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Dr. Bob is Robert Hsiung, MD,
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Posted by Peter Jay on February 4, 2002, at 15:39:22
How do I go about augmenting an SSRI with anafranil to further raise serotonin?
A friend of mine has OCD and she is on 100mg daily of Prozac (which I know is a realtively high dose). However she gets few side effects and is not getting a lot of benefit. I know that SSRIs like prozac can be augmented with anafranil (which she can take up to 175mg daily although she then gets somnolence).
Maybe she is not a good responder to prozac but it took so long to get her to 100mg that before re-starting with another SSRI or Effexor, i think it would be worth trying to augment the prozac.
Of course, the main problem with such augmentation will be a risk of too much serotonin and there will be a need to watch out for any symptoms of 'serotonin syndrome'. I accept this.
However, I am not clear how to proceed with the augmentation.
Should the SSRI be reduced (to something like 50mg or 60mg daily) and then a dose (25mg???) of anafranil started. And then to increase week by week by 10mg anafranil?
Or is it completely the other way around: get onto, say, 125 mg anafranil and then add Prozac?
I have to ask this here because her doc is not big on meds but much prefers CBT. (There is nothing wrong with CBT of course but better still to have CBT plus meds.) As a result her doc is not all that familiar with SSRI+anafranil. However, I gather it is a well-known combination used by many psychopharmacologists.
Can anyone advise?
Thank you
Peter
Posted by bob on February 4, 2002, at 16:07:06
In reply to How do I safely augment SSRIs with anafranil?, posted by Peter Jay on February 4, 2002, at 15:39:22
How long has she been on Prozac (both time and mg levels)?
Posted by Peter Jay on February 4, 2002, at 16:17:19
In reply to Re: How do I safely augment SSRIs with anafranil?, posted by bob on February 4, 2002, at 16:07:06
She took many months to get to where she is now because the half-life of Prozac is so long (maybe a week or so), so each dose increment was slow.
She started very caustiously (after a former bad response to 20mg Paxil which she discontinued) and it went like this:
5mg to 15mg over 3 weeks
20mg to 60mg over 8 weeks
70mg to 100mg over 6 weeks
at 100mg since mid-November (approx 11 weeks).I think she has given the prozac long enough to show therapeutic benefit. It has produced some benefit but nothing like as much as the 175mg of anafranil was doing.
I am thinking that as she is free of all adverse side effects then she may be metabolising the prozac in such a way that it does not produce sufficiently high serotonin levels in her. After all, at 100mg she should be displaying some signs (side effects) of high serotonin.
Can you suggest an approach for augmentation?
Thanks!
Peter
Posted by bob on February 4, 2002, at 21:06:41
In reply to Re: How do I safely augment SSRIs with anafranil? » bob, posted by Peter Jay on February 4, 2002, at 16:17:19
I don't know about augmentation for improving OCD symptoms. I'm not so sure it's common to mix SSRIs and Tricyclics. I too was on Anafranil and it was hard to tolerate for me. I'm assuming that's why she stopped taking it?
The way I see it, you can give the prozac a little longer, maybe another month or two, unless the state she's in is unbearable. The other suggestion is to try on of the other SSRIs. Luvox, in particular, would be what I would have her try, if I was a doctor. Many people claim that particular drug is quite effective. Another one she could try is Zoloft. They all have their own idiosyncrasies, and although Prozac may not be helping, another may.
Posted by petters on February 5, 2002, at 1:06:57
In reply to How do I safely augment SSRIs with anafranil?, posted by Peter Jay on February 4, 2002, at 15:39:22
> How do I go about augmenting an SSRI with anafranil to further raise serotonin?
>
> A friend of mine has OCD and she is on 100mg daily of Prozac (which I know is a realtively high dose). However she gets few side effects and is not getting a lot of benefit. I know that SSRIs like prozac can be augmented with anafranil (which she can take up to 175mg daily although she then gets somnolence).
>
> Maybe she is not a good responder to prozac but it took so long to get her to 100mg that before re-starting with another SSRI or Effexor, i think it would be worth trying to augment the prozac.
>
> Of course, the main problem with such augmentation will be a risk of too much serotonin and there will be a need to watch out for any symptoms of 'serotonin syndrome'. I accept this.
>
> However, I am not clear how to proceed with the augmentation.
>
> Should the SSRI be reduced (to something like 50mg or 60mg daily) and then a dose (25mg???) of anafranil started. And then to increase week by week by 10mg anafranil?
>
> Or is it completely the other way around: get onto, say, 125 mg anafranil and then add Prozac?
>
> I have to ask this here because her doc is not big on meds but much prefers CBT. (There is nothing wrong with CBT of course but better still to have CBT plus meds.) As a result her doc is not all that familiar with SSRI+anafranil. However, I gather it is a well-known combination used by many psychopharmacologists.
>
> Can anyone advise?
>
> Thank you
>
> PeterHi...
I can only say what I have been seeing from other refractary OCD. Start with Anafranil, up to 150 mg and then add ssri. The best ssri is to combo Anafranil with is fluvoxamin. Next best is citalopram. These two have the least risk to interact with clomipramine.
Sorry for bad spelling. Not from U.S
Best wishes...//Petters
Posted by Peter Jay on February 5, 2002, at 5:48:08
In reply to Re: How do I safely augment SSRIs with anafranil?, posted by petters on February 5, 2002, at 1:06:57
>
> Hi...
>
> I can only say what I have been seeing from other refractary OCD. Start with Anafranil, up to 150 mg and then add ssri. The best ssri is to combo Anafranil with is fluvoxamin. Next best is citalopram. These two have the least risk to interact with clomipramine.
>
Least risk in what sense? Can you explain this a bit more please?She is reluctant to try fluvoxamine because of its reputation (shared with paroxetine) of having a more side effects than the other SSRIs.
Strangely, she had side-effect trouble with citalopram and this is often considered to have the least side effects of all the SSRIs.
Thank you for any more info.
Posted by petters on February 5, 2002, at 11:17:45
In reply to Re: How do I safely augment SSRIs with anafranil? » petters, posted by Peter Jay on February 5, 2002, at 5:48:08
> >
> > Hi...
> >
> > I can only say what I have been seeing from other refractary OCD. Start with Anafranil, up to 150 mg and then add ssri. The best ssri is to combo Anafranil with is fluvoxamin. Next best is citalopram. These two have the least risk to interact with clomipramine.
> >
>
>
> Least risk in what sense? Can you explain this a bit more please?
>
> She is reluctant to try fluvoxamine because of its reputation (shared with paroxetine) of having a more side effects than the other SSRIs.
>
> Strangely, she had side-effect trouble with citalopram and this is often considered to have the least side effects of all the SSRIs.
>
> Thank you for any more info.Hi...
Why are she reluctant to use fluvoxamine?
Last risk for these two ssri in combo with clomipramine is serotonin syndrom. You are right with Citalopram. It has often fewer side effect than other ssri. But everyone is different, and a few can react as she did.
Sertralin is also possible to use in these case, as an add on to clomipramine.
Best Wishes...//Petters
Posted by jane d on February 5, 2002, at 23:25:01
In reply to How do I safely augment SSRIs with anafranil?, posted by Peter Jay on February 4, 2002, at 15:39:22
Peter,
First of all I'd like to apologize if the following is too simplistic. I couldn't tell from your posts just what you already know.
The problem with combining these particular drugs (Anafranil/clomipramine and Prozac), as Petters has said, is that each of these drugs hasthe potential to increase the level of the other one by effecting the enzyme system that breaks the drugs down. It's a matter of the whole being greater than the sum of the parts. In other words if your friend adds the clomipramine to the Prozac the effect is like she had raised the Prozac at the same time. Sometimes that it the whole point but since she is already taking such a high dose of Prozac your friend may not have room to go that much higher. I worry that your friend is risking serotonin syndrome.
There's a lot being published about these interactions (the cytochrome p450 system) but my impression is that it will still not tell you how to do this safely. There is still a lot that is unknown. Some drugs haven't been studied. Hypothetical reactions don't alwaays occur as predicted. There are also individual variations between one person and the next. Perhaps one of these variations is why your friend is not reacting to the Prozac; perhaps not.
I hate to say this but I really think that, instead of trying to calculate the doses yourself, your best bet here would be to use this energy looking for a new psychiatrist. Perhaps just for a consultation about the medication if your friend is otherwise happy with the first one. At least that way she gets the benefit of the doctors clinical experience to add to what is published.
Jane
Posted by Peter Jay on February 6, 2002, at 3:41:33
In reply to Re: How do I safely augment SSRIs with anafranil?, posted by petters on February 5, 2002, at 11:17:45
Jane
Thanks for your reply.
You are quite right that an new psychiatrist might be the answer but we are in the UK and have to use the public National Health Service. Changing psychiatrists can take a very, very long time. Nor can we afford to pay for the doctor privately. We are kind of stuck with the doc we have. He is not a bad doc it's just that he is not familiar with some of the med combos.
> The problem with combining these particular drugs (Anafranil/clomipramine
> and Prozac), as Petters has said, is that each of these drugs hasthe
> potential to increase the level of the other one by effecting the enzyme
> system that breaks the drugs down.(1) I can not pretend to be an expert on the complexities of the Cytochrome P450 system but I am aware that there are several sorts of interactions possible here of the enzymes involved. I gather that the P450 system sometimes makes two meds may act synergistically and sometimes the P450 system makes them start to cancel each other out.
(2) In addition to these possible Cytochrome P450 interactions, there is the question of the two meds involved here (Prozac and Anafranil) working together so successfully on raising serotonin levels that the serotonin level because too high. It may be that my friend is partly resistant to one or the other of these two meds and specifically she may be resistant to the specific way in which one prevents the re-uptake of anafranil.
It is mainly the second of the two things above which I am concerned by. Of course (2) may be caused by (1) which makes it even more complicated!
However, I understand that such augmentation is often practised for refractory patients. So I was hoping not to have to delve into the science of it but just to understand what is common clinical practise in approaching such augmentation. I don't want to find that adding a tiny amount of one of these two meds suddenly raises the level of serotonin with the result that we end up with a serotonin overdose!
I am sure that somebody here will either have experienced this augmentation and/or will know about it. Here to hoping tat they will reply!
Peter Jay
Posted by jane d on February 6, 2002, at 22:29:46
In reply to Re: How do I safely augment SSRIs with anafranil? » petters, posted by Peter Jay on February 6, 2002, at 3:41:33
Peter,
I thought you probably did know all that stuff but I didn't want to take the chance that you might not. Does your friend also understand? I hope you get a response from someone with some first hand experience.
Jane
Posted by Peter Jay on February 7, 2002, at 2:57:16
In reply to Re: How do I safely augment SSRIs with anafranil? » Peter Jay, posted by jane d on February 6, 2002, at 22:29:46
> Peter,
>
> I thought you probably did know all that stuff but I didn't
> want to take the chance that you might not. Does your
> friend also understand? I hope you get a response from
> someone with some first hand experience.
>
> Jane
JaneThank you for taking the time to raise these issues. I know *of* these issues but I do not have any real knowledge or experience of working with them.
All in all, I am finding it very hard to get some info on this. I think many docs or knowledgeable people may be reluctant to advise on something which is slightly 'advanced' and is not often done by regular psychiatrists. However I feel their fears are misplaced because my friend is hardly going to pop a bundle of tabs in her mouth and just see what happens! Of course my friend will take it very carefully. Her OCD means that her propensity for potential self-harm is very low indeed.
I am surprised at the general reluctance of docs to assist or advise me in this matter and their attitude is in contrast to the bucket-loads of advice available on the Net to those who want to take MAOIs (like phenelzine or even the rather different MAOI selegiline) or even to combine them!
I must keep looking for the info. Maybe there is some advisory info on a professional med site. Please let me know if you or anyone else come across such a thing. My friend's situation is not so good and she is not able to get the quality of advice that she needs from the public health system here.
Peter Jay
Posted by Michael D on February 8, 2002, at 4:15:56
In reply to How do I safely augment SSRIs with anafranil?, posted by Peter Jay on February 4, 2002, at 15:39:22
What, exactly, is anafranil?
Michael Dewolf
Posted by Peter Jay on February 8, 2002, at 8:20:20
In reply to Re: How do I safely augment SSRIs with anafranil?, posted by Michael D on February 8, 2002, at 4:15:56
> What, exactly, is anafranil?
>
> Michael Dewolf
I don't like to say this but http:/www.google.com is your friend!
Posted by bob on February 8, 2002, at 12:04:12
In reply to Re: How do I safely augment SSRIs with anafranil?, posted by Michael D on February 8, 2002, at 4:15:56
> What, exactly, is anafranil?
>
> Michael DewolfAnafranil is the brand name for Clomipramine HCL. It is a tricyclic antidepressant with a highly serotonergic component. It was the gold standard for OCD before SSRIs came along, and is still when SSRIs prove ineffective for an individual.
This is the end of the thread.
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