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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 31 to 55 of 72. Go back in thread:
Posted by Escapee on August 27, 2016, at 5:58:45
In reply to ..........., posted by Escapee on August 20, 2016, at 12:06:34
To start with I had an awful time 2 weeks prior to Thursdays appointment.
When I decided to switch from Marplan (isocarboxazid) to Nardil (phenelzine) I called my doc's secretary and I emailed her a detailed (but not complicated) plan to reduce all my med dosages and which ones I was stopping & keeping. She said she would forward the email to my doc. With no reply via mobile or landline, Email or post that was enough for me to carry on titrating everything downwards.
When I finally started washout, the start of the 2nd week went bad. I admitted myself to A&E (suggested by NHS Direct 111) for 1 night asking if they could give me a bed in the psychiatric in-patient ward. There declined my request. They gave me a bed for the night (actually it was a lovely soft reclining leather chair) and I went home the next day. Next night I went in again doped to the eye balls on Quetiapine & Zopiclone. It was technically an OD compared to my prescribed dosage of 150mg. 700mg to 800mg maybe more quetiapine plus 7.5mg Zopiclone but I never intentionally meant to end my life. No way! But I did want a long deep sleep. Never thought much of it until my legs went like jelly And my head spun. So I called for ambulance and again they kept me in for the night.
I was seen by several 'liaison' psychiatrists. They were all very helpful, except when the last Psych came to discharge me and dropped the bomb. She said she had spoken to my Pdoc and said he was shocked and said he never told me to come off anything and for me to get back on everything ASAP! His plan was to simply cross-titrate the MAOIs! I could not believe it. So the secretary never forwarded my email? And if he never read the email how did he know I wanted to switch the phenelzine?? Did I mention it and forgot? Dam
So I went back on everything except for Marplan. Couple dose changes. Amitriptyline up to 100mg instead of 150 & Clonazepam from 4 to 2.5mg.
Since 12+yrs ago they are still the same 15mg pills. They need refrigeration, smell LUSH & are deep orange colour. Can't remember them being that strong a colour, plus I actually had the Nardil brand pills. I thought I used to get generic phenelzine. Memory loss perhaps.
I'm just glad I'm back on Nardil. I wonder what will happen.....
Escapee
Posted by SLS on August 27, 2016, at 9:22:24
In reply to Started Nardil, posted by Escapee on August 27, 2016, at 5:58:45
> I'm just glad I'm back on Nardil. I wonder what will happen.....
I am sure you know that Nardil often becomes less effective once it is discontinued and restarted. If this is the case with you, I wouldn't become too demoralized. This is what happened to me. There are multiple augmentation strategies that are available to treat this circumstance. First things first. I don't think it makes sense to add anything to phenelzine until you reach a dosage of 1.0 mg/kg body weight.
- Scott
Posted by Escapee on August 27, 2016, at 11:09:56
In reply to Re: Started Nardil » Escapee, posted by SLS on August 27, 2016, at 9:22:24
> > I'm just glad I'm back on Nardil. I wonder what will happen.....
>
> I am sure you know that Nardil often becomes less effective once it is discontinued and restarted. If this is the case with you, I wouldn't become too demoralized. This is what happened to me. There are multiple augmentation strategies that are available to treat this circumstance. First things first. I don't think it makes sense to add anything to phenelzine until you reach a dosage of 1.0 mg/kg body weight.
>
>
> - ScottYou are right Scott. But one can only hope. It has been over 12yrs tho.
Biggest mistake ever made was coming off Nardil, at the time at least. I realized it never actually stopped working as once stopped my SA soared thru the roof. But the depression was stubborn. But compared to the Isocarb I only tried a few addons/augmentations with Phenelzine- modafinil, trimipramine, L-tryptophan (Optimax), bupropion, lamotrigine... My doc at the time had said he'd read of a study done using sertraline to augment phenelzine. It was offered to me, but he said he'd given it to one other patient who suffered 'annoying' side effects tho nothing serious. Anyway I declined, but remembered.
Most augmentations tried with Isocarb were never tried with Phenelzine. I'm surprised he wanted me to stay on all other meds whilst cross titrating. Maybe coz he is cautious of my sometimes stubborn depression.
Quetiapine fine, may even help prevent mood swings which I experienced 1st time round on phenelzine. From really outgoing to curtains drawn teary gloomy with little explanation, only to perk up again the next day. I thought maybe it was short-lived med-induced Bipolar? Doc said it wasn't.
I'm far from hoping for a miracle, but optimistic nonetheless. I know my docs fine to take it to 120mg if necessary.
Mind you my docs most familiar with tranylcypromine (Parnate) than any of the other MAOIs. So that's a pretty good safety net I'd say. The combinations are seemingly endless between the 3 irreversible MAOIs & addons/augmenters which would shock most GPs and others a-like.
I'm surprised to see you follow the 1mg per kg weight rule. I dont buy it. And the patients info slip STILL says a maintenance dose of as low as one tablet (15mg) every other day. What is that about and why does it still appear on the slip when the slip also states: last revised on 04/2015! I mean, was that how they used to, or still do (some doctors) prescribe it successfully?
The food interactions are still totally outdated too! Don't eat yogurt??? I eat a 450ml pot of live yogurt every day.
Craziness.Escapee
Posted by SLS on August 27, 2016, at 13:55:17
In reply to Re: Started Nardil » SLS, posted by Escapee on August 27, 2016, at 11:09:56
I think it is a dangerous game to add any SSRI to phenelzine. My impression is that it will result in serotonin syndrome almost every time.
The 1 mg phenelzine/kg body weight serves pretty well. That leaves me at 90 mg/day, which just so happens to be optimal for me. 75 mg/day is too low, and increasing the doaage produces no further improvement. The formula is a guideline - nothing more. Some people will need more; others will need less. I have gone to 120 mg/day. You need to be careful with phenelzine, though. The ratio of dose/blood level is not linear. Phenelzine inhibits its own metabolism, so every 15 mg increase in dosage will produce a larger and larger increase in blood level. It is much easier to overdose on phenelzine than on tranylcypromine.
Because you have not taken phenelzine in so long, I don't think you can necessarily expect that it will not work well. In the past, some doctors would have their relapsing patients discontinue phenelzine for three or more months in order to recapture a response to it. One of my doctors had a patient switch back and forth between phenelzine and tranylcypromine once a relapse occurred for each one.
I think you can be cautiously optimistic.
- Scott
Posted by Escapee on September 6, 2016, at 19:08:23
In reply to Re: Started Nardil » Escapee, posted by SLS on August 27, 2016, at 13:55:17
> I think it is a dangerous game to add any SSRI to phenelzine. My impression is that it will result in serotonin syndrome almost every time.
>
> The 1 mg phenelzine/kg body weight serves pretty well. That leaves me at 90 mg/day, which just so happens to be optimal for me. 75 mg/day is too low, and increasing the doaage produces no further improvement. The formula is a guideline - nothing more. Some people will need more; others will need less. I have gone to 120 mg/day. You need to be careful with phenelzine, though. The ratio of dose/blood level is not linear. Phenelzine inhibits its own metabolism, so every 15 mg increase in dosage will produce a larger and larger increase in blood level. It is much easier to overdose on phenelzine than on tranylcypromine.
>
> Because you have not taken phenelzine in so long, I don't think you can necessarily expect that it will not work well. In the past, some doctors would have their relapsing patients discontinue phenelzine for three or more months in order to recapture a response to it. One of my doctors had a patient switch back and forth between phenelzine and tranylcypromine once a relapse occurred for each one.
>
> I think you can be cautiously optimistic.
>
>
> - ScottThanks for your input! I will talk to my doc about the relapse method you explain.
I can feel Nardil working already. A bit speedy but that happened last time before my mood lifted and the anxiolitic effect kicked in.
Posted by SLS on September 6, 2016, at 19:37:19
In reply to Re: Started Nardil » SLS, posted by Escapee on September 6, 2016, at 19:08:23
> > I think it is a dangerous game to add any SSRI to phenelzine. My impression is that it will result in serotonin syndrome almost every time.
> >
> > The 1 mg phenelzine/kg body weight serves pretty well. That leaves me at 90 mg/day, which just so happens to be optimal for me. 75 mg/day is too low, and increasing the doaage produces no further improvement. The formula is a guideline - nothing more. Some people will need more; others will need less. I have gone to 120 mg/day. You need to be careful with phenelzine, though. The ratio of dose/blood level is not linear. Phenelzine inhibits its own metabolism, so every 15 mg increase in dosage will produce a larger and larger increase in blood level. It is much easier to overdose on phenelzine than on tranylcypromine.
> >
> > Because you have not taken phenelzine in so long, I don't think you can necessarily expect that it will not work well. In the past, some doctors would have their relapsing patients discontinue phenelzine for three or more months in order to recapture a response to it. One of my doctors had a patient switch back and forth between phenelzine and tranylcypromine once a relapse occurred for each one.
> >
> > I think you can be cautiously optimistic.
> >
> >
> > - Scott
>
> Thanks for your input! I will talk to my doc about the relapse method you explain.
> I can feel Nardil working already. A bit speedy but that happened last time before my mood lifted and the anxiolitic effect kicked in.<big smile>
I really hope that things work out for you.
Good luck.
- Scott
Posted by Escapee on September 6, 2016, at 19:39:46
In reply to Re: Started Nardil » Escapee, posted by SLS on September 6, 2016, at 19:37:19
Posted by Escapee on September 23, 2016, at 16:39:43
In reply to Thanks :) (nm) » SLS, posted by Escapee on September 6, 2016, at 19:39:46
Well...Things have gone slightly wrong. I've been having problems with a side effect. A nasty one. Urine retention. Thought I was prepared for it but no. I have had to reduce from 45mg to 30mg. I can feel the loss of efficiency but can pee again lol.
I remember vividly last time I started Nardil back in 2004. I hit 60mg in 5 weeks and felt great! But within a month after that it started. Couldn't 'go' no matter how long I stood there. I took myself to hospital, along with my swollen belly. They fitted a catheter without hesitation. I refused to lower the dose so lived with the catheter for about 5 weeks. When they took it out I could pee normally. YAY!
This time I do not want a catheter! I will increase very slowly. A full week on 30mg. Then 2 weeks on 30 one day, 45 the next. Then up to 45mg every day for at least 2 weeks. See how I go from there.
I have type 1 diabetes and have been told I am more prone to such side effects. DAMMIT!
So all I can do is see how things go.
Escapee
Posted by Escapee on September 23, 2016, at 16:43:00
In reply to Nardil update., posted by Escapee on September 23, 2016, at 16:39:43
Also decreasing the quetiapine to 100mg at night. Still not loosing any weight. If anything I am gaining. Maybe it was the holiday...
Posted by SLS on September 23, 2016, at 18:40:50
In reply to Nardil update., posted by Escapee on September 23, 2016, at 16:39:43
I had difficulties urinating when I combined Nardil 75 mg/day with desipramine 200 mg/day. It didn't show up right away. I used Urecholine (bethanecol) to help. Eventually, things improved to the point where I no longer needed the bethanecol. Maybe you'll get lucky. If not, you can try Marplan (isocarboxazid).
- Scott
Posted by Escapee on September 23, 2016, at 19:06:07
In reply to Re: Nardil update. » Escapee, posted by SLS on September 23, 2016, at 18:40:50
> I had difficulties urinating when I combined Nardil 75 mg/day with desipramine 200 mg/day. It didn't show up right away. I used Urecholine (bethanecol) to help. Eventually, things improved to the point where I no longer needed the bethanecol. Maybe you'll get lucky. If not, you can try Marplan (isocarboxazid).
>
>
> - ScottThanks Scott. I've actually just come off of Marplan after 10yrs or so. Back on Nardil. Last time I did indeed asked for bethanecol and another med. Was denied both. Perhapse this doc might be more willing, esp as he knows how stubborn my depression can be.
Posted by SLS on September 23, 2016, at 20:46:49
In reply to Re: Nardil update. » SLS, posted by Escapee on September 23, 2016, at 19:06:07
> > I had difficulties urinating when I combined Nardil 75 mg/day with desipramine 200 mg/day. It didn't show up right away. I used Urecholine (bethanecol) to help. Eventually, things improved to the point where I no longer needed the bethanecol. Maybe you'll get lucky. If not, you can try Marplan (isocarboxazid).
> Thanks Scott. I've actually just come off of Marplan after 10yrs or so. Back on Nardil. Last time I did indeed asked for bethanecol and another med. Was denied both. Perhapse this doc might be more willing, esp as he knows how stubborn my depression can be.
Nardil can be a real pain in the butt. Just to let you know, I was finally able to go up to 90 mg/day with just some mild urinary hesitancy. It took awhile, though. You might not have any better choice but to take bethanecol and increase the Nardil dosage in 7.5 mg increments.
Good luck.
:-)
- Scott
Posted by Escapee on September 24, 2016, at 8:44:00
In reply to Re: Nardil update. » Escapee, posted by SLS on September 23, 2016, at 20:46:49
> Nardil can be a real pain in the butt. Just to let you know, I was finally able to go up to 90 mg/day with just some mild urinary hesitancy. It took awhile, though. You might not have any better choice but to take bethanecol and increase the Nardil dosage in 7.5 mg increments.
>
> Good luck.
>
> :-)
>
>
> - Scott
>
>Thanks man. The fact that dropping from 45 back to 30 has given me relief tells me I might get away with increasingly more slowly. Will start adding back 15mg every other day for now. See how it goes. I dont like breaking Nardil pill apart. There is no half indent, and also dont want to chance ruining the efficacy esp as they need refrigeration.
I'm not depressed but not as good as I was at 45, even tho it was far from perfect. 60 did it last time almost instantly all those yrs back.
Yes, Marplan & Nardil side effects (for me) are slow to show up and gradually fade. Wonder how it causes this side effect. Impotence too when on Nardil and a bit when on Marplan. Marplan side effects are def milder tho.
I still have 2 other ADs and quetiapine keeping me afloat. Increased the clonazepam 1mg/day too to help the slight increase of anxiety 'again'.
See my doc in 17days time. Will try and get more frequent appointments until this problem is sorted.
Escapee
Posted by SLS on September 24, 2016, at 9:27:27
In reply to Re: Nardil update. » SLS, posted by Escapee on September 24, 2016, at 8:44:00
I would not use the every-other-day dosing strategy with Nardil. I've been there.
The half-life of Nardil is only 12 hours. You would be surprised just how quickly Nardil withdrawal sets in. MAO inhibition is not the only thing that Nardil does. I can't go 48 hours without suffering a change in dreaming and feeling less well. I think some of this is the loss of MAO inhibition. Some of it may be a loss of GABA transaminase inhibition. Some is probably the loss of some sort of stimulant effect that has not yet been investigated. Again, I would just break the 15 mg tablets in half, one tablet at a time as needed. Each 1/2 tablet should remain 100% effective - certainly after standing for only 24 hours. I have had doctors do this with me, especially when Nardil was to be added to a TCA. In addition, it is my guess that skipping days will not allow the body to acclimate itself to Nardil. Pulsing the dosage might make side effects worse or slower to abate.
It is just something to think about.
- Scott
Posted by Escapee on September 24, 2016, at 10:57:19
In reply to Re: Nardil update. » Escapee, posted by SLS on September 24, 2016, at 9:27:27
Thanks! You make a lot of sense.
I am 'cushioned' somewhat by the bupropion and amitriptyline. Also the GABAergic effects of clonazepam plus whatever actions my pregabalin has.
But you are probably right that its best to keep dosing regular. I have found phenelzine pills to be somewhat hygroscopic. Easy fix that by keeping the half pill in a tub with a sprinkling of dry rice.
The pill coating is definitely hygroscopic. Melts in the mouth very quickly too. I love the taste! Possibly has some kinda placebo effect. That I have just put something good in in my mouth :)
Same with the smell.My urine retention has disappeared already. I will start adding 7.5mg Monday.
Escapee
Posted by Escapee on September 24, 2016, at 11:37:00
In reply to Re: Nardil update. » SLS, posted by Escapee on September 24, 2016, at 10:57:19
Found one site claiming Marplan to have a half life of about 36 hours!
http://www.mind.org.uk/information-support/drugs-and-treatments/antidepressants-a-z/isocarboxazid/Wiki shows nothing but a question mark lol.
When I 1st took Nardil, from what I recall Nardil's half-life was 2-3hrs! That was wiki. I'm sure RX list said the same. Maybe further studies proved that to be wrong. Or perhaps I am mistaken.
This is an interesting statement:
"The irreversible MAOIs are rapidly absorbed and generally quickly eliminated, with plasma elimination half-lives of 1.54 hours.35,43 However, because of their irreversible inhibition of MAO, the physiological effects of phenelzine, isocarboxazid, and tranylcypromine persist for up to 23 weeks.13 Thus, their pharmacodynamic half-life is greater than the pharmacokinetic half-life alone would suggest."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2075358/
Under the heading 'Drug Interactions'. Second paragraph.
Posted by SLS on September 24, 2016, at 13:56:42
In reply to Re: Nardil update., posted by Escapee on September 24, 2016, at 11:37:00
It is Parnate (tranylcypromine) that has the 2-3 hour half-life. Parnate goes in, some of which attaches to the MAO enzyme irreversibly (almost). The rest of it is quickly eliminated from the blood stream, but the "damage" to the enzymes have already been done.
Nardil (phenelzine) is a weird one. Despite its having a 12 hour half-life, it builds up in the brain exponentially as the dosage is increased linearly. This is because Nardil inhibits its own metabolism. It is broken down by MAO. Since it inhibits MAO, the rate of metabolism decreases with increasing dosage. This is important to consider when dosing. The difference between 45 mg/day to 60 mg/day yields a greater percentage jump in drug activity than the difference between 30 mg/day and 45 mg/day. For this reason, it is good practice to make dosage increases at a minimum of 3 week intervals - one week to gain sufficiently more MAO inhibition, and two more weeks to respond to it.
http://www.rxlist.com/nardil-drug/clinical-pharmacology.htm
It takes courage to go back on a drug that had forced you to use a catheter last time. That's not much fun - I know.
- Scott
Posted by Escapee on September 24, 2016, at 14:37:39
In reply to Re: Nardil update. » Escapee, posted by SLS on September 24, 2016, at 13:56:42
Thank you for the info.
My doctor did indeed want me to get to 45mg within a couple of weeks, but without compromising my side effect profile which he knows all too well.
I also have type 1 diabetes. So renal function is particularly important for me.
He said he wanted us to take things 'slowly'. I have to agree with him. I could be taking Nardil for the rest of my life. I'm fine with that so I am fine with taking things one stage at a time.
But tranylcypromine is still on the back burner. A safety net if you like.
Escapee
Posted by Escapee on September 25, 2016, at 4:15:01
In reply to Re: Nardil update. » SLS, posted by Escapee on September 24, 2016, at 14:37:39
I felt awful yesterday (Sat). I was in tears in the evening but for no aparent reason. OK so i am pissed about having to drop 15mg of Nardil as things were starting to happen at 45mg. I felt more confident, robust. So I guess it was chemical.
I took an 7.5mg dose last night. So thats 15mg morning, 15mg afternoon & 7.5mg at night. Good to keep it all spread out at least at 1st. When the side effects subside I should get away with taking the full dose between morning & late afternoon.
Last time I remember that the anxiety was relieved & confidence risen shortly after dosing. Perhaps the GABAergic effects increase with each dose, similar to a benzo? Idk. But I believe that if I bunch up the doses too close together right now I will have more severe side effects.
Its Sunday. Woke up early. Feel ok. Eye still killing. See what happens.
Posted by SLS on September 25, 2016, at 6:52:51
In reply to Re: Nardil update., posted by Escapee on September 25, 2016, at 4:15:01
> I felt awful yesterday (Sat). I was in tears in the evening but for no aparent reason. OK so i am pissed about having to drop 15mg of Nardil as things were starting to happen at 45mg. I felt more confident, robust. So I guess it was chemical.
>
> I took an 7.5mg dose last night. So thats 15mg morning, 15mg afternoon & 7.5mg at night. Good to keep it all spread out at least at 1st. When the side effects subside I should get away with taking the full dose between morning & late afternoon.
>
> Last time I remember that the anxiety was relieved & confidence risen shortly after dosing. Perhaps the GABAergic effects increase with each dose, similar to a benzo? Idk. But I believe that if I bunch up the doses too close together right now I will have more severe side effects.I am inclined to agree with you.
- Scott
Posted by Escapee on September 25, 2016, at 16:05:39
In reply to Re: Nardil update. » Escapee, posted by SLS on September 25, 2016, at 6:52:51
>>But I believe that if I bunch up the doses too close together right now I will have more severe side effects.
>
> I am inclined to agree with you.Actually I cant take this so I'm gonna add another 7.5mg to my morning dose as well. I was taking 30mg in the morn & 15mg in the afternoon, as directed by my doc. And I was actually feeling better with that. I started the gym, started going to support groups and made much needed appointments. Not exactly in a good mood but 'doing things'. And I had energy too without fatigue.
The social anxiety seemed to have been stumped out, at least partially. Negative thought looping had stopped. Felt less self conscious. Avoidance was loosing its power and procrastination had faded somewhat. I was even thinking about working again! 1st time in 11yrs.Right now I dont feel like doing any of the above. Seems I was on a roll and that hitting 60mg would have possibly pulled me right out of my hole! Hmm...
Still, I will do my best. I have a busy day tomorrow, if I actually succeed with my efforts and dont back out! Counselling assessment in the afternoon, group in the evening and the gym afterwards. Thats a lot for me! Gonna have to give myself a big push though.
The good news is that the 'mentioned' side effect has ceased. The water works are flowing freely again, with the help of some mild diuretics (Stinging Nettle extract & di-potassium phosphate) and drinking lots of water.
So to make things clear thats 22.5mg/morning, 15mg/afternoon and 7.5mg/night.
If said side effect does begin to show up I can take the 7.5mg off the morning or night dose instead of a whole 15mg. Sounds silly, but these tiny measurements are making the difference right now.
Escapee
Posted by J Kelly on September 26, 2016, at 8:16:04
In reply to Re: Nardil update. » SLS, posted by Escapee on September 25, 2016, at 16:05:39
Sounds like one side effect is out of the way :)
Btw- my pdoc made a point of telling me that doses should always be split up. That is, 15mg at a time. He says that "bunching" doses together is not as effective as splitting them up. Not sure if there's truth to that or not.
Hope you have a productive day!
Jade
Posted by Escapee on September 26, 2016, at 11:17:58
In reply to Re: Nardil update. » Escapee, posted by J Kelly on September 26, 2016, at 8:16:04
> Btw- my pdoc made a point of telling me that doses should always be split up. That is, 15mg at a time. He says that "bunching" doses together is not as effective as splitting them up. Not sure if there's truth to that or not.
Hi. Yes what your doc said does make sense. For some reason my doc wanted me to slowly work up to 30mg morning & 15mg lunch. Perhaps he wasn't aware of my previous side effects. Tho I never told him about them and it was 12yrs ago!
Posted by J Kelly on September 26, 2016, at 17:43:09
In reply to Re: Nardil update. » J Kelly, posted by Escapee on September 26, 2016, at 11:17:58
So what were your side effects 12 years ago? Why did you d/c it? How effective for you was it back then?
Jade
Posted by Escapee on September 26, 2016, at 20:15:37
In reply to Re: Nardil update. » Escapee, posted by J Kelly on September 26, 2016, at 8:16:04
> Btw- my pdoc made a point of telling me that doses should always be split up. That is, 15mg at a time. He says that "bunching" doses together is not as effective as splitting them up. Not sure if there's truth to that or not.
Thankyou jade. Thats exactly what I will do. 15/morn, 15/afternoon & 15/night.
Tho eventually I hope to be taking the full dose split between morning & Afternoon. From experience Nardil feels far more powerful that way!
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