![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by David G on May 1, 2008, at 13:52:36
>>>> I placed this under Medication but I think it really goes here.<<<
Been on Welburtrin (4 years) and Lamictol (1 year) but feel the need to try a different path. I have aspergers with bipolar and the meds keep me from getting depressed. But then again I don't feel much of anything now and I'm tired of it. I also have Chronic Fatigue (poz for EB virus) - I don't get pain but I do get malaise both mentally and physically.
My doc and I have discussed MAOI's as an alternative. I need to keep my energy up (if normal is a 10 and coma is 0, I'm about 6-7 on a good day). I've reviewed the standard lit out there about drug and food interactions and the generalized side effects. I have a few questions though:
1) Has anyone tried a patch and if so, what did you think?
2) What kind of antihistamine do you take if you have a cold/flu? Any problems with anti-biotics? Yes, I have to take them (allergies, asthma, and COPD)
3) I've seen mention of intestinal problems but is that really from the drug or is that from (unknowingly) eating things from the Do Not Eat list? I've also seen contradictions regarding if fish can be eaten or not.
4) If you have tried different MAOI's, which ones did you like or not? Why?
5) I've seen reference to MAOI's increasing respiration infections like bronchitus and sinusitus? Anyone have input on that?Thanks!
Posted by Crotale on June 2, 2008, at 17:25:52
In reply to Considering an MAOI, posted by David G on May 1, 2008, at 13:52:36
> My doc and I have discussed MAOI's as an alternative.
Hi there. Both Wellbutrin and Lamictal can be combined safely with MAOIs, just so you know.
> I need to keep my energy up (if normal is a 10 and coma is 0, I'm about 6-7 on a good day). I've reviewed the standard lit out there about drug and food interactions and the generalized side effects.
A lot of the lists of food interactions (even those provided by doctors, hospitals, pharmacists, etc.) are not based on well-documented case reports or accurately measured levels of biogenic amines (tyramine, etc.). I believe there's a list here on Dr. Bob's site that's more accurate.
> 2) What kind of antihistamine do you take if you have a cold/flu?
Antihistamines (diphenhydramine, chlorpheniramine) are safe to use with MAOIs. It's decongestants (pseudoephedrine, ephedrine, phenylpropanolamine, etc.) that you need to watch out for.
> Any problems with anti-biotics?
None that I'm aware of.
> 3) I've seen mention of intestinal problems but is that really from the drug or is that from (unknowingly) eating things from the Do Not Eat list?
It's a side effect. The food interactions result in elevated blood pressure.
> I've also seen contradictions regarding if fish can be eaten or not.
You may want to avoid pickled herring, just in case, but fish in general is fine.
> 4) If you have tried different MAOI's, which ones did you like or not? Why?
I prefer Parnate (am still taking it now). Nardil and Marplan both pooped out after a few months and caused massive weight gain. Selegiline didn't help much, and it made me jittery. YMMV, of course, but weight gain with Nardil is extremely common.
> 5) I've seen reference to MAOI's increasing respiration infections like bronchitus and sinusitus? Anyone have input on that?
No...where did you read this?
Crotale
Posted by elanor roosevelt on June 2, 2008, at 23:56:13
In reply to Re: Considering an MAOI » David G, posted by Crotale on June 2, 2008, at 17:25:52
I took PArnate for a while
it did not help my depression
however, i found i had no joint or muscle discomfort and no respiratory problems
this had been a concern for megood luck
Posted by undopaminergic on June 3, 2008, at 12:50:11
In reply to Re: Considering an MAOI » David G, posted by Crotale on June 2, 2008, at 17:25:52
> > My doc and I have discussed MAOI's as an alternative.
>
> Hi there. Both Wellbutrin and Lamictal can be combined safely with MAOIs, just so you know.
>
> > I need to keep my energy up (if normal is a 10 and coma is 0, I'm about 6-7 on a good day). I've reviewed the standard lit out there about drug and food interactions and the generalized side effects.
>
> A lot of the lists of food interactions (even those provided by doctors, hospitals, pharmacists, etc.) are not based on well-documented case reports or accurately measured levels of biogenic amines (tyramine, etc.). I believe there's a list here on Dr. Bob's site that's more accurate.
>
> > 2) What kind of antihistamine do you take if you have a cold/flu?
>
> Antihistamines (diphenhydramine, chlorpheniramine) are safe to use with MAOIs.
>Chlorpheniramine (CPI) was an extremely bad example, because it is one of only two antihistamines that are known to be unsafe with MAOIs (the other one is brompheniramine, BPI). The reason is that CPI and BPI are serotonin reuptake inhibitors, and their use under MAO inhibition poses the risk of serotonin syndrome.
In contrast, another antihistamine - cyproheptadine (Periactin) - is an effective antidote to serotonin syndrome, due its serotonin 5-HT2A-receptor blocking property.
> It's decongestants (pseudoephedrine, ephedrine, phenylpropanolamine, etc.) that you need to watch out for.
>This is true, but they can sometimes be useful against MAOI-induced hypotension. Amphetamines are similar to the anticongestants mentioned above, and cause a dose-dependent elevation of blood pressure, and hypertensive crisis if the dose is high enough. Nevertheless, when used with caution, amphetamines can be used not only to treat hypotension, but also to augment an unsatisfactory response to MAOIs.
Methylphenidate (MPH) is relatively safe and may reduce tyramine sensitivity, as well as exert a stabilising effect on blood pressure. Modafinil is likely to be even safer than MPH, and caffeine is very safe. Cocaine (COC) may theoretically cause serotonin toxicity, but there are no reports of serotonin syndrome (or hypertensive crisis) with the combination of COC and MAOIs - possibly due to COC's short duration of action.
Most tricyclic antidepressants, except clomipramine and imipramine, can be used with MAOIs. So can reboxetine and atomoxetine, and like methylphenidate, they may reduce tyramine sensitivity. On the other hand, all SSRIs and SNRIs have the capacity to precipitate serotonin syndrome in combination with MAOIs. Tianeptine, on the other hand, (and amineptine) combine safely with MAOIs.
Alpha2-adrenergic antagonists, such as yohimbine, idazoxan, and mirazapine, should be used with caution due to their noradrenaline-releasing properties, which may give rise to hypertensive reactions. Yohimbine may furthermore have MAOI-inhibitory features, opening the possibility for a MAOI overdose.
Most antipsychotics, with the possible exception of ziprasidone - due to its monoamine reuptake inhibiting features - pose no notable risks in combination with MAOIs. Chlorpromazine is in fact an effective antidote to serotonin toxicity.
Dopamine direct agonists have no propensity to interact with MAOIs, and neither do the NMDA-antagonists amantadine and memantine. However, the NMDA-antagonist and cough suppressant dextromethorphan also has significant serotonin reuptake inhibiting properties and is unsafe.
Most analgesics, including aspirin and paracetamol (acetaminophen) are safe. Of the narcotic analgesics, pethidine (meperidine) and tramadol pose definite risks of serotonin toxicity, although they have sometimes been combined with MAOIs without problems. The case of fentanyl and methadone is more uncertain, but theoretical serotonergic properties have been reported, so caution is warranted. Other opiates, such as codeine, oxycodone, morphine, and buprenorphine, are very safe to use with MAOIs.
Potent noradrenaline precursors, L-dopa and L-dops, have the potential to cause hypertensive reactions, whereas tyrosine and phenylalanine are relatively safe. The direct serotonin precursor 5-hydroxytryprophan (5-HTP) poses a definite risk of serotonin toxicity, and it is likely that high doses of tryptophan also are risky.
The trace amine and dietary supplement phenylethylamine (PEA), and of course tyramine, are comparable to amphetamines and definitely elevate blood pressure in a dose-dependent manner, resulting in hypertensive crisis if enough is consumed rapidly enough.
> > Any problems with anti-biotics?
>
> None that I'm aware of.Possibly linezolid, as it is a MAOI itself, and combining it with another MAOI could theoretically result in MAOI overdose.
Posted by Crotale on June 17, 2008, at 23:26:29
In reply to Re: Considering an MAOI, posted by undopaminergic on June 3, 2008, at 12:50:11
> Chlorpheniramine (CPI) was an extremely bad example, because it is one of only two antihistamines that are known to be unsafe with MAOIs (the other one is brompheniramine, BPI). The reason is that CPI and BPI are serotonin reuptake inhibitors, and their use under MAO inhibition poses the risk of serotonin syndrome.
That's interesting; I had never heard that. I suspect they are not very strong SRIs, as I have used ChlorTrimeton (chlorpheniramine) a number of times (for allergies and the like) and never had any problem.
> > It's decongestants (pseudoephedrine, ephedrine, phenylpropanolamine, etc.) that you need to watch out for.
>
> This is true, but they can sometimes be useful against MAOI-induced hypotension. Amphetamines are similar to the anticongestants mentioned above, and cause a dose-dependent elevation of blood pressure, and hypertensive crisis if the dose is high enough. Nevertheless, when used with caution, amphetamines can be used not only to treat hypotension, but also to augment an unsatisfactory response to MAOIs.I recommend against using these drugs in this manner except under a doctor's supervision. I once had a hypertensive crisis due to accidental ingestion of something that apparently had ephedrine in it. (Some kind of over-the-counter herbal "food supplement," IIRC.)
When I had orthostatic hypotension (don't get this any more) I used to use salt tablets to balance out my BP. Much less risky than decongestants or other vasoconstrictors.
Cocaine has the potential to cause either serotonin syndrome or hypertensive crisis (the latter owing to its catecholaminergic activity). Amphetamine likewise has the potential to cause a hypertensive reaction, although it has been used safely with MAOIs in many cases.
> Most tricyclic antidepressants, except clomipramine and imipramine, can be used with MAOIs.
In general, secondary amine tricyclics (e.g., desipramine, nortriptyline, amoxapine, maprotiline (this last is sometimes called a "tetracyclic": in reality it has an ethylene bridge on the centre ring)) are safest to use with MAOIs because they tend to have relatively little activity at the serotonin transporter. Clomipramine is probably the most dangerous of the TCAs, but imipramine and amitriptyline are also tertiary amine tricyclics and have significant effect on serotonin reuptake.
> On the other hand, all SSRIs and SNRIs have the capacity to precipitate serotonin syndrome in combination with MAOIs.
If by SNRIs you mean drugs like Effexor (venlafaxine) (serotonin-norepinephrine reuptake inhibitors?) then yes, they are just as contraindicated with MAOIs as are SSRIs. OTOH the other ones you mentioned, atomoxetine and reboxetine, could be called "selective norepinephrine reuptake inhibitors," with hardly any effect on serotonin reuptake. These are safe with MAOIs just as the secondary-amine tricyclics are, and for similar reasons.
> Alpha2-adrenergic antagonists, such as yohimbine, idazoxan, and mirazapine, should be used with caution due to their noradrenaline-releasing properties, which may give rise to hypertensive reactions.
I actually don't know of any cases of hypertensive crisis attributed to this combination. Mirtazapine I think is considered a bad risk because of the potential for serotonin syndrome.
> Yohimbine may furthermore have MAOI-inhibitory features, opening the possibility for a MAOI overdose.
It's true that MAOIs should not be combined with other MAOIs, but I have never heard of an interaction happening between yohimbine and MAOI, nor do I believe there have been any reports of such interaction (in humans or rats).
> Most antipsychotics, with the possible exception of ziprasidone - due to its monoamine reuptake inhibiting features - pose no notable risks in combination with MAOIs.
This is interesting. I did not know this about ziprasidone. Which monoamine transporters does it block?
> Chlorpromazine is in fact an effective antidote to serotonin toxicity.
Yes, I've heard of Thorazine (chlorpromazine) and other neuroleptics being used in this way.
> Of the narcotic analgesics, pethidine (meperidine) and tramadol pose definite risks of serotonin toxicity, although they have sometimes been combined with MAOIs without problems.
Not Demerol (meperidine/pethidine), I don't think. The risk of an interaction with that one is quite well-documented.
> The case of fentanyl and methadone is more uncertain, but theoretical serotonergic properties have been reported, so caution is warranted. Other opiates, such as codeine, oxycodone, morphine, and buprenorphine, are very safe to use with MAOIs.
I have actually taken all of these, with the exception of codeine, while taking MAOIs (mainly Parnate) and none of them has caused any ill effects. In fact, I have been taking buprenorphine on a more or less daily basis for several years in combination with Parnate, so I can certainly vouch for that one! Most of the others I've taken at least a fair number of times (while under a doctor's care, of course). I never had any problems with hypertension, hyperpyrexia, etc. with any of them.
Posted by BrightEyed+Blueberry on July 5, 2008, at 2:24:14
In reply to Re: Considering an MAOI, posted by undopaminergic on June 3, 2008, at 12:50:11
Posted by BrightEyed+Blueberry on July 5, 2008, at 2:26:36
In reply to Re: Considering an MAOI, posted by undopaminergic on June 3, 2008, at 12:50:11
What about hydroxyzine (Vistaril, Atarax), in your discussion quesiton #2 re: safe antihistamines to take while on an MAOI (I'm on EMSAM 6mg, possibly going up to 9mg shortly).
I ask cuz I just started taking benadryl to help me sleep, as that's the only med my doctor said I could take over the counter (for sleep or colds). She's prescribed me xanax and neurontin but that combo still wakes me up after 4 hours, and I'm not comfortable with going up on my xanax dosage, for tolerance/addiction/withdrawal issues. I mean, I hate drugging to sleep, but not sleeping is worse...My doctor won't let me try trazodone either.
She won't let me try wellbutrin under her care either, to augment my EMSAM. She said she didn't have enough malpractice insurance, so she goes my the medication insert. Not much leeway there. So, If I ever want to try other things t oaugment , like provigil or even buprenorphine, or any other stim--she said I'd have to check out doctors at places like UCSF or Stanford - ad I don't know if she was pulling that out of a hat or what!
However, may I ask, if anyone has been on Wellbutrin and an MAOI at the same time (EMSAM ideally), what was the highest dose you tolerated, and was it Wellbutrin SR or Wellbutrin XL (or the generic, I'm not picky about the generic wellbutrin issue at the moment. I just have a few full bottles of various dosages I may want to try - yes on my own, perhaps eventually. My pdoc says that it does effect Serotonin ... indirectly....(but...doesn't everything eventually balance out and effect other transmitters?) I sometimes just DONT get it.
And now that I realize I've hit the "malpractice insurance-wall/excuse" as to the limits my pdoc will go to with me in trying to remit my depression (i/we deserve more than that partial remission crapola), well, I know there are pdocs out there that will work harder with you---I assume they must carry more insurance - and hence the whew! extreme fees $$$$ they charge!
signing off, past my bedtime....
*Bright
> > > My doc and I have discussed MAOI's as an alternative.
> >
> > Hi there. Both Wellbutrin and Lamictal can be combined safely with MAOIs, just so you know.
> >
> > > I need to keep my energy up (if normal is a 10 and coma is 0, I'm about 6-7 on a good day). I've reviewed the standard lit out there about drug and food interactions and the generalized side effects.
> >
> > A lot of the lists of food interactions (even those provided by doctors, hospitals, pharmacists, etc.) are not based on well-documented case reports or accurately measured levels of biogenic amines (tyramine, etc.). I believe there's a list here on Dr. Bob's site that's more accurate.
> >
> > > 2) What kind of antihistamine do you take if you have a cold/flu?
> >
> > Antihistamines (diphenhydramine, chlorpheniramine) are safe to use with MAOIs.
> >
>
> Chlorpheniramine (CPI) was an extremely bad example, because it is one of only two antihistamines that are known to be unsafe with MAOIs (the other one is brompheniramine, BPI). The reason is that CPI and BPI are serotonin reuptake inhibitors, and their use under MAO inhibition poses the risk of serotonin syndrome.
>
> In contrast, another antihistamine - cyproheptadine (Periactin) - is an effective antidote to serotonin syndrome, due its serotonin 5-HT2A-receptor blocking property.
>
> > It's decongestants (pseudoephedrine, ephedrine, phenylpropanolamine, etc.) that you need to watch out for.
> >
>
> This is true, but they can sometimes be useful against MAOI-induced hypotension. Amphetamines are similar to the anticongestants mentioned above, and cause a dose-dependent elevation of blood pressure, and hypertensive crisis if the dose is high enough. Nevertheless, when used with caution, amphetamines can be used not only to treat hypotension, but also to augment an unsatisfactory response to MAOIs.
>
> Methylphenidate (MPH) is relatively safe and may reduce tyramine sensitivity, as well as exert a stabilising effect on blood pressure. Modafinil is likely to be even safer than MPH, and caffeine is very safe. Cocaine (COC) may theoretically cause serotonin toxicity, but there are no reports of serotonin syndrome (or hypertensive crisis) with the combination of COC and MAOIs - possibly due to COC's short duration of action.
>
> Most tricyclic antidepressants, except clomipramine and imipramine, can be used with MAOIs. So can reboxetine and atomoxetine, and like methylphenidate, they may reduce tyramine sensitivity. On the other hand, all SSRIs and SNRIs have the capacity to precipitate serotonin syndrome in combination with MAOIs. Tianeptine, on the other hand, (and amineptine) combine safely with MAOIs.
>
> Alpha2-adrenergic antagonists, such as yohimbine, idazoxan, and mirazapine, should be used with caution due to their noradrenaline-releasing properties, which may give rise to hypertensive reactions. Yohimbine may furthermore have MAOI-inhibitory features, opening the possibility for a MAOI overdose.
>
> Most antipsychotics, with the possible exception of ziprasidone - due to its monoamine reuptake inhibiting features - pose no notable risks in combination with MAOIs. Chlorpromazine is in fact an effective antidote to serotonin toxicity.
>
> Dopamine direct agonists have no propensity to interact with MAOIs, and neither do the NMDA-antagonists amantadine and memantine. However, the NMDA-antagonist and cough suppressant dextromethorphan also has significant serotonin reuptake inhibiting properties and is unsafe.
>
> Most analgesics, including aspirin and paracetamol (acetaminophen) are safe. Of the narcotic analgesics, pethidine (meperidine) and tramadol pose definite risks of serotonin toxicity, although they have sometimes been combined with MAOIs without problems. The case of fentanyl and methadone is more uncertain, but theoretical serotonergic properties have been reported, so caution is warranted. Other opiates, such as codeine, oxycodone, morphine, and buprenorphine, are very safe to use with MAOIs.
>
> Potent noradrenaline precursors, L-dopa and L-dops, have the potential to cause hypertensive reactions, whereas tyrosine and phenylalanine are relatively safe. The direct serotonin precursor 5-hydroxytryprophan (5-HTP) poses a definite risk of serotonin toxicity, and it is likely that high doses of tryptophan also are risky.
>
> The trace amine and dietary supplement phenylethylamine (PEA), and of course tyramine, are comparable to amphetamines and definitely elevate blood pressure in a dose-dependent manner, resulting in hypertensive crisis if enough is consumed rapidly enough.
>
> > > Any problems with anti-biotics?
> >
> > None that I'm aware of.
>
> Possibly linezolid, as it is a MAOI itself, and combining it with another MAOI could theoretically result in MAOI overdose.
Posted by christophrejmc on July 12, 2008, at 2:27:09
In reply to Re: Considering an MAOI » undopaminergic, posted by BrightEyed+Blueberry on July 5, 2008, at 2:26:36
Sleep was difficult for me, too, with EMSAM. I think Xanax worked but I don't develop tolerance to its sedative effect. I'm sure I also used Ambien with some success. Trazodone is probably something that you definitely want to avoid. I'm not sure how much risk there is of serotonin syndrome at small dosages used for sleep, but it's just not worth the danger.
I have used Wellbutrin with EMSAM. I think it was the XL version although I'm not sure. Wellbutrin tends to make me slightly anxious (at least at first) and gives me headaches; EMSAM seemed to make both side-effects worse (but it wasn't an occipital headache and my blood pressure was never very high while I was on them). I forget the current view of Wellbutrin's mechanisms, but I do believe it increases the release of norepinephrine. This isn't necessarily bad, but if you don't have as many enzymes available to break it down, it's obviously going to add to the effect. I've never heard that Wellbutrin affects serotonin, but I don't think it's in any way that really matters; it has very low affinity for serotonin receptors or the uptake pump and I don't think it directly affects its release in any way that would make it dangerous in that regard. (I'm relying on my [very much flawed] memory here, you should look it up and present the research to your doc if you want to try it.)
I had the exact same experience with Provigil--no serious side-effects, but the ones that I had had from Provigil without EMSAM were magnified. The headaches were much worse than with Wellbutrin. I've also used Provigil and Parnate before and that was actually smoother than with EMSAM.
I've also taken Ritalin and Dexedrine with MAOIs. There were actually much fewer side-effects from this than with Wellbutrin or Provigil. It is potentially dangerous, though.
I believe there is a reasonable amount of evidence that buprenorphine can be combined with MAOIs. But you would have to have a very open-minded and trusting doctor to receive buprenorphine even by itself... and it doesn't sound like you have one of those doctors. (My doc lets me try all kinds of things that are off-label and appreciates when I bring in research, but I'm quite sure there's no way, even after seeing her for nearly ten years, that she would consider giving me bup.)
Posted by BrightEyed+Blueberry on July 12, 2008, at 4:06:48
In reply to Re: Considering an MAOI » BrightEyed+Blueberry, posted by christophrejmc on July 12, 2008, at 2:27:09
First wanted to thank you for responding-- i appreciate it. Thank you! ( naturally starts to follow from the "write-down 5 things you're grateful for every day, first thing in the morning"--intervention to combating depression! So far....)
Several years ago I would occasionally take Temgesic (buprenorphine .2 sublingual) - I was only on SSRIS at the time, and Wellbutrin (though for a short time I was overseas for 6 months and weaned off all ADs (subsequently getting depressed, which I wouldn't have believed, laying on beaches in tranquil off-the-beaten trackm cheap tropical enclaves--damn biological depression!... The usual occurred--lost all interest in doing anything-type depression returned, along with sleeping, and more sleeping (atypical))
In either case, on above ADs or off all ADs, the Tems helped me - especially the Next/NEXT day (but it really made me nod out--id take it in the evening, give it 45 minutesm and then I'd go cross-eyed on my laptop/book and that was my cue to just lay down and sleep--then I'd nod in and out of "sleep" and have movie-like almost lucid "dreams." However, the next day I'd have to take naps throughout the day, sleep off and on. I didn't "feel" obviously euphoric, but was told by others that I seemed mellow and lacking in my more typical...irritable/cranky/ even "hard-edged" "good" moods.
So, it mellowed me out--as opposed to having really obviously stimulating ("hard-edged") effects of EMSAM or wellbutrin or amphetamine-class substances (btw, ive never had a euphoric response to cocaine--while everyone else was "blowing" away and having a good time. Talk about hard-edged irritability - no thanx). But either I was really sensitive to it or took too many (2-4? tis been so long) .2 tablets under the tongue [i was always confused of the dosage; i took nowhere near what apparently is taken for heroin-addiction <gasp>! Damn I dont think I'd ever wake up on those dosages!]
0I'm guessing Tems the anti-depressant effects are re:opioids, (which I haven't ever researched because I know my doc would NEVER go there) as opposed to the "3 muskateer" monoamine standards: serotonin, norep, and dopamine? Anyway, with EMSAM, with wellbutrin, with Adderal - I've got the hard edge without the serotonin-ahhh feeling - which i liken to having a good stretch....but i have energy, motivation, focus, to varying degrees....
Anyway, I'm not ready to start ordering tems from overseas, I'm sure it's not as easy as it was back in 2000, and I'm not as quick to experiment now that I've started the MAOI route. I feel I had a strong response to it in the past, and I don't know if being on EMSAM would make me even more sensitive to it (therapeutic) or less. In addition, I guess , when going up to 9mg, EMSAM will act as an MAO-a inhibitor as well as MAO-b...and that will bring the "serotonin" effects back into my life. At that point its more like Nardil & Parnate....I just hope going to 9mg doesn't make me apathetic like Effexor did, add back in the usual sexual side effects, and ...I don't know, I just don't know what to expect (from EMSAM 9mg, from tryibg bupe again while on EMSAM/an MAOI), and Effexor just put me off SSRIs for good ( i know its an SNRI technically). OH, curiously, I just remembered - I did try tems while on Effexor/Wellbutrin...a couple years ago...It had less to no effect on me-nada. So, something to do with the norepinephrine reuptake inhibition cancelled out bupe's effects on me? Yes, no? Why?!
I've digressed and babbled and wandered as I wondered, going from the subject of buprenorphine's past therapeutic effects on me to the subject of MAOI-a's to the subject of 9mg EMSAM=NArdil/Parnate to the subject of dopaminergic/noaradrenergic's "hard edges" vs serotonin's "soft" edge's and possible relationship to apathy and sexual side effects to the subject of Effexor /its NRI(?) aspect cancelling out all therapeutic effects of Tems for me and my wondering why?
I'm thinking of hustling in to CBT shortly - otherwise I feel like I'm relying to much on PDOC & Meds Russian Roulette, which makes me feel like a minor league drug addict and codependent (and a child constantly being denied permission to try or have my ideas really listened to.) And I'm not judging addicts or codependents; I would not speak on issues about which I know!
Unfortunately I don't have a doctorate, but i do have a graduate degree in clinical psych and did focus on biopsych/neuropsyc, but that was ages ago, and I don't think my doctor...appreciates that? she bats down my ideas one by one as I walk in her door-so i send her long, researched and cited emails ahead of time to make her have to do some thinking first! Guess I'm a toe-stepper with my current pdoc--eventually may have to part ways.
good night! lookin like another EMSAM one!
*Bright
> Sleep was difficult for me, too, with EMSAM. I think Xanax worked but I don't develop tolerance to its sedative effect. I'm sure I also used Ambien with some success. Trazodone is probably something that you definitely want to avoid. I'm not sure how much risk there is of serotonin syndrome at small dosages used for sleep, but it's just not worth the danger.
>
> I have used Wellbutrin with EMSAM. I think it was the XL version although I'm not sure. Wellbutrin tends to make me slightly anxious (at least at first) and gives me headaches; EMSAM seemed to make both side-effects worse (but it wasn't an occipital headache and my blood pressure was never very high while I was on them). I forget the current view of Wellbutrin's mechanisms, but I do believe it increases the release of norepinephrine. This isn't necessarily bad, but if you don't have as many enzymes available to break it down, it's obviously going to add to the effect. I've never heard that Wellbutrin affects serotonin, but I don't think it's in any way that really matters; it has very low affinity for serotonin receptors or the uptake pump and I don't think it directly affects its release in any way that would make it dangerous in that regard. (I'm relying on my [very much flawed] memory here, you should look it up and present the research to your doc if you want to try it.)
>
> I had the exact same experience with Provigil--no serious side-effects, but the ones that I had had from Provigil without EMSAM were magnified. The headaches were much worse than with Wellbutrin. I've also used Provigil and Parnate before and that was actually smoother than with EMSAM.
>
> I've also taken Ritalin and Dexedrine with MAOIs. There were actually much fewer side-effects from this than with Wellbutrin or Provigil. It is potentially dangerous, though.
>
> I believe there is a reasonable amount of evidence that buprenorphine can be combined with MAOIs. But you would have to have a very open-minded and trusting doctor to receive buprenorphine even by itself... and it doesn't sound like you have one of those doctors. (My doc lets me try all kinds of things that are off-label and appreciates when I bring in research, but I'm quite sure there's no way, even after seeing her for nearly ten years, that she would consider giving me bup.)
>
>
Posted by Crotale on July 15, 2008, at 12:48:34
In reply to Re: Considering an MAOI » BrightEyed+Blueberry, posted by christophrejmc on July 12, 2008, at 2:27:09
> I believe there is a reasonable amount of evidence that buprenorphine can be combined with MAOIs.
I take buprenorphine and Parnate. I've been on this combination for several years. There aren't any interactions.
-Crotale
Posted by christophrejmc on July 18, 2008, at 2:07:28
In reply to Re: Considering an MAOI » christophrejmc, posted by BrightEyed+Blueberry on July 12, 2008, at 4:06:48
EMSAM should not have the apathetic or sexual side-effects common to the SSRIs. Actually, most people find the pill form of selegiline quite pro-sexual (I think I noticed it a little on EMSAM, but not as much as the oral form). I'm not really sure what you mean about the serotonin effects from SSRIs, but that's probably just because they've never really worked for me.
It's interesting what you said about Effexor/Wellbutrin cancelling the effects of buprenorphine, I've never heard that. I think bup may be my next step, but I'll have to wait until my sleep/narcolepsy stuff is treated and see how that goes.
I've thought about CBT, too. I know it's supposed to be quite effective but I'm not sure if I really have the time to invest in it (which is silly, because I have an enormous amount of free time compared to most people... it all just seems to get used up).
I hope you're doing well on the EMSAM.
-Chris
Posted by Crotale on August 3, 2008, at 19:27:59
In reply to Re: Considering an MAOI » BrightEyed+Blueberry, posted by christophrejmc on July 18, 2008, at 2:07:28
> Actually, most people find the pill form of selegiline quite pro-sexual
That's interesting...I took it a number of years ago and I just found it jittery.
Do you think the patch would be less so?
> It's interesting what you said about Effexor/Wellbutrin cancelling the effects of buprenorphine, I've never heard that.
Me neither, I wonder where it came from.
> I think bup may be my next step, but I'll have to wait until my sleep/narcolepsy stuff is treated and see how that goes.
I didn't know you have narcolepsy. MAOIs should be helpful with that.
Good luck with the buprenorphine thing. I've had some problems with it because a lot of doctors seem to misunderstand the Drug Addiction Treatment Act (DATA, the 2000 law that allows for the use for Schedule III-V drugs for treating drug addiction by doctors who have a special waiver, so that addicts can get substitution treatment without having to go to a methadone clinic). They have this idea that they can't prescribe buprenorphine, period, without a waiver. (In fact it only applies to treating addiction. A physician doesn't need a waiver to use opioids to treat depression or pain.) I started taking buprenorphine in 1999 and after Subutex and Suboxone became available I began having real problems. I even brought a copy of the law to show the doctor that it didn't require a waiver except for treating addiction, but he insisted that I was wrong. Eventually I found a doctor who had a clue, fortunately. He's about an hour and a half away, less fortunately, but I'm generally happy with him. This might seem surprising, but I've found psychiatry residents to be some of the best doctors. Maybe they're more open-minded or less arrogant; maybe they keep up with recent research and new ideas; maybe it's a combination of factors.
> I've thought about CBT, too. I know it's supposed to be quite effective but I'm not sure if I really have the time to invest in it (which is silly, because I have an enormous amount of free time compared to most people... it all just seems to get used up).
Well, I don't know if this is a problem for you, but therapy is quite expensive as well as time-consuming, and insurance may or may not cover it.
My experience (personal and otherwise) with CBT has been that it's better for anxiety disorders, personality disorders, and specific problems like relationship issues or substance abuse or low self-esteem or posttraumatic stress (technically an anxiety disorder, but one that I think is particularly responsive to therapy). Also, it's really important (this from personal experience) to have a good therapeutic alliance. If you don't really respect, trust, and like your therapist, it's hard to get much out of it, no matter how effective the technique theoretically is.
-Crotale
Posted by Crotale on August 3, 2008, at 22:22:53
In reply to Re: Considering an MAOI » christophrejmc, posted by BrightEyed+Blueberry on July 12, 2008, at 4:06:48
> Several years ago I would occasionally take Temgesic (buprenorphine .2 sublingual)
I wish this was available in the US. It would make life a lot easier for me! I gather the bioavailability is supposed to be similar SL and IM (which is how I take it). The only SL formulations we have here are Subutex and Suboxone, which don't come in anything less than 2mg. The injectable solution, Buprenex (my pharmacist says there's going to be a generic soon), is 0.3mg/mL. I tried taking it SL but it didn't seem to work. I really don't like having to inject it; the worst part is the amount of medical waste, not to mention ordinary trash it generates!
> - I was only on SSRIS at the time, and Wellbutrin (though for a short time I was overseas for 6 months and weaned off all ADs (subsequently getting depressed, which I wouldn't have believed, laying on beaches in tranquil off-the-beaten trackm cheap tropical enclaves--damn biological depression!
Clearly not winter depression! My sister says she gets this, but for me some of the worst times have been in the summer. I know what you mean about how frustrating it is when you do everything you can think of to feel good and you don't get an ounce of enjoyment.
> ... The usual occurred--lost all interest in doing anything-type depression returned, along with sleeping, and more sleeping (atypical))
I'm the opposite: I hardly sleep at all, waking up in the middle of the night or early in the morning, plus I stop eating. (Alas, I don't lose much weight, as I also hardly get any exercise. When I stopped taking Nardil - it had stopped working and all I was getting were the side effects - I did lose some of the weight I'd gained on it, but that was a while ago; I've regained it since then on various other meds I've tried.)
It sounds like there's at least one feature of atypical depression that you're missing: mood reactivity. That is, it sounds like when you're depressed, you don't feel better temporarily when something good happens. Am I right?
> In either case, on above ADs or off all ADs, the Tems helped me - especially the Next/NEXT day (but it really made me nod out--id take it in the evening, give it 45 minutesm and then I'd go cross-eyed on my laptop/book and that was my cue to just lay down and sleep--then I'd nod in and out of "sleep" and have movie-like almost lucid "dreams."
This sounds like the "opium dreams" that a lot of people experience on opioids. I don't get this at all; every opioid I've tried has acted more like a stimulant for me (besides buprenorphine, that includes morphine, codeine, hydrocodone, and hydromorphone). If I take too much I just get jittery and revved up, although not in the "hard-edged" way as you describe your response to stimulants. Oh yeah, not to mention I get sick to my stomach. The very concept of 2mg buprenorphine (that's the minimum *possible* dose; the actual recommended dose is 12-16 mg/day!) freaked me out when I read about Subutex and Suboxone...I couldn't possibly tolerate that stuff!
> So, it mellowed me out--as opposed to having really obviously stimulating ("hard-edged") effects of EMSAM or wellbutrin or amphetamine-class substances (btw, ive never had a euphoric response to cocaine--while everyone else was "blowing" away and having a good time. Talk about hard-edged irritability - no thanx).
This isn't that uncommon an effect with stimulants actually, including cocaine. Contrary to stereotype, not everybody gets high on the stuff. (I've never been interested in trying it myself, but I knew some people in college who were major cokeheads and a number who at least tried it once or twice...including a couple who never wanted to touch it after the first time!)
> But either I was really sensitive to it or took too many (2-4? tis been so long) .2 tablets under the tongue [i was always confused of the dosage; i took nowhere near what apparently is taken for heroin-addiction <gasp>! Damn I dont think I'd ever wake up on those dosages!]
I reduced it from 0.3 to about 0.2-0.25 (total of at most 1mg/day) to combat the side effects (nausea, constipation, itching, dry mouth, etc.). It sounds like maybe you were taking too much, if I have problems with side effects I try lowering the dose or dividing it (so you might take just one tab at a time, 2-4 times a day).
(I see you find the "blocking" dose used to treat addiction as scary as I do!)
> I'm guessing Tems the anti-depressant effects are re:opioids, (which I haven't ever researched because I know my doc would NEVER go there) as opposed to the "3 muskateer" monoamine standards: serotonin, norep, and dopamine?
Heh. :)
It is an opioid effect, but as a partial agonist, I think it's subtler and less euphoric. This is based on what drug addicts say about it in comparison to, say, hydrocodone. (I've always had weird responses to opioids, as I noted, so I'm afraid my experiences won't be terribly useful for you.)
I'm not sure about the dosing for EMSAM, but selegiline at higher doses should have the serotonergic effects.
> Anyway, with EMSAM, with wellbutrin, with Adderal - I've got the hard edge without the serotonin-ahhh feeling - which i liken to having a good stretch....but i have energy, motivation, focus, to varying degrees....
A problem with selegiline is that it has some L-amphetamine metabolites. These tend to have a lot of the unpleasant side effects without the more pleasant and/or useful effects that d-amphetamine gives a lot of people. (the d-isomer is about 4x as potent centrally, IIRC, as the l-, while l-amph is a little more potent in its cardiovascular effects). I didn't care for d-amph much but I take modafinil occasionally to help me concentrate.
> Anyway, I'm not ready to start ordering tems from overseas, I'm sure it's not as easy as it was back in 2000, and I'm not as quick to experiment now that I've started the MAOI route.
Buprenorphine is fine with MAOIs, I've been taking it with Parnate for much of the last nine years. I don't know for sure if there are any specific interactions with selegiline; I guess there might be a possibility of a pharmacokinetic interaction resulting from competitive inhibition of CYP3A4, although I think it's unlikely based on the research. If you ever do decide to try it, I would say start with a low dose and see how you do.
> I feel I had a strong response to it in the past, and I don't know if being on EMSAM would make me even more sensitive to it (therapeutic) or less.
I don't think it should have any effect either way, but like I said, you might want to take care, especially since it seemed to hit you pretty hard (with the sedation and whatnot) at the doses you used to take.
> I just remembered - I did try tems while on Effexor/Wellbutrin...a couple years ago...It had less to no effect on me-nada. So, something to do with the norepinephrine reuptake inhibition cancelled out bupe's effects on me? Yes, no? Why?!
I don't know why this would be. Maybe the ADs were stimulating and this reversed the sedating effect you usually get with the temgesic? I don't know...did you try it just once, or more than that, and how much did you take?
BTW as far as trazodone goes, that's okay in low doses with MAOIs too. Again, I don't know if there's any particular pharmacokinetic interaction with selegiline at clinical doses but I wouldn't think so. Personally I found I developed tolerance to the sedative effect of trazodone, which is probably related to its antihistamine activity. There's an antihistamine called hydroxyzine which is quite sedating and which might be worth a try, particularly if you also have allergies.
> I'm thinking of hustling in to CBT shortly - otherwise I feel like I'm relying to much on PDOC & Meds Russian Roulette, which makes me feel like a minor league drug addict and codependent (and a child constantly being denied permission to try or have my ideas really listened to.) And I'm not judging addicts or codependents; I would not speak on issues about which I know!
I dunno, CBT is supposedly effective for depression but I think it's better when dealing with a particular issue or problem...I mentioned this in my last post, in reply to christophrejmc (but just as much for you or anyone else who cares to read it).
> Unfortunately I don't have a doctorate, but i do have a graduate degree in clinical psych and did focus on biopsych/neuropsyc, but that was ages ago, and I don't think my doctor...appreciates that? she bats down my ideas one by one as I walk in her door-so i send her long, researched and cited emails ahead of time to make her have to do some thinking first! Guess I'm a toe-stepper with my current pdoc--eventually may have to part ways.
Something else I mentioned in my latest response to christophrejmc: I don't know what the equivalent is where you are, but I've found that residents (i.e. med school graduates who are in their postgraduate specialty training to be a psychiatrist) are often better in this way, in that they seem more willing to listen and take my ideas seriously.
> good night! lookin like another EMSAM one!
I'll think of you as I don't sleep. (Actually I've been sleeping better...well, not-sleeping less. :-})
All my best,
-Crotale
Posted by brighteyed+blueberry on August 25, 2008, at 15:41:32
In reply to Re: Considering an MAOI » christophrejmc, posted by Crotale on August 3, 2008, at 19:27:59
The patch has been less jittery than the pill form-and less sexually activating..but I'm on 9mg now..and have been doing very well.
I started 9mg about 5 weeks ago. As with the 6mg patch, I felt a difference within 5-7 days. And th feeling better has stayed with Me-not a placebo effect. I'm not one for whom placebo effects tend to occur-un fact, all SSRIs and effexor took closer to 8 weeks before I felt noticeably "better"-again, depending whether that particular med helped Me significantly or not. (6mg also started working for Me noticeably within 7 days; wellbutrin seemed to kick in faster than SSRIS too-about 2 weeks).
My sleep-has gotten *better* since I upped my doseage!! I turned into an insomniac for the first time in my life with emsam-awaking with the Sun especially, the slightest noise or ray of light.now I get 7-8 hours sleep-get up usually between 7-8, cuz my toddler wakes Me. I'm still a lighter sleeper on it, but earplugs aren't necessary. I prefer to have my eye mask handy, and to darken the room, but it doesn't have to be "just so" and for Me to have meds lined up for Me to get sleep(benadryl, or xanax, or neurontin).
Dunno why bupe seemed to loose its effect on Me when I was on effexor. Just my experience. And it was temgesic-i understand it comes in *much* lower dose than the subutex/suboxone-.2 siblingual. Pre-effexor, 2-3 under the tongue was enough-during effexor, maybe I took 6 at most-nothing but the sleep effect next day....
> > Actually, most people find the pill form of selegiline quite pro-sexual
>
> That's interesting...I took it a number of years ago and I just found it jittery.
>
> Do you think the patch would be less so?
>
> > It's interesting what you said about Effexor/Wellbutrin cancelling the effects of buprenorphine, I've never heard that.
>
> Me neither, I wonder where it came from.
>
> > I think bup may be my next step, but I'll have to wait until my sleep/narcolepsy stuff is treated and see how that goes.
>
> I didn't know you have narcolepsy. MAOIs should be helpful with that.
>
> Good luck with the buprenorphine thing. I've had some problems with it because a lot of doctors seem to misunderstand the Drug Addiction Treatment Act (DATA, the 2000 law that allows for the use for Schedule III-V drugs for treating drug addiction by doctors who have a special waiver, so that addicts can get substitution treatment without having to go to a methadone clinic). They have this idea that they can't prescribe buprenorphine, period, without a waiver. (In fact it only applies to treating addiction. A physician doesn't need a waiver to use opioids to treat depression or pain.) I started taking buprenorphine in 1999 and after Subutex and Suboxone became available I began having real problems. I even brought a copy of the law to show the doctor that it didn't require a waiver except for treating addiction, but he insisted that I was wrong. Eventually I found a doctor who had a clue, fortunately. He's about an hour and a half away, less fortunately, but I'm generally happy with him. This might seem surprising, but I've found psychiatry residents to be some of the best doctors. Maybe they're more open-minded or less arrogant; maybe they keep up with recent research and new ideas; maybe it's a combination of factors.
>
> > I've thought about CBT, too. I know it's supposed to be quite effective but I'm not sure if I really have the time to invest in it (which is silly, because I have an enormous amount of free time compared to most people... it all just seems to get used up).
>
> Well, I don't know if this is a problem for you, but therapy is quite expensive as well as time-consuming, and insurance may or may not cover it.
>
> My experience (personal and otherwise) with CBT has been that it's better for anxiety disorders, personality disorders, and specific problems like relationship issues or substance abuse or low self-esteem or posttraumatic stress (technically an anxiety disorder, but one that I think is particularly responsive to therapy). Also, it's really important (this from personal experience) to have a good therapeutic alliance. If you don't really respect, trust, and like your therapist, it's hard to get much out of it, no matter how effective the technique theoretically is.
>
> -Crotale
Posted by JadeKelly on October 29, 2008, at 17:50:46
In reply to Considering an MAOI, posted by David G on May 1, 2008, at 13:52:36
> >>>> I placed this under Medication but I think it really goes here.<<<
>
> Been on Welburtrin (4 years) and Lamictol (1 year) but feel the need to try a different path. I have aspergers with bipolar and the meds keep me from getting depressed. But then again I don't feel much of anything now and I'm tired of it. I also have Chronic Fatigue (poz for EB virus) - I don't get pain but I do get malaise both mentally and physically.This is my first post so I hope you get it. Not very timely! My son is bipolar and has COPD, and I am on an MAOI and get frequent sinusitis, so thought maybe I could help a little. I'm sorry for your struggles, been there!
>
> My doc and I have discussed MAOI's as an alternative. I need to keep my energy up (if normal is a 10 and coma is 0, I'm about 6-7 on a good day). I've reviewed the standard lit out there about drug and food interactions and the generalized side effects. I have a few questions though:
>
> 1) Has anyone tried a patch and if so, what did you think?Tried the patch. I felt it in days (1/2 patch) then nothing. Got up to 9 patch and figured if I had to watch food anyway why not Parnate? Again, worked within days but had hypertensive issue. Started again and its a great AD if you can get through the initial side effects. Have to watch food but the trade was a no-brainer for me.
> 2) What kind of antihistamine do you take if you have a cold/flu? Any problems with anti-biotics? Yes, I have to take them (allergies, asthma, and COPD)
Most antibiotics are fine from what I here, BUT CHECK TO BE SURE! I have taken all strengths/types Augmentin with Parnate for sinusitis. Its fine. You better check on those antihistimines. I've heard some o.k., some not. From my experiences with my son (Bipolar AND COPD)I'd suggest you really think carefully about what meds you may need in future that could cause problems with MAOI. With a 2 week washout, you could be in deep *stuff* if you develop a pneumonia, manic state, etc. I'd talk carefully with your pulmonologist and Pdoc and make sure you have a plan, just in case, while on MAOI.
> 3) I've seen mention of intestinal problems but is that really from the drug or is that from (unknowingly) eating things from the Do Not Eat list? I've also seen contradictions regarding if fish can be eaten or not.Havent heard of any stomach problems with MAOI's, just hypertensive crisis. Be careful, NOT FUN!
> 4) If you have tried different MAOI's, which ones did you like or not? Why?
Just patch and Parnate. Chose Parnate as its stimulating and usually no weight gain (I'm vane).
Patch maybe good option for you if you respond to 6mg. Although still med issues.> 5) I've seen reference to MAOI's increasing respiration infections like bronchitus and sinusitus? Anyone have input on that?
I get frequent sinusitis, didnt notice a difference. But if you have COPD, could be a deal breaker. But what do I know, just be vigilant in your research and discussions with your docs re: all possible outcomes mixing MAOI's with meds you may require later.
>
> Thanks!Good Luck to You!!! Jade
Posted by Lowell on November 30, 2008, at 10:03:08
In reply to Re: Considering an MAOI, posted by JadeKelly on October 29, 2008, at 17:50:46
In regards to the questions re: MAOI, I might be able to flesh out some of the answers. Before I begin, please take your list of questions to your doctor. He or she knows your illnesses and medications best and any potential contraindications.
I am also not a doctor. While I believe most of my information is correct, please double check it!
1. Regarding the patch... there is more than one type of MAOI. The patch is MAOI-B and works differently than the MAOI-A so it really depends on what the doctor is trying to accomplish.
From my understanding, the patch will afford side effects from tryamine because the drug still affects the tyramine mechanism in the brain.
2. For allergy problems, try Zyrtec (always check on the back to verify). Regarding colds, only aspirin, cepacol and Vicks' rapor rub are remedies I know of.
3. The only fish that can not be eaten of which I am aware is caviar. If there is a fish pate, add that in. Before going out or grocery shopping, bring your list of NOT ALLOWED TO EAT. Rule of thumb: anything that is good or has been aged is banned.
You will get used to it and it is not as bad as other things but do follow it for the repercussions can be heart arrythymias, heart attacks, stroke, coma, death, etc... you see the subtle trend here...
4. MAOIs I think are underused and are a godsend. From some studies I have read, MAOIs are one of the most effective antidepressants and they are also highly helpful in treatment resistant major depression. Unfortunately, that tiny, little, tyramine thing makes them unpopular.
5. Which MAOI to use? Ask your doctor... if he is suggesting an MAOI, chances are he already knows which type, MAOI-A or MAOI-B, he wants.
It is good to ask. Give yourself answers. Donate a little satisfaction to your curiosity.
You have a lot to think about and process. Good luck. Hope all ends up going well.
Posted by desolationrower on December 1, 2008, at 15:06:29
In reply to Re: Considering an MAOI, posted by Lowell on November 30, 2008, at 10:03:08
HI Lowel, welcome to the board. I agree with what you have said, except that the patch is generally safe for tyramine. There have not been any reported reactions with it that i'm aware of. The patch gets the MAOI deprenyl directly into the blood, so less of the intestinal MAO is inhibited: thus, it is still there to destroy dietary tyramine. Additionally, deprenyl has some peculiar properties that make it inhibit the tyramine pressor effect, such that it is the least likely of the irreversable full MAOIs to hypertensive crisis. Unfortunatly giving someone oral deprenyl and then seeing the effect of tyramine hasn't been tested, and is not something one can do safely at home, so it isn't clear how strong this effect is. It may be related to the amphetamine metabolites blocking tyramine uptake, or maybe something else. Unfortunatly itdoes seem to be a somewhat weaker antidepressant than the other two MAOIs that are more studied, at least anecdotaly. I didn't notice as strong effect from it as from tranylcypromine, although deprenyl gave me a giant libido boost. All the MAOIs have other effects besides the inhibition of MAO, so one's reaction to them is probably going to vary more than to some other drugs. But i think they are all very useful and parnate for me has been the only antidepressant to work.
-d/r
This is the end of the thread.
Psycho-Babble Neurotransmitters | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
[email protected]
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.