Posted by klein on April 27, 2014, at 7:41:01
In reply to Start over with clomipramine or combination?, posted by MuseMemento on April 26, 2014, at 20:19:01
> I've just finished, unsuccessfully, a trial of methylphenidate 20 mg in addition to 300 mg bupropion xl, 20 mg escitalopram and 2 mg abilify. Tuesday is the next appointment with the pdoc and TCAs will be the next step. So, question, I know we'll be either discontinuing or tapering off the escitalopram to make way for clomipramine but should I also discontinue the bupropion, which had previously been my only successfuly AD, and abilify or change only the one agent at a time? I'm not sure the abiilify ever helped or that the bupropion is adding anything currently. I also know that there's an enzymatic interaction between clomipramine and bupropion which increases the plasma levels of clomipramine but I also smoke currently and it seems that may even the effect out. Treatment is for MDD, OCD, GAD, possibly PTSD. Thanks for any replies.
As bupropion works for you and clomipramine + metabolites blood levels can be measured very reliably, maybe you could cut down your dose of Wellbutrin and keep close tabs on any interactions. Maybe even quit the Wellby for a while, then cautiously and slowly reintroduce it, measuring your clomipramine blood levels to avoid toxicity.Anafranil didn't do much for me when I tried it last year, but I was on a lowish dose because my doctor has an unfounded fear of QT prolongation (I'm in my late 30s and my EKG always come out fine). Imipramine and amitriptyline were much better.
However, if your main concern is OCD, clomipramine a good med to try. If you don't respond to it, your doctor could carefully add Luvox, which is apparently the best combination available for treatment-resistant OCD (I don't know if this is due to fluvoxamine adding anything specific to the mix, or if it simply inhibits a bunch of enzymes, thus raising clomipramine levels).
As for the Abilify.. what are you taking it for? 1-5mg usually works well for MDD, but you can go up to 15mg (max dose for MDD is 15mg and 30mg for bipolar etc). Its long half like makes it a pain to deal with, as it can take a full 2 weeks to notice the effects of a dosage modification. And the dosage needs to be tweaked really often. If you need an AAP onboard, maybe you could switch to something else? Cautiously though, some of the newer AAPs are also reuptake inhibitors (eg ziprasidone)
Good luck!
poster:klein
thread:1064818
URL: http://www.dr-bob.org/babble/20140419/msgs/1064837.html