![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 4 to 28 of 28. Go back in thread:
Posted by Crotale on June 20, 2008, at 12:46:19
In reply to To Scott - Nortriptyline Not Good For Atypical Dep, posted by bulldog2 on May 18, 2008, at 16:54:28
A number of the SSRIs tend to elevate TCA levels. Prozac and Paxil are particularly known for this as both block the liver enzyme cytochrome p450-2d6 (Luvox blocks cyp-3a4 which may also cause problems with elevated TCA levels). Something to watch out for with this combo. I believe Celexa is considered less likely to raise serum levels of other drugs.
SSRIs for atypical depression aren't 100% established as effective as are MAOIs. Personally I like the MAOI-TCA combo. Nardil should be okay with nortrip although desipramine might be a better choice. Avoid clomipramine, amitriptyline with MAOIs; I'd avoid imipramine and doxepin too. These are called tertiary amine TCAs; the chemical difference between a tertiary amine and its secondary amine metabolite is the loss of a methyl group on the side chain (N-demethylation). Most of the TCAs have a propylamine side chain (exceptions include amoxapine and trimipramine).
Err, what's Ixel?
Posted by SLS on June 20, 2008, at 14:00:35
In reply to Re: To Scott - Nortriptyline Not Good For Atypical » bulldog2, posted by Crotale on June 20, 2008, at 12:46:19
> A number of the SSRIs tend to elevate TCA levels. Prozac and Paxil are particularly known for this as both block the liver enzyme cytochrome p450-2d6 (Luvox blocks cyp-3a4 which may also cause problems with elevated TCA levels). Something to watch out for with this combo. I believe Celexa is considered less likely to raise serum levels of other drugs.
>
> SSRIs for atypical depression aren't 100% established as effective as are MAOIs. Personally I like the MAOI-TCA combo. Nardil should be okay with nortrip although desipramine might be a better choice. Avoid clomipramine, amitriptyline with MAOIs; I'd avoid imipramine and doxepin too. These are called tertiary amine TCAs; the chemical difference between a tertiary amine and its secondary amine metabolite is the loss of a methyl group on the side chain (N-demethylation). Most of the TCAs have a propylamine side chain (exceptions include amoxapine and trimipramine).
>
> Err, what's Ixel?Minalcipran. SNRI. I believe it is being investigated as a treatment for fibromyalgia and other pain disorders.
I have had a number of experiences with MAOI + TCA combinations. The two safest in my estimation are desipramine and nortriptyline. I can only guess that *perhaps* trimipramine would be safe, too, given its apparant lack of monoamine reuptake inhibition. Imipramine definitely produced serotonin syndrome when I added it to Nardil. I had no such trouble with desipramine.
- Scott
Posted by Crotale on June 20, 2008, at 19:27:33
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by SLS on June 20, 2008, at 14:00:35
> > Err, what's Ixel?
>
> Minalcipran. SNRI. I believe it is being investigated as a treatment for fibromyalgia and other pain disorders.What a weird brand name.
Point of clarification: what does "SNRI" mean on this board? (selective NE reuptake inhibitor (e.g. Strattera), or serotonin-NE reuptake inhibitor (e.g. Effexor)?)
> I have had a number of experiences with MAOI + TCA combinations. The two safest in my estimation are desipramine and nortriptyline. I can only guess that *perhaps* trimipramine would be safe, too, given its apparant lack of monoamine reuptake inhibition. Imipramine definitely produced serotonin syndrome when I added it to Nardil. I had no such trouble with desipramine.
Desipramine is the most selective for NE-reuptake. It's also the "cleanest" in terms of not antagonizing other receptors (alpha-adrenergic, muscarinic-ACh, type-1 histaminic, etc.).
I'm not sure about trimipramine, although according to my pharmacology textbook it has hardly any effect at the serotonin transporter, same as desipramine (but is "dirtier" in other respects). I've used amoxapine with Parnate, as well as desipramine and nortriptyline, and it didn't cause serotonin syndrome either. According to my textbook it also has little effect at most other receptors except alpha1-NE and D2, although that isn't consistent with my experience of its side effects.
Other TCAs that should be safe with MAOIs (or at any rate, shouldn't cause 5-HT syndrome) are maprotiline (although this one is supposed to be more likely to cause seizures than other TCAs) and protriptyline (but this one is supposedly more cardiotoxic than the rest). Their possible greater toxicity is the reason I don't recommend these two.
Posted by Crotale on July 27, 2008, at 14:09:17
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by SLS on June 20, 2008, at 14:00:35
> Minalcipran. SNRI. I believe it is being investigated as a treatment for fibromyalgia and other pain disorders.
I forgot to ask something (this has been confusing me on this board for a while): does "SNRI" = "selective norepinephrine reuptake inhibitor" [like Strattera] or "serotonin/norepinephrine reuptake inhibitor" [like Effexor]?
And what would you call the other one, then?
> Imipramine definitely produced serotonin syndrome when I added it to Nardil.
You mixed imipramine with Nardil?
Scott, I forgot to mention this: you have really gigantic balls. At least, in the metaphorical sense.
(I got CSS just from taking Cymbalta. No risky mixtures required.)
-Crotale
(who is impressed, in sort of a freaked out way)
Posted by SLS on July 28, 2008, at 17:57:08
In reply to MAOI-TCA combos » SLS, posted by Crotale on July 27, 2008, at 14:09:17
> > Minalcipran. SNRI. I believe it is being investigated as a treatment for fibromyalgia and other pain disorders.
> I forgot to ask something (this has been confusing me on this board for a while): does "SNRI" = "selective norepinephrine reuptake inhibitor" [like Strattera] or "serotonin/norepinephrine reuptake inhibitor" [like Effexor]?The answer is both...
The acronymn, "SNRI", was originally used to denote a selective norepinephrine reuptake inhibitor. I believe it came into use around the time viloxazine, reboxetine and atomoxetine were first referred to as such. Later, "SNRI" came to mean serotonin/norepinephrine reuptake inhibitor of which there are three representatives: Effexor, Pristiq, and Cymbalta.
> And what would you call the other one, then?"NARI" has since come to mean noradrenergic reuptake inhibitor.
"SRI" = serotonin reuptake inhibitor (in addition to other properties).
> > Imipramine definitely produced serotonin syndrome when I added it to Nardil.
> You mixed imipramine with Nardil?Yes. My condition was extremely resistent to monotherapy. It only took doctors and me 26 years to find a treatment that produced a robust antidepressant response.
:-/
> Scott, I forgot to mention this: you have really gigantic balls. At least, in the metaphorical sense.
I was desperate. I even took a single dose of Effexor while taking Parnate to see for myself if a SRI would cause SS when combined with a MAOI. The answer is yes. It only took 45 minutes to emerge. I was completely incoherent and couldn't stand up. My muscles tensed up and made it impossible to get out of bed. Luckily, the reaction lasted for only an hour or so. Parnate + imipramine was without ill effect, whereas Nardil + imipramine produced moderate SS.
> (I got CSS just from taking Cymbalta. No risky mixtures required.)
You'll here of this occasionally, where SS will be produced by SRI monotherapy.
One day, medical science will provide us with ways to choose certain drugs and reject others based upon gene activity and PET scans. Until then, don't give up on using clinical trial-and-error algorithms. I don't expect you will need to wait 26 years to achieve remission.
By the way, my current treatment consists of:
nortriptyline 150mg
Nardil 90mg
Lamictal 200mg
Abilify 20mg
Deplin 7.5mg
N-acetylcysteine 1800mg
- Scott
Posted by Phillipa on July 28, 2008, at 20:11:48
In reply to Re: MAOI-TCA combos » Crotale, posted by SLS on July 28, 2008, at 17:57:08
Glad to see you. Love Phillipa
Posted by Crotale on July 29, 2008, at 18:03:21
In reply to Re: MAOI-TCA combos » Crotale, posted by SLS on July 28, 2008, at 17:57:08
> The answer is both...
Oh dear....
> The acronymn, "SNRI", was originally used to denote a selective norepinephrine reuptake inhibitor. I believe it came into use around the time viloxazine, reboxetine and atomoxetine were first referred to as such. Later, "SNRI" came to mean serotonin/norepinephrine reuptake inhibitor of which there are three representatives: Effexor, Pristiq, and Cymbalta.
So, on this board, "SNRI" could mean either?
> "NARI" has since come to mean noradrenergic reuptake inhibitor.
>
> "SRI" = serotonin reuptake inhibitor (in addition to other properties).Well, yeah, I was thinking of the "selective" ones. Admittedly, the term "selective" is more a pharmaceutical co. gimmick than anything else, but "SSRI" has been around something like 20 years, IIRC (as long as Prozac)...it's not going anywhere. And it makes sense to refer to the "selective NE reuptake inhibitors" (as opposed to something like venlafaxine or, say, amoxapine (which is "selective" in the sense that it has more or less no SRI activity, only NRI, but which also blocks various receptors) in an analogous manner. How about:
S/NRI for serotonin/norepinephrine RI
and
SNaRI for selective noradrenergic RI
?> Yes. My condition was extremely resistent to monotherapy. It only took doctors and me 26 years to find a treatment that produced a robust antidepressant response.
Glad to hear you did find one eventually (err). How long has it been working?
> I was desperate. I even took a single dose of Effexor while taking Parnate to see for myself if a SRI would cause SS when combined with a MAOI.
"Just curious," huh?
> The answer is yes. It only took 45 minutes to emerge.
Yeah, I know. I did the same thing, only with Nardil, but for different reasons (was suicidal).
> I was completely incoherent and couldn't stand up. My muscles tensed up and made it impossible to get out of bed. Luckily, the reaction lasted for only an hour or so. Parnate + imipramine was without ill effect, whereas Nardil + imipramine produced moderate SS.
Do you think it's liable to be worse if you add the MAOI to the SRI or vice versa? (just curious this time, not planning on trying it)
> > (I got CSS just from taking Cymbalta. No risky mixtures required.)
>
> You'll here of this occasionally, where SS will be produced by SRI monotherapy.It was pretty freaky. The muscular rigidity wasn't as bad as with the Effexor/Nardil combo, but my BP was all over the place, I felt like I was burning up, and I was delirious.
> One day, medical science will provide us with ways to choose certain drugs and reject others based upon gene activity and PET scans.
(Or something of the sort...)
> Until then, don't give up on using clinical trial-and-error algorithms. I don't expect you will need to wait 26 years to achieve remission.
Well, it's only been 18 for me so far, with a couple of temporary successes. ECT has actually gone pretty well, but it hasn't been long enough for me to count it a success yet.
I won't say I've exactly given up on trial-and-error, but the prevalence of "me-too drugs" these days is discouraging.
> By the way, my current treatment consists of:
>
> nortriptyline 150mg
> Nardil 90mg
> Lamictal 200mg
> Abilify 20mg
> Deplin 7.5mg
> N-acetylcysteine 1800mgI had problems with TCA metabolism although I never did determine whether it was an interaction with something else I was on or an individual thing like a mutation in one of the cytochrome P450 genes (AFAIK 2D6 seems to be the one responsible for a lot of the interindividual variability in TCA metabolism). I tried Abilify recently; it made me jittery at much lower doses than you're on (and I already have problems with sleep). Never tried any form of folate...maybe I should.
Incidentally: what's the NAC for? Liver issues? I've only ever heard of that being used to prevent hepatotoxicity reactions.
-Crotale
Posted by SLS on July 30, 2008, at 4:21:15
In reply to Re: MAOI-TCA combos » SLS, posted by Crotale on July 29, 2008, at 18:03:21
> > The answer is both...
>
> Oh dear....
>
> > The acronymn, "SNRI", was originally used to denote a selective norepinephrine reuptake inhibitor. I believe it came into use around the time viloxazine, reboxetine and atomoxetine were first referred to as such. Later, "SNRI" came to mean serotonin/norepinephrine reuptake inhibitor of which there are three representatives: Effexor, Pristiq, and Cymbalta.
> So, on this board, "SNRI" could mean either?
> > "NARI" has since come to mean noradrenergic reuptake inhibitor.
> >
> > "SRI" = serotonin reuptake inhibitor (in addition to other properties).
> Well, yeah, I was thinking of the "selective" ones.I guess what I wrote was misleading. SSRI is still the prefered acronym for Prozac, Zoloft, Luvox, Paxil, Celexa, and Lexapro, even though these drugs have other properties that have not, up until now, figured in to theories of how these drugs work.
> > Yes. My condition was extremely resistent to monotherapy. It only took doctors and me 26 years to find a treatment that produced a robust antidepressant response.
> Glad to hear you did find one eventually (err). How long has it been working?Partial response for 1 1/2 years. It has been more robust since adding Deplin. I am making slow, but steady gains.
>
> > I was desperate. I even took a single dose of Effexor while taking Parnate to see for myself if a SRI would cause SS when combined with a MAOI.
>
> "Just curious," huh?
>
> > The answer is yes. It only took 45 minutes to emerge.
>
> Yeah, I know. I did the same thing, only with Nardil, but for different reasons (was suicidal).
> > I was completely incoherent and couldn't stand up. My muscles tensed up and made it impossible to get out of bed. Luckily, the reaction lasted for only an hour or so. Parnate + imipramine was without ill effect, whereas Nardil + imipramine produced moderate SS.
> Do you think it's liable to be worse if you add the MAOI to the SRI or vice versa? (just curious this time, not planning on trying it)
> > > (I got CSS just from taking Cymbalta. No risky mixtures required.)
> >
> > You'll here of this occasionally, where SS will be produced by SRI monotherapy.
> It was pretty freaky. The muscular rigidity wasn't as bad as with the Effexor/Nardil combo, but my BP was all over the place, I felt like I was burning up, and I was delirious.
> > One day, medical science will provide us with ways to choose certain drugs and reject others based upon gene activity and PET scans.
> (Or something of the sort...)
> > Until then, don't give up on using clinical trial-and-error algorithms. I don't expect you will need to wait 26 years to achieve remission.> Well, it's only been 18 for me so far, with a couple of temporary successes.
That might as well be 26 years. The problems with these two numbers is that they are so large. The longer one remains depressed, the worse is the damage to the brain that is produced.
ECT has actually gone pretty well, but it hasn't been long enough for me to count it a success yet.
>
> I won't say I've exactly given up on trial-and-error, but the prevalence of "me-too drugs" these days is discouraging.
>
> > By the way, my current treatment consists of:
> >
> > nortriptyline 150mg
> > Nardil 90mg
> > Lamictal 200mg
> > Abilify 20mg
> > Deplin 7.5mg
> > N-acetylcysteine 1800mg
>
> I had problems with TCA metabolism although I never did determine whether it was an interaction with something else I was on or an individual thing like a mutation in one of the cytochrome P450 genes (AFAIK 2D6 seems to be the one responsible for a lot of the interindividual variability in TCA metabolism). I tried Abilify recently; it made me jittery at much lower doses than you're on (and I already have problems with sleep). Never tried any form of folate...maybe I should.
> Incidentally: what's the NAC for? Liver issues? I've only ever heard of that being used to prevent hepatotoxicity reactions.Like acetaminophen poisoning.
It also acts as an antioxidant and a reactant in the production of glutathione, which is lower in people with mood disorders. It is a neuroprotectant of brain tissue from a loss of neurons due to the presence of chronic stress. It seems to prevent the acceleration of apoptosis.
>
> -Crotale
- Scott
Posted by Phillipa on July 30, 2008, at 20:02:41
In reply to Re: MAOI-TCA combos, posted by SLS on July 30, 2008, at 4:21:15
Scott are you doing ECT? Love Phillipa
Posted by SLS on August 1, 2008, at 5:08:43
In reply to Re: MAOI-TCA combos » SLS, posted by Phillipa on July 30, 2008, at 20:02:41
> Scott are you doing ECT? Love Phillipa
No. I tried it quite a few years ago, but it didn't help.
- Scott
Posted by Phillipa on August 1, 2008, at 20:00:07
In reply to Re: MAOI-TCA combos » Phillipa, posted by SLS on August 1, 2008, at 5:08:43
Scott that's what I thought. I interpreted your post wrong. Sorry about that Love Phillipa
Posted by Crotale on August 3, 2008, at 18:50:53
In reply to Re: MAOI-TCA combos, posted by SLS on July 30, 2008, at 4:21:15
> I guess what I wrote was misleading. SSRI is still the prefered acronym for Prozac, Zoloft, Luvox, Paxil, Celexa, and Lexapro, even though these drugs have other properties that have not, up until now, figured in to theories of how these drugs work.
True, aside from secondary and tertiary effects related to the SRI thing. One that comes to mind is fluoxetine's active metabolite norfluoxetine (like the TCAs fluoxetine undergoes N-demethylation), which, at steady state, occurs in quite high concentrations and inhibits both 5-HT and NE transporters. Some recent research has suggested that S/NRIs may be more effective than SSRIs, so perhaps fluoxetine is actually more effective than the more "selective" SRIs.
I've become terribly confused about all the new pharmaceutical products lately, to the point where I've given up trying to learn the brand names of most of them. Partly it's this anomia thing from the ECT - I used to be a lot better at remembering drug names, among other things. (BTW do you have any suggestions for how I might deal with that? Unless much worse cognitive effects emerge, I really don't want to quit since it seems to be working so well, but I would like to try to find a way to eliminate or reduce this side effect.) Partly it's all these (pretty gratuitous, IMO, although I guess some of them do have fewer side effects) "new" drugs that are really just enantiomers or other minor variants of existing drugs, so that there are twice as many brand names to remember, but very few actual new medications. It was bad enough when all these drugs with virtually identical mechanisms (although, as you point out, there are differences; not only are there other pharmacodynamic effects besides "SSRI," and whatnot, but pharmacokinetic distinctions can also be important in choosing an AD), but now it feels like the industry has given up on finding new mechanisms and is just trying to make more money by getting "new" drugs approved with minimal effort.
> Partial response for 1 1/2 years. It has been more robust since adding Deplin. I am making slow, but steady gains.
Good for you. I admire your persistence.
> > Well, it's only been 18 for me so far, with a couple of temporary successes.
>
> That might as well be 26 years. The problems with these two numbers is that they are so large. The longer one remains depressed, the worse is the damage to the brain that is produced.Tell me about it. Sometimes I can't believe it's been so long. It's not entirely chronic for me, but the degree to which I recover between episodes is getting less and less over time.
That reminds me of something that's been frustrating me for a long time. Do you have any idea what mental disorder, or neurological impairment, or whatever, might be associated with difficulty driving? It's not exactly that I haven't been able to *learn* to drive, just that I'm bad at it. So bad that I've never been able to get a license. A lot of people (including driving instructors) insist that I'm intelligent and that I therefore ought to be able to get a driver's license, but it really isn't about that. I haven't been able to figure out what it *is* about. (It doesn't seem to be caused by my mood state, although I would guess I drive worse when I'm depressed. I don't think it's anxiety either.)
> > Incidentally: what's the NAC for? Liver issues? I've only ever heard of that being used to prevent hepatotoxicity reactions.
>
> Like acetaminophen poisoning.Precisely. Once someone I knew said, in reference to those opioid-APAP combos (and the fact that they're less controlled than pure opioids): "They add *poison* to it to make it 'safer?'" (He wasn't exactly a fan of the drug war.)
> It also acts as an antioxidant and a reactant in the production of glutathione, which is lower in people with mood disorders. It is a neuroprotectant of brain tissue from a loss of neurons due to the presence of chronic stress. It seems to prevent the acceleration of apoptosis.
That's interesting. I'm afraid I'm rather ignorant when it comes to "food supplements" (NAC is one I'm a bit more familiar with because of its use as a treatment for APAP overdose). I tried to learn about them at one point but so many of them were apparently worthless that it drove me nuts and I eventually gave up. It'd be nice if someone were to publish a book of those that are genuinely useful and discussions of their pharmacology - I'd buy that.
Best wishes and good luck in all your pursuits,
-Crotale
Posted by KarenRB53 on October 12, 2008, at 18:16:48
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by SLS on June 20, 2008, at 14:00:35
> > A number of the SSRIs tend to elevate TCA levels. Prozac and Paxil are particularly known for this as both block the liver enzyme cytochrome p450-2d6 (Luvox blocks cyp-3a4 which may also cause problems with elevated TCA levels). Something to watch out for with this combo. I believe Celexa is considered less likely to raise serum levels of other drugs.
> >
> > SSRIs for atypical depression aren't 100% established as effective as are MAOIs. Personally I like the MAOI-TCA combo. Nardil should be okay with nortrip although desipramine might be a better choice. Avoid clomipramine, amitriptyline with MAOIs; I'd avoid imipramine and doxepin too. These are called tertiary amine TCAs; the chemical difference between a tertiary amine and its secondary amine metabolite is the loss of a methyl group on the side chain (N-demethylation). Most of the TCAs have a propylamine side chain (exceptions include amoxapine and trimipramine).
> >
> > Err, what's Ixel?
>
> Minalcipran. SNRI. I believe it is being investigated as a treatment for fibromyalgia and other pain disorders.
>
> I have had a number of experiences with MAOI + TCA combinations. The two safest in my estimation are desipramine and nortriptyline. I can only guess that *perhaps* trimipramine would be safe, too, given its apparant lack of monoamine reuptake inhibition. Imipramine definitely produced serotonin syndrome when I added it to Nardil. I had no such trouble with desipramine.
>
>
> - Scott
>I've been looking for posts on Imipramine and found yours. I've been diagnosed with Atypical depression with Major Depression episodes. Prozac worked well for 10 yrs on and off (mostly on) but pdoc wants me to try something else and has suggested Imipramine. Any advice appreciated.
Karen
Posted by SLS on January 18, 2009, at 6:05:24
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by KarenRB53 on October 12, 2008, at 18:16:48
Oh, crap, Karen. I never saw your post. I don't visit this board very often.
> I've been looking for posts on Imipramine and found yours. I've been diagnosed with Atypical depression with Major Depression episodes. Prozac worked well for 10 yrs on and off (mostly on) but pdoc wants me to try something else and has suggested Imipramine. Any advice appreciated.
Imipramine was synthesized in 1957 and first marketed in 1959. It was the very first tricyclic antidepressant. For many years, it remained the "gold standard" by which all other antidepressants were compared. It is a very effective drug. If you were responsive to Prozac, I think imipramine is a worthy choice to give a short trial of 4-6 weeks. In my estimation, one cannot consider their trial with imipramine adequate unless a dosage of 200mg is reached. Imipramine inhibits the reuptake of both norepinephrine (NE) and serotonin (5-HT) as does the major active metabolite of Prozac, so this might be your doctor's rationale for its choice. If it is, your doctor is smarter than the average bear. If you are currently taking Prozac, you might want to try ADDING desipramine first. Desipramine is the active metabolite of imipramine. It potently inhibits the reuptake of NE. Although it does not inhibit the reuptake of 5-HT at all, this is precisely what makes it complementary to Prozac.
Imipramine carries with it a moderate load for anticholinergic side effects (dry mouth, constipation, sweating, heart palpitations, accelerated heart-rate, blurred-vision, and difficulties initiating urination). Of course, these are not always problematic. It depends on the individual. However, I found that these side effects lessened with continued use. Desipramine, on the other hand, carries no anticholinergic burden. Side effects are reduced compared to imipramine, although accelerated heart-rate is noticeable. A resting rate of 90-110 can be expected. However, the heart doesn't have to pump as hard, so it is not such a terrible thing. Oh. Weight gain is often more of a problem with imipramine than it is with desipramine.
- Scott
Posted by KarenRB53 on January 18, 2009, at 8:43:36
In reply to Re: To Scott - Nortriptyline Not Good For Atypical » KarenRB53, posted by SLS on January 18, 2009, at 6:05:24
> Oh, crap, Karen. I never saw your post. I don't visit this board very often.
>
> > I've been looking for posts on Imipramine and found yours. I've been diagnosed with Atypical depression with Major Depression episodes. Prozac worked well for 10 yrs on and off (mostly on) but pdoc wants me to try something else and has suggested Imipramine. Any advice appreciated.
>
> Imipramine was synthesized in 1957 and first marketed in 1959. It was the very first tricyclic antidepressant. For many years, it remained the "gold standard" by which all other antidepressants were compared. It is a very effective drug. If you were responsive to Prozac, I think imipramine is a worthy choice to give a short trial of 4-6 weeks. In my estimation, one cannot consider their trial with imipramine adequate unless a dosage of 200mg is reached. Imipramine inhibits the reuptake of both norepinephrine (NE) and serotonin (5-HT) as does the major active metabolite of Prozac, so this might be your doctor's rationale for its choice. If it is, your doctor is smarter than the average bear. If you are currently taking Prozac, you might want to try ADDING desipramine first. Desipramine is the active metabolite of imipramine. It potently inhibits the reuptake of NE. Although it does not inhibit the reuptake of 5-HT at all, this is precisely what makes it complementary to Prozac.
>
> Imipramine carries with it a moderate load for anticholinergic side effects (dry mouth, constipation, sweating, heart palpitations, accelerated heart-rate, blurred-vision, and difficulties initiating urination). Of course, these are not always problematic. It depends on the individual. However, I found that these side effects lessened with continued use. Desipramine, on the other hand, carries no anticholinergic burden. Side effects are reduced compared to imipramine, although accelerated heart-rate is noticeable. A resting rate of 90-110 can be expected. However, the heart doesn't have to pump as hard, so it is not such a terrible thing. Oh. Weight gain is often more of a problem with imipramine than it is with desipramine.
>
>
> - Scott
>
>Thanks so much for responding Scott. I did try the Imipramine but broke out in hives so my pdoc took me off. I then went back on Prozac because the depression was pretty bad but have since tapered off again and now he has me trying Lexapro (Cipralex in Canada). Its only my 5th day at 2.5mg. I do have heart palpitations but not too bad Whats your opinion of this med compared to Prozac? I appreciate any advice you can give.
Posted by SLS on January 18, 2009, at 17:02:09
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by KarenRB53 on January 18, 2009, at 8:43:36
> Thanks so much for responding Scott. I did try the Imipramine but broke out in hives so my pdoc took me off. I then went back on Prozac because the depression was pretty bad but have since tapered off again and now he has me trying Lexapro (Cipralex in Canada). Its only my 5th day at 2.5mg. I do have heart palpitations but not too bad Whats your opinion of this med compared to Prozac? I appreciate any advice you can give.
Lexapro is often the first drug chosen by doctors in the U.S. The reason for this is that it has a higher success rate than the other SSRIs with the possible exception of Prozac. Side effects are typical for an SSRI. I really don't have a good feel for this, though. They are no worse than others and better than some. However - and this is very important - most people experience the emergence of anxiety at day 14 or so. This should resolve by day 21. See if you can get through it. Some people claim they feel fatigued or tired on Lexapro, but these are not people who responded well to it. Other people find it stimulating. I don't know, but maybe your heart palpitations are a good sign that it will be energizing for you.
Good luck with it and keep us posted.
:-)
- Scott
Posted by KarenRB53 on January 18, 2009, at 18:40:49
In reply to Re: To Scott - Nortriptyline Not Good For Atypical » KarenRB53, posted by SLS on January 18, 2009, at 17:02:09
> > Thanks so much for responding Scott. I did try the Imipramine but broke out in hives so my pdoc took me off. I then went back on Prozac because the depression was pretty bad but have since tapered off again and now he has me trying Lexapro (Cipralex in Canada). Its only my 5th day at 2.5mg. I do have heart palpitations but not too bad Whats your opinion of this med compared to Prozac? I appreciate any advice you can give.
>
> Lexapro is often the first drug chosen by doctors in the U.S. The reason for this is that it has a higher success rate than the other SSRIs with the possible exception of Prozac. Side effects are typical for an SSRI. I really don't have a good feel for this, though. They are no worse than others and better than some. However - and this is very important - most people experience the emergence of anxiety at day 14 or so. This should resolve by day 21. See if you can get through it. Some people claim they feel fatigued or tired on Lexapro, but these are not people who responded well to it. Other people find it stimulating. I don't know, but maybe your heart palpitations are a good sign that it will be energizing for you.
>
> Good luck with it and keep us posted.
>
> :-)
>
>
> - Scott
>
Thanks Scott. Its only been 6 days but the anxiety definitely isn't any better, if anything its worse. I feel heavy in the chest, like I can't get enough air and I'd say it feels like anxiety and it might be but it started at the same time I started the Lexapro. I want to give it a good try but am concerned.Karen
Posted by Phillipa on January 18, 2009, at 21:06:45
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by KarenRB53 on January 18, 2009, at 18:40:49
Can you add a benzo to the lexapro for a while? Phillipa
Posted by KarenRB53 on January 18, 2009, at 21:46:44
In reply to Re: To Scott - Nortriptyline Not Good For Atypical » KarenRB53, posted by Phillipa on January 18, 2009, at 21:06:45
> Can you add a benzo to the lexapro for a while? Phillipa
I do take Ativan. I've been taking it for quite awhile because the Prozac caused agitation especially when it stopped working for me.
Karen
Posted by SLS on January 18, 2009, at 21:50:44
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by KarenRB53 on January 18, 2009, at 18:40:49
> > > Thanks so much for responding Scott. I did try the Imipramine but broke out in hives so my pdoc took me off. I then went back on Prozac because the depression was pretty bad but have since tapered off again and now he has me trying Lexapro (Cipralex in Canada). Its only my 5th day at 2.5mg. I do have heart palpitations but not too bad Whats your opinion of this med compared to Prozac? I appreciate any advice you can give.
> >
> > Lexapro is often the first drug chosen by doctors in the U.S. The reason for this is that it has a higher success rate than the other SSRIs with the possible exception of Prozac. Side effects are typical for an SSRI. I really don't have a good feel for this, though. They are no worse than others and better than some. However - and this is very important - most people experience the emergence of anxiety at day 14 or so. This should resolve by day 21. See if you can get through it. Some people claim they feel fatigued or tired on Lexapro, but these are not people who responded well to it. Other people find it stimulating. I don't know, but maybe your heart palpitations are a good sign that it will be energizing for you.
> >
> > Good luck with it and keep us posted.
> >
> > :-)
> >
> >
> > - Scott
> >
> Thanks Scott. Its only been 6 days but the anxiety definitely isn't any better, if anything its worse. I feel heavy in the chest, like I can't get enough air and I'd say it feels like anxiety and it might be but it started at the same time I started the Lexapro. I want to give it a good try but am concerned.
>
> KarenGosh. I don't what to recommend. I can't say with confidence that the anxiety will disappear in the manner I previously described. That doesn't mean it won't. It is possible that your system has been sensitized by the Prozac, and understanding that Prozac is still in your system, it is difficult to predict the interaction. It is a personal decision as to whether the anxiety is too excruciating to tolerate. I hope you can get through what may be a startup side effect.
- Scott
Posted by SLS on January 18, 2009, at 21:52:34
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by KarenRB53 on January 18, 2009, at 21:46:44
> > Can you add a benzo to the lexapro for a while? Phillipa
>
> I do take Ativan. I've been taking it for quite awhile because the Prozac caused agitation especially when it stopped working for me.Aha!
- Scott
Posted by KarenRB53 on January 18, 2009, at 21:55:33
In reply to Re: To Scott - Nortriptyline Not Good For Atypical » KarenRB53, posted by SLS on January 18, 2009, at 21:50:44
> > > > Thanks so much for responding Scott. I did try the Imipramine but broke out in hives so my pdoc took me off. I then went back on Prozac because the depression was pretty bad but have since tapered off again and now he has me trying Lexapro (Cipralex in Canada). Its only my 5th day at 2.5mg. I do have heart palpitations but not too bad Whats your opinion of this med compared to Prozac? I appreciate any advice you can give.
> > >
> > > Lexapro is often the first drug chosen by doctors in the U.S. The reason for this is that it has a higher success rate than the other SSRIs with the possible exception of Prozac. Side effects are typical for an SSRI. I really don't have a good feel for this, though. They are no worse than others and better than some. However - and this is very important - most people experience the emergence of anxiety at day 14 or so. This should resolve by day 21. See if you can get through it. Some people claim they feel fatigued or tired on Lexapro, but these are not people who responded well to it. Other people find it stimulating. I don't know, but maybe your heart palpitations are a good sign that it will be energizing for you.
> > >
> > > Good luck with it and keep us posted.
> > >
> > > :-)
> > >
> > >
> > > - Scott
> > >
> > Thanks Scott. Its only been 6 days but the anxiety definitely isn't any better, if anything its worse. I feel heavy in the chest, like I can't get enough air and I'd say it feels like anxiety and it might be but it started at the same time I started the Lexapro. I want to give it a good try but am concerned.
> >
> > Karen
>
> Gosh. I don't what to recommend. I can't say with confidence that the anxiety will disappear in the manner I previously described. That doesn't mean it won't. It is possible that your system has been sensitized by the Prozac, and understanding that Prozac is still in your system, it is difficult to predict the interaction. It is a personal decision as to whether the anxiety is too excruciating to tolerate. I hope you can get through what may be a startup side effect.
>
>
> - ScottAs Phillipa just asked, I do take Ativan which I've been taking for quite some time. I think I'm just asking, do you think this is simply a startup side effect as you mention and if thats the case I will try to ride it out. In your opinion how long do you think I should persevere? I've read that Lexapro either works or it doesn't and it doesn't usually take too long before you know if its going to work. Hope that makes sense.
Karen
Posted by SLS on January 18, 2009, at 22:11:39
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by KarenRB53 on January 18, 2009, at 21:55:33
> > > > > Thanks so much for responding Scott. I did try the Imipramine but broke out in hives so my pdoc took me off. I then went back on Prozac because the depression was pretty bad but have since tapered off again and now he has me trying Lexapro (Cipralex in Canada). Its only my 5th day at 2.5mg. I do have heart palpitations but not too bad Whats your opinion of this med compared to Prozac? I appreciate any advice you can give.
> > > >
> > > > Lexapro is often the first drug chosen by doctors in the U.S. The reason for this is that it has a higher success rate than the other SSRIs with the possible exception of Prozac. Side effects are typical for an SSRI. I really don't have a good feel for this, though. They are no worse than others and better than some. However - and this is very important - most people experience the emergence of anxiety at day 14 or so. This should resolve by day 21. See if you can get through it. Some people claim they feel fatigued or tired on Lexapro, but these are not people who responded well to it. Other people find it stimulating. I don't know, but maybe your heart palpitations are a good sign that it will be energizing for you.
> > > >
> > > > Good luck with it and keep us posted.
> > > >
> > > > :-)
> > > >
> > > >
> > > > - Scott
> > > >
> > > Thanks Scott. Its only been 6 days but the anxiety definitely isn't any better, if anything its worse. I feel heavy in the chest, like I can't get enough air and I'd say it feels like anxiety and it might be but it started at the same time I started the Lexapro. I want to give it a good try but am concerned.
> > >
> > > Karen
> >
> > Gosh. I don't what to recommend. I can't say with confidence that the anxiety will disappear in the manner I previously described. That doesn't mean it won't. It is possible that your system has been sensitized by the Prozac, and understanding that Prozac is still in your system, it is difficult to predict the interaction. It is a personal decision as to whether the anxiety is too excruciating to tolerate. I hope you can get through what may be a startup side effect.
> >
> >
> > - Scott
>
> As Phillipa just asked, I do take Ativan which I've been taking for quite some time. I think I'm just asking, do you think this is simply a startup side effect as you mention and if thats the case I will try to ride it out. In your opinion how long do you think I should persevere? I've read that Lexapro either works or it doesn't and it doesn't usually take too long before you know if its going to work. Hope that makes sense.Where did you read this? What did they mean by that? Any controlled studies? Anecdotal. I respect anecdotal data, but I have to first come to trust the reporter.
You must still give it a minimum of 3 weeks in my opinion before you feel the very beginnings of an improvement. Anything sooner is a gift. I am always skeptical of anything written about clinical psychopharmacology that deals in absolutes. The successful treatment of your illness will give you your life back. Are you willing to bet on the material you read being absolutely true in your case?
I will say this, though. I would not like to see you suffer extreme anxiety for 3 weeks. I don't think that is a good sign of eventual response. You might want to stop earlier if this reaction persists. Effexor might actually be a better drug if generalized anxiety disorder (GAD) is present.
- Scott
Posted by KarenRB53 on January 18, 2009, at 22:20:09
In reply to Re: To Scott - Nortriptyline Not Good For Atypical » KarenRB53, posted by SLS on January 18, 2009, at 22:11:39
> > > > > > Thanks so much for responding Scott. I did try the Imipramine but broke out in hives so my pdoc took me off. I then went back on Prozac because the depression was pretty bad but have since tapered off again and now he has me trying Lexapro (Cipralex in Canada). Its only my 5th day at 2.5mg. I do have heart palpitations but not too bad Whats your opinion of this med compared to Prozac? I appreciate any advice you can give.
> > > > >
> > > > > Lexapro is often the first drug chosen by doctors in the U.S. The reason for this is that it has a higher success rate than the other SSRIs with the possible exception of Prozac. Side effects are typical for an SSRI. I really don't have a good feel for this, though. They are no worse than others and better than some. However - and this is very important - most people experience the emergence of anxiety at day 14 or so. This should resolve by day 21. See if you can get through it. Some people claim they feel fatigued or tired on Lexapro, but these are not people who responded well to it. Other people find it stimulating. I don't know, but maybe your heart palpitations are a good sign that it will be energizing for you.
> > > > >
> > > > > Good luck with it and keep us posted.
> > > > >
> > > > > :-)
> > > > >
> > > > >
> > > > > - Scott
> > > > >
> > > > Thanks Scott. Its only been 6 days but the anxiety definitely isn't any better, if anything its worse. I feel heavy in the chest, like I can't get enough air and I'd say it feels like anxiety and it might be but it started at the same time I started the Lexapro. I want to give it a good try but am concerned.
> > > >
> > > > Karen
> > >
> > > Gosh. I don't what to recommend. I can't say with confidence that the anxiety will disappear in the manner I previously described. That doesn't mean it won't. It is possible that your system has been sensitized by the Prozac, and understanding that Prozac is still in your system, it is difficult to predict the interaction. It is a personal decision as to whether the anxiety is too excruciating to tolerate. I hope you can get through what may be a startup side effect.
> > >
> > >
> > > - Scott
> >
> > As Phillipa just asked, I do take Ativan which I've been taking for quite some time. I think I'm just asking, do you think this is simply a startup side effect as you mention and if thats the case I will try to ride it out. In your opinion how long do you think I should persevere? I've read that Lexapro either works or it doesn't and it doesn't usually take too long before you know if its going to work. Hope that makes sense.
>
> Where did you read this? What did they mean by that? Any controlled studies? Anecdotal. I respect anecdotal data, but I have to first come to trust the reporter.
>
I read this on another site "CrazyMeds". Just their opinion as no anecdotal data was given.> You must still give it a minimum of 3 weeks in my opinion before you feel the very beginnings of an improvement. Anything sooner is a gift. I am always skeptical of anything written about clinical psychopharmacology that deals in absolutes. The successful treatment of your illness will give you your life back. Are you willing to bet on the material you read being absolutely true in your case?
>No, I'm not. I definitely want to give it enough time to see if it works for me.
> I will say this, though. I would not like to see you suffer extreme anxiety for 3 weeks. I don't think that is a good sign of eventual response. You might want to stop earlier if this reaction persists. Effexor might actually be a better drug if generalized anxiety disorder (GAD) is present.
>
>
> - Scott
>I wanted to try Effexor but my pdoc said that because I have hypertension (which is being treated and well under control), he didn't want me to try it.
Is it alright if I keep in touch?Thanks so much,
Karen
Posted by SLS on January 19, 2009, at 7:41:38
In reply to Re: To Scott - Nortriptyline Not Good For Atypical, posted by KarenRB53 on January 18, 2009, at 22:20:09
> Is it alright if I keep in touch?
Of course. :-)
I do take sabbaticals from time to time, so please don't take it personally if I disappear on you.
- Scott
This is the end of the thread.
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