Posted by Questionmark on May 9, 2004, at 2:54:12
In reply to Re: ok, here's what my pdoc said » Questionmark, posted by zeugma on May 8, 2004, at 20:35:04
> <Hi. Since you seem to have severe anxiety, i would increase the Klonopin dosage regardless of what else you do (as long as you're not tOO afraid of physical dependency, though i think it's worth it anyway).
> Beyond that, my suggestion would be to add in clomipramine (Anafranil) since you're already on a TCA and the side effects would probably not be as severe (and since you already appear to be able to tolerate TCAs' side effects fairly well). Also, you sound as if pro-NE effects are beneficial to you, which is another reason to go with the clomipramine over the Lexapro. If you find that the clomipramine is not suitable or helpful enough, then you should move to the Lexapro. Furthermore, it would be easier to move from nortriptyline to clomipramine and then Lexapro than from nortriptyline to Lexapro to clomipramine.
> Good luck. >
>
> Thanks, ? (not questioning your sincerity, merely expressing my gratitude)
>
> It was my thought exactly that i could substitute 25 mg of clomipramine for 25 mg of nortriptyline, and then later, if the clomipramine worked, deconstruct it into Lexapro. He said that clomipramine had more interactions w/ other meds than lexapro, and that was his main reason for favoring the Lex. Also, he said that clomipramine was much more sedating than nortriptyline, and as my depression currently is marked by prominent vegetative signs (exhaustion, slowed movement and thought, anhedonia) that the lexapro would work better than clomipramine. And theoretically, lex with a diminished dose of nortriptyline plus strattera leaves me with substantial pro-NE effect, simulating an action of clomipramine anyway. But he left the choice up to me. he said switching in 25 mg clomipramine with 25 mg nortriptyline would be feasible.
>
> About the klonopin: he wrote me a prescription for double the amount i currently take (ie, for 1.5 mg/day). I had wanted to switch klonopin in for another benzo, because of a possible depressogenic effect (he actually brought this up, but it was in my notes, of course) but, as he put it, he wanted to move one chess piece at a time. but he was clearly indicating that my next move, after lowering the nortriptyline (and giving the dose reduction until Monday or Tuesday to kick in) my next move could be to up the Klonopin. I take his writing the prescription for 1.5 mg as indicating that, if I chose and consulted with him, I could either up the klonopin, add clomipramine (since it isn't a controlled substance, he could call in a script) or open the Lexapro starter pack and cut a pill in half (or quarters, or take the whole pill as the pack directs). Or keep the status quo for a little longer. A lot obviously depends on my mood between now and next week (currently awful, unsurprisingly). But I agree with your reasoning as to how to sequence the changes, while also seeing his point about the Lexapro being less sedating. It's the weekend, so my anxiety is lowered while the fatigue, anhedonia, etc., are more subjectively distressing. If the Klonopin is contributing to these symptoms, which it may well be, it's best to keep it where it is for the moment.
>
> As for dependency, that is not a consideration. I have ADD, so i will always need Strattera or a stimulant, and I actually fear dependency from SSRI's as much as dependency on benzos. Besides, my pdoc knows my history of social phobia and he also knows that I have tried MANY, MANY other approaches to resolve it (CBT, Prozac, Zoloft, Buspar, years of conventional therapy), and I think that in his mind it is preferable to give Klonopin a good run for its money before trying a MAOI (I concur with his reasoning here, as I tolerate TCA's pretty well and NE reuptake inhibition is therapeutic for me).
>
Okay, let's see. First of all, i think harryp's idea with the Parnate could be good, except that it's often not very good for anxiety, and can sometimes be downright terrible for it. Maybe Parnate plus Klonopin would be a good combination though (which is something i've always been curious to try, since the Parn would help negate the Klon's negative effects on cognition and mood, and the Klon would counter Parnate's anxiogenic and overemotional effects.) Actually, since you have such anergic, anhedonic depression (suggesting inhibited transmission of NE, DA, or both), then i wonder if your anxiety is related to low catecholamine transmission as well (of course, it's possible they could be low in some areas and high or normal in others-- i have no idea). If this is the case, then maybe something like Parnate WOULD be quite beneficial for you. Just a thought.Good points about the depressiogenic effects of Klonopin and the greater sedative effects of clomipramine (compared to nortriptyline). i'm guessing that the clomip. and the nortrip. are relatively similar in regards to anticholinergic potency. And the clomip. is more sedative due to its H1 antagonistic (or antihistaminic) effects. So if you don't already know, find out how you react and deal with antihistamine effects (maybe buy some benadryl/diphenhydramine?) Some people like it; some people can't stand it (anti-H1 effects that is). That should help you decide about the clomipramine. Also take note that (though you're probably already aware) clomipramine is extremely serotonergic (very potent 5-ht reuptake inhibitor). As far as adverse reactions with other drugs go, just try to find out the liver enzymes affected by any drugs you think you may take in the near future and compare this with those inhibited by clomipramine. If none of the enzymes are the same (or none are strongly inhibited), then you should have nothing to worry about. One thing you should realize though is that i think if you smoke this will significantly increase the concentrations of either clomipramine or its metabolite imipramine, or both (can't remember-- i think will just up the clomipramine).
Lexapro might be quite good for your anxiety but it probably won't be good at all for the type of depression you have (just my guess). But maybe with a noradrenergic drug like nortriptyline or Strattera it would be useful. It also should have less side effects than clomipramine would. Oh, and as harryp also mentioned, desipramine might really be worth looking into. For some reason i see desipramine as being better than Strattera, though similar. i'm not sure why, i just have a poor image of Strattera (mostly from alot of anecdotes i think), though maybe it's inaccurate. Alot depends on how much serotonin stimulation you think you need, among other things of course. If little to none, then clomipramine and Lexapro are not even worth considering.
Yeah, i think you should find the right, good, effective antidepressant drug or combination, and then when you have satisfactorily established that, then gradually add in Klonopin until your anxiety is under control as well.
Sounds promising. Good luck.
poster:Questionmark
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URL: http://www.dr-bob.org/babble/20040505/msgs/344990.html