![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by johnj on December 15, 2002, at 21:33:18
Hello,
I was hoping anyone that was on a TCA could let me know how they titrated off. I went from 50 mg nortryptline to 40 and don't feel so good. I was suprised that such a small amount could affect me. Last week, by accident, took 70 instead of my normal 50. I thought I took a 25 mg plus 2-10mgs, but I took my normal 50 plus the 2 tens. The second day I felt horrible and figured out what I had done. My doc wants me to get down to 30 mgs and then start lexapro. Since I have a lot of anxiety I don't know if the ssri is a good idea. It was sure nice the second day I was on 40 to feel more in touch with the world and I was not irritable at all, but my sleep sucks and I have muscle spams due to the lack of sleep. Man, I hate these drugs...a necessary evil is so true. Thanks all
johnj
You out there Colin Wallace or Ron Hill?
Posted by JaneB on December 15, 2002, at 23:04:00
In reply to TCA discontinuation???, posted by johnj on December 15, 2002, at 21:33:18
> Hello,
> I was hoping anyone that was on a TCA could let me know how they titrated off. I went from 50 mg nortryptline to 40 and don't feel so good. I was suprised that such a small amount could affect me. Last week, by accident, took 70 instead of my normal 50. I thought I took a 25 mg plus 2-10mgs, but I took my normal 50 plus the 2 tens. The second day I felt horrible and figured out what I had done. My doc wants me to get down to 30 mgs and then start lexapro. Since I have a lot of anxiety I don't know if the ssri is a good idea. It was sure nice the second day I was on 40 to feel more in touch with the world and I was not irritable at all, but my sleep sucks and I have muscle spams due to the lack of sleep. Man, I hate these drugs...a necessary evil is so true. Thanks all
> johnj
> You out there Colin Wallace or Ron Hill?Does your pdoc want you on Lexapro to help with sleep? Wasn't nortryptiline helping you? Are most docs switching to Lexapro nowadays? Or did you ask for it? Have you tried Klonopin to help with sleep? I am also struggling and looking for answers.
JaneB
Posted by oracle on December 16, 2002, at 0:05:34
In reply to TCA discontinuation???, posted by johnj on December 15, 2002, at 21:33:18
Given the length of action & long half life
I would not expect missing a dose or taking a little less to make much difference the next day,
with TCA's.
Posted by SLS on December 16, 2002, at 6:20:07
In reply to Re: TCA discontinuation???, posted by oracle on December 16, 2002, at 0:05:34
> Given the length of action & long half life
> I would not expect missing a dose or taking a little less to make much difference the next day,
> with TCA's.For some people, nortriptyline can have a very narrow therapeutic window. If you take too much, you can lose the antidepressant effect. I don't know if this is one of those instances, but I had a similar experience with the drug.
- Scott
Posted by johnj on December 16, 2002, at 8:33:38
In reply to Why lexapro? » johnj, posted by JaneB on December 15, 2002, at 23:04:00
My pdoc wants me to try lexapro. Nortryp was doing a decent job but it has always made me kind of irritible and does not allow me to work out. Things get really wacky if I excercise. Dizziness can be bad some days, but not others. Constipation is very bad. TCA's are definately the dirty drugs. I don't know what else to try. I tried remeron...major space cadet feeling. Not sure what to do. I am highly med sensitive.
Posted by johnj on December 16, 2002, at 8:38:15
In reply to Re: TCA discontinuation???, posted by SLS on December 16, 2002, at 6:20:07
Scott:
I have been told the same thing. I do really believe the 70 mg really wacked me out. I want to say the 40 shouldn't have affected me much but yesterday was terrible so I took 50 last night. I will see after a day or two how I feel. I am thinking it would be better to go to 30 and add the lexapro right away since titrating down doesn't help me much. The lack of sleep just kills me and I woke up at 5 this morning. I heard there is a new drug called cymbalta coming out from lily. Don't know what to try. But, I have been on nortyptiline for 10 years and any shift could really affect me. What do you take now?
Posted by Ritch on December 16, 2002, at 9:38:59
In reply to TCA discontinuation???, posted by johnj on December 15, 2002, at 21:33:18
> Hello,
> I was hoping anyone that was on a TCA could let me know how they titrated off. I went from 50 mg nortryptline to 40 and don't feel so good. I was suprised that such a small amount could affect me. Last week, by accident, took 70 instead of my normal 50. I thought I took a 25 mg plus 2-10mgs, but I took my normal 50 plus the 2 tens. The second day I felt horrible and figured out what I had done. My doc wants me to get down to 30 mgs and then start lexapro. Since I have a lot of anxiety I don't know if the ssri is a good idea. It was sure nice the second day I was on 40 to feel more in touch with the world and I was not irritable at all, but my sleep sucks and I have muscle spams due to the lack of sleep. Man, I hate these drugs...a necessary evil is so true. Thanks all
> johnj
> You out there Colin Wallace or Ron Hill?John, I always seemed to get a mild hypomania as a "rebound" effect from discontinuing the sedative TCA's (and Remeron). When I was taking 150mg of doxepin I dropped it in half to 75mg with no problems, and then dropped that to 25mg with no problems (got some insomnia when I stopped it entirely, however). I found nortriptyline to work quite well with an SSRI in the past (Celexa and then Zoloft). Lexapro shouldn't interact with the nortriptyline since it doesn't significantly inhibit p450IId6 liver enzymes (it shouldn't effect the level of nortripytline in your blood by adding it). When I was taking Zoloft with it (nortriptyline), the Zoloft boosted the levels of NT significantly (Z. does inhibit metabolism/clearance of NT), and I got a little jumpy as a result. hope this helps
Posted by oracle on December 16, 2002, at 11:16:57
In reply to Re: TCA discontinuation???, posted by SLS on December 16, 2002, at 6:20:07
> For some people, nortriptyline can have a very narrow therapeutic window. If you take too much, you can lose the antidepressant effect. I don't know if this is one of those instances, but I had a similar experience with the drug.
>
>
> - ScottDo you find that ~75 mgs is the lower limit for
AD activity in nortriptyline ?
Posted by SLS on December 16, 2002, at 13:36:27
In reply to Re: TCA discontinuation???, posted by oracle on December 16, 2002, at 11:16:57
> > For some people, nortriptyline can have a very narrow therapeutic window. If you take too much, you can lose the antidepressant effect. I don't know if this is one of those instances, but I had a similar experience with the drug.
> >> Do you find that ~75 mgs is the lower limit for
> AD activity in nortriptyline ?
Hi Oracle.The dosage of nortriptyline most often used is 75mg. The normal range is between 50-100mg. It is rather simple to figure out how much to take. After years of study, it has been found that one can determine the right dosage of nortriptyline by measuring blood levels. The therapeutic range for blood levels is 50-150 ng/ml. What this means is that you need a minimum of 50 ng/ml to respond. However, once the blood level exceeds 150 ng/ml, the response tends to disappear. This is what is called a "therapeutic window". Blood levels act more as a guideline. It is still necessary to test at what value in the therapeutic range an individual responds. Some people need to take as much as 150mg of nortriptyline to establish a therapeutic level. In rare cases, higher dosages (up to 200mg) are necessary to maintain a response despite blood levels being above 150 ng/ml.
Nortriptyline can be a pain in the ass, but when it works, it works great!
I have what seems to be some sort of bipolar depression that is resistant to treatment. I am currently adding desipramine (very slowly) to a combination of Lamictal 300mg + Nardil 90mg + Zyprexa 5mg. If this doesn't work, I'll try duloxetine (Cymbalta) if it becomes available or Lexapro if it doesn't. I am also waiting to see how people react to a drug named Abilify (aripiprazole). It was recently approved by the FDA to be used as an antipsychotic in treating schizophrenia. However, it looks like it might have antidepressant properties as well. I'm taking Zyprexa because it, too, has antidepressant properties, especially when combined with antidepressants.
- Scott
Posted by oracle on December 16, 2002, at 17:34:04
In reply to Re: TCA discontinuation???, posted by SLS on December 16, 2002, at 6:20:07
> > Given the length of action & long half life
> > I would not expect missing a dose or taking a little less to make much difference the next day,
> > with TCA's.
>
> For some people, nortriptyline can have a very narrow therapeutic window. If you take too much, you can lose the antidepressant effect. I don't know if this is one of those instances, but I had a similar experience with the drug.
>
>
> - ScottBut we are just talking about one day or one dose'es worth of change. Again, given the half-life of this med I would not expect this to effect the "narrow therapeutic window" provided
the change was just one day. At least this is my experience, having been on AD since 1984. In 84
most all we had was TCA's and I found the long half life ment I could miss a day with no ill effect. I never noticed a missed dose.
Posted by SLS on December 17, 2002, at 0:41:03
In reply to Re: TCA discontinuation???, posted by oracle on December 16, 2002, at 17:34:04
> But we are just talking about one day or one dose'es worth of change. Again, given the half-life of this med I would not expect this to effect the "narrow therapeutic window" provided
> the change was just one day. At least this is my experience, having been on AD since 1984. In 84
> most all we had was TCA's and I found the long half life ment I could miss a day with no ill effect. I never noticed a missed dose.
Hi Oracle.Nortriptyline is a strange one - it is the odd-ball among tricyclics. Some people - myself included - are unable to find a single right dosage. While on it, I would experience an improvement during the first 12-24 hours of changing the dosage from 75mg to 100mg and similarly from 100mg to 75mg. "Missing" one 25mg dose of nortriptyline proved to have a dramatic and deleterious effect on me within 12 hours. I have seen this kind of thing reported elsewhere. Unfortunately, I can't come up with any citations right now.
- Scott
Posted by johnj on December 17, 2002, at 10:12:10
In reply to Re: TCA discontinuation???, posted by oracle on December 16, 2002, at 17:34:04
I will try this again since my other post didn't make it.
Within 10 days this is what I did. Increase accidently from 50 to 70 of nortryptline. On the 2nd day in the evening I felt like hell. I realized my mistake and went back to 50 and felt decent. I lowered to 40 and on the 2nd day my sleep was disturbed and even worse on the 3rd day. I went back to 50 on the 4th night and slept even worse. Took 50 last night and feel much better today. So, things changed after a day, but if I miss a dose I don't sleep so well. This drug definately doesn't take 4 to 6 weeks to work. Maybe for depression it does, but to help my sleep it worked fairly quick. I am med sensitive so I know really quick what is going to work and that is why I am leary of lexapro.
Posted by oracle on December 17, 2002, at 18:06:25
In reply to Re: TCA discontinuation??? » oracle, posted by johnj on December 17, 2002, at 10:12:10
The sedating qualities of a TCA (better sleep and less anxiety) happen at once with a TCA and are not related to the true antidepressant effect.
Sometimes side effects are good things.
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.