Posted by dbbs on February 19, 2014, at 12:43:09
Hi there! Long time listener, first time caller. I know some of you guys have a lot of experience with MAOIs, and I had some questions to ask I can't seem to find the answers to elsewhere. Thanks for reading my post, and thanks doubly for any informative answers.
Backstory:
Currently I'm being prescribed Nardil/phenelzine at 45mg/day. My medical provider (a psychiatric nurse practitioner) was the only one at the clinic I go to who was willing to prescribe an MAOI at all, but she's been very cautious about it because even though her age (about 50) I don't think she has prescribed one in many years, if ever. I'm also on Klonopin/clonazepam 5mg/day - yes, a high dose, but I have severe panic attacks & PTSD flashbacks that come and go all day, and clonazepam has been the only thing to calm that down, though I wish it didn't make me so sedated. In addition to the 5mg of clonazepam, for medical reasons I also take 150mg of Dantrium/dantrolene Sodium (for back spasticity), 440mg of Aleve/naproxen Sodium a day (for back inflammation), a Multivitamin (to supplement what's missing in my diet), a B-Complex vitamin (to offset the B6 deficiency caused by Nardil), and Fish Oil (to offset the unhealthy ratio of Omega-6 to Omega-3 fatty acids that I normally get.) I occasionally take Claritin/loratadine for allergies.
Even after just a week plus on Nardil, it has been significant improvement over the 7 or 8 med combo I was taking, though I do miss the Dexedrine spansules/dextroamphetamine extended release capsules for my ADHD. The problem is that Dexedrine doesn't really touch me much when I'm depressed - it just makes me able to focus on video games (not the intended use I'm sure.) Sure, this helps distract me when I'm depressed, but I'd really rather get up and DO things and no be depressed - my doctor actually said I may regret going off the the Dexedrine, but I feel like the depression is a more pressing matter. And in just a week on Nardil I have improved mildly - taken care of yard and patio duties I've left going for years (amazing how so my plants have survived this long with just the rainwater in the desert...) and vacuuming... though my room is almost as cluttered as ever.
I'm not sure if this is me experiencing the so-called "Nardil mania" I've heard others referencing that comes on at the second week or so - I certainly don't feel good and I've asked my family members if I seem manic, and they all say no, just that I seem mildly less depressed. My thought is that if it's not "Nardil mania", then it's possibly the MAOI kicking in faster because I've already been on antidepressants for years and my receptors were prepared for the slight boost in neurotransmitters that's probably already been achieved.
Just so you know, my diagnoses are:
-Major Depressive Disorder (Atypical - hypersomnia, hyperphagia, etc)
-Post Traumatic Stress Disorder
-Attention Deficit Hyperactivity Disorder - Hyperactive-Impulsive Type (though depending on the doctor, it has been listed as inattentive and combined type - but that's my current Dx)
-Panic Disorder
-I also have injuries in my mid & lower back and some disc bulging and degeneration, with some evidence of neuropathic pain developing. I am 30 years old, 6'0"/183cm, 290lbs./131.5kg (severe depression and mostly untreated back issues really don't help with the weight loss), have all my shots (except rabies, grr!) and have a history of ear infections. Blood pressure and heart rate get high when I'm panicked, but otherwise 120/80 BP and 70bpm are normal for me. Don't know why you'd want to know all that, but maybe it helps.
My actual questions:1.) My doctor is VERY inexperienced with Nardil, especially the dosages involved. She has me set to take 45mg/day for two months. Is it possible that this will have an effect on me? I think because my anxiety disorders she would rather I give Nardil a complete trial first before trying me on Parnate/tranylcypromine, so I can't switch to that, not yet.
1b.)I know the goal is to destroy 80-85% of the MAO in my body to achieve therapeutic efficacy, so even if I can't convince her to raise the dose higher, this should be possible at some point even if I'm stuck with a 45mg/day dose (assuming my body doesn't make MAO faster than phenelzine can react with it), right?
2.) Are there any recently published, publicly available, and scientifically accepted sources I print out to show her that I would benefit more from a 60mg-75mg dosage (what I'm shooting for.)
3.) I know that Nardil as a reasonably nonselective irreversible MAOI will (probably significantly) increase deficient levels of phenethylamine in my brain. I know that phenethylamine deficiency is by some models either a symptom or causative factor in ADHD. In other models it's a lack of norepinephrine and dopamine. All of these are boosted by Nardil. Is there a reasonable chance this may help me with my ADHD?
3b.) If not, can anyone provide me with any publicly available, recently published scientific papers regarding the use of very low dose Dexedrine Spansules/Dextrostat/dextroamphetamine IR or ER (the levoamphetamine in Adderall causes my panic & heart rate levels to skyrocket for some reason - several times in the hospital with them switching my Dexedrine to Adderall XR because of no Dexedrine in stock & several ECGs later, this has been established) - or even papers regarding the use of very low dose Adderall/Adderall XR/dextroamphetamine-amphetamine mixed salts in combination with Nardil? I know this has been used at very low doses with positive effect, but I know if this becomes an issue later I better have some pretty well grounded scientific evidence to back this up to get even a chance at it.
Ritalin/methylphenidate is a no go (anxiety goes through the roof) but Vyvanse/lisdexamfetamine is a possibility, also, I've just never been prescribed it. Also, Provigil/modafinil is a no go, not covered by insurance. Adderall is a no go too, it's just I'm sure papers on Adderall would be proof enough for her to give me a low dose of Dextrostat or Dexedrine.
3c.) Along the same line of medication supplements and changes, if I gain no lasting benefit from Nardil or achieve only an incomplete response (even at a higher dose), would one recommend I ask for a switch to Parnate/tranylcypromine, or is there another medicine that I could supplement the Nardil with? Of the medicines I know are safe, I've taken quite a few of them - but they have almost all had such huge antihistamine effects that I've slept for 24-36+ hours straight after single doses and slept for most of 2-4 weeks to give the medicine a "full trial" before I finally couldn't handle the sleep anymore. I would say the worst culprits were prazosin, amitryptiline, Remeron/mirtazapine, Seroquel/quetiapine, Risperdal/risperidone, and a couple first generation typical antipsychotics they tried me on very briefly at the hospital. I have malignant hypothermia, and I know this can in some cases be comorbid with neuroleptical malignant syndrome, and I'm very leery of taking certain known problematic antipsychotics because of this - but so far I've just had some really negative side effects that didn't kill me, though I did feel quite zombified for months after taking each one for a duration. One dose of haloperidol did turn me into a snarling, loud, angry, and quite terrible feeling monster, so it's possible that one could have triggered neuroleptical malignant syndrome if continued, but I didn't want to test that theory out.
The only antipsychotic that worked positively without side effect for me was Abilify/aripiprazole, but getting that covered here by my insurance requires I go through a trial of several different antipsychotics, even those unapproved as adjunctive treatment in MDD, Whle I have tried several antipsychotics in the past; most of the ones I was on before were paid through private insurance when I was employed. Unfortunately, they want me to re-test me on several of them I've already been on - through my public insurance as part of 'step-up' therapy. This is minly because Abilify is so expensive, of course. I'm not willing to put up with several months of antipsychotic hell again just for the chance of them approving Abilify.
I was thinking maybe nortripytline, but even that is a potent antihistamine, and I'd like to avoid those, unless the antihistamine sleep effect wears off by morning? Any experience with that? I can't wait till Abilify goes generic; I'll be asking for it the very next day, even if Nardil is working great. That stuff really helped me get out of a suicidal slump when I was in the hospital. I really have no idea if the Nardil will work for me as is or not, I just like to have a "game plan" so I can be prepared for suggestions if this doesn't work right (an unfortunate side effect of no antidepressant or adjunctive therapy aside from Abilify ever working properly on me.)
Please note:
I cannot switch doctors (aside from within the clinic) and my experience with the other medical practitioners in the clinic has been BAD. I am stuck in the public mental health system in Arizona because I'm out of work, have SMI status, and am on AHCCCS - Arizona's Medicaid system. In its defense, it's really it's not bad - I've had friends in the UK on the NHS get much worse and far less prompt and appropriate responses than I have here.
The good news is I am receiving medicine, receiving therapy, taking an active role in my treatment and being given an opportunity to play that role, and on top of that if I feel there is a problem with my medication I can go in during the morning Monday-Friday and see my doctor without an appointment if I feel my meds are really wrong. I have no complaints about my medical provider, in fact, I feel quite lucky as she has listened to me and has been willing to hear me out and usually gives me what I ask to try if it's reasonable.
But, reasonable includes medicines she's familiar wit, and I completely understand that. She's willing to work with me, but I know she's extremely cautious with the MAOI (as evidenced by the fact that her appointments have gone from every 2-3 months to every week while being inducted on the MAOI.)
Any thoughts/suggestions regarding my questions or additional information? Keep in mind, switching doctors is not an option here. Neither is ordering from the internet to supplement (I'm so poor it took me a week to get money together to buy some new pens, and that's not because I've spent my money on other things!) I have to work within the constraints allotted.
*** Keep in mind, even though I used the phrase "Nardil mania" up there, I am only using it because I have heard people use that phrase used to describe a portion of the induction phase of Nardil. I have never once been diagnosed with Bipolar I or II and have never once experienced a truly manic, hypomanic, or mixed state naturally or induced from medicine. The fact that I did one or two hours of yard work a day for 2 days I am 100% sure does not qualify me as manic by any definition of the word, it just qualifies me as less depressed and more motivated than normal. So, any suggestion that I am in self denial of a bipolar diagnosis or should push for a bipolar diagnosis - and/or that I may be on the wrong med (trust me, I've even tried some of the bipolar meds off-label for depression) - will be ignored; that is, unless I actually go into one of those states naturally and not because of medication. Sorry for being blunt here, I just want this understood. ***
Thank you so very much again! I appreciate it.
poster:dbbs
thread:1060862
URL: http://www.dr-bob.org/babble/20140214/msgs/1060862.html