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Dr. Bob is Robert Hsiung, MD,
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Posted by linkadge on July 27, 2019, at 10:28:55
In reply to Re: I need some advice regarding my medication regimen, posted by Hordak on July 27, 2019, at 9:38:32
If you want something for weight gain and anxiety, mirtazapine would be a good option / adjunct.
However, it does have a long half life, and can leave you sedated during the day.
Linkadge
Posted by linkadge on July 27, 2019, at 10:31:30
In reply to Re: I need some advice regarding my medication regimen » linkadge, posted by Hordak on July 27, 2019, at 9:50:24
Escitalopram and sertraline are similar. Sertraline tends to be a bit more stimulating than escitalopram. If sertraline is sort of working, you might first try adding some mirtazapine or nortriptyline. Nortriptyline might be better in terms of motivation, but mirtazapine would probably be better for sleep / anxiety / appetite.
Personally, I like nortriptyline better than mirtazapine, BUT my sleep became increasingly fragmented on nortriptyline, so I switched back to mirtazapine.
Linkadge
Posted by ed_uk2010 on July 27, 2019, at 11:36:48
In reply to Re: I need some advice regarding my medication regimen » linkadge, posted by Hordak on July 27, 2019, at 9:50:24
>Do you think that the combination of Escitalopram and Nortriptyline would be worth a try?
Not sure whether doctor would agree to that due to potential ECG (EKG) changes. You'd need cardiac monitoring if you did it.
Posted by Hordak on July 27, 2019, at 13:13:36
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 27, 2019, at 10:28:55
> If you want something for weight gain and anxiety, mirtazapine would be a good option / adjunct.
>
> However, it does have a long half life, and can leave you sedated during the day.
>
> LinkadgeIs it true that tolerance builds fast? I have heard that the H1 receptor desensitizes fast...
Posted by Hordak on July 27, 2019, at 13:17:30
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 27, 2019, at 10:31:30
> Escitalopram and sertraline are similar. Sertraline tends to be a bit more stimulating than escitalopram. If sertraline is sort of working, you might first try adding some mirtazapine or nortriptyline. Nortriptyline might be better in terms of motivation, but mirtazapine would probably be better for sleep / anxiety / appetite.
>
> Personally, I like nortriptyline better than mirtazapine, BUT my sleep became increasingly fragmented on nortriptyline, so I switched back to mirtazapine.
>
> Linkadge
>maybe too much stimulation. I overheat on Sertraline.
So i think there are the possibilities:
1.) Sertraline + (Nortriptyline or Mirtazapine)
2.) Escitalopram + (Nortriptyline or Mirtazapine)
3.) TCA?btw.: What about Paroxetine?
Posted by Hordak on July 27, 2019, at 13:19:22
In reply to Re: I need some advice regarding my medication regimen » Hordak, posted by ed_uk2010 on July 27, 2019, at 11:36:48
> >Do you think that the combination of Escitalopram and Nortriptyline would be worth a try?
>
> Not sure whether doctor would agree to that due to potential ECG (EKG) changes. You'd need cardiac monitoring if you did it.You think that qt prolongation might potentiate when taking both drugs combined?
Posted by linkadge on July 27, 2019, at 15:10:41
In reply to Re: I need some advice regarding my medication regimen » linkadge, posted by Hordak on July 27, 2019, at 13:17:30
You build tolerance to the sedating effects (usually) of mirtazapine after a few weeks. I never had much success with paroxetine. I would say that escitalopram is much cleaner and probably more effective.
Posted by Hordak on July 27, 2019, at 17:32:07
In reply to Re: I need some advice regarding my medication regimen » Hordak, posted by linkadge on July 27, 2019, at 15:10:41
> You build tolerance to the sedating effects (usually) of mirtazapine after a few weeks. I never had much success with paroxetine. I would say that escitalopram is much cleaner and probably more effective.
What's your take on tricyclics, especially the classic ones: Amitriptyline, Clomipramine, Imipramine
Posted by Christ_empowered on July 28, 2019, at 12:20:29
In reply to Re: I need some advice regarding my medication regimen, posted by Hordak on July 27, 2019, at 17:32:07
hi. the tca drugs are...perhaps not surprisingly...rather toxic. remember; the original tca, imipramine, was supposed to be a rip off of Thorazine. when tested in hospitalized people, the 'schizophrenics' got worse, and the 'severe depressives' got a mood lift...and about 1/4 of them turned manic.
there is one...i've never taken it, i don't know if its available where you live....surmontil. it is sedating, a later developed tca that somehow helps get to sleep and then doesn't produce the artificial, not so refreshing sleep of most sedatives...
and i think its more closely related to clozapine...i forget the specifics, but its supposed to be helpful for the more agitated depressives among us, less cardio-toxicity, wide dosage range, etc. etc. etc.
it also dawned on me...remeron+wellbutrin. the remeron could possibly help improve appetite, the wellbutrin is a relatively mild stimulant, one of the less apathy-inducing drugs out there.
is gabapentin an option? even on an as needed basis, i would think it might be helpful, particularly during the antidepressant start up period.
just some random thoughts. i hope things get better for you.
Posted by Hordak on July 28, 2019, at 16:06:44
In reply to Re: I need some advice regarding my medication regimen, posted by Christ_empowered on July 28, 2019, at 12:20:29
> hi. the tca drugs are...perhaps not surprisingly...rather toxic. remember; the original tca, imipramine, was supposed to be a rip off of Thorazine. when tested in hospitalized people, the 'schizophrenics' got worse, and the 'severe depressives' got a mood lift...and about 1/4 of them turned manic.
>
> there is one...i've never taken it, i don't know if its available where you live....surmontil. it is sedating, a later developed tca that somehow helps get to sleep and then doesn't produce the artificial, not so refreshing sleep of most sedatives...
>
> and i think its more closely related to clozapine...i forget the specifics, but its supposed to be helpful for the more agitated depressives among us, less cardio-toxicity, wide dosage range, etc. etc. etc.
>
> it also dawned on me...remeron+wellbutrin. the remeron could possibly help improve appetite, the wellbutrin is a relatively mild stimulant, one of the less apathy-inducing drugs out there.
>
> is gabapentin an option? even on an as needed basis, i would think it might be helpful, particularly during the antidepressant start up period.
>
> just some random thoughts. i hope things get better for you.Thanks man!
surmontil is Trimipramine... we've got it in Germany. It is being used as a sedative, but has most probably no antidepressive effects!? Very strong H1 and strong HT2A & alpha1-adrenergic antagonism. Somewhat related to Mirtazapine when it comes to function.
My biggest fear when it comes to TCAs is constipation and orthostatic hypotension :=D
Wellbutrin is an interesting drug, BUT I have anxiety and weight gain issues, so I am not sure if it's wise to take it :=D
Gabapentin, Pregabalin are definitely an option, but in the end the psychiatrist has to decide... O_o
Posted by sigismund on July 29, 2019, at 11:21:42
In reply to Re: I need some advice regarding my medication regimen, posted by Christ_empowered on July 28, 2019, at 12:20:29
Surmontil (trimipamine) gave me a good refreshing sleep at low doses for a few years.
The TGA decided to discontinue it in Australia, though it is legal to buy it at high prices online.
It can also be acquired through a compassionate access program, sufficiently difficult to discourage every doctor and pharmacist to whom I spoke.
I could speculate about the motives of the TGA but it sounds paranoid.
Posted by sigismund on July 29, 2019, at 11:23:21
In reply to Re: I need some advice regarding my medication regimen » Christ_empowered, posted by Hordak on July 28, 2019, at 16:06:44
I like gabapentin and pregabalin except for the fact that my feet swell up.
Posted by linkadge on July 29, 2019, at 19:09:45
In reply to Re: I need some advice regarding my medication regimen, posted by Christ_empowered on July 28, 2019, at 12:20:29
I would disagree that the TCAs are 'toxic'.
It really depends on the TCA. Clomipramine is a very tolerable medication. Many docs don't even know that anafranil is a TCA. It is like a combination of a balanced SNRI (SSRI + NRI metabolite) and mirtazapine. It is still considered the 'gold standard' for OCD and is probably one of the most effective antidepressants. The anticholinergic side effects vary from TCA to TCA. Nortriptyline, for example, is less anticholingeric than amitriptyline.
Yes, the TCAs can induce mania. I haven't seen any conclusive evidence that TCAs are more likely to cause mania than SSRIs. However, if they do, it might be a sign of their superior antidepressant effects.
They are not selective and they hit a lot of targets. However, this may make them more effective in certain cases. Many of them can be taken at night, which can reduce daytime side effects and they tend to be much less disruptive on sleep than SSRIs.
Imipramine and amitriptyline are still a very effective antidepressants. They are (IMHO) much stronger for depression than any SSRI and the side effects are different (less sexual dysfunction, for example).
The SSRIs are safer in overdose, but this is a very poor rationale for selecting an antidepressant. Supposedly only a very (very) small portion of completed suicides are actually from antidepressant overdoses.
Linkadge
Posted by linkadge on July 29, 2019, at 19:14:31
In reply to Re: I need some advice regarding my medication regimen » Christ_empowered, posted by Hordak on July 28, 2019, at 16:06:44
Suposedly (in head to head trials) surmontil is as effective for depression as imipramine. This is hard for some to believe, but it may be evidence that there is an additional (yet undiscovered) common mechanism of the TCAs. I remember reading that a metabolite of trimipramine inhibits MAO-B and DAT. Also, like other TCAs is has an indirect effect on opioid systems. However, it is a VERY strong antihistamine (I took 25mg and slept till 4:00 pm the next day).
Honestly, if you were to try one TCA, I would highly recommend clomipramine.
Linkadge
Posted by mtom on July 30, 2019, at 10:38:04
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 29, 2019, at 19:14:31
Problem is, everyone reacts differently to each antidepressant.
Sertraline (Zoloft), tried many years ago, was horrifically activating for me. More recently Citalopram (Celexa) also made me very agitated and anxious along with other side effects. So switched to Escitalopram (Lexapro-Cipralex). Still made me very anxious, slightly less so than Celexa, and other side effects. But some people find it helps anxiety (!?).
So recently started decreasing Escitalopram while adding very low dose Mirtazapine (Remeron). Have been cross-titrating slowly for about 7 weeks, gradually decreasing Escitalopram while also gradually increasing Mirtazapine (I'm unusually sensitive to AD side effects).
I'm now taking very low dose Escitalopram and 7.5 gm Mirtazapine. And I have started to feel better for the first time in over a year. It's not consistent yet, buy my anxiety is definitely less on average, and I'm having some happier days. The Mirtazapine made me slightly groggy in mornings and after each dose increase, but this wore off. I'm also underweight - I've put on just a few pounds so far. The biggest downside has been an increase in Nightmares and Vivid dreams, but this also happened on higher doses of Escitalopram, and for the Mirtazapine, they increased upon starting and after dose-increases but gradually faded over a couple of weeks.
So, just sharing my experience. Mirtazapine is prescribed by some doctors as an add-on to SSRI's in addition to use on its own.
Posted by ed_uk2010 on July 31, 2019, at 6:29:21
In reply to Re: I need some advice regarding my medication regimen, posted by sigismund on July 29, 2019, at 11:21:42
>The TGA decided to discontinue it in Australia
Hi S,
Not just that the manufacturer discontinued it from the Australian market due to very low sales? That's what usually happens.
Posted by ed_uk2010 on July 31, 2019, at 6:31:06
In reply to Re: I need some advice regarding my medication regimen » ed_uk2010, posted by Hordak on July 27, 2019, at 13:19:22
> You think that qt prolongation might potentiate when taking both drugs combined?
It is a possibility to be aware of. Effects of drugs on cardiac conduction can be additive.
Posted by Hordak on August 5, 2019, at 19:23:22
In reply to Re: I need some advice regarding my medication regimen, posted by sigismund on July 29, 2019, at 11:21:42
> Surmontil (trimipamine) gave me a good refreshing sleep at low doses for a few years.
>
> The TGA decided to discontinue it in Australia, though it is legal to buy it at high prices online.
>
> It can also be acquired through a compassionate access program, sufficiently difficult to discourage every doctor and pharmacist to whom I spoke.
>
> I could speculate about the motives of the TGA but it sounds paranoid.
It's available where I live...
Posted by Hordak on August 5, 2019, at 19:24:28
In reply to Re: I need some advice regarding my medication regimen, posted by sigismund on July 29, 2019, at 11:23:21
> I like gabapentin and pregabalin except for the fact that my feet swell up.
I would like to try them. How do they feel?
Posted by Hordak on August 5, 2019, at 19:59:13
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 29, 2019, at 19:14:31
> Suposedly (in head to head trials) surmontil is as effective for depression as imipramine. This is hard for some to believe, but it may be evidence that there is an additional (yet undiscovered) common mechanism of the TCAs. I remember reading that a metabolite of trimipramine inhibits MAO-B and DAT. Also, like other TCAs is has an indirect effect on opioid systems. However, it is a VERY strong antihistamine (I took 25mg and slept till 4:00 pm the next day).
>
> Honestly, if you were to try one TCA, I would highly recommend clomipramine.
>
> Linkadge
>
>
>I would very much like to try Clomipramine.
I've been on Mirtazapine 15mg for two weeks (a friend of mine had some tablets and gave them to me). Appetite and metabolizm were insane: I gained 15 pounds in two weeks. Sleep felt like being hit by a hammer, strange dreams. I felt weak. Two weeks were probaby too short to assess its potential.
Escitalopram + Nortriptyline => good combo?
Posted by Hordak on August 6, 2019, at 8:31:54
In reply to Re: I need some advice regarding my medication regimen, posted by mtom on July 30, 2019, at 10:38:04
> Problem is, everyone reacts differently to each antidepressant.
>
> Sertraline (Zoloft), tried many years ago, was horrifically activating for me. More recently Citalopram (Celexa) also made me very agitated and anxious along with other side effects. So switched to Escitalopram (Lexapro-Cipralex). Still made me very anxious, slightly less so than Celexa, and other side effects. But some people find it helps anxiety (!?).
>
> So recently started decreasing Escitalopram while adding very low dose Mirtazapine (Remeron). Have been cross-titrating slowly for about 7 weeks, gradually decreasing Escitalopram while also gradually increasing Mirtazapine (I'm unusually sensitive to AD side effects).
>
> I'm now taking very low dose Escitalopram and 7.5 gm Mirtazapine. And I have started to feel better for the first time in over a year. It's not consistent yet, buy my anxiety is definitely less on average, and I'm having some happier days. The Mirtazapine made me slightly groggy in mornings and after each dose increase, but this wore off. I'm also underweight - I've put on just a few pounds so far. The biggest downside has been an increase in Nightmares and Vivid dreams, but this also happened on higher doses of Escitalopram, and for the Mirtazapine, they increased upon starting and after dose-increases but gradually faded over a couple of weeks.
>
> So, just sharing my experience. Mirtazapine is prescribed by some doctors as an add-on to SSRI's in addition to use on its own.Could you please elaborate on your experiences with Sertraline. That would be very helpful. Thank you :=)) And how were Citalopram and Escitalopram compared to Sertraline? Were they less agitating than Sertraline?
Did you try 30mg Mirtazapine?
Posted by mtom on August 6, 2019, at 10:53:31
In reply to Re: I need some advice regarding my medication regimen, posted by Hordak on August 6, 2019, at 8:31:54
> Could you please elaborate on your experiences with Sertraline. That would be very helpful. Thank you :=)) And how were Citalopram and Escitalopram compared to Sertraline? Were they less agitating than Sertraline?
>
> Did you try 30mg Mirtazapine?I had an intense reaction to 1 Sert (Zoloft). Woke through the night feeling I was going to explode, heat, chills, physical agitation and anxiety, etc. Believe it was mild Serotonin Syndrome (my blood pressure was also notably higher than my norm when saw Dr a couple days later - also a SS symptom). HOWEVER - I had been taking St. John's Wort for 2-3 months including that day. Had told Dr when she gave me Zoloft, she didn't know what SJW was and said irrelevant - this was a long time ago, SJW had just started growing in popularity & no info out on interactions. SJW had done nothing anyway & interaction did not occur to me. It was a weekend so until my Dr office opened I used Benzos which I had on hand for occasional use for Flying, Dentists, etc (was not experiencing general anxiety in those days). The reaction wore off gradually over a few days.
Now, I am VERY sensitive to AD's and react to almost all I have tried with increased anxiety & other side effects (including citalopram and escitalopram even on very low subclinical doses - intense, but not to the degree of my Zoloft reaction which was likely exacerbated by the SJW). I know only 2 others personally who have tried Zoloft - 1 no problem, still takes it, other found it too activating but has no problems on Citalopram.
Still taking a very small dose Mirtazapine, started with 3.75 and very recently worked up to 7.5 mg (and still a very small dose Escitalopram). My Doctors want me to stay at this for a few weeks then discuss further increases. No increase in anxiety yet with Mirt, in fact anxiety is somewhat better. But other SE's, some described in my first post. Doubt I will go as high as 30.
My new Pdoc told me he believes some people do well on lower doses of AD's than the "standard" recommendations, but most Docs just prescribe the "standard" in the belief that lower doses are subclinical and won't work. This is likely true for most people, but not all. And of course there is an understandable rush to get relief asap. I also believe it takes longer for some people than others to feel an effect, and some Docs have a tendency to increase dose very quickly if no quick effect. This may often be the right thing to do, but sometimes the effect just takes longer.
Again, everyone is different. I see you wrote that Sert helped your anxiety but brought on other negative symptoms. I also found Citalopram & Escitalopram decreased my motivation further, although it was already low due to depression.
But others I know on Cit and Escit have not experienced this effect. Since starting Mirtazapine (Remeron) I have had a few days of feeling better with increased motivation, but these have been intermittent & inconsistent so far, although noticeable when they occur. And it's possible this is in part because I've been tapering Escitalopram at the same time.
It's even possible that the "Medical" CBD Oil I started taking a few months ago is helping the anxiety, who knows? Little research, but lots of anecdotal reports. I also take it for autoimmune arthritis pain & it's definitely helped with that. Medical Cannabis is available by Prescription from Doctors in Canada, supplied by government regulated licensed providers. As of late last year, Cannabis in Canada is also available through licensed shops without a prescription.
Posted by Hordak on August 6, 2019, at 18:45:13
In reply to Re: I need some advice regarding my medication regimen » Hordak, posted by mtom on August 6, 2019, at 10:53:31
Thank you very much for your detailed answer! It definitely sounds like mild Serotonine Syndrome. As far as I know combining SSRIs with SJW can lead to Serotonine Syndrome, at least some mild forms of it. Your sensitivity to ADs may be a consequence of poor metabolizing @ CYP450. Have you ever had it tested?
Motivation and ambition on SSRIs really seem to be a problem for many patients. Yes, anxiety-wise Sertraline wasn't that bad, but getting things done on Sertraline is more difficult than without Sertraline. Sertraline numbs me, especially the hedonic urge to do stuff... ^^ maybe Escitalopram in combination with something like Mirtazapine / Nortriptyline is the way to go.
"Medical" CBD Oil is definitely interesting. I didn't try it yet, but it's time... :=D
Unfortunately medical cannabis is difficult to get in Germany. You have to be a cancer patient in terminal stage or other fatal disease with lots of pain to get it prescribed.
Posted by mtom on August 6, 2019, at 20:44:26
In reply to Re: I need some advice regarding my medication regimen » mtom, posted by Hordak on August 6, 2019, at 18:45:13
Hi Hordack - yes I did have genetic testing last year for medications. Citalopram & Escitalopram are metabolized by the 450 enzymes CYP 3C19 for which I am a "normal metabolizer" and CYP 3A4 which they did not test. When I inquired they said too many variations of this enzyme and insufficient data to make recommendations. Some literature also says CYP 2D6 involved and I am an "intermediate metabolizer" for this enzyme, 1 of my 2 alleles is a no activity mutation. CYP 2D6 is involved in the metabolism of Many AD's. This could be relevant to my hypersensitivity to side effects.
My CYP 2B6 showed an "increased response to Bupropion (Wellbutrin)". My Dr had already crossed this off the list before anyway as she instinctively thought it might be too activating for me. Good call.
Sertraline is metabolized by a number of enzymes including those above, and that may have contributed to my reaction. However my Genetic Report did not elaborate on Sertraline, only mentioned 1 enzyme, I got more complete data from other sources.
The Test did not include Mirtazapine (Remeron), again when I asked they said insufficient data. But my research shows it's also metabolized by 2D6 for which I have 1 non-functional allele, yet I have not experienced increased anxiety on Mirt (yet - still on low dose).
These tests are still in their infancy and except for a few drugs that they steered me away from, e.g. Wellbutrin plus "all" Antipsychotics they included in report (with the notation "increased risk of tardive dyskenesia" - don't want to risk that!), data was mostly brief and incomplete, and my subsequent follow-ups did not provide me with more information. They provided no useful information on drug interactions. And these are important as many are substrates for or inhibitors of the same enzymes (and not just AD meds). Even CBD Oil impacts some of these same enzymes and interactions are hypothesized, but the dosage required for interactions may be higher than that usually taken.
These tests will gradually get better, funding is an issue of course whenever non-pharmaceutical research is involved. But many Doctors are saying that "Personalized Medicine" based on specific genetics will be the future of medicine..... eventually.....
Additional Note: Neither of 2 Pdocs I've consulted even knew these tests existed?! Yet still questioned their veracity - a little arrogant I thought when they admitted knowing nothing about them.
Posted by sigismund on August 7, 2019, at 8:26:41
In reply to Re: I need some advice regarding my medication regimen, posted by Hordak on August 5, 2019, at 19:24:28
>How do they feel?
In low doses a bit like a benzo with a slight mood lift?
In higher doses they make you a bit stupid.
Good for social anxiety.
They affect your 'central perception' and therefore are used for pain.
This is the end of the thread.
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