Re: Parnate (long) » Bob

> > > My current regimen is getting slowly more complex. I currently take the following:
> > >
> > > Nortriptyline 200mg (75mg 2x per day and 50mg at bedtime)

> > For most people, this is too much. If you haven't already checked your blood level, you can do that and get a good idea if a dosage adjustment is necessary. The reason I mention this is because nortriptyline has a very real therapeutic window. More is not better. If the dosage of nortriptyline is too high, it stops working.

> Yes, I've had my blood levels taken many times. The recent few times have been between 130 and 147 mcg/L.

Those are ideal numbers. You are likely a rapid metabolizer of CYP450 2D6. Be careful when adding Prozac, Paxil, or Wellbutrin. These drugs will cause the blood level of nortriptyline to rise sharply.

> > Have you ever tried desipramine? I am doing better on desipramine than I had been doing on nortriptyline. I find that it gives me more mental energy. I get more things done. I take 300 mg/day. I am optimistic that I will respond more robustly to desipramine than to nortriptyline. Stay tuned...

> I have not tried desipramine and would not rule it out. My doctor seems to think it is a harsher med in his experience.

It is - at first. Perhaps being harsher on the brain is a good thing in your case. Back in the old days, it was recognized that someone who responds to desipramine might not respond to nortriptyline, and vice versa.

> > > Brintellix 10mg (5mg 2x per day)

> > I have no personal experience with this drug, and have not seen enough anecdotes to have an opinion. I have had experience with Viibryd, and have a doctor who has used it quite a bit. I would recommend talking to your doctor about it. Compared to Britellix, Viibryd is a more potent serotonin reuptake inhibitor. Viibryd is also a 5-HT1a partial agonist (like aripiprazole and buspirone), while Brintellix is a full agonist. I don't know for sure what the significance of this is, but my guess is that a partial agonist would act more like a stabilizer of serotonin activity.

> Yes, it's difficult to say exactly what the advantages of partial over full agonists may be. I wasn't really aware Viibryd was a potent partial agonist. Seems worth considering for sure. When you say you have experience with it does that mean you've taken it yourself

Yes. I found it to be remarkably clean with respect to side effects. I responded to it in the third week. Unfortunately by the fifth week, I lost it. I find it meaningful when a drug can budge my brain at all.

> > I would explore higher dosages. For me, the sweet-spot is 10 mg/day. I lose the antdepressant effect at 5 mg/day. However, my depression is of an unusual type of bipolar disorder.

> God knows my depression is of an unusual type. How did you arrive at 10mg being your sweet spot? Did you ever take it at higher levels?

I started Abilify at 20 mg/day. It helped. It still does. However, I found that at 20 mg/day, I had a mild-to-moderate amount of blunting of cognition and affect, along with some brain fog. Eventually, I reduced the dosage as an experiment and found that these side effects disappeared. 10 mg/day worked. 5 mg/day did not.

> > > Lithium 112.5mg at bedtime
> >
> > Why not 300 mg/day (150 mg x 2)?
>
> I'm taking the Eskalith CR 450mg pill. I could divide that in half for 225mg however it seems to slow me down at higher doses. I just take a quarter so that I have "trace" amounts of lithium present. Probably not doing much buy I'm taking it nonetheless.

The folks at Harvard / Massachusetts General found that low dosage lithium was represented by a dosage range of 300-600 mg/day, with the average effective dosage being 450 mg/day. For me, 450 mg/day is too much. I experience apathy, flat affect, passivity, and an overall worsening of depression. I've experimented with lower dosages and found that I felt better at 300 mg/day.

> > Does it help depression? What about thyroxine T4?

> Like anything else I've taken I got a real nice boost as an adjunct to my ADs and then that eventually faded somewhat -- still the T3 seems to help a little. My doctor and the literature seem to concentrate on T3 more than T4.

T3 has been the thyroid hormone most studied, primarily because it was chosen first to be investigated. I think the choice was mostly arbitrary. Personally, my depression is severely exacerbated by T3 (Cytomel). T4 was a completely different drug for me. It helped - just not enough. You might want to get your TSH checked and make sure that it is below 2.0 mIU/L.

> > > Pramipexole .375mg (.125mg 3x per day)

> > I'm not a big fan of full agonists of dopamine receptors. They usually don't help that much or for that long. I have seen two exceptions, though.

> I realize that pramipexole might not be the best approach but I'm running out of options and suffer with significant anhedonia even on all these meds.

Anhedonia has been problematic for me, too. I found SNRIs to be better than SSRIs to treat this. I also found Nardil to be better for anhedonia than Parnate. I stay with Parnate because, when added to TCA, it is more forgiving with respect to the side effects of hypotension, hyperhidrosis, and urinary retention.

> > I try not to leave any stone unturned.

> I too would like to leave no stone unturned but it is quite difficult to transition on and off medicines.

The logical move might be to switch from nortriptyline to desipramine now and leave everything else in place. I would suggest titrating to a target of 200 mg/day. More severe cases indicate increasing the dosage to 300 mg/day. You don't need a washout period. I don't necessarily suggest this, but I have switched by skipping a day of nortriptyline and starting desipramine the next morning at 50 mg/day.

Some see things as they are and ask why.
I dream of things that never were and ask why not.

- George Bernard Shaw

Re: Parnate (long) » Bob

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