Questions about Strattera (and Fluanxol) » NKP, posted by linkadge on July 11, 2020, at 8:02:28
> Hi there,
>
> I'm in a similar situation. I have been diagnosed with ADD, but the diagnosis doesn't fit 100%. I'm also not sure if the attention problems are more a result of other medications. That being said, straterra does help with a number of symptoms. Like yourself, I only take 25mg. I have no plans to increase because this dose is working.
>
> Straterra is a norepinephrine reuptake inhibitor. This means in primarily increases the level of norepinephrine in the brain. Norepinephrine levels are linked to things like energy, motivation, attention, working memory etc. While it is approved only for ADD/ADHD it has been used off label alongside SSRIs for secondary symptoms like energy levels, concentration etc. SSRIs like zoloft, can make attention worse for some people.
>
> In terms of whether Fluanxol will cancel out the straterra, it is a bit complex, but the short answer is no. Although atomoxetine is a norepinephrine reuptake inhibitor, it can also increase dopamine levels in certain brain regions (i.e. the prefrontal cortex). The reason for this is that, in the prefrontal cortex, dopamine is cleared out (to an extent) by the norepinephrine transporter. Increasing dopamine in the prefrontal cortex can help concentration, motivation etc. Now, I'm not sure what symptoms you are taking the Fluanxol for. However, you are taking it in the lower dose range (perhaps more as a sedative)? As you mention, low doses may activate dopamine in certain brain regions. If it does block dopamine to some extent, the atomoxetine will counteract this. Also, the Fluanxol doesn't block norepinephrine.
>
> As far as side effects and action, straterra can take some time to reach its full therapeutic effect. I noticed improvement in the first week and continued improvement into the 2nd and third weeks. Side effects however, typically appear early in treatment. So, if you don't have a side effect now, chances are low that one will suddenly appear (although anything is possible). The main thing to watch with straterra is your blood pressure and pulse. In terms of dose, my doctor said it can vary quite a bit from person to person. I've read this online too. Yes, 80mg may be required for bad ADHD, just as 3-6mg of Fluanxol may be required for schizophrenia.
>
> Linkadge
>I've had two main side-effects from the Strattera, neither of which has subsided after more than two months: nausea for a few hours after taking it, and intense goosebumps (which aren't unpleasant, but certainly unusual).
Posted by NKP on July 12, 2020, at 15:10:52
In reply to Re: Questions about Strattera (and Fluanxol), posted by undopaminergic on July 11, 2020, at 12:03:46
> > Just to add, if you don't have schizophrenia, there are alternatives to Fluanxol. Have you tried trazodone?
> >
> > An alternative to Fluanxol would be seroquel. Although it too is an antipsychotic, it actually metabolizes to norquetiapine (a norepinephrine reuptake inhibitor, like atomoxetine).
> >
> > If you are using Fluanxol for anxiety, there are alternatives.
> >
> > Linkadge
>
> I just wanted to point out that Fluanxol seems to have little sedative potential. It is an anti-histamine, but I never noticed I got tired or apathetic from it, which is unlike trimipramine and clozapine.
>
> Fluanxol has antidepressant effects, but the mechanism of action in this respect is unknown. For what it's worth, I didn't notice an an antidressant effect myself.
>
> I've used doses of 4+ mg, and for several months, so I'm pretty familiar with this drug.
>
> Seroquel is more sedative than Fluanxol, and probably a lot less effective for psychosis. It has little anti-dopaminergic action at typical doses. Then again, so does clozapine, which is regarded as a kind of gold standard for antipsychotics.
>
> -undopaminergic
>I do not find Fluanxol to be sedating at all. On the contrary, I take it in the mornings (the package says not to take it later than 16:00 in the afternoon) and find that I have difficulty falling asleep at night.
Posted by NKP on July 12, 2020, at 15:21:02
In reply to Re: Questions about Strattera (and Fluanxol) » NKP, posted by linkadge on July 11, 2020, at 8:06:11
> Just to add, if you don't have schizophrenia, there are alternatives to Fluanxol. Have you tried trazodone?
>
> An alternative to Fluanxol would be seroquel. Although it too is an antipsychotic, it actually metabolizes to norquetiapine (a norepinephrine reuptake inhibitor, like atomoxetine).
>
> If you are using Fluanxol for anxiety, there are alternatives.
>
> LinkadgeI've not tried Trazodone. I don't feel particularly anxious.
I've been on antidepressant medication six times in the past. Looking back, there seems to be a pattern:
1. I reach a low point where I decide to go on medication.
2. Over time, I get better while on the medication.
3. I eventually decide to stop using the medication, feeling that I don't need it.
4. Go to 1.Comparing my functioning on medication vs off medication over a period of many years, I can say that I've generally functioned better on medication than off.
Despite this, I'm considering stopping the Fluanxol at least, possibly the Zoloft too, and staying just on the Strattera, and maybe increasing its dose.
Posted by linkadge on July 13, 2020, at 7:33:41
In reply to Re: Questions about Strattera (and Fluanxol), posted by NKP on July 12, 2020, at 15:06:05
SSRIs can increase the risk of diabetes (usually in association with weight gain) but it is certainly not guaranteed.
As for antipsychotics, the atypicals are actually associated with more risk (especially olanzapine) whereas the typicals have a lower risk.
Again as for the Fluanxol, I would assess why you are using it. If it is for any psychotic like symptoms then it is justified. However, if it is just being used as a sedative, there are much better options. If an antipsychotic is needed, then you could try something like abilify.
Linkadge
Posted by linkadge on July 13, 2020, at 7:41:55
In reply to Re: Questions about Strattera (and Fluanxol), posted by NKP on July 12, 2020, at 15:21:02
It may be worth trying strattera on its own, BUT I would caution you that it is not an antidepressant. I understand that it shares some properties as antidepressants and may improve mood for people with primary ADHD (and depression secondary to ADHD). However, I did not do well on atomoxetine by itself. It did improve energy / motivation but my mood was very sour on it. Have you ever tried wellbutrin? It would not have the typical SSRI like side effects, and can actually improve concentration (like straterra).
I would communicate with your doctor your concerns. There certainly are other options for depression that may be much more tolerable than zoloft + antipsychotic. For example, trintellix is an option that has a proven pro-cognitive effect. If you're taking Fluanxol as a depression adjunct, you could try abilify. It is approved for depression augmentation and has a much lower risk of blood sugar issues. Fluanxol is a bit strange in the absence of any psychotic like symtpoms.
Linkadge
Posted by NKP on July 18, 2020, at 3:33:25
In reply to Re: Questions about Strattera (and Fluanxol) » NKP, posted by linkadge on July 13, 2020, at 7:41:55
Minor update: My doctor (a family doctor, not psychiatrist) advised that I not touch my Zoloft or Fluanxol, based on my response when I tried to reduce my Fluanxol dose to 0.25 mg/day, and we've increased my Strattera dose to 40 mg/day, as I've experienced some, but inadequate, improvement in the symptoms I had for which the Strattera was prescribed.
This is the end of the thread.
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