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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by ace on April 24, 2004, at 0:59:52
Never have seen this done, thats why im a bit reluctant to try it at the moment....so has anyone out their ever tried remeron with an maoi??
if so, what was it like??
Thankyou guys!
Ace.
Posted by SLS on April 24, 2004, at 7:31:41
In reply to anyone ever combine REMERON and MAOI????, posted by ace on April 24, 2004, at 0:59:52
This might be a stretch, but...
I 1992, I was being treated with investigational drugs at the NIH. I was first exposed to idazoxan, a potent NE alpha-2 antagonist similar to Remeron and the antithesis of clonidine, for several months. I was then abruptly switched to clorgyline, an irreversible MAOI-A. This action resulted in my experiencing a hypotensive crisis. My blood pressure became so low, that I entered a state of delirium that lasted for days. I don't recall exactly what my blood pressure was, but I believe they were talking about it being somewhere around 30-35 Hg. I will presume for the sake of argument that this was the result of the upregulation of presynaptic NE alpha-2 autoreceptors induced by idazoxan and the subsequent application of the MAOI. I guess if someone were to extrapolate this rebound effect inside out, perhaps the extreme reverse would yield a hypertensive effect. I don't know enough about the pharmacology behind the hypotensive effects of MAOIs to be able to comment on some of the possible mechanisms involved with this interaction. However, it should be noted that the sudden withdrawal of clonidine, a NE alpha-2 agonist in the presence of a beta-blocker yields a serious hypertensive reaction. This would be a sort of inverse analogue to what I experienced with the withdrawal of idazoxan in the presence of a pro-adrenergic drug (MAOI).
Be careful. You better do your homework on this one. It might not be a bad idea to have some propranalol on hand. I don't know if clonidine would be of value in an emergency.
- Scott
Posted by SLS on April 24, 2004, at 7:50:25
In reply to Re: anyone ever combine REMERON and MAOI???? » ace, posted by SLS on April 24, 2004, at 7:31:41
> Be careful. You better do your homework on this one.
You might want to consult with a pharmacologist. As I said, it might not be a bad idea to have some propranalol on hand, but I really don't know if this would be the best choice. Clonidine might be of value, but it probably depends on its affinity and competiveness with Remeron for the NE alpha-2 receptor. Perhaps a selective NE alpha-1 antagonist like prazosin would be best. Phentolamine is available only as an injectable. There is always nifedipine. I don't know which of these agents would be the exact antidote. The pharmacologist would offer a better guess than me, but it would still be a guess.
- Scott
Posted by SLS on April 24, 2004, at 8:08:43
In reply to Re: anyone ever combine REMERON and MAOI???? » ace, posted by SLS on April 24, 2004, at 7:31:41
Big oops!
Major error. Ouch.
The following passage from my previous post is in error:
"However, it should be noted that the sudden withdrawal of clonidine, a NE alpha-2 agonist in the presence of a beta-blocker yields a serious hypertensive reaction"
"sudden withdrawal" should read "addition"
This stuff can be complex, and I made an error in describing my analogy using clonidine as an example. I'll blame the mix-up on the cognitive impairments of severe depression. I'm still pretty smart, though. :-)It is not the withdrawal of clonidine that results in the hypertensive crisis when combined with propranolol. It is its addition.
clonidine + propranolol = paradoxical hypertensive reaction.
Sorry.
- Scott
Posted by SLS on April 24, 2004, at 8:20:39
In reply to Read this first. Major oops - sorry, posted by SLS on April 24, 2004, at 8:08:43
Damn it.
I was right the first time.
Maybe I shouldn't reread my posts after posting them.
Please disregard the "Read this first" post.
I am very angry right now. This illness is a mother-(fill in with appropriate term)!
Damn it.
- Scott
Posted by King Vultan on April 24, 2004, at 11:02:55
In reply to anyone ever combine REMERON and MAOI????, posted by ace on April 24, 2004, at 0:59:52
> Never have seen this done, thats why im a bit reluctant to try it at the moment....so has anyone out their ever tried remeron with an maoi??
>
> if so, what was it like??
>
>
> Thankyou guys!
> Ace.No, I haven't personally, but it is safe. I typically use the excellent receptor chart in "Psychotropic Drugs", which is based on the classic Seeman and Richelson studies from the 90's. Remeron's major effect is a powerful histamine H1 blockade, followed by a serotonin 5-HT2 blockade. The next one is an alpha-2 adrenergic blockade, which IMO, is only problematic if it is a major effect of a drug, as it is in yohimbine. In Remeron, the effect is approximately two orders of magnitude below that of the histamine blockade and should not be a problem.
I've been having trouble sleeping on Nardil and considered Remeron but decided to go with trazodone because of its much shorter half life. Remeron appears to have more daytime sedation and weight gain problems. I just saw my doctor yesterday and discussed the issue of sleep aids in some detail. He gave me a trazodone prescription for 2 x 50 mg and had me start at 25 mg last night, and even that effected an improvement over what I have been experiencing, which is two to three hours of sleep a night.
Todd
Posted by SLS on April 24, 2004, at 11:48:41
In reply to Re: anyone ever combine REMERON and MAOI????, posted by King Vultan on April 24, 2004, at 11:02:55
> > ....so has anyone out their ever tried remeron with an maoi??
> No, I haven't personally, but it is safe. I typically use the excellent receptor chart in "Psychotropic Drugs", which is based on the classic Seeman and Richelson studies from the 90's.
Unless there exists a precedent for combining these two drugs, I don't think it is wise to attempt to deduce what the pharmacodynamic interactions will be by looking at a chart of receptors and pronounce it safe as if it were fact. My gut tells me that there would be no problem, but without empirical evidence demonstrating the safety of this combination, I am unwilling to give any assurances.
Can you offer something more definitive given the importance of the decision to be made and the consequences of guessing wrong? I look forward to seeing what you come up with, because this is a combination I would consider for myself.
- Scott
Posted by King Vultan on April 24, 2004, at 20:51:08
In reply to Re: anyone ever combine REMERON and MAOI???? » King Vultan, posted by SLS on April 24, 2004, at 11:48:41
>
> Unless there exists a precedent for combining these two drugs, I don't think it is wise to attempt to deduce what the pharmacodynamic interactions will be by looking at a chart of receptors and pronounce it safe as if it were fact. My gut tells me that there would be no problem, but without empirical evidence demonstrating the safety of this combination, I am unwilling to give any assurances.
>
> Can you offer something more definitive given the importance of the decision to be made and the consequences of guessing wrong? I look forward to seeing what you come up with, because this is a combination I would consider for myself.
>
>
> - Scott
>
>I guess I have to disagree a bit with this philosophy--if it were always the case that we were afraid to try new things, there would be no new empirical evidence. In general, the safety of other drugs with MAOIs are driven by their pharmacological profiles, and one can conclude the relative safety of a particular drug by comparing its pharmacological profile to those of drugs that are known to be either safe or unsafe. There are some exceptions to this, such as the case of Demerol, but these are few and tend to be well known.
I've posted a link to an article a couple times in the last month in regard to trazodone being used to treat MAOI insomnia; in the same section it also mentions the use of Remeron and reports that it has been used to successfully treat serotonin syndrome. I would post the link again but am home on my pathetic webtv rather than at work on my computer, and it is much more tedious doing stuff like that (though, the double quotes feature seems to work pretty well even with webtv, Dr. Bob).
Todd
Posted by SLS on April 24, 2004, at 21:33:14
In reply to Re: anyone ever combine REMERON and MAOI???? » SLS, posted by King Vultan on April 24, 2004, at 20:51:08
Regarding the combination of Nardil and Remeron:
> > My gut tells me that there would be no problem, but without empirical evidence demonstrating the safety of this combination, I am unwilling to give any assurances.
> I guess I have to disagree a bit with this philosophy--if it were always the case that we were afraid to try new things, there would be no new empirical evidence.
Hi Todd.It was my point that the combination be tried with caution and with an antidote immediately available should there be a hypertensive reaction. We wouldn't want Andrew to think of himself as an expendable guinea pig. :-)
- Scott
Posted by Flipsactown on April 24, 2004, at 21:53:38
In reply to Read this first. Major oops - sorry, posted by SLS on April 24, 2004, at 8:08:43
Posted by ace on April 25, 2004, at 22:59:20
In reply to Re: anyone ever combine REMERON and MAOI????, posted by SLS on April 24, 2004, at 21:33:14
>
> Hi Todd.
>
> It was my point that the combination be tried with caution and with an antidote immediately available should there be a hypertensive reaction.Nifedipine is right by my side, and the telephone- to ring an ambulance!
We wouldn't want Andrew to think of himself as an expendable guinea pig. :-)
Certainly not! Thy Nardil Champion sees no parallels between himself and a pig!!
>
> - ScottAce!
Posted by SLS on April 26, 2004, at 6:24:19
In reply to Re: anyone ever combine REMERON and MAOI???? » SLS, posted by ace on April 25, 2004, at 22:59:20
Bye the way, what was the impetus behind choosing Remeron?
- Scott
This is the end of the thread.
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