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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 17 to 41 of 82. Go back in thread:
Posted by rose45 on March 29, 2022, at 9:30:12
In reply to Re: combining nardil and parnate » rose45, posted by SLS on March 28, 2022, at 10:53:02
> > thank you all for your good wishes. I dont know what to do.
>
> http://www.dr-bob.org/babble/20220128/msgs/1119153.html
>
>
> - ScottKen Gillman suggests noritryptiline as a 'bridging' med. Do you have any thoughts on that ?
Posted by undopaminergic on March 29, 2022, at 10:29:08
In reply to Re: combining nardil and parnate » rose45, posted by SLS on March 29, 2022, at 9:28:11
> > >
> > > I think empirical observations trump theory.
> > >
> > >
> > > - Scott
> >
> > Thanks for the warning Scott. Im sure you are not the only one who has had a bad experience.
> > Interesting that Ken Gillman who is an expert on MAOIs seems to think that it is safe to cross-switch.
...
>
> 4. I would be very interested to know how Gillman came to his conclusion. Did he offer evidence for his rationale?
>https://psychotropical.com/swapping-from-one-maoi-to-another-maoi/
I suggest reading it in full and then reporting your experience to him. He might have relevant questions for you to consider, that may ideally lead to an explanation of this mystery.
"Empirical observations" cut both ways. In this case they would seem to suggest a direct switch is perfectly safe in the majority of cases, though without invalidating your experience.
-undopaminergic
Posted by PeterMartin on March 31, 2022, at 17:19:31
In reply to Re: combining nardil and parnate » undopaminergic, posted by SLS on March 28, 2022, at 10:51:55
I so appreciate you and your commentary. I am 100% in agreement over the risk here not being worth any potential benefit.
I've been lurking in the MAOI reddit group and it's scary how careless the posters can be. I don't understand it, really, because in 20 lyrs using this forum people were almost always looking to keep people safe. Over on Reddit it feels more like people are trying to get high.
I'm dreading the day someone dies from dumb advice about combining Nardil/Parnate w things they shouldn't be and it makes national news. Some of us rely on these medicines and they're always at risk based on low usage.
Oh and can totally confirm penial catheter is horrible. However, when you cannot pee and your bladder is full.....that's dangerous.
Posted by PeterMartin on March 31, 2022, at 17:24:27
In reply to Re: combining nardil and parnate, posted by undopaminergic on March 29, 2022, at 10:29:08
for his rationale?
> >
>
> https://psychotropical.com/swapping-from-one-maoi-to-another-maoi/
>
> I suggest reading it in full and then reporting your experience to him. He might have relevant questions for you to consider, that may ideally lead to an explanation of this mystery.
>
> "Empirical observations" cut both ways. In this case they would seem to suggest a direct switch is perfectly safe in the majority of cases, though without invalidating your experience.
>
> -undopaminergic
>Gilman isn't the end all be all when it comes to MAO inhibitors. I think SLS's comment about us not knowing all the properties of these drugs is critical. I was look up studies on Marplan a few weeks ago and was surprised to find it lowers the lethal dosage of Amphetamine by some ridiculous amount whereas Nardil and Parnate didn't......odd considerong everyone always says Marplan is "weak". We just don't know.
Random, by does anyone combine SSRIs? I don't recall hearing of that.
Posted by SLS on April 1, 2022, at 1:23:14
In reply to Re: combining nardil and parnate ) SLS, posted by PeterMartin on March 31, 2022, at 17:19:31
> I so appreciate you and your commentary. I am 100% in agreement over the risk here not being worth any potential benefit.
>
> I've been lurking in the MAOI reddit group and it's scary how careless the posters can be. I don't understand it, really, because in 20 lyrs using this forum people were almost always looking to keep people safe. Over on Reddit it feels more like people are trying to get high.
>
> I'm dreading the day someone dies from dumb advice about combining Nardil/Parnate w things they shouldn't be and it makes national news. Some of us rely on these medicines and they're always at risk based on low usage.
>
> Oh and can totally confirm penial catheter is horrible. However, when you cannot pee and your bladder is full.....that's dangerous.
---------------
Thank you, Peter Martin.I think many people see in themselves a network of pendulums that represent their going back and forth in various aspects of their belief system. This was truer of me in college than in retirement.
Earlier this evening, I was talking with my fiance, and we began discussing alternative depression treatments. A major part of the conversation was looking at hope. There are at least two types of hope that I understand: Blind Hope and Sighted Hope.
I relied on my eyes and intellect to find hope through the collection of information. I always had 1-3 drugs "on-deck" if the one I was trying failed. My doctor always said that we should just concentrate on the current treatment. Little did my doctor know that I had the ability to walk and chew gum at the same time. Sighted hope for me came in the form of a list of treatments that offered a potential success.
It is only when I am down to zero alternatives on my list that I default to blind hope in order to keep suicide off the list.
And herein lies a very real source of sighted hope that anyone can see the simple common sense being exercised...
One of my clinical research physicians at the NIH and I had a conversation that is perhaps the most hopeful of hopes:
For every new drug that becomes available, a certain percentage of people who had not responded to any previous treatmentx will respond to it who had been refractory to treatment.
- Scott
Posted by SLS on April 1, 2022, at 1:48:51
In reply to Re: combining nardil and parnate, posted by rose45 on March 29, 2022, at 9:30:12
> > > thank you all for your good wishes. I dont know what to do.
> >
> > http://www.dr-bob.org/babble/20220128/msgs/1119153.html
> >
> >
> > - Scott
>
> Ken Gillman suggests noritryptiline as a 'bridging' med. Do you have any thoughts on that ?
I would say the choice of a bridge drug would depend on the symptom cluster being treated. For instance, in the cases of a bipolar mixed-states, anger, or agitation, I think Zyprexa would make a better bridge than nortriptyline. However, nortiptyline would make a good bridge with a depression where melancholic symptoms predominate. I would also consider using an atypical neuroleptic - my tentative choices being asenapine (Saphris) and olanzapine (Zyprexa).
- Scott
Posted by Lamdage22 on April 1, 2022, at 1:50:13
In reply to Re: combining nardil and parnate ) SLS » PeterMartin, posted by SLS on April 1, 2022, at 1:23:14
True, you can also try Psychotherapy or lifestyle changes. Hope does not have to rely solely on new drugs. I only get excited when really new stuff comes out that does not go into the me-too category. Some meds are less 'me too' than others. Those are the ones that excite me. I would get excited for a Neuroleptic without metabolic side effects for example. Or PH94B for social anxiety.
> For every new drug that becomes available, a certain percentage of people who had not responded to any previous treatmentx will respond to it who had been refractory to treatment.
>
>
> - Scott
>
>
Posted by SLS on April 1, 2022, at 2:28:14
In reply to Re: combining nardil and parnate ) SLS, posted by Lamdage22 on April 1, 2022, at 1:50:13
Hi, Lamdage.
> True, you can also try Psychotherapy or lifestyle changes. Hope does not have to rely solely on new drugs.
Absolutely! Great point. Thanks for adding it.
Obviously, you have a longer list of treatments than I do. It is so easy for me to forget about healing the psyche in order to prevent the psycho-social stress that can feed depression. I'm pretty sure there are lots of people who have a healthy brain and an injured psyche. AND there are people who need to target both the brain and the psyche.
- Scott
Posted by Lamdage22 on April 1, 2022, at 2:39:13
In reply to Re: combining nardil and parnate ) SLS » Lamdage22, posted by SLS on April 1, 2022, at 2:28:14
Well, I have basically declared my psychopharmaceutical treatment finished 6 years ago. I told myself all further improvement needs to come from non pharmaceutical measures. Med trials destabilized me and the bottom line is: Meds are just not that good for me.
Posted by Lamdage22 on April 1, 2022, at 2:42:54
In reply to Re: combining nardil and parnate ) SLS, posted by Lamdage22 on April 1, 2022, at 2:39:13
I got personality issues, too though. You are not going to fix those with meds. It is not just strictly a mood or thought problem that is easy to fix medically.
Posted by undopaminergic on April 1, 2022, at 3:54:18
In reply to Re: combining nardil and parnate ) SLS, posted by Lamdage22 on April 1, 2022, at 1:50:13
> True, you can also try Psychotherapy or lifestyle changes. Hope does not have to rely solely on new drugs. I only get excited when really new stuff comes out that does not go into the me-too category. Some meds are less 'me too' than others. Those are the ones that excite me. I would get excited for a Neuroleptic without metabolic side effects for example.
>There are already neuroleptics with low risk of weight gain. In a nutshell, they are drugs without antihistamine effects. Examples are haloperidol and amisulpride.
What would excite me more is antipsychotics without antidopaminergic effects.
-undopaminergic
Posted by Lamdage22 on April 1, 2022, at 4:00:04
In reply to Re: combining nardil and parnate ) SLS, posted by undopaminergic on April 1, 2022, at 3:54:18
> There are already neuroleptics with low risk of weight gain. In a nutshell, they are drugs without antihistamine effects. Examples are haloperidol and amisulpride.
>
> What would excite me more is antipsychotics without antidopaminergic effects.
>
> -undopaminergic
>True. I meant ones I havent tried yet. I didnt tolerate for other reasons. (Ami)Sulpiride is scary cause it can cause movement disorder.
Posted by undopaminergic on April 1, 2022, at 4:30:12
In reply to Re: combining nardil and parnate ) SLS, posted by Lamdage22 on April 1, 2022, at 4:00:04
> > There are already neuroleptics with low risk of weight gain. In a nutshell, they are drugs without antihistamine effects. Examples are haloperidol and amisulpride.
> >
> > What would excite me more is antipsychotics without antidopaminergic effects.
> >
> > -undopaminergic
> >
>
> True. I meant ones I havent tried yet. I didnt tolerate for other reasons. (Ami)Sulpiride is scary cause it can cause movement disorder.
>Where do you get that idea from? As I understand it, all neuroleptics, even clozapine, can cause movement disorders, and the risk isn't especially high with amisulpride/sulpiride.
-undopaminergic
Posted by SLS on April 1, 2022, at 9:51:45
In reply to Re: combining nardil and parnate ) SLS, posted by Lamdage22 on April 1, 2022, at 2:39:13
> Well, I have basically declared my psychopharmaceutical treatment finished 6 years ago. I told myself all further improvement needs to come from non pharmaceutical measures. Med trials destabilized me and the bottom line is: Meds are just not that good for me.
You are smart to keep your mind open to a diversity in treatment modalities. Just make sure that the presentation of your illness is as accurately diagnosed as is currently possible. I have seen too many people being treated for depression year after year only to find that instituting a regime appropriate for adult ADD changed their lives. For one person, it was Strattera that turned his life around. Within a few weeks, he had cleaned and organized his apartment for the first time in decades.
Some people don't like having to "admit" that the current state of psychiatry offers a diagnostic guideline that more often than not, achieves the goal of choosing those drugs that are *observed* to work for a given symptom cluster and life chart.
Don't buy into nihilism.
.
The following is is a truism that I probably wrote just a few posts upward. It is an example of a rationale to have "sighted" faith. I have witnessed this truism many times in real people with real cases of TRD. I was exposed to a great many people who suffer apparently untreatable mood illnesses.
The truism is strongly advocated by physicians who have made a career of specialize in treating TRD. cases. It provides a rationale for having an inpenetrable "Sighted" Hope" rather than relying on "Blind Hope" or "Blind Faith" The goal is to help reduce the impulse to commit autoeuthanasia.* For every new treatment that becomes available, a certain percentage of previously intractable cases will go on to respond to it.
* Similarly, some people who have used multiple drugs in combination (polypharmacy) take years to find the exact array of drugs at exactly the right dosages. You will never run out of permutations.
I am currently responding to the exact same combination of drugs that I experienced only a partial improvement with 15 years ago. I can't help asking myself where those 15 years went. Happiness was staring at me right in the face. I could have had another 15 years of joy and achievement.
I have no right to ask that question and look for blame when God gifted me with the blessing of having any years of remission at all. My greatest fear, and the one that had plagued me for decades, is that I would die with never having lived.
So what is different now compared to 15 years ago? Right drugs, wrong dosages.
* Nortriptyline was too high at 150 mg/day. Reducing the dosage to 100 mg/day produced blood levels well within the well-known dosage window that nortriptyline demonstrates.
* Lamictal was too low at 200 mg/day. Increasing the dosage to 300 mg/day hit the bullseye.
* Nardil at 90 mg/day is the ONLY dosage that works for me. Again, it acts on me with a dosage window. I was all over the place with Nardil dosage, so I can't recall at what dosage I was at during this period of unsatisfactory results.
Nardil:
75 mg/day=depression
90 mg/day=remission
105 mg/day=functional relapse* I don't recall the dosage of lithium I had been taking, but [for me] the pharmacological action follows a biphasic dose-response curve. At high dosages, lithium yields a reduction of glutamate activity. At lower dosage, the neuronal efflux of glutamate is potentiated. This is reflected in clinical data. High dosages of lithium are necessary to squash mania, but can make depression worse. Conversely, low dosages of lithium can improve depression, but is ineffective for mania. For rapid-cycling presentations, my guess is that only high dosages of lithium will have the desired effect.
I discovered the biphasic dose-response curve of lithium many years ago. Subsequently, I stumbled upon two studies that demonstrated that my observations of myself aligned with what appears in the medical literature. There are no more than three studies with robust and confirming results. The two investigative targets were:
1. Neurobiological
2. Clinical observations of real people.
Even the dosages studied found the same cutoff as I observed in myself. 300-450 mg/day seems to be the "sweet spot".
A very simplistic explanation is that increasing interstitial and synaptic levels of glutamate (low dosages of lithium) improves depression. Decreasing interstitial and synaptic glutamate (high dosages of lithium) treats mania, both acutely and prophylactically.
Finally, while in remission, I tried lowering the dosage of each drug one at a time. I relapsed upon the dosage reduction of all four drugs. I was actually shocked that lithium turned out to be a necessary agent in my treatment regime. Although I experienced a mild improvement immediately after beginning lithium. After a year or so of lithium treatment, I had no idea whether or not lithium was helping with depression. However, I elected to continue lithium at 300 mg/day for the sole purpose of lowering my risk of getting Alzheimer's Dementia. Little did I know that my mother would contract Alzheimer's at age 80.
I am very ware that I have been incredibly blessed to be able to live before I die.
* Try to embrace uncertainty. You are no more certain that you will never find remission than that you will.
Once you *think* that you have run out options to earn sighted hope, this would be the time to rely on blind hope / blind faith instead. This is where uncertainty becomes your best friend.
I hope something here makes sense.
- Scott
Posted by Lamdage22 on April 1, 2022, at 9:58:08
In reply to Re: combining nardil and parnate ) SLS, posted by SLS on April 1, 2022, at 9:51:45
True. We might as well find remission some time. That is how depression lies to us. "Things can never improve".
Posted by Lamdage22 on April 1, 2022, at 10:03:37
In reply to Re: combining nardil and parnate ) SLS, posted by undopaminergic on April 1, 2022, at 4:30:12
> Where do you get that idea from? As I understand it, all neuroleptics, even clozapine, can cause movement disorders, and the risk isn't especially high with amisulpride/sulpiride.
>
> -undopaminergicThe german wikipedia article. It say tardive dykinesia is as likely as with typical neuroleptics. Howeverit also says the leaflet says the risk is about 1%. 1-10% is prolactin elevation though. I don't like
Posted by SLS on April 1, 2022, at 10:08:46
In reply to Re: combining nardil and parnate ) SLS, posted by undopaminergic on April 1, 2022, at 3:54:18
> > True, you can also try Psychotherapy or lifestyle changes. Hope does not have to rely solely on new drugs. I only get excited when really new stuff comes out that does not go into the me-too category. Some meds are less 'me too' than others. Those are the ones that excite me. I would get excited for a Neuroleptic without metabolic side effects for example.
> >
>
> There are already neuroleptics with low risk of weight gain. In a nutshell, they are drugs without antihistamine effects. Examples are haloperidol and amisulpride.
>
> What would excite me more is antipsychotics without antidopaminergic effects.
>
> -undopaminergic
>There certainly are neuroleptics that have a reduced incidence of weight-gain. However, it may be that none of those drugs make effective bridges to be used to reduce the intensity of withdrawal syndromes or preventing a full relapse.
A "bridge" is meant to be a temporary treatment to mitigate any suffering that occur during a washout period.
For me, I think there are 2 drugs that make good candidates tor being a bridges.
1. Zyprexa (olanzapine)
2. Saphris (asenapine)Although Abilify (aripiprazole) might work well to mitigate an antidepressant withdrawal syndrome, discontinuing it is problematic and produces anxiety as its own withdrawal syndrome.
- Scott
Posted by rose45 on April 1, 2022, at 12:05:47
In reply to Re: combining nardil and parnate ) SLS, posted by SLS on April 1, 2022, at 10:08:46
> > > True, you can also try Psychotherapy or lifestyle changes. Hope does not have to rely solely on new drugs. I only get excited when really new stuff comes out that does not go into the me-too category. Some meds are less 'me too' than others. Those are the ones that excite me. I would get excited for a Neuroleptic without metabolic side effects for example.
> > >
> >
> > There are already neuroleptics with low risk of weight gain. In a nutshell, they are drugs without antihistamine effects. Examples are haloperidol and amisulpride.
> >
> > What would excite me more is antipsychotics without antidopaminergic effects.
> >
> > -undopaminergic
> >
>
>
>
> There certainly are neuroleptics that have a reduced incidence of weight-gain. However, it may be that none of those drugs make effective bridges to be used to reduce the intensity of withdrawal syndromes or preventing a full relapse.
>
> A "bridge" is meant to be a temporary treatment to mitigate any suffering that occur during a washout period.
>
> For me, I think there are 2 drugs that make good candidates tor being a bridges.
>
> 1. Zyprexa (olanzapine)
> 2. Saphris (asenapine)
>
> Although Abilify (aripiprazole) might work well to mitigate an antidepressant withdrawal syndrome, discontinuing it is problematic and produces anxiety as its own withdrawal syndrome.
>
>
> - ScottIsn't Olanzapine also very difficult to come off?
Posted by Lamdage22 on April 1, 2022, at 12:10:47
In reply to Re: combining nardil and parnate ) SLS, posted by rose45 on April 1, 2022, at 12:05:47
Some blood work might be good, too. I think when meds dont work, it could be because nutrients are lacking.
Posted by PeterMartin on April 1, 2022, at 12:17:28
In reply to Re: combining nardil and parnate ) SLS, posted by Lamdage22 on April 1, 2022, at 12:10:47
> Some blood work might be good, too. I think when meds dont work, it could be because nutrients are lacking.
I've learned that a lot of times when meds don't work (or suddenly stop working), it's due to my pharmacy giving me a different generic manufacturer. It's extremely frustrating since most pharmacists/doctors/patients will doubt that there can be any difference. I saw this post on reddit recently about potential for differences between generics (even batches), and found it reassuring since I've noticed but faced skepticism.
====
Question/Title of thread:
"Do different manufactures for the same medication really make a difference? Or is that just some my patients like to complain about lol""I know some people prefer the size and shape of specific manufacturers because of issues like cutting the medication in half, or swallowing; but pharmacologically, they are exactly the same, no?"
====
====
Top comment reply:
====
"For those whove never worked in manufacturing, I can tell you that regardless of what is being made, the working site / company matters.Drugs would be build to specmeaning they all have the same specs for mixing and chemical composition. But the number of variations in manufacturing are legion: how much tolerance is in equipment used, how frequently do they lubricate bearings, how often do they change dies, how do they get notified of and handle quality errors in production, what humidity and temperature does the mixing happen at, how sensitive is the measuring equipment, where do they get their raw materials from, do they empty their inventory fifo or lifo and what impact does that have on chemical mixing, etc. At one company I worked we even used a pill making machine that we repurposed for a different use because it was designed to handle sensitive powdersand I can tell you there is PLENTY that could vary not only manufacturer to manufacturer, but sure to site within the same manufacturer or even department to department within the same site."
Link for full thread: https://old.reddit.com/r/pharmacy/comments/tpe4nm/do_different_manufactures_for_the_same_medication/
Posted by Lamdage22 on April 1, 2022, at 12:22:45
In reply to Re: combining nardil and parnate ) SLS, posted by PeterMartin on April 1, 2022, at 12:17:28
> I've learned that a lot of times when meds don't work (or suddenly stop working), it's due to my pharmacy giving me a different generic manufacturer.
I think that is because the statutory provisions are lax in the US. No offense.
Posted by SLS on April 1, 2022, at 20:09:36
In reply to Re: combining nardil and parnate ) SLS, posted by rose45 on April 1, 2022, at 12:05:47
Hi, Rose.
> > A "bridge" is meant to be a temporary treatment to mitigate any suffering that occur during a washout period.
> >
> > For me, I think there are 2 drugs that make good candidates tor being a bridges.
> >
> > 1. Zyprexa (olanzapine)
> > 2. Saphris (asenapine)
> >
> > Although Abilify (aripiprazole) might work well to mitigate an antidepressant withdrawal syndrome, discontinuing it is problematic and produces anxiety as its own withdrawal syndrome.
> >
> >
> > - Scott
>
> Isn't Olanzapine also very difficult to come off?
That's a good point. I have not had a problem with olanzapine discontinuation the few time I took it. Maybe I just got lucky. Is anxiety a withdrawal symptom of olanzapine discontinuation?I don't think I ever asked you how you were feeling.
Don't worry, I won't start now...
Silliness aside, are you hanging in there?
- Scott
Posted by SLS on April 1, 2022, at 20:16:40
In reply to Re: combining nardil and parnate ) SLS, posted by Lamdage22 on April 1, 2022, at 12:10:47
> Some blood work might be good, too. I think when meds dont work, it could be because nutrients are lacking.
I totally agree with you. Unfortunately, you and I were born a little too early along the course of history. There is still much work yet to be done in putting all of the pieces of the many puzzles together: the biological, the psychological, and the nutritional.
Which nutrients do you think are most important in maintaining mental health?
- Scott
Posted by Lamdage22 on April 1, 2022, at 20:57:47
In reply to Re: combining nardil and parnate ) SLS » Lamdage22, posted by SLS on April 1, 2022, at 20:16:40
> Which nutrients do you think are most important in maintaining mental health?
> - ScottAll nutrients you are deficient in. There are few if any nutrients that don't play a role in mental health. Some directly, others indirectly. Physical health has more influence on mental health than most people think. I'd say blood test the nutrients that people are most often deficient in.
Posted by Lamdage22 on April 2, 2022, at 0:42:05
In reply to Re: combining nardil and parnate ) SLS, posted by Lamdage22 on April 1, 2022, at 20:57:47
> > Which nutrients do you think are most important in maintaining mental health?
> > - Scott
>
> All nutrients you are deficient in. There are few if any nutrients that don't play a role in mental health. Some directly, others indirectly. Physical health has more influence on mental health than most people think. I'd say blood test the nutrients that people are most often deficient in.
>
The nutrients not only people in general but people with your specific condition are most often deficient in.
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Dr. Bob is Robert Hsiung, MD,
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Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
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