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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 48 to 72 of 98. Go back in thread:
Posted by strugglingsteve on May 19, 2006, at 17:41:35
In reply to Re: Emsam 9 mg patch, posted by gibber on May 19, 2006, at 11:26:09
I just read most of that link and where do you get the idea that no diet is needed at the higher patch strengths? What I got was they were pretty adamant about needing the diet at the higher patch strengths....
> The best information about the diet specific to EMSAM is at http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4186B2_02_01-FDA-Emsam.pdf
>
> The jist is that no special diet is required at any dosage, however the FDA is not in agreement with that and any doctor would say you need to obey the diet.
Posted by SFY on May 20, 2006, at 10:24:31
In reply to Re: Everyone PLEASE share your ENSAM updates? » sweetnlow, posted by pulse on May 19, 2006, at 15:52:57
> 6 mg.
>
> The longest I could ever apply (other than 24 hrs.,those 1st four days, i.e. attempt #1) (attempt #2 was every other day, for 24 hrs.) ....was 4 hours (1/6 of time others are handling.) Attempt 3, I may forget now, but probably 2-3-4 hrs., applied no more than 3 times (usually only twice) a day, at intervals, but WAY before bedtime, as the teeth-clenching & insomnia were as bad, if not worse, than Zoloft.
>
> Attempt #4 - the waterloo it was more than obvious I was fast approaching- was 1-2 hours (may have forgotten and left on 3 hrs once) ONCE a day!
>
> None of this was done as some kind of goofy parlor trick...it was absolutely necessary. Still, the result was that I simply couldn't handle Emsam.
>
> Now, if they'd made, say, a 2mg. patch, maybe...who knows? I'm fairly sure BMS will put no further expense into lower dosages, though.
>
> pulseIf you're looking for a lower dose, why not try oral selegiline? At doses up to 10 to 15 mg./day, there are no dietary restrictions.
Posted by Last Chance on May 20, 2006, at 12:42:11
In reply to Re: Everyone PLEASE share your ENSAM updates? » pulse, posted by SFY on May 20, 2006, at 10:24:31
I am still waiting for my patches. I have tried oral Selegeline, but only for 2 weeks - started at five and went to 10mg. It just made me agitated - maybe I should have hung in there longer - Easy to say in retrospect. Richard
Posted by pulse on May 20, 2006, at 15:23:45
In reply to Re: Everyone PLEASE share your ENSAM updates? » pulse, posted by SFY on May 20, 2006, at 10:24:31
Thank you for your suggestion of oral selegiline, but I believe my response would be the same as Last Chance's, i.e. agitation only.
MY BIG concern from get-go was: not taking ANY oral med - as it passes right through the gut.
Until this year, my main problem/ dx was always Major Depression. Of course as one p-doc said, "with MDD, who wouldn't have anxiety ...never knowing - even on meds for it - when the next episode might hit me. I personally think they go hand in hand, if you have MDD, in nearly everyone, especially the more depressed you become. Now that I've thought of this, I must REALLY wonder how they found enough people with ONLY MDD for all their studies. I'm skeptical in a big way re: this.
End of last year, I went through 2 very traumatic events within 2 weeks of each other. My best guess is that this is why I'm still having so much more anxiety than ever before - PTSD commonly hitting within weeks to months AFTER events of this kind.
Having to go back on Zelnorm for constipation due entirely to Emsam, perhaps, after my washout is complete, I will be able to again tolerate Prozac (?).
Quitting the patch has made my tummy immediately MUCH better.BTW, I recently found out that some people get sick from the gelatin in capsules. Then, I found out that, unfortunately, brand name Prozac has stopped making their 10 mg. tablet. I can still get the generic in 10 mg. tablets. There is no other option left for me; I've tried all other ADs, in all classes (except Nardil, and I'm not willing to), and many, many combos. (I also can't tolerate ANY mood stabilizer GI-wise, for any additional help toward full remission).
pulse
Posted by Phillipa on May 20, 2006, at 18:55:44
In reply to Re: Everyone PLEASE share your ENSAM updates? » SFY, posted by pulse on May 20, 2006, at 15:23:45
Well what if the episode never ends it's been l0years for me. What started out as panic attacks has bencome MDD with agoraphobia , panic, fear of even my kids(grown) And going anywhere alone and being alone. What do I do take? Love Phillipa
Posted by pulse on May 20, 2006, at 23:39:23
In reply to Re: Everyone PLEASE share your ENSAM updates? » pulse, posted by Phillipa on May 20, 2006, at 18:55:44
My history seems quite different from yours, and I'm not that familiar with your story, as I only pop in here from time to time.
So, I wouldn't presume to tell you what to take.
Regards,
pulse
Posted by Jost on May 21, 2006, at 14:11:16
In reply to Re: Emsam 9 mg patch » strugglingsteve, posted by SFY on May 17, 2006, at 12:37:50
The Emsam package insert proscribes the following for those on the 9mg/24 hours. (This list is the full list, directly copied):
1. Meat, poultry, fish
- air dried, aged and fermented meats, sausages and salamis
- pickled herring
-any spoiled or improperly stored meat, poultry and fish. These are foods that have a change in color, odor, or become moldy.
-spoiled or improperly stored animal livers2. Vegetables
- broad bean pods (fava bean pods)
3. Dairy (milk products)
-aged cheeses
4. Drinks
-all tap beers and other beers that have not been pasteurized
5. Other
-concentrated yeast extract (such as Marmite)
-sauerkraut
-most soybean products (including soy sauce and tofu)
-over-the-counter supplements containing tyramineWill post acceptable foods in separate message. This will especially include drinks and cheeses that are acceptable.
Jost
Posted by Jost on May 21, 2006, at 14:19:42
In reply to Re: Emsam 9 mg patch--foods to be avoided, posted by Jost on May 21, 2006, at 14:11:16
This is the list from the Emsam package insert of acceptable foods, containing little or no tyramine, for those taking 9 mg and 12 mg/24 hours.
1 Meat, Poultry, Fish
-Fresh meat, poultry and fish, including fresh processed meats (such as lunch meats, hot dogs, breakfast sausage and cooked sliced ham)
2. Vegetables
-All other vegetables (except broad beans--see other list)
3. Dairy
-Processed cheeses, mozarella, ricotta cheese, cottage cheese, and yogurt
4. Drinks
-As with other antidepressants, concomitant use of alcohol with Emsam is not recommended. (Bottled and canned beers and wines contain little or no tyramine.)
5. Other
-Brewer's yeast, baker's yeast
-Soy milk
-Pizzas from commercial chain restaurants prepared with cheeses low in tyramine(Note: the unacceptable list applied also to those on 12 mg, of course.)
Jost
Posted by ZeitGuest on May 21, 2006, at 20:12:05
In reply to Re: Everyone PLEASE share your ENSAM updates? (nm), posted by zero on May 17, 2006, at 10:23:10
Day 17 on EMSAM.
So far, no beneficial effects yet.
As for negative effects, just one: I have had a noticeable increase in irritability, which may be my version of anxiety. Little things seem to be irritating me more than usual.
I've always had a proclivity for crankiness. When I was on Prozac (for ten years or so, give or take a few months off here and there in an effort to try new meds), the crankiness/nervousness was definitely mitigated. (I think I'm mildly afflicted by OCD, and pre-poopout Prozac completely irradicated that symptom.) But on EMSAM I've been feeling much more irritable than usual, and feeling more aggravated by mundane frustrations. Not sure if EMSAM itself is causing this, or if the patch (6mg) is just not working and I'm now steeping in my "natural state."
I definitely haven't felt motivated, energized or more sociable, as some on this site have. I was hoping that EMSAM would help me with my social anxiety and mild depression.
I'm wondering if some of the earlier "early adopters" on this site are still experiencing beneficial effects from EMSAM with regard to social anxiety. I believe RobertDavid commented on that effect early in his trial. So, RobertDavid, are you still feeling more socially engaged/motivated on EMSAM?
Posted by lymom3 on May 21, 2006, at 20:47:30
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by ZeitGuest on May 21, 2006, at 20:12:05
I am crankier too. Some days I think it's getting better, some days I'm not so sure. I know that over doing caffeine has a bad effect...become excessively tired.
I do feel other benefits and I'm on week 3, so I'm going to stick with it...might evaluate adding a med to help with that in a week or two.
Posted by ZeitGuest on May 21, 2006, at 21:43:33
In reply to Re: Everyone PLEASE share your EMSAM updates? » ZeitGuest, posted by lymom3 on May 21, 2006, at 20:47:30
> I am crankier too. Some days I think it's getting better, some days I'm not so sure. I know that over doing caffeine has a bad effect...become excessively tired.
> I do feel other benefits and I'm on week 3, so I'm going to stick with it...might evaluate adding a med to help with that in a week or two.lymom3:
What other benefits are you feeling?
Posted by RobertDavid on May 21, 2006, at 21:57:36
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by ZeitGuest on May 21, 2006, at 20:12:05
> I'm wondering if some of the earlier "early adopters" on this site are still experiencing beneficial effects from EMSAM with regard to social anxiety. I believe RobertDavid commented on that effect early in his trial. So, RobertDavid, are you still feeling more socially engaged/motivated on EMSAM?
He's pretty much everything I have experienced since going on EMSAM 6 weeks ago:Quick response to mental clarity in particular. That contiues for me, I'm just sharper, have better consentration and my energy remains high. Over the last 2 weeks it's been pretty much the same, most came within 4 weeks for me.
When I first started EMSAM I dreamed a lot, though I am not dreaming quite as much as in the beginning, I'm still dreaming more than before. Initially I wasn't sleeping as many hours, but I woke up with more energy. I still have more energy, pehaps not quite the amount I felt in the beginning.
I've always dealt with insomnia. I'm still not sleeping like I want to and am working on ways to improve it. EMSAM overall isn't a medicine I'd suggest will help people sleep should they have insomnia. My doctor and I looked at some options like adding 12.5 mgs seroquel. I did sleep, but I was zonked the next day and seroquel brought back the foggy headed feeling I got rid of with EMSAM. Lunesta helps some on occation. A few nights I took the patch off at bedtime and did sleep a little better, but then after putting the patch back on in the morning it would take till about noon to get the energy I like.
Since I do not deal with major depression (SAD & GAD primary disorters) I suspect that an even smaller dose of EMSAM, say a 10 or 15mg patch would be ideal. I get more than enough of what I'm looking for with the 20 mgs, it's really good, but perhaps a smaller dose would still be enough, but help with sleeping, not sure.
I have written to Dr. Alexander Botkin who I understand was one of the leading reaserchers in the EMSAM studies to discuss the issues with cutting the patch in half, to find out if it leaks selegiline as some have suggested, to find out if there would be an uneven dose by cutting the patch in half or to just see if the drug companies don't want people to cut patches to save money such as someone getting a 40mg patch, cutting it in half to make a two 20mg patchs to save money (which I suspect, not sure). It also seems to me that there were smaller patch doses in the original study and wonder if there are plans to release one, maybe for Parkinsons patients who only need a small dose. It's just something I'm looking into as I'm a firm believer in playing with dose till you find the right med(s) at the right doses.
I do feel EMSAM is stimulating, but that's what I wanted to lift me from my mental fog, mild depression that perhaps klonopin aggrivated, not sure, but klonopin certainly tackles my social and generalized anxiety. Other stimulants I have tried were just to stimulating (even provigil) and made me more anxious in the long run. With EMSAM I seem to get the energy and mood boost without the anxiety, I'd just like to find a way to sleep better. When I sleep good, I feel my best.
I did notice that when I added EMSAM to the 2mgs of klonopin (taking for 12 years) I was more social. It might have been do to the fact that I have more energy which makes me more social and since I take klonopin I can't really say how much EMSAM specifically has improved my social anxiety or what it would have been like for me if I wasn't takingn klonopin. I can say I get around more, do more things, feel better.
What I have learned is that for me, caffeine does not go well with EMSAM. I have never been a big coffee drinker as it has increased my anxiety before, but now I get jacked up quick, real quick and come crashing down. I have wasted a couple of days after drinking coffee and have sworn it off.
In my quest to try to find the right dose for me, I've lowered down on klonopin from 2 mgs to 1.5. That has caused some issues (during the tapering) that is normal for me to feel when lowering klonopin dose (increased insmonia for several days, slight increase in anxiety for a week along with being irritable). I'm going to stay at the 1.5 dose for a while and see how I feel. I felt so good so fast I probably jumped to gun to try to conclude if EMSAM will be effective without klonopin.
So I'm better, much better overall. I have no doubt I'm on the best med I've ever tried for mild depression, energy, mental clarity. I would like to see how effective a smaller dose of EMSAM would be for me, but not sure if that's possible, but am looking into it.
I know I'm doing well as I'm no longer focusing on other meds I once considered trying. I'm just focusing on the dose these two meds. The answer for me is probably a long term klonopin/EMSAM combo. At some point I'm going to settle on dose and go on with my life until the next potential breakthrough that may come out to be a better solution.
In my opinion EMSAM is something that should give many hope, another option, it will work for some, not all. As I've always said it's just trial and error with this meds. Rob
Posted by RobertDavid on May 22, 2006, at 0:13:34
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by RobertDavid on May 21, 2006, at 21:57:36
In a follow up to my above post I just recieved an email from Dr. Alexander J. Bodkin, MD, an EMSAM reasercher involved in the studies.
Anyway, I specifically asked him if the patch could be cut in half and if so what effects cutting it might have such as selegiline leaking, uneven dose delivery or other possible issues. The following was his response:
"No harm in carefully cutting them in half. Wash you hands afterward. Nothing will ooze out. Many lab animals got their EmSam that way over the years. If its good enough for lab animals its good enough for people. Lab scientists are very careful about dosage precision.
Good luck to you."Interesting. May give some options to those trying to fine tune their dose. FYI Rob
Posted by strugglingsteve on May 22, 2006, at 0:24:58
In reply to Re: Emsam 9 mg patch--acceptable foods, posted by Jost on May 21, 2006, at 14:19:42
As far as cheese goes, does that include fresh whole milk mozzarella or just the processed kind from dominoes? As to lunch meat, what about bologna??
> This is the list from the Emsam package insert of acceptable foods, containing little or no tyramine, for those taking 9 mg and 12 mg/24 hours.
>
> 1 Meat, Poultry, Fish
>
> -Fresh meat, poultry and fish, including fresh processed meats (such as lunch meats, hot dogs, breakfast sausage and cooked sliced ham)
>
> 2. Vegetables
>
> -All other vegetables (except broad beans--see other list)
>
> 3. Dairy
>
> -Processed cheeses, mozarella, ricotta cheese, cottage cheese, and yogurt
>
> 4. Drinks
>
> -As with other antidepressants, concomitant use of alcohol with Emsam is not recommended. (Bottled and canned beers and wines contain little or no tyramine.)
>
> 5. Other
>
> -Brewer's yeast, baker's yeast
> -Soy milk
> -Pizzas from commercial chain restaurants prepared with cheeses low in tyramine
>
> (Note: the unacceptable list applied also to those on 12 mg, of course.)
>
> Jost
Posted by ZeitGuest on May 22, 2006, at 0:27:56
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by RobertDavid on May 21, 2006, at 21:57:36
Thanks for the update, Rob.
One thing I find confusing about the EMSAM literature is the dosing specs. On my box it says, "20mg (6mg/24 hours)." Does that mean that each patch contains 20mg of selegiline, but only 6mg of that total gets metabolized by one's system in a 24-hour period?
Posted by ZeitGuest on May 22, 2006, at 0:31:49
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by ZeitGuest on May 22, 2006, at 0:27:56
Does anyone know at what dosing level EMSAM begins to inhibit MAO-A?
Posted by strugglingsteve on May 22, 2006, at 0:33:50
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by RobertDavid on May 22, 2006, at 0:13:34
I am well into my 6th week on emsam, about 4 days into being on the 9 mg patch. I am seeing some improvement in my agitation level and I am not quite as depressed as I was a couple days ago. I am still really depressed but any little improvement I will take. The bigger patch is more noticable and I miss the 6 mg patch cause I never even felt it at all when I was on it. I take zyprexa too and that is why I get sleep for I have a feeling the emsam is making it more difficult for me to sleep. My libido is still non existant and I am hoping emsam doesnt have anything to do with it. I was almost normal sexually the first two weeks on emsam but then it went down thereafter so I am hoping its the illness and not the med on that one since the trials had almost no sexual side effect problems.
Posted by RobertDavid on May 22, 2006, at 0:44:54
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by strugglingsteve on May 22, 2006, at 0:33:50
Studies would suggest it shouldn't have a negative effect on sex drive. Here is a quote from one article:
The sexual dysfunction rate with Emsam was similar to that with placebo, and mean weight change from baseline was "minimal."
Posted by RobertDavid on May 22, 2006, at 0:45:56
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by ZeitGuest on May 22, 2006, at 0:27:56
> Thanks for the update, Rob.
>
> One thing I find confusing about the EMSAM literature is the dosing specs. On my box it says, "20mg (6mg/24 hours)." Does that mean that each patch contains 20mg of selegiline, but only 6mg of that total gets metabolized by one's system in a 24-hour period?That's what I understand from my research on it.
Posted by ttee on May 22, 2006, at 16:31:22
In reply to Re: Everyone PLEASE share your EMSAM updates?, posted by RobertDavid on May 22, 2006, at 0:13:34
What I want to know is how did they shave those poor animals to get the EmSam patch on them? They must have made some Tinie Tiny patches for the test vermin.
Posted by laima on July 22, 2006, at 10:12:03
In reply to Re: Everyone PLEASE share your EMSAM updates? » ZeitGuest, posted by RobertDavid on May 22, 2006, at 0:45:56
I too am utterly confused. My doctor just attended an "EMSAM conference" with other psychiatrists and researchers from the drug company. Part of the info that came out of this is that there is mass confusion about what the doses mean! Also that the 6 is considered too low of a dose to help many, many people. I am moving up from the 6 to the 9- which I hear is far more potent than the 6. The 9, per doctor's report of what the company reps explained, is roughly 60-90mg oral selegeline. That sounds like a lot! I don't get it.
> > One thing I find confusing about the EMSAM literature is the dosing specs. On my box it says, "20mg (6mg/24 hours)." Does that mean that each patch contains 20mg of selegiline, but only 6mg of that total gets metabolized by one's system in a 24-hour period?
>
> That's what I understand from my research on it.
Posted by RobertDavid on July 22, 2006, at 11:39:23
In reply to Re: Everyone PLEASE share your EMSAM updates » RobertDavid, posted by laima on July 22, 2006, at 10:12:03
I think like all medications, EMSAM will be perscribed at different doses as everyones chemistry is different. I believe those with Major Depression Disorter will need higher doses and have the best chance of taking EMSAM as mono therapy (though many will still need to augment it with something for insomnia and agitation).
Some like me who have Social and or Generalized Anxiety disorters may find that EMSAM helps with a milder form of depression, lack of energy and mental fogg that can go with these disorters, but will most likely need other meds to tackle the anxiety such as klonopin. I consider EMSAM to be just an addition to klonopin. For me, klonopin is the SAD and GAD stopper.
I don't think you can really compare oral vs the patch. I'm not the scientist type and perhaps others can answer this better, but it's my understanding that the patch works differently, has different effects and side effects, has a 24 hour stream of medication instead of a very short half live via oral dosing.
But certainly the higher the patch dose, the more selegiline will be in your blood levels which will have a bigger effect on MAO-A which can further kick in the anti depressant benefits and perhaps anti anxiety benefits.
One of the things that has helped me the most is doing daily cardio (treadmill). Before EMSAM I just didn't feel like working out, no energy to do it. I have to say regular exersize is probably the best medicine I'm taking. It's certainly common knowledge that it helps your endorphins/neurotransmitters. Just my take. Rob
Posted by Jost on July 22, 2006, at 17:43:25
In reply to Re: Everyone PLEASE share your EMSAM updates » laima, posted by RobertDavid on July 22, 2006, at 11:39:23
Has anyone had any recommendations for agitation and insomnia?
I've been taking about 9 mg/day for a while, but in the form of 18mg/ 12 hr, then 12 hrs off, on recommendation of pdoc.
I've been thinking that I've experienced a lot of agitation for about a week-ten days.
I don't quite remember when I started with various levels of the drug. I got the 12 mg patch on Jun 27, but it was sometime after that that I started being agitated-- say Jul 12-13.
Earlier my problem was mostly insomnia. Now I have better sleep,but more agitation. So the larger dose for a shorter time is too much.
Hm. I cut down some yesterday, and more today but maybe it also takes more time for the agitation to lessen.
Anyone have any specific ideas about the agitation?
I'm also not going to keep up with seroquel, I get a bad reaction, some tic type stuff, very minor, but enough to be too worrisome. So I have to rely on other things for sleep-- which I'm a bit concerned about. What has anyone used for that, other than seroquel?
But more concerned about the agitation, if it does continue. I'm sure I need more than 6 mg/24hr.
By the way, I'm sure cutting the patches in half is okay, also. My pdoc is very careful and said it's fine.
If you fold the package carefully, and line up the small knicks in the sides, they're very easy to cut in half. Of course, only one half has the fold, where it's easier to apply. But it's easy to manage.
Jost
Posted by laima on July 22, 2006, at 18:34:26
In reply to Re: Everyone PLEASE share your EMSAM updates » RobertDavid, posted by Jost on July 22, 2006, at 17:43:25
Thanks for the cutting-patches report. I never asked my doctor about it- thought of it after my apointment.
I haven't experienced the agitation, can't comment. Hopefully someone else will.
> Has anyone had any recommendations for agitation and insomnia?
>
> I've been taking about 9 mg/day for a while, but in the form of 18mg/ 12 hr, then 12 hrs off, on recommendation of pdoc.
>
> I've been thinking that I've experienced a lot of agitation for about a week-ten days.
>
> I don't quite remember when I started with various levels of the drug. I got the 12 mg patch on Jun 27, but it was sometime after that that I started being agitated-- say Jul 12-13.
>
> Earlier my problem was mostly insomnia. Now I have better sleep,but more agitation. So the larger dose for a shorter time is too much.
>
> Hm. I cut down some yesterday, and more today but maybe it also takes more time for the agitation to lessen.
>
> Anyone have any specific ideas about the agitation?
>
> I'm also not going to keep up with seroquel, I get a bad reaction, some tic type stuff, very minor, but enough to be too worrisome. So I have to rely on other things for sleep-- which I'm a bit concerned about. What has anyone used for that, other than seroquel?
>
> But more concerned about the agitation, if it does continue. I'm sure I need more than 6 mg/24hr.
>
> By the way, I'm sure cutting the patches in half is okay, also. My pdoc is very careful and said it's fine.
>
> If you fold the package carefully, and line up the small knicks in the sides, they're very easy to cut in half. Of course, only one half has the fold, where it's easier to apply. But it's easy to manage.
>
> Jost
>
>
Posted by Last Chance on July 24, 2006, at 14:20:08
In reply to Re: Everyone PLEASE share your EMSAM updates » Jost, posted by laima on July 22, 2006, at 18:34:26
Hello - I am still doing half a 6mg patch and only leaving it on during the day - much less agitation this way - sleep is ok, but still not long, only 5 or 6 hrs. Strong cup of coffee in the morning and one in the afternoon - .25 klonapin in morning and evening - and I have been taking .25 Xanax under my tongue when I will be heading to some kind of social situation. So this is working pretty good - general depression and anxiety are definitely better, with the occasional exception. So that's my regimen now - oh, I do not have as much motivation and evergy as I did on a higher dose, but as hot as it has been lately that is probably a good thing. Richard
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