![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by that_guy23 on November 13, 2008, at 11:12:57
I've had my pdoc. now for 2 to3 years off and on. She is supposed to be very good, and I was recommended to her after as a highly recommended pdoc.
She was always easy to talk to and had made suggestions, I always went with whatever she had given me.
It was probably only the 2nd drug I had asked for the other being zoloft. This one was nardil.I suggested this only when I heard of it a week prior.
started researching all the drugs that are out there, especially nardil. She went with it, but immediately ran for a book. Than after 5 weeks at 75, I was actually starting to feel a difference, the she upped it 105!
I knew I had read of starting 45 and up to 90, but I just went with it. I started getting horrible orthostatic hypotension, and couldn't do anything for almost a month.
I dropped down to 90 after 1 week than to 75 after another 2 weeks. I am now at 75 where I felt change, but feel nothing anymore only the OH and other minor SE's.
The last Appt. I tried to get an augmentation and asked for small dose of ritalin, focalin or
concerta. No way. I mentioned provigal, lyrica, and lamictal. She said that mood stabalizers were only used in bipolar, is this true?Anyway since Ive been on nardil, it seems she doesn't know alot, she isn't willing to add anything, and I told her, when she asked about going on a tca like nortiptyline which I had already been on from her, that I wasn't stopping nardil!
There wasn't much said after that, and she endedd appt 20 mins early.
What do I do? I really want to go again with a bunch of articles on maoi's,particularly nardil, and tell her I really need something to at least to help the OH.
Any suggestions, greatly appretiated
Posted by Maxime on November 13, 2008, at 11:48:44
In reply to are there alot of pdocs. Not familiar with maoi's?, posted by that_guy23 on November 13, 2008, at 11:12:57
I think that your pdoc might be an idiot. A lot of pdocs are unfamiliar with MAOIs.
Mood stabilisers are often used to augment anti-depressants ... they aren't just for bipolar disorder.
You might have a hard time getting someone to give you Ritalin with an MAOI, but it has been done. I was on Parnate and Adderall and all was good.
Get as much information as you can and give it to her
Here is info on using a stimulant with an MAOI. Good luck!
1: J Clin Psychopharmacol. 1991 Apr;11(2):127-32.
CNS stimulant potentiation of monoamine oxidase inhibitors in
treatment-refractory depression.Fawcett J, Kravitz HM, Zajecka JM, Schaff MR.
Department of Psychiatry, Rush-Presbyterian-St. Luke's Medical Center,
Chicago,
Illinois.We report on our clinical experience with a combination of a CNS stimulant (either pemoline or dextroamphetamine) and a monoamine oxidase inhibitor (MAOI) for treating 32 depressed patients (mainly outpatients) refractory to standard
antidepressant pharmacotherapy. This combination, though not approved by the FDA, appears to be safe and effective. Twenty-five (78%) of these patients experienced at least 6 months of symptom remission with a stimulant + MAOI combination. Many patients required adjunctive antidepressant treatment, including tricyclics and lithium. Side effects were not excessive, though 6 patients (3 unipolar and 3 bipolar) cycled to mania (N = 1) or hypomania (N = 5). None developed hypertensive crises. With properly motivated and complaint patients and careful clinical monitoring by the prescribing psychiatrist, stimulant potentiation of MAOIs may be a viable option for treatment-resistant depressed patients.PMID: 2056139 [PubMed - indexed for MEDLINE]
2: J Clin Psychiatry. 1985 Jun;46(6):206-9.Combined MAOI, TCA, and direct stimulant therapy of treatment-resistant depression.
Feighner JP, Herbstein J, Damlouji N.
Patients with "treatment resistant" depression who do not respond to standard methods or relapse over time have a moral and legitimate right to innovative
therapy. Combined treatment with monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), and stimulants has been resisted by practitioners because of hypertensive and hyperthermic crises noted in certain cases. This paper reports a case series demonstrating the safety and efficacy of adding a stimulant to an MAOI or to a combination of TCA and MAOI in the treatment of intractable depression.PMID: 3997787 [PubMed - indexed for MEDLINE]
MAOIs in high doses and with stimulantsDate: Sat, 1 Apr 1995 13:33:03 -0800 (PST)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Non-response to tranylcypromineThe commonest reason people do not respond to tranylcypromine (Parnate) is an inadequate dose. When using an MAOI I follow platelet MAO levels and keep increasing the dose is sufficient to reduce those levels almost to zero. This often takes > 60 mg/day of tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant improvement, the next thing I usually do is to add a psychostimulant such as methylphenidate or dextroamphetamine to the cocktail. Starting with small doses, the dose is gradually increased until the patient is taking about 30 mg/day of dextroamphetamine, or twice as much methylphenidate.
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: MAOIs in high doses and with stimulantsThere are recently been a number of warnings posted there that MAOIs should not be prescribed together with psychostimulants. While that is the conventional wisdom, if universally implemented, it would deprive many severely and intractably depressed people from relief.
In the olden days, the early 1960s, we used to treat some patients with resistant depressions with up to 200 mg/day of tranylcypromine and if that was not effective potentiate it with dextroamphetamine, starting with 2.5 mg once a day and gradually increasing to 15 or 20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine was only able to continue in his professional work by taking 170 mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since the isocarboxazid became unavailable, he has been doing almost as well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is often necessary to use combinations [and doses] of medication that are conventionally considered to be contraindicated.
From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
From: Donald Franklin Klein <dfk2@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine . Very useful for orthostatic hypotension.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder.
From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regimen, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulantsBy the way, I do not get signed consent. I do not think that that holds up very well anyway. Well documented clear chart notes indicating the clinical rationale and including what is told to the patient should always be standard practice and especially with atypical treatment modalities such as this.
Posted by Merge on November 13, 2008, at 11:52:30
In reply to are there alot of pdocs. Not familiar with maoi's?, posted by that_guy23 on November 13, 2008, at 11:12:57
Many doctors are not familiar with MAOIs and will not even prescribe them. I took MAOIs for several years and my doctor was very familiar with them as well as all of the potential side effects I could experience (in regards to other medications and food) - I would be very wary of letting someone treat me with with MAOIs if they weren't very familiar with them. I'm guessing that is why your doctor doesn't want to augment with anything...because she doesn't know enough about them to know what is safe to augment with.
Your doctor is incorrect in saying that mood stabilizers are only used with bi-polar...I have been on several mood stabilizers (Lamictal and Lithium, at different times) that were meant to augment my primary anti-depressant - and I am not, nor have I ever been, bi-polar. My understanding is that augmenting with these drugs, and others, is fairly common and widely accepted - I also don't think I'd be comfortable being treated by a doctor who did not know this.
I'm not saying it will be easy, but I would try to find a new doctor who has a much greater knowledge of MAOIs. Good luck.
Posted by desolationrower on November 13, 2008, at 12:27:36
In reply to Re: are there alot of pdocs. Not familiar with maoi's?, posted by Merge on November 13, 2008, at 11:52:30
I think this is true. I eventually decided to self-medicate after several docs refused to prescribe one to me. It is also hard to know ahead if a doctor is willing to consider them.
-d/r
Posted by Phillipa on November 13, 2008, at 13:06:53
In reply to Re: are there alot of pdocs. Not familiar with maoi's?, posted by Merge on November 13, 2008, at 11:52:30
My pdoc is familiar with Maoi's but will not prescribe them. But she uses lamictal and other mood stabalizers for augmenting depression. Phillipa
Posted by azalea on November 13, 2008, at 14:38:00
In reply to Re: are there alot of pdocs. Not familiar with maoi's?, posted by desolationrower on November 13, 2008, at 12:27:36
I disagree that it's hard to know ahead of time. You can look up pdocs in the phonebook, then call and ask if they prescribe MAOIs. If the secretary doesn't know, leave your number and ask for a return phone call.
> I think this is true. I eventually decided to self-medicate after several docs refused to prescribe one to me. It is also hard to know ahead if a doctor is willing to consider them.
>
> -d/r
Posted by desolationrower on November 13, 2008, at 15:08:29
In reply to Re: are there alot of pdocs. Not familiar with mao » desolationrower, posted by azalea on November 13, 2008, at 14:38:00
I psychiatrists like that and asked, and the reply was always something about how one can't prescribe a medicine over the phone, and why was i asking about that, and that i'd be prescribed what was best in their professional opinion, etc etc
-d/r
Posted by that_guy23 on November 13, 2008, at 20:27:17
In reply to Re: are there alot of pdocs. Not familiar with maoi's?, posted by Merge on November 13, 2008, at 11:52:30
tes I know that some people wouldn't feel safe if the y though there doctor would prescribe it, but I felt lucky to get it, and do alot of research, eat the right foods, exercise, I don't even drink anymore, the most that Iv'e went against is after 2 months, I ate a couple chocolate bars. Thats why I want to tell her that I would take the meds, I was hoping ritalin, in small doses, at my own risk. I've read so many articles and people who haven;t been effected by theses 2 drugs. If she doesn't know and I am probably the only one she prescribes, maybe she would do research on it.
What do you think?
Posted by azalea on November 13, 2008, at 20:28:26
In reply to Re: are there alot of pdocs. Not familiar with mao, posted by desolationrower on November 13, 2008, at 15:08:29
Interesting. Thanks for sharing your experience!
> I psychiatrists like that and asked, and the reply was always something about how one can't prescribe a medicine over the phone, and why was i asking about that, and that i'd be prescribed what was best in their professional opinion, etc etc
>
> -d/r
Posted by bleauberry on November 14, 2008, at 16:04:13
In reply to are there alot of pdocs. Not familiar with maoi's?, posted by that_guy23 on November 13, 2008, at 11:12:57
How about get off nardil and on to parnate?
If nardil is doing nothing for you, get off it? I cannot understand the reasoning of adding something else to a dud. On the other hand, if you had a 50% remission and were looking to improve upon that, then yeah, augmentation and lifestyle changes are justified I believe. But when a med is hardly doing anything, when the side effects are more prominent than the miniscule benefits, if any, I say move on. Why stick with a dud just because it was great for someone else but not you?
Posted by that_guy23 on November 14, 2008, at 21:09:19
In reply to Re: are there alot of pdocs. Not familiar with maoi's?, posted by bleauberry on November 14, 2008, at 16:04:13
I have not been on it long enough, and Im not going to switch to parnate, maybe in the future. I have tried so many drugs that have failed, up to 10, and this one I will not give up before 4 months from beginning, I told myself that at I don't plan on changing my mind now.
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.