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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 37. This is the beginning of the thread.
Posted by floatingbridge on January 24, 2011, at 17:30:55
I am in a bind. I'm majorly depressed, highly reactive to triggers, chronic pain of a fibromyalgia-type, social anxiety high, motivation negative. I have some critical life stressors involving my child. So high stakes.
Why am I asking? As if a magic formula might be revealed :) After about a month, I see pdoc tomorrow. This is my 'cocktail': (It does not keep me pain free by any means.) (Fatigue!)
Cymbalta 30mg
Dex about 60mg
Xanax xr about 1.5mg
Xanax 0-1.5/2.0 mg as needed
Ultram 200mg
Lithium 300mg
Norco 10-30mg as neededI was thinking add Lyrica? Mood lifting
and stabilizing? And add pain relief. No way parnate would address this mess?I wanted off the cymbalta but my
physiatrist encouraged me to stay. My pdoc & him are now working together so changes are more complicated (great :| )Abilify and seroquel are out.
Anyone?
sick of being sick,
fb
Posted by Phillipa on January 24, 2011, at 17:59:48
In reply to umm. advice from anyone tracking/knows me?, posted by floatingbridge on January 24, 2011, at 17:30:55
FB geez that's quite a cocktail. Want to add or subtract? Love Phillipa
Posted by floatingbridge on January 24, 2011, at 19:08:42
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by Phillipa on January 24, 2011, at 17:59:48
Ugh. Both, Phillipa. Too many and not quite right....
Posted by g_g_g_unit on January 24, 2011, at 19:14:45
In reply to umm. advice from anyone tracking/knows me?, posted by floatingbridge on January 24, 2011, at 17:30:55
> I am in a bind. I'm majorly depressed, highly reactive to triggers, chronic pain of a fibromyalgia-type, social anxiety high, motivation negative. I have some critical life stressors involving my child. So high stakes.
>
> Why am I asking? As if a magic formula might be revealed :) After about a month, I see pdoc tomorrow. This is my 'cocktail': (It does not keep me pain free by any means.) (Fatigue!)
>
> Cymbalta 30mg
> Dex about 60mg
> Xanax xr about 1.5mg
> Xanax 0-1.5/2.0 mg as needed
> Ultram 200mg
> Lithium 300mg
> Norco 10-30mg as needed
>
> I was thinking add Lyrica? Mood lifting
> and stabilizing? And add pain relief. No way parnate would address this mess?
>
> I wanted off the cymbalta but my
> physiatrist encouraged me to stay. My pdoc & him are now working together so changes are more complicated (great :| )
>
> Abilify and seroquel are out.
>
> Anyone?
>
> sick of being sick,
>
> fbHmm .. if you have fibromylgia-like symptoms and chronic pain, then restorative sleep should be a priority, so Lyrica is definitely a good idea. It might also reduce your need for xanax?
I'm not sure about Parnate. It seems to be a little hit-and-miss; plus insomnia is a big issue on it.
Posted by Phillipa on January 24, 2011, at 20:06:50
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by g_g_g_unit on January 24, 2011, at 19:14:45
FB you would have to let go of some of the meds to add lyrica. Just my opinion. Which do you feel does the least? Phillipa
Posted by floatingbridge on January 24, 2011, at 22:13:57
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by g_g_g_unit on January 24, 2011, at 19:14:45
Phillipa, I would add the lyrica and dump the ultram.
However, I don't see 30mg of cymbalta as a good AD. Yes, it helps with pain, but I still need norco (less though :))
I just feel like I've been sitting on a med fence for years now, one ssri, snri after another, and after a period of feeling relatively well (intro of dex), I'm doing a
slow sink.Oh, I feel like why bother. My pdoc will balk, then I will (like over the darn emsam) and nothing will change!!!
Sorry. You got more than you asked for :(
Parnate is silly, I suppose. Emsam? Cr*p.
ggg, your clarity about lyrica makes the most sense. Thanks.
Posted by Phillipa on January 24, 2011, at 23:21:34
In reply to P + GGG: umm. advice from anyone tracking/knows me, posted by floatingbridge on January 24, 2011, at 22:13:57
FB when EMSAM was new I really really wanted to try it as the way I saw it it was a patch. A patch you can see right? So if side effects got bad I could remove the patch and see the med was no longer going into my body and was a matter of time til gone. I still have that sample box of EMSAM but pdoc said no as she had one other patient on it who had taken Maoi's and she liked the EMSAM but she got a rash so bad that even the dermatologist said go off it. But my doc said I think too stimulating for you but then you can cut the patch into small pieces like quarters or halves and find a right dose. So never tried it. I'd try that before parnate. And I'm saying this as emsam is stimulating and you are taking the stimulant so maybe could go off it? What do I know we're all different. I wonder pain and autoimmune if a connection. Since computer working okay so far will look. And right cymbalta was good for pain nada for anxiety. I don't think was depressed. who knows? Love Phillipa
Posted by g_g_g_unit on January 25, 2011, at 0:28:38
In reply to P + GGG: umm. advice from anyone tracking/knows me, posted by floatingbridge on January 24, 2011, at 22:13:57
> Parnate is silly, I suppose. Emsam? Cr*p.
>Ah, sorry, I thought treating pain was the priority and didn't realize you were in a funk mood-wise. If you're still having refractory depressive symptoms, then you should definitely keep an MAOI in mind, especially if your current combination (SNRI + benzo + stimulant + opiate!) is failing you.
My only concern was that I wasn't sure if Parnate would assist your pain, and I also thought that the insomnia might place a further burden on your physical health. But if you can implement a decent sleep strategy?
What does your psychiatrist think about MAOIs?
Posted by polarbear206 on January 25, 2011, at 20:06:43
In reply to umm. advice from anyone tracking/knows me?, posted by floatingbridge on January 24, 2011, at 17:30:55
> I am in a bind. I'm majorly depressed, highly reactive to triggers, chronic pain of a fibromyalgia-type, social anxiety high, motivation negative. I have some critical life stressors involving my child. So high stakes.
>
> Why am I asking? As if a magic formula might be revealed :) After about a month, I see pdoc tomorrow. This is my 'cocktail': (It does not keep me pain free by any means.) (Fatigue!)
>
> Cymbalta 30mg
> Dex about 60mg
> Xanax xr about 1.5mg
> Xanax 0-1.5/2.0 mg as needed
> Ultram 200mg
> Lithium 300mg
> Norco 10-30mg as needed
>
> I was thinking add Lyrica? Mood lifting
> and stabilizing? And add pain relief. No way parnate would address this mess?
>
> I wanted off the cymbalta but my
> physiatrist encouraged me to stay. My pdoc & him are now working together so changes are more complicated (great :| )
>
> Abilify and seroquel are out.
>
> Anyone?
>
> sick of being sick,
>
> fbHello :) 30mg of Cymbalta is a low dose. You can probably eliminate some of the drugs on your list if you increase the dosage. I think some of your meds are working against one another. less is best IMOP.
Posted by floatingbridge on January 26, 2011, at 14:39:41
In reply to Re: umm. advice from anyone tracking/knows me?, posted by polarbear206 on January 25, 2011, at 20:06:43
Hi PB, nice to see you :)
Cymbalta has to go, unfortunately. I have severe GI reactions--which is really cr*ppy because it really does reduce the fibro pain.
I had taken it to 60, then 90. I was in bed w/ stomach pain daily. Ugh. 30mg is tolerable but unreliable :( Sick today after eating. That's not good.
Agreed--less is more.
How do you see some meds working against each other?
Thanks.
fb
Posted by sigismund on January 26, 2011, at 16:09:07
In reply to umm. advice from anyone tracking/knows me?, posted by floatingbridge on January 24, 2011, at 17:30:55
Hey, I know you need pain relief so maybe this is wrong, but my basic feeling from using it is that Ultram is crap, but anyway, ignore that if you want.
You once said (but maybe it is no longer true?) that Dexedrine had broken the back of your depression.
How do you feel about discontinuing that for the unknown result of Emsam?
And then there's the too many drugs thing; they can't be good for your health.
Though I do of course understand how it is to be between a rock and a hard place.
Posted by Phillipa on January 26, 2011, at 20:16:09
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by sigismund on January 26, 2011, at 16:09:07
FB Sigi has a good point? Love Phillipa
Posted by floatingbridge on January 26, 2011, at 23:18:05
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by sigismund on January 26, 2011, at 16:09:07
Sigi, you have a great memory. I said that exactly about (my dear, sweet) dexedrine. I don't know. Dropping one life line for another. However, I am plain tired of the ssri/ssni trials that leave me nowhere. Cymbalta cut the pain--pretty amazing--but the s/e's were debilitating. I feel better at 20mg than 30mg--clearer head. It's been so long to be almost snri free. I had forgotten.
Ultram goes. I agree. Now regular
tramadol felt great--but my physiatrist freaked at the escalation. It kinda helped pain, but mostly my mood. Not at all like norco.Oh, for some reason I'm rambling.
I'm hoping this works:
Emsam
Lyrica
Xanax as needed or low daily doseCould that be the magic three?
Some doc in Stanford intimated that stims would not be out of the picture for me if I went to emsam or parnate. Best for 'existental depression' he said. I walked around for awhile feeling very sophisticated and French until I remembered it was a fancy way of saying 'you're screwed'.
I gotta get better. I have to help my son.
Hey Sigi, thanks for the input. Phillipa, you too.
Posted by sigismund on January 27, 2011, at 1:22:24
In reply to Re: umm. advice from anyone tracking/knows me? » sigismund, posted by floatingbridge on January 26, 2011, at 23:18:05
>Best for 'existental depression' he said
We're not quite as brisk as the British, but that wouldn't pass muster here, which is a great pity because I can do a reasonable number in existential depression. The trouble is the only doctors you can stand talking to have it too, and they have learned to do without. You have to swat up on ADHD. I mean, maybe not....I heard from a young friend that a very attractive 20yo young woman was prescibed Dexedrine because she felt down.
Posted by floatingbridge on January 27, 2011, at 2:13:03
In reply to Re: umm. advice from anyone tracking/knows me?, posted by sigismund on January 27, 2011, at 1:22:24
Sigi, I'm supposed to be sleeping now....
I didn't understand your post...swat up on adhd. I am a bit dense and sleepy, and just argued with my husband about meds and depression. He doesn't think I'm doing so bad because I'm not weeping uncontrollably; I'm telling him this depression feels different--flat, no motivation, no pleasure. He says I'm looking for a magic wand. I am.Please don't make fun of the existential part. After reading up on it, it explains my vulnerability to depression as a child. Besides, the term describes a large chunk of peoples' various depressions.
Off to bed. Thanks for writing.
Posted by SLS on January 27, 2011, at 2:24:55
In reply to umm. advice from anyone tracking/knows me?, posted by floatingbridge on January 24, 2011, at 17:30:55
> Cymbalta 30mg
> Dex about 60mg
> Xanax xr about 1.5mg
> Xanax 0-1.5/2.0 mg as needed
> Ultram 200mg
> Lithium 300mg
> Norco 10-30mg as neededI was thinking more like a combination of Nardil and either amitriptyline or nortriptyline. You would have to discontinue the Ultram and the Cymbalta in order to use a MAOI. It's nothing too fancy. I would like to hear others' opinions on this. Nardil is often used successfully for treating anxiety disorders.
You know, it is frustrating to have so few proven tools to work with for treating FM. I know a doctor who used sibutramine to treat FM. He claimed it was a miracle drug. Sibutramine is no longer available in the US. However, that it is a SNRI is interesting. I guess that's just a little more evidence that combining the reuptake of serotonin and norepinephrine might be something to try along with Lyrica. You could perhaps combine a SSRI with nortriptyline of desipramine. Desipramine isn't chosen as often.
You might want to add a tricyclic now. You could go with amitriptyline. It is a proven entity. Its daughter metabolite, nortriptyline, might be as effective, but has not investigated as often. The problem with amitriptyline is that it can produce sedation, weight-gain, somnolence, and anticholinergia as side effects. You could try NOR first, and go with AMI if necessary. People become tolerant of TCA side effects after prolonged treatment.
I do know one woman who was able to combine Nardil with doxepin. Doxepin can be calming and promote sleep, although I don't know how it affects sleep quality. It is a potent antihistamine.
And then there is trimipramine. This drug is atypical for a TCA. It does not inhibit the reuptake of neither NE nor 5-HT.It produces improvements in sleep architecture and can be calming. Although I don't know anyone who has combined trimipramine with a MAOI, it might be worth looking into. It is sometimes chosen for FM.
Add Lyrica and see how you react to it. You might then add a TCA after you are convinced that Lyrica is not making your depression worse.
That seems like such a mess, but no more complicated than what you are taking now.
What are your thoughts on these treatments?
- Scott
Posted by floatingbridge on January 27, 2011, at 14:04:07
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by SLS on January 27, 2011, at 2:24:55
Scott, you saying add a tca's to the lyrica before trying an maoi--if I read you correctly. I know my gp mentioned some you did as the next step (if Lyrica fails).
Nardil scares me. I do have some vanity. I don't mind being mildly overweight, but Nardil has a rep.
The d*mn FM skews everything. Grrrr.
Hmmm. Let me know if I read you right. I would try the tca's.
Thank you for your thoughts. They have me thinking.
Like trying effexor--which I tolerated years ago.... I was thinking the more stimulating Maoi's like emsam or parnate. Fatigue +anxiety :-O
fb
> > Cymbalta 30mg
> > Dex about 60mg
> > Xanax xr about 1.5mg
> > Xanax 0-1.5/2.0 mg as needed
> > Ultram 200mg
> > Lithium 300mg
> > Norco 10-30mg as needed
>
> I was thinking more like a combination of Nardil and either amitriptyline or nortriptyline. You would have to discontinue the Ultram and the Cymbalta in order to use a MAOI. It's nothing too fancy. I would like to hear others' opinions on this. Nardil is often used successfully for treating anxiety disorders.
>
> You know, it is frustrating to have so few proven tools to work with for treating FM. I know a doctor who used sibutramine to treat FM. He claimed it was a miracle drug. Sibutramine is no longer available in the US. However, that it is a SNRI is interesting. I guess that's just a little more evidence that combining the reuptake of serotonin and norepinephrine might be something to try along with Lyrica. You could perhaps combine a SSRI with nortriptyline of desipramine. Desipramine isn't chosen as often.
>
> You might want to add a tricyclic now. You could go with amitriptyline. It is a proven entity. Its daughter metabolite, nortriptyline, might be as effective, but has not investigated as often. The problem with amitriptyline is that it can produce sedation, weight-gain, somnolence, and anticholinergia as side effects. You could try NOR first, and go with AMI if necessary. People become tolerant of TCA side effects after prolonged treatment.
>
> I do know one woman who was able to combine Nardil with doxepin. Doxepin can be calming and promote sleep, although I don't know how it affects sleep quality. It is a potent antihistamine.
>
> And then there is trimipramine. This drug is atypical for a TCA. It does not inhibit the reuptake of neither NE nor 5-HT.It produces improvements in sleep architecture and can be calming. Although I don't know anyone who has combined trimipramine with a MAOI, it might be worth looking into. It is sometimes chosen for FM.
>
> Add Lyrica and see how you react to it. You might then add a TCA after you are convinced that Lyrica is not making your depression worse.
>
> That seems like such a mess, but no more complicated than what you are taking now.
>
> What are your thoughts on these treatments?
>
>
> - Scott
>
Posted by floatingbridge on January 27, 2011, at 17:47:06
In reply to Re: umm. advice from anyone tracking/knows me? » SLS, posted by floatingbridge on January 27, 2011, at 14:04:07
Upon rereading, besides being embarrassed by seeing all the typos and grammar bloops, I saw something about Lyrica worsening depression...? I didn't know this. I guess it a possible side to any treatment.
So far, I've tapered to about
Cymbalta 15mg
Ultram still 200mg. Should I take halves?
Dexedrine is at about 50. I'm hoping to give it up last. (My dear friend dexedrine. Sigh.)Can one change from one maoi to another w/o a washout? Say if Emsam is ineffective....
Posted by SLS on January 27, 2011, at 18:09:18
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by floatingbridge on January 27, 2011, at 17:47:06
> Upon rereading, besides being embarrassed by seeing all the typos and grammar bloops,
Yeah. I could hardly bring myself to read it.
:-)
> I saw something about Lyrica worsening depression...?
Yes. Some people like me react badly to Neurontin and Lyrica, both of which are ligands of the alpha-2-delta subunit of the voltage-gated calcium channel.
> I didn't know this. I guess it a possible side to any treatment.
Too many, I'm afraid.
> Can one change from one maoi to another w/o a washout?
No. Possible stroke.
> Say if Emsam is ineffective....
Let us hope that it isn't.
- Scott
Posted by Phillipa on January 27, 2011, at 19:13:18
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by floatingbridge on January 27, 2011, at 17:47:06
FB is husband supportive why weeping to be depressed? Have you taken him to any doc's appointments with you? Also on a positive note if 6mg of EMSAM works for you no dietary restrictions!!!! Love Phillipa ps plus supposed to be stimulating. Fingers and toes crossed!!!!
Posted by roscopeeco on January 29, 2011, at 3:57:03
In reply to umm. advice from anyone tracking/knows me?, posted by floatingbridge on January 24, 2011, at 17:30:55
Man...I am sorry you are feeling this way. Did you ever take Ultram or Dex alone or has it always been in combination with the other meds. I don't think polypharmacy is a tricky thing. I would reboot your program and start with a foundation. A medication that you know works.
Posted by floatingbridge on January 29, 2011, at 21:02:28
In reply to Re: umm. advice from anyone tracking/knows me?, posted by roscopeeco on January 29, 2011, at 3:57:03
Hi roscoepeeco,
Hey, thanks for your suggestion. How very sound and concise. And sensible. I think this is close to what Scott was saying if not the same. Thank you. I don't know where your med knowledge is from, but I certainly appreciate it--here and in other posts I've read.
So update is:
Cymbalta 10mg. (Too fast. Had supreme head-zaps. Went up close to 15 by adding some sprinkles. Better.)
Dex 45
Ultram 0 mg
Xanax XR 1.0 mg
Xanax as needed 0 mg
Lyrica 75mg x day
My pdoc wanted me to start Lyrica AFTER Cymbalta, which makes sense if you're a doctor, but as me and a mother, if Lyrica was going to help, why wait? I need help NOW. That said, despite the decrease in snri after at least, jeez, 12 years, my mood is alright. I just feel very wonky.
I am going to try for dex, lyrica, xanax, and extra therapy. Maybe? (Hope, Hope, Hope.) If my boat springs a leak, I'll try emsam.
Wish me luck, and I really appreciate ALL the input. You guys/gals are great.
fb
> Man...I am sorry you are feeling this way. Did you ever take Ultram or Dex alone or has it always been in combination with the other meds. I don't think polypharmacy is a tricky thing. I would reboot your program and start with a foundation. A medication that you know works.
Posted by floatingbridge on January 29, 2011, at 22:53:50
In reply to Re: umm. advice from anyone tracking/knows me?, posted by roscopeeco on January 29, 2011, at 3:57:03
Add a little norco. 10mg-20mg per day. That's still over the golden 3 rule.
Ultram not the same, though I like the idea of extended release...really, I had superior results from the same dose or less of generic ultracet. However, it never touched the deepest pain :(
A time released norco? But then, it probably wouldn't work as effectively either.
My physiatrist tries to prescribe whatever dosage in the least amount of pills. Says pill-popping, even when necessary creates a negative psychological template.
The psychology of pain is very interesting.
Posted by Conundrum on January 30, 2011, at 11:17:15
In reply to Re: umm. advice from anyone tracking/knows me? » floatingbridge, posted by SLS on January 27, 2011, at 2:24:55
>
> I do know one woman who was able to combine Nardil with doxepin. Doxepin can be calming and promote sleep, although I don't know how it affects sleep quality. It is a potent antihistamine.
>
I was thinking the same thing, that doxepin is a sedating TCA. It is adrenergic so in theory it should help with pain, but its probably not as stimulating as desipramine which could interfere with sleep.I would imagine you could add an SSRI to it if it is not cutting it for depression and anxiety. An MAO wouldn't be a bad option either but I would imagine you would still need the TCA for pain so it might make sense to try a TCA alone first.
Just a thought.
Posted by Conundrum on January 30, 2011, at 11:19:33
In reply to Re: umm. advice from anyone tracking/knows me? » SLS, posted by floatingbridge on January 27, 2011, at 14:04:07
> Nardil scares me. I do have some vanity. I don't mind being mildly overweight, but Nardil has a rep.
You might gain weight on nardil, but it is possible to lose the weight you gain from nardil. I know because I've seen someone do it. If a med can get you out doing things then it might have a better impact on health than a med that does not work. Thats not saying parnate would not work. I Just wouldn't be to scared of Nardil.
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