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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 25. This is the beginning of the thread.
Posted by PeterMartin on September 7, 2017, at 16:36:38
I need to switch from Marplan to Parnate (or maybe Nardil) due to an upcoming insurance change.
I asked my doctor once a while back about whether or not he'd require a washout if I were to switch from Marplan to Nardil. After first thinking one wouldn't be needed he looked it up in a book (oldschool) and said well it probably would be needed.
In the past I know I've switched from Parnate to Marplan w/ only a few days completely off meds. And I'm not really worried about side effects since I'm on moderate dose of Marplan (30 when 40 is the recommended min) and I'd be going to a low dose of Parnate (I'm guessing 20 to 30).
Is anyone aware of any pubmed studies or articles that support a shorter than 14day washout when switching from one MAOI to another? I would hope to use this info to at least cut down the time. The risk of depression relapse is more of a concern to me than elevated bp. I have a bp cuff and would surely be monitoring....
Thanks for any info.
BTW I think this link lets you posts new threads for anyone having issues:
https://www.dr-bob.org/cgi-bin/pb/babble.pl
Posted by rjlockhart37 on September 7, 2017, at 21:04:51
In reply to Studies to show doc for shorter MAOI)MAOI washout?, posted by PeterMartin on September 7, 2017, at 16:36:38
"While it is generally safe to begin a different antidepressant after a 14-day washout, patients should be monitored closely after the washout period since there have been case reports of interactions, including serotonin syndrome, following 14-day washout periods.58 Similar caution should be exercised when switching from one MAOI to another, although more rapid switches (18 days) have been safely performed.57,59 A washout period of five half-lives for an antidepressant and its active metabolites should be provided before initiating an MAOI.57 This would require approximately a 45 week washout period for fluoxetine"
Posted by rjlockhart37 on September 7, 2017, at 21:10:21
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by rjlockhart37 on September 7, 2017, at 21:04:51
rapid switches (1-8) days for MAOI switches have been reported succesful, yet your doctor should provide you with more info. I googled this for a long time found this study, rapid switch is 1-8 days, not 18, was a typo, i tried to use the source, good luck
Posted by PeterMartin on September 8, 2017, at 0:42:03
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by rjlockhart37 on September 7, 2017, at 21:10:21
> rapid switches (1-8) days for MAOI switches have been reported succesful, yet your doctor should provide you with more info. I googled this for a long time found this study, rapid switch is 1-8 days, not 18, was a typo, i tried to use the source, good luck
>Thank you for that and thanks for clarifying the 1-8 days. See my doc tomorrow so I'll print this out / fingers crossed....
Posted by SLS on September 8, 2017, at 1:14:39
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by PeterMartin on September 8, 2017, at 0:42:03
> > rapid switches (1-8) days for MAOI switches have been reported succesful, yet your doctor should provide you with more info. I googled this for a long time found this study, rapid switch is 1-8 days, not 18, was a typo, i tried to use the source, good luck
> >
>
> Thank you for that and thanks for clarifying the 1-8 days. See my doc tomorrow so I'll print this out / fingers crossed....
I don't think that it is such a good idea to cherry-pick articles to show your doctor. I suffered a major reaction when switching from Nardil to Parnate without a wash-out period. I was in the hospital for three or four days. I was incoherent and didn't know where I was. All I remember is an extreme amount of pain as they inserted a catheter into my penis. Otherwise, I was oblivious to my surroundings. It is likely that it was serotonin syndrome.Nardil -> MAOI
1 day is too short.
8 days might be okay.
10 days is often used.
14 days is safe.I suppose it's possible that your individual physiology would allow you to switch directly From Marplan to either Parnate or Nardil. I am not aware of any way to test for this.
For what it's worth, my guess is that one can switch from Parnate to Nardil faster than from Nardil to Parnate. I don't know enough about Marplan to be able to comment on this.
- Scott
Posted by PeterMartin on September 8, 2017, at 2:51:59
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout? » PeterMartin, posted by SLS on September 8, 2017, at 1:14:39
I hear ya but the risk of depression is a big one.
I was on Parnate for a few months (3 I think) before switching to Marplan. Didn't washout. The doctor I had at the time was very nonchalant - perhaps to much so but I don't have any issues. Looking back my high regard for Marplan may have in part been contributed to by the Parnate jump start.
I'll see what my doctor says tomorrow. I trust his judgement and mkst likely he'liberal' do it by the book. 14 days. Will suck.
Posted by SLS on September 8, 2017, at 5:47:20
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by PeterMartin on September 8, 2017, at 2:51:59
> I hear ya but the risk of depression is a big one.
>
> I was on Parnate for a few months (3 I think) before switching to Marplan. Didn't washout. The doctor I had at the time was very nonchalant - perhaps to much so but I don't have any issues. Looking back my high regard for Marplan may have in part been contributed to by the Parnate jump start.
>
> I'll see what my doctor says tomorrow. I trust his judgement and mkst likely he'liberal' do it by the book. 14 days. Will suck.Yes, it will suck, but it would be the safest way to go. 10 days should be okay, though.
Just remember, Marplan is in the same chemical class as Nardil (hydrazine). There is some thought (including mine) that Nardil binds to MAO more tightly than does Parnate, and that this extends the time for which monoamine neurtransmitter levels remain elevated. My guess is that Nardil is more serotonergic, and would have a greater liability to produce serotonin syndrome. I don't know if these things also apply to Marplan, but I suspect that they do.
I am not the most conservative person in the world regarding the creative application of psychotropic medication. However, going from Nardil to Parnate without a washout was a mistake. So, too, was my taking a single, very small dose of Effexor as an experiment while taking Parnate. Both of these things precipitated serotonin syndrome.
Will you be able to switch from Marplan to Nardil without a washout? Maybe. You might want to have some cyproheptadine (Periactin) handy in case you run into trouble with serotonin syndrome. I would perform an Internet search to find a list of symptoms of this reaction.
- Scott
Posted by pedr on September 8, 2017, at 13:22:11
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by PeterMartin on September 8, 2017, at 2:51:59
> I hear ya but the risk of depression is a big one.
this is where I'm at since I'm considering switching from effexor to Parnate and am confronted with that 14 day washout period. Frankly it terrifies me how bad I will almost certainly feel. It's not just 14 days either since you have to taper off of your meds before that 14 day period even begins. It's a real pig.
Posted by pedr on September 8, 2017, at 13:22:15
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by PeterMartin on September 8, 2017, at 2:51:59
> I hear ya but the risk of depression is a big one.
this is where I'm at since I'm considering switching from effexor to Parnate and am confronted with that 14 day washout period. Frankly it terrifies me how bad I will almost certainly feel. It's not just 14 days either since you have to taper off of your meds before that 14 day period even begins. It's a real pig.
Posted by baseball55 on September 8, 2017, at 18:03:48
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by pedr on September 8, 2017, at 13:22:15
I had a friend who was taking some SSRI (can't recall which) and it was not working. She was depressed all the time. When I suggested parnate, she said she was afraid of the washout. Why? The SSRI wasn't working, so how would two weeks without the SSRI make anything worse than it was?
I did a 14 day washout before starting parnate and was a complete and utter mess - needed to be hospitalized. But honestly, I needed to be hospitalized even before they decided to start me on parnate. Lexapro was just not working at all. So I can't say I was any worse during the washout than before it.
Posted by rjlockhart37 on September 8, 2017, at 20:56:44
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by baseball55 on September 8, 2017, at 18:03:48
if I implied a rapid switch, please take that back, they said some cases were successful, but at the start of the article their saying the standard is usually 14-16 days, Prozac would take longer but it's a SSRI, but also i read the toxicity of transfer MAOI's too quickly, i was tired when i researched it and found an article on rapid transfers
Posted by PeterMartin on September 9, 2017, at 0:15:16
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by rjlockhart37 on September 8, 2017, at 20:56:44
He looked through the literature and has other patients on Parnat/Nardil/etc. I've only been on 30mg of Marplan for the past few months also (40mg is min target dose).
7 days w/o me saying anything at all.
Not worried about SS - Worried about slipping into a dark depression.
Thanks everyone - hopefully Parnate works if the depression/withdrawal kicks in this week....
Posted by pedr on September 11, 2017, at 15:34:20
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by PeterMartin on September 9, 2017, at 0:15:16
Sorry if it's been mentioned already but check out http://psychotropical.info/maois-swapping-combining, especially the "Swapping and bridging candidates" section. He recommends nortriptyline for bridging. Hope this is of use.
Posted by PeterMartin on September 11, 2017, at 19:19:47
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by pedr on September 11, 2017, at 15:34:20
> Sorry if it's been mentioned already but check out http://psychotropical.info/maois-swapping-combining, especially the "Swapping and bridging candidates" section. He recommends nortriptyline for bridging. Hope this is of use.
Ahh there's a good sit e I forgot about - thanks!
I'm sticking w the 1wk but it's getting bumpy now having been off Marplan since Friday. Feel very "heavy". Haven't completely crashed yet but my brain is definitely missing my Marplan does.
Posted by pedr on September 15, 2017, at 8:48:33
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout?, posted by PeterMartin on September 11, 2017, at 19:19:47
> > Sorry if it's been mentioned already but check out http://psychotropical.info/maois-swapping-combining, especially the "Swapping and bridging candidates" section. He recommends nortriptyline for bridging. Hope this is of use.
>
> Ahh there's a good sit e I forgot about - thanks!
>
> I'm sticking w the 1wk but it's getting bumpy now having been off Marplan since Friday. Feel very "heavy". Haven't completely crashed yet but my brain is definitely missing my Marplan does.
>
>You're welcome, it is a good resource isn't it. "From the horse's mouth" so to speak.
Good luck with the remainder of the transition.
Posted by PeterMartin on September 25, 2017, at 1:58:20
In reply to Re: Studies to show doc for shorter MAOI)MAOI washout? » PeterMartin, posted by pedr on September 15, 2017, at 8:48:33
First few days after the week washout and then starting Parnate 30mg were pretty good. 4th or 5th day I think I felt better than I have in a while. Compassionate about others more than usual.
That all changed fast. Bad depression now. Very spacey. Don't feel like myself. No libido. Over eating (food craving). Want to head to bed hrs before it's necessary.
Yay.
Hope this works. But my optimism is fading quickly. I know I need to get to 40 but still a few weeks away from that. I've been on nuvigil for a few months so I'm going to try skipping that for at least a day to see if I'm reacting poorly to that all of sudden.
Just had to vent though. This sucks. Sorry for anyone dealing w depression at the moment......first time I've been this way in yrs....
Posted by PeterMartin on September 25, 2017, at 22:24:02
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress, posted by PeterMartin on September 25, 2017, at 1:58:20
Called my doctor and he oked me slowly going up to 60 by the time I see him next which isn't for a month. Phew.
Really hope this works for me.
If anyone has positive stories about Parnate that might encourage me that'd be great.
Posted by PeterMartin on September 29, 2017, at 3:16:56
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress, posted by PeterMartin on September 25, 2017, at 22:24:02
Huge change since going up to 40. 100x better. Really refreshing. I'm a little up up and down but I think that's related to the immediate affects Parnate has.
No blood pressure spikes after doses which force me off it on my only other trial in 2010. I'm 97% sure I'm just one of those people who has a reaction when taking Lithium + an MAOi. I had a similar boat issue on Marplan and it took a long time to figure out the reason.Not taking Lithium anymore.
Anyway I hope this state of mind continues.....
Posted by PeterMartin on September 29, 2017, at 3:19:30
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress, posted by PeterMartin on September 29, 2017, at 3:16:56
Btw is it true that Parnate acts a norepinephrine reuptake inhibitor at doseages of 40mg+? I'm pretty sure I read someone say that here recently but that was new information to me.
Thanks for any clarification.
Posted by porkpiehat on October 2, 2017, at 11:48:07
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress, posted by PeterMartin on September 29, 2017, at 3:16:56
> Huge change since going up to 40. 100x better. Really refreshing. I'm a little up up and down but I think that's related to the immediate affects Parnate has.
How are things going? I'm curious what happened at 40 mgs...I was there for two or three days. My experience has been less compassion, huge zoneyness, complete disinterest in eating, friends, exercise. Compulsive behaviors shot up.
On parnate total of 6-7months. I've been holding at 20-30 mgs and was planning a switch to Nardil. What was this 40mg threshold like? Unless it is vastly different in terms of the above symptoms I'm out!
Posted by SLS on October 2, 2017, at 16:20:49
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress » PeterMartin, posted by porkpiehat on October 2, 2017, at 11:48:07
I'm sorry to word things so tersely, but you have wasted months taking a drug at dosages that are subtherapeutic. I understand your reluctance to continue your trial of Parnate - or any other drug - that isn't working.
What is the worst thing that can happen if you elect to increase the dosage of Parnate? If you are intolerant of the drug, you will be able to discontinue it. However, I encourage you to more fully explore Parnate at therapeutic dosages (40-80 mg/day) since you are already taking it. Are the effects you describe intolerable at this point? Can you function?
Nardil works for some people for whom Parnate does not. However, the possible side effects with Nardil are no picnic. I am curious, though. Why have you chosen treatment with MAOIs?
- Scott
Posted by porkpiehat on October 7, 2017, at 23:04:53
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress » porkpiehat, posted by SLS on October 2, 2017, at 16:20:49
> I'm sorry to word things so tersely, but you have wasted months taking a drug at dosages that are subtherapeutic. I understand your reluctance to continue your trial of Parnate - or any other drug - that isn't working.
>
> What is the worst thing that can happen if you elect to increase the dosage of Parnate? If you are intolerant of the drug, you will be able to discontinue it. However, I encourage you to more fully explore Parnate at therapeutic dosages (40-80 mg/day) since you are already taking it. Are the effects you describe intolerable at this point? Can you function?
>
> Nardil works for some people for whom Parnate does not. However, the possible side effects with Nardil are no picnic. I am curious, though. Why have you chosen treatment with MAOIs?
>
>
> - ScottHi Scott:
I am extremely med sensitive and typically respond better at lower doses. As I said, I find that a complete disinterest in people, dating, school, combined with exhaustion and compulsive behaviors to be a drawback and the zoned out apathy was worse at a higher dose.
I know some of these symptoms sound like depression, but they are specific to the parnate. Like, they get worse within an hour of taking the drug.
I started MAOI hoping to get off the SSRI train and feeling better without so much emotional blunting. I feel way more blunted than on nothing or Celexa right now.
If the argument can be made that 30mgs parnate makes you feel worse and at 40-60 mgs the effects of the drug change remarkably than I will consider. Right now I am most concerned with the nervousness, chain smoking, and compulsive shopping/alcohol cravings I am getting, which remind me of speed or cocaine. There are times when I'm alone I fear I am bordering on psychosis.
I am functioning and can get up and go to work everyday but I feel more alienated from my social life and personal self-care with every passing day. I am also taking 50mgs trazodone for sleep, 150mgs gabapentin also sleep, and 100-150 mg lamictal. Maybe that is contributing to my response.Antipsychotics typically make me more detached and apathetic and occasionally dissociated or very angry. I know this has "bipolar" written all over it.
Posted by SLS on October 8, 2017, at 13:31:28
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress » SLS, posted by porkpiehat on October 7, 2017, at 23:04:53
Hi.
Of course, you know that I am just trying to help. I apologize for sounding too reprimanding. I am just frustrated for you, and thought that you might have been just 10 mg/day of Parnate short of greatly improving your quality of life.
I can certainly understand your being sensitive to the side effects of medications at higher dosages, and that you might obtain the best result at dosages that are generally considered to be subtherapeutic. A good friend of mine is in the same category.
I cannot predict how you would react to 40 mg/day of Parnate with certainty, and I can appreciate that you cannot take the chance of dropping out of work.
I found that Nardil was more of a "mood brightener" than Parnate, and produced an improvement in interest, motivation, and reward (a reduction of anhedonia). It is not true that Parnate is always better for mental energy than is Nardil. For me, it is quite the opposite. Unfortunately, Nardil does not produce a stable improvement for me for any length of time, so I am "stuck" with Parnate and drugs that are used in combination with it in order to produce a more persistent antidepressant effect. I miss the mood brightening, clarity of thought, and increase in reward that Nardil gives me. Right now, I have opted to remain on Parnate for a few more months and then evaluate its worth to me.
- Scott
Posted by Porkpiehat on October 8, 2017, at 21:05:23
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress, posted by SLS on October 8, 2017, at 13:31:28
Sorry if my post seemed aggressive I' was just particularly frustrated last night. I've been weighing going back up on he parnate all day. Im noticing at lower doses a return to feeling nervous self conscious and flat footed around people.
But now 2 hrs after dosing I'm back to having a complete disinterest in interacting with people that's not as bad during the day before I dose. That's just not me. I'm actually interested in your thoughts about the dopamine factor, especially in regards to the paranoia, and the role of lamictal (it allows dopamine release to be enhanced in certain parts of the brain?) i also think there is some relavent info in the way Wellbutrin made me zoned and socially apathetic.
I guess I could ramp back up fairly aggressively to see if my initial rxn was a ramp up effect. But if I start Marplan soon it would just make the washout and ramp up period longer and more painful.
Posted by porkpiehat on October 23, 2017, at 10:25:49
In reply to Re: Update: 1wk wash, 10days 30mg Parnate. Depress, posted by PeterMartin on September 29, 2017, at 3:19:30
> Btw is it true that Parnate acts a norepinephrine reuptake inhibitor at doseages of 40mg+? I'm pretty sure I read someone say that here recently but that was new information to me.
>
> Thanks for any clarification.I'm pretty sure the parnate molecule (or a metabolite of it) is a mild stimulant/amphetamine...which is why people feel an immediate boost. I'm not sure what is responsible for the daytime crash. Both were too much for me.
What dose of parnate are you on right now and how are you feeling? I did the opposite switch without a washout. I miss the focus and morning energy I had with parnate, and the relief from some of my borderline-style sypmtoms. Still at 30 Marplan hoping these things improve.
I'm psyched for you and parnate if you are "over the hump"!
This is the end of the thread.
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