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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 29. This is the beginning of the thread.
Posted by former poster on November 13, 2015, at 18:32:49
Emsam 6mg q.d.
Fluvoxamine 75mg. b.i.d.
Clonazepam 1mg b.i.d.Comments appreciated.
Posted by Christ_empowered on November 13, 2015, at 19:45:10
In reply to My new cocktail, posted by former poster on November 13, 2015, at 18:32:49
I didn't know you could mix Emsam and Luvox like that. That's crazy. How do you feel?
The Klonopin dose is fairly standard I think. Only thing I could think of...be careful when/if you decide to taper. Speaking from personal experience...try switching to valium or something first, and then taper off that.
Good luck!
Posted by SLS on November 13, 2015, at 20:37:51
In reply to My new cocktail, posted by former poster on November 13, 2015, at 18:32:49
> Emsam 6mg q.d.
> Fluvoxamine 75mg. b.i.d.
> Clonazepam 1mg b.i.d.
>
> Comments appreciated.I can't believe your doctor has you taking Emsam and fluvoxamine ocncurrently. He is either the smartest doctor or the dumbest. Either he is very sure that the 6 mg/24 of Emsam is safe while higher dosages are not, or else you are taking an incredibly dangerous combination. There are few more dangerous combinations of psychotropics than adding a serotonin reuptake inhibitor to a MAOI. Emsam is not specific for MAO-B, it is only selective. It loses its selectivity at higher dosages.
You should become familiar with the symptoms of serotonin syndrome. If you develop any of them, you should immediately stop both drugs, not just one, and contact your doctor.
Please refer to several sources of symptom descriptions. Most are not complete.
You really should have someone watch you, as you might become incoherent and incapacitated early during an acute reaction. Monitoring your body temperature for elevation is a good idea. Many fatalities are due to hyperpyrexia.
I imagine it is possible that your doctor has taken this all into consideration. I can't really know. If he knows what he's doing, I apologize for alarming you.
Please see the end of this post.
--------------------------------------------
Here's one list of symptoms of serotonin syndrome:
Mental status changes
Confusion; incoherence (51%)
Agitation (34%)
Hypomania (21%)
Anxiety (15%)
Coma (29%)Cardiovascular
Sinus tachycardia (36%)
Hypertension (35%)
Hypotension (15%)Gastrointestinal
Nausea (23%)
Diarrhea (8%)
Abdominal pain (4%)
Salivation (2%)Motor Abnormalities
Myoclonus (58%)
Hyperreflexia (52%)
Muscle rigidity (51%)
Restlessness (48%)
Tremor (43%)
Ataxia/incoordination (40%)
Shivering (26%)
Nystagmus (15%)
Seizures (12%)Other
Diaphoresis (45%)
Unreactive pupils (20%)
Tachypnea (26%)
Hyperpyrexia (45%)--------------------------------------------
"Who should not use EMSAM?
Using EMSAM with certain antidepressants and certain pain, cold and cough symptom medicines may cause a potentially life-threatening problem called serotonin syndrome (See What are the possible side effects of EMSAM?).
Do not use EMSAM if you:
take certain medicines including: selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, or paroxetine; serotonin and norepinephrine reuptake inhibitors (SNRI) such as venlafaxine or duloxetine; clomipramine or imipramine... "
--------------------------------------------
Be careful.
- Scott
Posted by Horse on November 14, 2015, at 0:00:00
In reply to My new cocktail, posted by former poster on November 13, 2015, at 18:32:49
I admit I inhaled sharply when I saw your combo. So, tell us what your doctor advised.
I always wish you the best...let us know how you do.
Posted by former poster on November 14, 2015, at 0:29:07
In reply to Re: My new cocktail » former poster, posted by Horse on November 14, 2015, at 0:00:00
I was concerned too but my pharmacist said the combination was safe.
I was under the impression Emsam affected dopamine and norepinephrine at the 6mg dose with serotonin kicking in at 9mg and above doses. Can someone correct me on this?
Posted by SLS on November 14, 2015, at 6:27:50
In reply to Re: My new cocktail » Horse, posted by former poster on November 14, 2015, at 0:29:07
Did you read the link I posted? It also contains the following:
"Pharmacodynamics
MAO exists as two isoenzymes, referred to as MAO-A and MAO-B. Selegiline has a greater affinity for MAO-B, compared to MAO-A. However, at antidepressant doses, selegiline inhibits both isoenzymes. In an in vivo animal model used to test for antidepressant activity (Forced Swim Test), selegiline administered by transdermal system exhibited antidepressant properties only at doses that inhibited both MAO-A and MAO-B activity in the brain. In the CNS, MAO-A and MAO-B play important roles in the catabolism of neurotransmitter amines such as norepinephrine, dopamine, and serotonin, as well as neuromodulators such as phenylethylamine."
Central serotonin syndrome is not the same as the peripheral tyramine reaction, and I am dubious that they are mutually inclusive. Ask this same pharmacist if the safety of Emsam extends to higher dosages. If it were me, I would want a detailed explanation as to why the combination of Emsam with a serotonin reuptake inhibitor is safe when the drug company clearly states otherwise.
MAO-inhibitors do not work for depression unless MAO-A is inhibited in the brain. Even pargyline is ineffective until dosages that inhibit MAO-A are reached. The irreversible inhibitor specific for MAO-A, clorgyline, does not inhibit MAO-B at all at any dosage. It is perhaps the most clinically effective antidepressant in the world. This was the position of the NIH in 1993. Since it became unavailable shortly thereafter, further study in humans became impossible. There was some concern regarding cardiac side effects. Valvulopathy, maybe? They didn't tell me.
- Scott
Posted by Former poster on November 14, 2015, at 9:58:51
In reply to Re: My new cocktail » former poster, posted by SLS on November 14, 2015, at 6:27:50
Thanks for the link Scott. The list of interactions seem a bit overdone. Typical of corporations. Do Drs and patients follow these lists 100%? Still I'm starting to question my Dr and pharmacists expertise. Are pharmacists this unreliable? Aren't interactions supposed to be their specialty?
What should I do now? Could bupropion be a safer and effective substitute for Emsam?
Posted by Christ_empowered on November 14, 2015, at 11:03:58
In reply to Re: My new cocktail » SLS, posted by Former poster on November 14, 2015, at 9:58:51
yeah...pretty much, I'd stop taking an SSRI w/ an MAOI. I think that's what we're all thinking. Bupropion is not only cheaper, it'll be far, far safer and may even be very effective. You could also try Provigil, Ritalin.
If you really like EMSAM, maybe you could add a TCA? I seem to recall reading that some docs would do that, back in the day. Like I wrote above, I think some stimulants can go OK w/ MAOIs, like a low dose amphetamine or something.
I thought your doc had some secret knowledge I didn't. Now, I'm kind of scared for you. What's with your pharmacist? I think a lot of healthcare pros these days just go along with what the doc ordered, even when its clearly not OK.
I hope everything works out for you.
Posted by SLS on November 14, 2015, at 12:59:28
In reply to Re: My new cocktail » SLS, posted by Former poster on November 14, 2015, at 9:58:51
I agree with everything C_E had to say.
It occurs to me that it would be more logical to explore higher dosages of Emsam before adding things to it. If you are going to add a TCA to Emsam, you should avoid imipramine and clomipramine, as they are too serotonergic. Desipramine and nortriptyline are the best choices.
- Scott
Posted by linkadge on November 14, 2015, at 15:05:05
In reply to Re: My new cocktail » Former poster, posted by SLS on November 14, 2015, at 12:59:28
There are many case reports of the safe combination of an SSRI and selegiline for Parkinson's.
I would take the two cautiously but not automatically assume there is a significant concern.
Linkadge
Posted by SLS on November 14, 2015, at 16:50:00
In reply to Re: My new cocktail, posted by linkadge on November 14, 2015, at 15:05:05
> There are many case reports of the safe combination of an SSRI and selegiline for Parkinson's.
>
> I would take the two cautiously but not automatically assume there is a significant concern.
>
> LinkadgeI believe the dosages of oral selegiline taken for Parkinson's results in blood levels that are low enough to yield MAO-B inhibition exclusively. Oral selegiline is almost entirely metabolized in the the liver during fast-pass. In other words, oral selegiline does not affect serotonin metabolism.
- Scott
Posted by SLS on November 14, 2015, at 19:07:03
In reply to Re: My new cocktail » linkadge, posted by SLS on November 14, 2015, at 16:50:00
> Oral selegiline is almost entirely metabolized in the the liver during fast-pass.
Sorry. That should be "first-pass".
Selegiline is the name currently used for the drug L-deprenyl. Immediately after ingestion, L-deprenyl is metabolized (first-pass metabolism) extensively in the liver to the inactive L-isomers of amphetamine and methamphetamine.
- Scott
Posted by Phillipa on November 14, 2015, at 21:32:07
In reply to Re: My new cocktail, posted by SLS on November 14, 2015, at 19:07:03
Consult 2 other pharmacists first. And why are these the meds your doctor selected. Just curious Phillipa
Posted by former poster on November 15, 2015, at 7:31:16
In reply to Re: My new cocktail, posted by Phillipa on November 14, 2015, at 21:32:07
I thought 10mg oral Selegiline is equal to 6mg Emsam? At these doses only MAO-B is affected having little effect on Serotonin. I thought transdermal only reduced side effects compared to oral?
Before SSRI's were available I could only tolerate 10mg/day of Desipramine. TCA's never helped me but combining them with MAOI may be different. I shall call a couple different pharmacies today and get their opinion. Usually they are reluctant to give if you don't have a prescription filled with them.
Posted by SLS on November 15, 2015, at 8:46:30
In reply to Re: My new cocktail » Phillipa, posted by former poster on November 15, 2015, at 7:31:16
> I thought 10mg oral Selegiline is equal to 6mg Emsam? At these doses only MAO-B is affected having little effect on Serotonin. I thought transdermal only reduced side effects compared to oral?
> Before SSRI's were available I could only tolerate 10mg/day of Desipramine. TCA's never helped me but combining them with MAOI may be different. I shall call a couple different pharmacies today and get their opinion. Usually they are reluctant to give if you don't have a prescription filled with them.You have been presented with facts, opinions, and citations. Consider your sources. Use Google and Medline/Pubmed yourself to verify them.
- Scott
Posted by Phillipa on November 15, 2015, at 9:41:49
In reply to Re: My new cocktail » Phillipa, posted by former poster on November 15, 2015, at 7:31:16
I haven't found this at all. I show up in person and ask in person. Phase it " I have question I am looking for a new pharmacy. I also have a RX from my doctor for xxx. Is this a safe combination of med? I was told it wasn't. Would you mind checking for me? I so appreciate your knowledge." That is just me. I had one RX once tell me that a pain med for some surgery was considering was not safe with the even small dose of SSRI I am on. In this instance I cancelled the surgery. I figured if the doc didn't know his meds. How could I trust him otherwise? Just my experience. Phillipa
Posted by former poster on November 15, 2015, at 12:04:39
In reply to Re: My new cocktail » former poster, posted by Phillipa on November 15, 2015, at 9:41:49
I called another pharmacy and they confirmed serotonin syndrome. Good advice! Thanks. Never trust a pharmacist, or doc.
This is good really because I'm tired of paying a high price for Emsam.
In the past I did ask to have Emsam increased but the doc said no. I think he has maoi-phobia. Maybe I'll recommend a good SSRI for him to take?
Posted by Christ_empowered on November 15, 2015, at 12:14:57
In reply to Re: My new cocktail » Phillipa, posted by former poster on November 15, 2015, at 12:04:39
can you get a new doc? Now that I think about...a pdoc who makes that sort of an error...well, that's not OK. That's your life.
Posted by linkadge on November 15, 2015, at 12:20:10
In reply to Re: My new cocktail, posted by Christ_empowered on November 15, 2015, at 12:14:57
I wouldn't assume it was an error.
I take the herb fo-ti (mao-b inhibitor) with venlafaxine, and the combination works very well.
Since selegiline is selective towards mao-b, I think a lower dose would likely not cause a problem.
Linkadge
Posted by SLS on November 15, 2015, at 15:48:48
In reply to My new cocktail, posted by former poster on November 13, 2015, at 18:32:49
I guess I wasted my breath.
- Scott
Posted by former poster on November 15, 2015, at 15:55:51
In reply to Re: My new cocktail, posted by linkadge on November 15, 2015, at 12:20:10
>>Serotonin syndrome:
Mental status changes
Confusion; incoherence (51%)
Agitation (34%)
Hypomania (21%)
Anxiety (15%)
Coma (29%)Cardiovascular
Sinus tachycardia (36%)
Hypertension (35%)
Hypotension (15%)Gastrointestinal
Nausea (23%)
Diarrhea (8%)
Abdominal pain (4%)
Salivation (2%)Motor Abnormalities
Myoclonus (58%)
Hyperreflexia (52%)
Muscle rigidity (51%)
Restlessness (48%)
Tremor (43%)
Ataxia/incoordination (40%)
Shivering (26%)
Nystagmus (15%)
Seizures (12%)Other
Diaphoresis (45%)
Unreactive pupils (20%)
Tachypnea (26%)
Hyperpyrexia (45%)Good point Linkadge and I'd like to point out that a lot of us are taking MAOI's daily unknowingly in their diet or in supplement form.
Not to discredit you SLS, I greatly appreciate your advice, but I get almost half of these symptoms daily while taking one SSRI alone.
Getting a new Pdoc would be next to impossible at this time.
I decided to not take the combo for now. Just curious however if Cyproheptadine is the best treatment for serotonin syndrome when not able to reach a hospital?
Posted by SLS on November 15, 2015, at 16:13:35
In reply to Re: My new cocktail » linkadge, posted by former poster on November 15, 2015, at 15:55:51
> >>Serotonin syndrome:
> Mental status changes
> Confusion; incoherence (51%)
> Agitation (34%)
> Hypomania (21%)
> Anxiety (15%)
> Coma (29%)
>
> Cardiovascular
> Sinus tachycardia (36%)
> Hypertension (35%)
> Hypotension (15%)
>
> Gastrointestinal
> Nausea (23%)
> Diarrhea (8%)
> Abdominal pain (4%)
> Salivation (2%)
>
> Motor Abnormalities
> Myoclonus (58%)
> Hyperreflexia (52%)
> Muscle rigidity (51%)
> Restlessness (48%)
> Tremor (43%)
> Ataxia/incoordination (40%)
> Shivering (26%)
> Nystagmus (15%)
> Seizures (12%)
>
> Other
> Diaphoresis (45%)
> Unreactive pupils (20%)
> Tachypnea (26%)
> Hyperpyrexia (45%)
>
> Good point Linkadge and I'd like to point out that a lot of us are taking MAOI's daily unknowingly in their diet or in supplement form.
> Not to discredit you SLS, I greatly appreciate your advice, but I get almost half of these symptoms daily while taking one SSRI alone.
> Getting a new Pdoc would be next to impossible at this time.
> I decided to not take the combo for now. Just curious however if Cyproheptadine is the best treatment for serotonin syndrome when not able to reach a hospital?Thank you for not discrediting me.
- Scott
Posted by SLS on November 15, 2015, at 16:14:12
In reply to Re: My new cocktail » former poster, posted by SLS on November 15, 2015, at 16:13:35
What a waste.
- Scott
Posted by Phillipa on November 15, 2015, at 17:09:32
In reply to Re: My new cocktail » Phillipa, posted by former poster on November 15, 2015, at 12:04:39
Glad you got an answer and first call also. Maybe also switch to this pharmacy since they seem to know interractions of medications. So what SSRI do you recommend for your pdoc? Why is it impossible to switch pdocs now? Phillipa
Posted by former poster on November 15, 2015, at 18:36:14
In reply to Re: My new cocktail » former poster, posted by Phillipa on November 15, 2015, at 17:09:32
>Why is it impossible to switch pdocs now? Phillipa
It would probably take 3 months before I got to see the new one and I'd probably get one that is even less desirable.
>What a wasteNot really. Haven't picked up the Emsam yet. I still have few patches from a previous prescription. At this point I don't know which medication to drop. One helps anxiety not depression, the other helps depression not anxiety.
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