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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by ed_uk on December 21, 2004, at 14:25:23
If you have taken a stimulant, what side effects did you experience? eg. dry mouth, palpitations, loss of appetite etc.
Posted by ed_uk on December 21, 2004, at 14:40:58
In reply to Stimulant Side Effects, posted by ed_uk on December 21, 2004, at 14:25:23
To those who have tried several different psychostimulants (for ADHD or hypersomnia or anything else).......
1) How did the effectiveness of Ritalin compare to Dexedrine or Adderall?
2) How did the side effects of Ritalin compare to Dexedrine or Adderall?
Ed.
Posted by zeugma on December 21, 2004, at 15:56:19
In reply to Re: Stimulant Side Effects, posted by ed_uk on December 21, 2004, at 14:40:58
Stimulants I've taken: standard release Ritalin, Cylert, Provigil, Ritalin LA.
The standard release Ritalin was co-prescribed with Prozac, and I believe the Prozac side effects completely obscured whatever the IR Ritalin could have done. Given my later experiences with Ritalin, I now believe the low dose of ritalin did nothing, good or bad, and the Prozac set off major panic attacks.
Cylert is the smoothest stimulant I have experienced. I was at a therapeutic dosage, and experienced none of the notorious crashing that plagues other stimulants. Unfortunately, I lost too much weight on it, and was taken off at my doctor's order. Now, of course, it is unavailable in much of the world and the treatment of last recourse in the U.S., due to hepatotoxicity concerns. A shame, because this stim appears unique in its smooth action (although when you get to a therapeutic dosage of Provigil, there is something close to this).
Provigil: A remarkable drug. It both woke me up and calmed me. My colleagues were blown away by how awake I seemed, and how calm. Writing posts was not the marathon activity it is now, where my speeding mind outruns my body's sluggishness and aggravates my lack of coordination: I was coordinated on this drug. And I did not need to increase my clonazepam, even transiently. Unfortunately, the side effects were so horrendous that I had to go off it, reluctantly, after a five-month trial in which I experimented with different dosages, combined it with Ritalin, etc., in an attempt to stay on it despite the s/e. I won't describe the side effects, as I don't have the energy right now, and I don't think they are typical. The drug, once you get up to 150 mg/day at am, doesn't have much of a crash. I wish I could have stayed on it, combining it with ritalin since the two appeared to work well together. Oh well.
Ritalin LA: At dosages of 20 mg/day or less, discernible effects only in the presence of Provigil. At 30 mg/day (once in am), a little more awake, a little less need for caffeine, truly horrible crash about noon (I typically take it at 6:30 am, so Novartis' claim that this is a once-a-day med is either false or I am an exceptional case). To remain functional through the afternoon, I have to take another 30 mg at noon. Side effects: anxiety through the roof, loss of appetite. The appetite loss is beginning to lift (it's been 2 months on this dose) and the anxiety? well, I have had to take clonazepam prn, sometimes as much as 2 mg/day. I don't like this but the anxiety is intense and counteracts the gain in wakefulness.
On weekends when I take 'med holidays' a single 30 mg capsule is worse than nothing, because it elevates my energy only slightly, and causes a terrible crash. Caffeine moderates the crash somewhat, but caffeine causes its own crashes (albeit lesser). On weekends, when I wake up at 11 am, I take a 30 mg capsule, but it seems to be the second capsule that does the real work (mornings are still bad on ritalin, but less bad than they used to be without a stim, and despite the warning on my pharmacy sheet, I need to have at least one cup of coffee in the am, and sometimes another as the first dose wears off around noon. The second dose usually needs less augmenting with caffeine, but I sometimes have to if I plan to be productive after 5 pm), and I am struggling with the dilemma of taking 30 mg extended release Ritalin at about 4 pm, when theoretically it will be releasing MPH at 8 pm, near enough to bedtime to give me insomnia (if I lose even an hour of sleep the effects are bad!).
The ritalin LA capsule is designed to mimic IR Ritalin 4 hrs. apart, and for me 5 hours or so is its duration of action. That's better than caffeine, at least, and it IS more effective.
I take it TCA's and amphetamines are a riskier combination. As it is, taking 100 mg nortriptyline potentiates the 60 mg Ritalin LA, for some reason. Maybe it's because 75 mg nortriptyline makes me drowsy and 100 mg doesn't, and I can't even speculate on why this might be. It seems like the 60 mg Ritalin just doesn't work as well without the higher nortrip dose (noradrenergic effects?).
There are those who say Adderall and dexedrine are smoother and less anxiogenic than Ritalin. the little information I have been able to glean indicates that amphetamines are more likely to have pharmacodynamic interactions with TCA's, and to be honest I have gotten somewhat used to ritalin's quirks that I am reluctant to switch. I've added back in buspirone, 15 mg hs, as it seems to do *something* that makes me feel better- it makes my sleep-wake transitions easier. this is not a delayed effect, it occurred immediately after reinstating the dose. I have so many sleep and wake problems that anything that makes them less oppressive is welcome.
-z
-z
Posted by ed_uk on December 21, 2004, at 16:42:44
In reply to a complete rundown, posted by zeugma on December 21, 2004, at 15:56:19
Hi Zeugma,
Thank you for your detailed reply :-)
If I was in your position, I really would consider trying dextroamphetamine since the methylphenidate isn't satisfactory for you.
All the best,
Ed.
Posted by zeugma on December 21, 2004, at 18:08:02
In reply to Re: a complete rundown » zeugma, posted by ed_uk on December 21, 2004, at 16:42:44
Hi Ed,
you're most welcome :) D-amphetamine has a better reputation re anxiogenicity, but the scattered info I have gleaned, plus my pdoc's hints, suggest that TCA-methylphenidate combinations are safer than TCA-amphetamine combinations.
I would like to hear from anyone with experience with this particular combination.
-z
Posted by ed_uk on December 21, 2004, at 18:14:57
In reply to anyone taken TCA w/amphetamine?, posted by zeugma on December 21, 2004, at 18:08:02
Hi Mr/Ms Zeugma.....
You may be interested in this info from Stockley's Drug Interactions.........
Tricyclic antidepressants + Methylphenidate or Dexamfetamine (Dextroamphetamine)
Methylphenidate can cause a very marked increase in the plasma levels of imipramine resulting in clinical improvement. Toxicity appears not to have been documented but two adolescents experienced severe mood deterioration while taking both drugs. However, a review of 142 patients suggests the absence of a significant interaction. An isolated report describes a blood dyscrasia in a child given both drugs.Clinical evidence
A study in ‘several patients’ demonstrated a dramatic increase in the plasma levels of desipramine and imipramine during concurrent treatment with imipramine and methylphenidate. In one patient on 150 mg imipramine daily it was observed that 20 mg methylphenidate daily increased the plasma levels of the imipramine from 100 to 700 micrograms/l and of desipramine from 200 to 850 micrograms/l over a period of 16 days. 1Similar effects have been described in other reports. 2,3 Study shows elevation of drug levels takes several days to occur, and several days to wear off. 3 A 9-year-old and a 15-year-old exhibited severe behavioural problems until the imipramine and methylphenidate they were taking were stopped. 4 In contrast a retrospective review in 142 children and adolescents taking either desipramine alone, or desipramine with dexamfetamine (dextroamphetamine) or methylphenidate, indicated the absence of a clinically significant interaction between desipramine and either stimulant. Pharmacokinetic parameters were similar in each group. 5 An isolated report describes leucopenia, anaemia, eosinophilia and thrombocytosis in a child of 10 when given imipramine and methylphenidate. 6
Mechanisms
In vitro experiments with human liver slices indicate that methylphenidate inhibits the metabolism of imipramine, resulting in its accumulation, and this is reflected in raised blood levels. 3 The blood dyscrasia may have been due to the rare additive effects of both drugs. 6Importance and management
Information is limited. Some therapeutic improvement is seen because of the very marked rise in the blood levels of the antidepressant due to methylphenidate, but whether this also can lead to tricyclic antidepressant toxicity is uncertain. It does not seem to have been reported, but the possibility should be considered, although there is evidence that the pharmacokinetics of desipramine is not significantly affected by either methylphenidate or dexamfetamine. Information about other tricyclic antidepressants is lacking. It has been suggested that concurrent use in children and adolescents may be undesirable, due to case reports of adverse behavioural effects. 4
Posted by zeugma on December 21, 2004, at 18:34:31
In reply to Re: anyone taken TCA w/amphetamine?, posted by ed_uk on December 21, 2004, at 18:14:57
Hi Ed,
These reports suggest that MPH interacts with imipramine and probably other tertiary amine TCA's, but not desipramine, a mode substrate for CYP 2D6, nor nortriptyline, metabolized by the same pathways as DMI.
This is why my pdoc's first choice was to have me on Strattera, as even drastic elevations of atomoxetine plasma levels are not highly toxic, and then nortriptyline, rather than clomipramine, since CMI is similar to IMI in its propensity for interactions, including documented ones with Provigil, as well as concerns with MPH. That's why I have Lexapro samples on my kitchen table. presumably, Lexapro + nortriptyline would approximate the effect of clomipramine without the added danger of pharmacokinetic interactions with MPH or provigil.
There was nothing specifically about amphetamine in the reports. the anxiety from ritalin is starting to fade, and so am I (seven hours after my last dose of Ritalin LA). I tried to keep myself awake with caffeine, but find that i really can't drink the stuff with the same abandon. I suppose a drug that keeps me alert till about 6 or 7 pm isn't that bad, although I do feel constrained by this. (on the other hand, insomnia is worse.)
by the way, I'm male. but plain old 'zeugma' will do :)
-z
Posted by ed_uk on December 21, 2004, at 18:49:32
In reply to Re: anyone taken TCA w/amphetamine? » ed_uk, posted by zeugma on December 21, 2004, at 18:34:31
>by the way, I'm male. but plain old 'zeugma' will do :)
Thank you for telling me. As you could probably tell, I was curious. For some reason, I like to know the sex of the person that I'm talking to!
Ed.
Posted by SDW on December 21, 2004, at 19:26:45
In reply to Stimulant Side Effects, posted by ed_uk on December 21, 2004, at 14:25:23
During the last 2 years, I have taken Adderal, Dexedrine, and Ritalin. Of the three, I find Adderall the most effective. Ritalin seemed to be a very weak stimulant compared to the others; if I took enough to provide a stimulant effect, I would have anxiety. Dexedrine is OK, but it is my doctor, actually, who prefers Adderall for his patients with chronic depression. He has a rationale for this but I forget what it was…In any case, he has let me try the others but I’ve been using only Adderal for well over one year with good results.
I must say I hate relying on stimulants – they are a poor substitute for natural energy and do not have any real antidepressant action in my case. I am only using this med so I can continue to function (minimally) with dysthymia (apathy-anhedonia -severe fatigue) and because I am still trying to find an AD (or combo) that will alleviate my fatigue as well as the other symptoms.
The only bothersome side effect has been excessive sweating from time to time, and transient insomnia if I take any after 3:oo pm.
Posted by TheOutsider on December 22, 2004, at 4:33:12
In reply to Re: anyone taken TCA w/amphetamine?, posted by ed_uk on December 21, 2004, at 18:49:32
I combined low dose dexedrine with Clomipramine without ill effect, infact they mixed very well!
Posted by dove on December 22, 2004, at 10:48:19
In reply to Re: Stimulant Side Effects, posted by ed_uk on December 21, 2004, at 14:40:58
Ritalin took effect more quickly as well as producing rapid heart-rate, severe anxiety, very severe and rapid crash, more severe depressive symptoms, and high blood pressure.
Adderall is slower to take effect but smoother. It has never induced rapid heart-rate or high blood pressure and I've been taking it for a couple of years. I prefer the regular Adderall versus the XR, since it gives you the option of breaking the tabs into even smaller amounts and it already lasts much longer than Ritalin.
It still has a bit of a let-down (crash), but nothing even comparable to Ritalin's or even coffee's for that matter.
I still have to pay attention to my depressive symptoms, and I counteract this side-effect by upping my Effexor with a bit of Prozac.
I experience very little increased anxiety on Adderall, worse during the first 3-4 months while initiating--took klonopin for that but haven't used any klonopin in like 5 months.
Ritalin did not help my ADHD, it seemed to aggravate it, and cause a worsening of every symptom. Adderall alleviates many major symptoms and doesn't cause me to feel like I'm losing my mind, or like I need to end my life, or like my heart is going to jump out of my chest and explode.
My daughter is a severe classic ADHD and she experienced similar feelings while on Ritalin. She became extremely and actively suicidal, and everytime she takes even the smallest sliver of a pill she experiences rapid and severe depression.
I know of others who become addicted to the rapid "up" that Ritalin provides, or find it enjoyable, I guess I'm not one of those people.
Hope this helps a little :-)
dove
Posted by ed_uk on December 22, 2004, at 11:50:52
In reply to Re: Stimulant Side Effects, posted by dove on December 22, 2004, at 10:48:19
Thank you dove, it does indeed help :-)
Ed.
Posted by zeugma on December 23, 2004, at 19:41:36
In reply to Re: anyone taken TCA w/amphetamine?, posted by TheOutsider on December 22, 2004, at 4:33:12
> I combined low dose dexedrine with Clomipramine without ill effect, infact they mixed very well!
>Thanks for letting me know. Are you still taking the combination?
-z
Posted by anxiety_free on December 24, 2004, at 0:13:16
In reply to anyone taken TCA w/amphetamine?, posted by zeugma on December 21, 2004, at 18:08:02
I take Tofranil (200mgs) along with Cymbalta (90mgs) and 60mgs Adderall. My doc thought the TCA would be best because its known to interact with amphetamines; I think he wanted a "jump start" effect. Anyway, it worked and still works...I personally like the combination. I also take 20mgs abilify and 30mgs buspar.
Posted by zeugma on December 24, 2004, at 10:54:03
In reply to Re: amphetamines and TCAs, posted by anxiety_free on December 24, 2004, at 0:13:16
> I take Tofranil (200mgs) along with Cymbalta (90mgs) and 60mgs Adderall. My doc thought the TCA would be best because its known to interact with amphetamines; I think he wanted a "jump start" effect. Anyway, it worked and still works...I personally like the combination. I also take 20mgs abilify and 30mgs buspar.
Hmm, that's pretty close to what I take. I take 100 mg nortriptyline, 60 mg Ritalin LA, about 1 mg clonazepam (I've gone up to 2 mg due to anxety from the stim, but am back down to 1) and 15 mg buspirone. How do you find the Tofranil-Cymbalta combination? Have you taken Ritalin, and if so, how does it differ from amphetamines? I know there's a 2:1 ratio in potency between D-amphetamine and methylphenidate (interestingly, there's the same ratio between methylphenidate, and d-methylphenidate, or Focalin) but besides the potency difference do you notice a difference in effect? Thanks,
-z
Posted by anxiety_free on December 24, 2004, at 11:41:47
In reply to Re: amphetamines and TCAs » anxiety_free, posted by zeugma on December 24, 2004, at 10:54:03
Hi! I was on the Ritalin LA+ Focalin combo, too...it wasn't quite doing the trick, so I asked for adderall instead. Ritalin is weaker and seems less "smooth" than adderall. The Tofranil-Cymbalta is all my doc's doing....it works really well, but I had little input other than saying I would like to try a TCA.
Posted by Dave001 on December 24, 2004, at 17:26:47
In reply to a complete rundown, posted by zeugma on December 21, 2004, at 15:56:19
> Ritalin LA: At dosages of 20 mg/day or less, discernible effects only in the presence of Provigil. At 30 mg/day (once in am), a little more awake, a little less need for caffeine, truly horrible crash about noon (I typically take it at 6:30 am, so Novartis' claim that this is a once-a-day med is either false or I am an exceptional case). To remain functional through the afternoon, I have to take another 30 mg at
I don't think you are an exception at all. I have the same problem with stimulants: the effects are ridiculously short-lived by comparison to the "standard" range of duration usually cited. I think that one of the main problems is that most often, the duration of therapeutic activity seems to be determined by the monitoring of hyperactive behavior in children, based on reports from parents, teachers, and physicians, etc. However, adults are much more conscious of their state of mind and alterations to it. That, not to mention metabolic differences between children and adults, may partially (or wholly) account for the discrepancies in reported durations of action.
Posted by Dave001 on December 24, 2004, at 17:35:06
In reply to anyone taken TCA w/amphetamine?, posted by zeugma on December 21, 2004, at 18:08:02
> Hi Ed,
>
> you're most welcome :) D-amphetamine has a better reputation re anxiogenicity, but the scattered info I have gleaned, plus my pdoc's hints, suggest that TCA-methylphenidate combinations are safer than TCA-amphetamine combinations.
>
> I would like to hear from anyone with experience with this particular combination.I was once on desipramine and 30 mg/day of d-AMPH w/o any problems. The stimulant, which I had been on prior to desipramine, did not seem to intensify in effect.
Posted by zeugma on December 26, 2004, at 1:41:49
In reply to Re: anyone taken TCA w/amphetamine? » zeugma, posted by Dave001 on December 24, 2004, at 17:35:06
I'll keep these reports in mind. The main problem I have with Ritalin, as I suggested in my earlier posts, is its duration of action: the regimen I'm on works if I take 30 mg at 6:30 am, another 30 mg at noon. On the weekend and during vacations I've generally been taking 30 mg whenever I wake up, usually around 11 am, and I feel pretty lousy. Today I took 30 mg at 12:30 pm, then took some 10 mg capsules I have left over around 5:30. It made me feel better than I usually do on weekends and holidays, but has kept me up all night long (it's 2:38 am east coast USA). But at least I had the energy to pick up some frozen pizza for dinner.
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