Posted by West on January 25, 2010, at 7:18:01
In reply to Re: switching from venlafaxine/mirtazap to moclobe, posted by europerep on January 24, 2010, at 10:39:58
> hmm, well she told me that lithium augmentation and quetiapine augmentation were the only possibilites left that would not require a washout-period, i.e. stopping venlafaxine.. she didn't even mention bupropion and lamotrigine, but I will certainly try these before stopping venlafaxine..
She is wrong about this. Venlafaxine doesn't appear to have any siginificant interaction with the cytochrome P450, in which the metabolism of so many drugs are involved, including bupropion (a CYP2D6 inhibitor). As I mentioned I have taken both and survived. The two have been combined safely in cases of refractory depression in at least two (admittedly anecdotal) documented cases in medical literature. The STAR*D algorithm also mentions it - you and your doctor should be looking at this right now - it was designed to address patients in exactly your current situation.
> I will go with lithium for now, since it is a quite well documented augmentation, also the CANMAT (Canadian Network for Mood and Anxiety Treatment) psychopharmacological guidelines of 2009 give it as the first augmentation strategy to be tried.. I'm a little scared about it, from what I've read here on the board, but then, some people (in the studies) achieved remission with it, so who knows..
This, among others is one option. Please do consider the others outlined in STAR*D.
> i do still have a prescription for zolpidem from a while ago, and my doc certainly wouldn't hesistate to give me another one if I asked for it, but I have to say I'm a little wary of these "Z-substances".. I mean I know they are not benzos, but I try to stay away from anything that has an abuse or dependency potential, because I really do not want to add a substance issue to my already quite f##ked up situation..
This is something to be concerned about I agree. It depends on how serious the situation is. Like anything, it will be a study in risk vs benefit.
> I believe - it's what my doc suggested - that I have a very fast metabolism, which does also make sense seeing how much i eat without gaining weight (well, on mirtazapine I have, but I think that is just the typical side effect).. that might explain why I do not show symptoms associated with high dose venlafaxine (as you said, twitchiness etc., high blood pressure, and so on)..well, anyway..
>
> on sciencedirect.com i found an article on four cases of resistant depression with partial response to venlafaxine, which was treatable by adding a SSRI (sertraline, paroxetine, citalopram) to the venlafaxine.. sounds strange, but it did actually work, one patient even had ECTs before, and with the combo she was in remission for nine months or so when the article was written.. maybe that would be an option, too.. I'll see, first I'll try the lithium anyway..I would venture to say that adding drugs with opposing mechanisms of action might have a greater outcome both in tolerability and efficacy. But it sounds as if, since you're suggesting it, you might benefit from a stronger serotonergic action. If this is the case, consider whether the bottom of venlafaxine, primarily an SSRI, has simply fallen out altogether. In which case you should be looking at switching to escitalopram or sertraline, perhaps augmenting a second drug as per the STAR*D algorythm
> oh btw, west, I thought you were a doctor who gave his advice to people on the board :) , but now I see you are "only" a patient too, right?..
You flatter me :) I am my own doctor...we all are here!
poster:West
thread:930533
URL: http://www.dr-bob.org/babble/20100122/msgs/934934.html