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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by ricker on August 5, 2008, at 12:51:10
Hi all,
I had previously mentioned I would be seeing my pdoc in 3wks.
Well, I just got back from my GP's and brought forward some suggestions I gathered from the Board.
My current cocktail is Zoloft, 150mg ...Remeron, 15mg ...clonazepam, 0.5mg tid and lamactil, 50mg.
I'v been taking this for approx. 2 years with the lamactil addition about 2 months ago, although I can't get passed the 50mg as I become quite irratable, bad headaches and insomnia.... and this just from a small increase in lamactil?
So, I get along quite well with my GP and pdoc, seeing them both for 14 years or so.
I told my doc that I will be asking my pdoc for a zoloft/nortriptyline trial ...feeling empty - irratable - verry lathargic for 6-8 mths warrants a trial in my books!
He has agreed to give it a try prior to me seeing my pdoc in three weeks! Yeah!!
Now, I did not get the impression he was certain as to zoloft/nortriptyline dosing?
He said "lets try a 50/50 mix....meaning 50mg of zoloft and 50 of nortriptyline.
I was thinking more along the lines of 75mg zoloft and 25mg nortriptyline?
I do become quite nervous/anxious when starting new trials and am worried The nortriptyline at the 50mg will be to stimulating? I've never been on it before.
If anyone has tried this combination, I would certainly appreciate your comments.
Please keep in mind I'll be continuing with the rivitrol and lamactil as well.
My selling point at my appointment was, "I'm scheduled to see my pdoc in 3 weeks so why not make the change now, if it works, great, if not, then I can revisit my options when I see my pdoc? :)
Regards, Rick
Posted by Phillipa on August 5, 2008, at 13:02:58
In reply to Just back from doc....questions?, posted by ricker on August 5, 2008, at 12:51:10
Also you could try the 25mg first and see how it affects you and if all is fine do the 50/50. Phillipa
Posted by Racer on August 5, 2008, at 14:18:31
In reply to Just back from doc....questions?, posted by ricker on August 5, 2008, at 12:51:10
I'd be concerned starting that combination without your psychiatrist on board from the start. Taking two serotinergic medications at one time can result in serotonin syndrome, which is potentially life threatening. Since your GP apparently isn't familiar with nortriptyline, he wasn't well able to discuss dosing, and dosing TCAs is very different from dosing other medications.
Nortriptyline has a known therapeutic window, and blood tests should be done to check whether or not you've reached it.
Good luck.
Posted by bleauberry on August 5, 2008, at 16:56:29
In reply to Just back from doc....questions?, posted by ricker on August 5, 2008, at 12:51:10
Sounds like a good plan. But, gotta keep in mind if you change the zoloft dose from where it is now, you are going to feel something from it. Could be confusing wondering if weird feelings or moods are related to starting a new med or having the dose of an old one coming down. Nortriptyline should make up for a good portion of that I would think. But still, just something to be aware of.
Studies show doses above 50mg zoloft are no more effective than 50mg, so I am not sure why they go higher. I guess it works for some people, regardless of studies. Studies show that the serotonin pumps are 100% blocked at 50mg.
Posted by ricker on August 5, 2008, at 20:19:38
In reply to Re: Just back from doc....questions? » ricker, posted by Racer on August 5, 2008, at 14:18:31
> I'd be concerned starting that combination without your psychiatrist on board from the start. Taking two serotinergic medications at one time can result in serotonin syndrome, which is potentially life threatening. Since your GP apparently isn't familiar with nortriptyline, he wasn't well able to discuss dosing, and dosing TCAs is very different from dosing other medications.
>
Now you have me worried, well, maybe just confused. lol.I thought nortriptylene was not serotinergic but, rather more of a nordrenaline type A/D?.
Boy, this stuff sure can get confusing, just when I thought things were beginning to make a bit of sence.
I may have to take a pharmecology course to keep up with everyone here! lol.
Regards, Rick
Posted by WhatToDoNext on August 6, 2008, at 12:12:07
In reply to Just back from doc....questions?, posted by ricker on August 5, 2008, at 12:51:10
Rick, I'm not sure what the plan is.....
Made my way up to 75mg Nortriptyline (25mg three times per day), Still on the Zoloft at 50mg.
Klonopin 1mg twice/day, Xanax XR 1mg twice / day
Today, I'm feeling a little more anxious than yesterday, but still much better than I've been. I'd say, yesterday, overall I felt about 60% better from my current baseline before the Nortriptlyine. Today, I'd give it a 40%. I am titrating up quickly, so perhaps the anxiety I'm feeling today is related to the quick titrate.
I can tell you that the constant uncomfortable feeling I had in my chest and throat is still gone. Didn't wake up all flabergasted like I normally do.
Anyway, the plan is to get me well so I can get back to work. So, I think we will titrate based on my response. I'm gonna hang here at 75mg for a few days, then go to 100mg and stay there till my next Pdoc appt, which is next Thursday. I'm staying on the Zoloft at 50mg/day for right now, but I think if the Nortriptyline works well for me, I will try and ditch the Zoloft as it never did anything for me.
Like I said in my previous post, I don't think I have a Serotonin problem based on lack of effect from the SSRI's and the supplemental 5-HTP I was taking. I appears that my problem may be all Norepinephrine reuptake.
The truth is, I don't care how I get better, so long as I get better. Nortriptyline covers you on both sides (i.e. Serotonin reuptake inhibition and Norepi reutake inhibition). Thats why I say, at some point, the Zolft should go away.
The therapeutic dose of Nortriptyline is 50-150mg per day, so starting at 50mg is a good idea. I would ditch the Lamictal if I were you as it doesn't appear to be helping you. I tried it, as they said I may be Bipolar II. I was on it for a few months at 200mg and got no response, so I just weaned off it. I guess I'm not Bipolar....lol
Your idea of more Zoloft and less Nortriptyline doesn't sound good to me. If your gonna take the Nortriptyline, you should take it at the range I wrote above. Zolfot is a great drug if you have a Serotnin problem, but if it's Norepinephrine, than the Nortriptyline should be the beeter med for ya. I believe the ration is 3:2 on Norepi & Serotonin, so your inhibiting the reuptake at higher levels with the Nortriptyline than Zoloft or any other SSRI or SNRI.
Remember, the pharmaceutical co.'s make money off new drugs and new Patents. Nortriptyline was used many years back as a first line treatment for depression and anxiety disorders as well as the other Tricyclics. Older Psychiatrists still use them as first line treaments, but the younger Docs stick with the SSRI's, as they get tons of free samples and drug reps coming in and pushing these meds. Plus, the media sells the drugs too.
I look at it kind of like putting toothpaste on a bee sting, or any old fashion home remedy. They still work and are still available.
The 5-HTP I spoke about can be bought over the counter in any health food store. It converts to Serotonin and crosses the blood brain barrier. So instead of taking an SSRI and faking the brain it has more Serotonin, you can take 5-HTP and actually have more Serotonin and wouldn't need an SSRI.
No one pushes 5-HTP. Again, no patent, and no money to be made by the drug co.'s . My pdoc didn't even know about 5-HTP. Look it up if you don't know about it.
K.I.T.
Steve
Posted by ricker on August 6, 2008, at 20:19:17
In reply to Re: Just back from doc....questions?, posted by WhatToDoNext on August 6, 2008, at 12:12:07
Steve, Thanks for the reply. I can relate with much of what you said.
My main a/d - from 1988 to 1994 was anafranil (clomipramine). I had been on it for so long and to be honest, other than very mild tremor, little dry mouth, it worked great. Kept my anxiety in check which inturn, basicaly eliminated depression. I also took 0.5mg klonopin 3x day.That was it, my 7 year remedy and it worked great. And then, the new and improved ssri's! HELLp!
To this day, I can remember my GP saying, "don't do it Rick, if it's working, leave it, you may not
have the same success second time around".
Ya, what we he know? My p/doc says these ssri's are great, and I won't get any of the physical side effects. Good grief?I really haven't struggled with anxiety as of of late, thank God, more of the world is about to end and I really don't care, very lathargic.
I read the arcticle regarding snri's and all that they're "not" cracked up to be.
The fact that nortriptylene and zoloft was a prefered treatment got me thinking?I also noticed you were trying the nortriptylene with zoloft. Actually, I will be taking my first 25mg dose tonight and increase by 25mg every other day. I'm going to take it all at night, same way I took the clomipramine.
I was thinking about stopping the lamactil lke you mentioned, I just want to make gradual changes.
Zoloft, I'll try and stop as well, just waiting to see my p/doc in 3 weeks.I thought the nortriptyline increase norepi only?, it's good to know I will get some serotonin benefit from it.
Of all the ssri's, zoloft was the only one that agreed with me, but I've become so empty and I do not want to increase it. I can almost feel my body shouting out saying, no more serotonin, please.
Kinda hard to explain.Anyway, goodluck with your treatment. I will keep in touch.
Rick
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