![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by mike99 on January 6, 2006, at 19:07:46
I am super-sensitive to stimulants from a cardiovascular standpoint.
I am interested in trying Strattera, but am concerned about its peripheral adrenergic side effects. I'm also concerned, reasonably or not, about it's liver warning.
My understanding is that Strattera primarily increases Norepinephrine in the brain, but will also cause peripheral sympathetic/adrenergic stimulation.
I am scared to death of trying Strattera because I've ended up in the ER twice on extremely low doses of stimulants (tachycardia, chest pain, way high blood pressure) and am concerned that given this extreme hypersensitivity to adrenergic effects I shouldn't even give Strattera a trial. I've had my heart checked out and it's fine (except for MVP, so Provigil is out of the question).
The reason I'm holding out hope for Strattera is that I didn't have any cardiovascular problems when I took Remeron, which also has SNRI actions.
Could anyone provide any feedback, experiences or thoughts on this? I'm wondering if perhaps I should skip Strattera and give Namenda or Aricept a try as they have minimal cardiovascular effects (I realize they're non-approved for ADHD and Aricept may cause slow heart rate).
Any feedback would be greatly appreciated (Ambien is the only other med I take).
Posted by mike99 on January 8, 2006, at 9:45:02
In reply to Cardiovascular Stimulation-Strattera vs Stimulants, posted by mike99 on January 6, 2006, at 19:07:46
How does the peripheral (heart rate/strength, blood pressure) stimulation of Strattera compare to that of stimulants?Has anyone had success with Strattera in this regard where they could not tolerate stims?
Posted by ed_uk on January 8, 2006, at 10:43:02
In reply to Cardiovascular Stimulation-Strattera vs Stimulants, posted by mike99 on January 6, 2006, at 19:07:46
Hi Mike
>I've ended up in the ER twice on extremely low doses of stimulants (tachycardia, chest pain, way high blood pressure) and am concerned that given this extreme hypersensitivity to adrenergic effects I shouldn't even give Strattera a trial.
Tell us more about this. Which drug? What dose?
Ed
Posted by vbAgent on January 8, 2006, at 15:41:49
In reply to Re: Cardiovascular Stimulation-Strattera vs Stimulants » mike99, posted by ed_uk on January 8, 2006, at 10:43:02
hi mike99, many people are hypersensitive to stimulants. This doesn't necessarily mean you can't benefit or that it's the wrong medication.
Have you considered using a beta blocker? Beta blockers, like Toprol or atenolol, are commonly combined with a stimulant to dull the cardiovascular activation. The (p)doc will want to aim for a beta blocker that has minimal impact on the CNS (central nervous system) in the brain; one that doesn't readily cross the blood-brain barrier.
About Strattera, I have tried it, but with little success. I experienced nausea and dizziness from it. This is NOT to say you will also exerience these adverse effects. Your mileage may vary.
I think staying on a low dose of a stimulant or non-stimulant, like Strattera, is a good idea in your case. Strattera *may* increase blood pressure. So, if you give it a trial run start with a low dose.
Posted by mike99 on January 8, 2006, at 16:52:33
In reply to Re: Cardiovascular Stimulation-Strattera vs Stimulants » mike99, posted by ed_uk on January 8, 2006, at 10:43:02
> Hi Mike
>
> >I've ended up in the ER twice on extremely low doses of stimulants (tachycardia, chest pain, way high blood pressure) and am concerned that given this extreme hypersensitivity to adrenergic effects I shouldn't even give Strattera a trial.
>
> Tell us more about this. Which drug? What dose?
>
> EdRitalin at 10 mg bid-tid caused me chest pain and mild tachycardia, but not so bad w/ the blood pressure. But the chest pain was very concerning.
The first day I took Adderall I took about 10 mgs (too much to start in retrospect) over several hours, and then about 7.5 each on the second and third days...Everything seemed fine until the third day when my heart just started beating and racing uncontrollably. I mean it was beating monstrously heavily, at about 160/min and my bp went up to around 165/100. This resolved on it's own over a few hours and after calling an ambulance. I subsequently had my heart checked and it was fine (echo, stress echo, even an MRI). The cardiologist said only to take stims "as tolerated".
About a year later I tried Dex, hoping perhaps cutting out the L-isomer would be of benefit and deciding to go much slower. I took only 1.25 mg twice for two days and then four times a day for the third and fourth days...again, no problem until on the fifth day my heart just started beating uncontrollably harder and faster over a few minutes. It finally settled down a bit in the ER, so I didn't have to be admitted, but it was still beating much harder and faster than usual for about 7-10 days after this episode. They had to rule out a heart attack and everything and the ER doc said not to take any more stimulants (not that I needed him to tell me that). The EKG read "incomplete right bundle branch block"...which scared me to death but he and at least 2 other cardiologists said my EKG was of no concern and just to stay away from the stims.
I honestly think I would die if I ingested a single 20 mg dose of Adderall or Dexedrine, which young children take all the time.
Honestly, after these experiences I will never under any circumstance (ie with an alpha/beta blocker) try another stimulant again.Interestingly, even L-Tyrosine and Zoloft have caused me chest pain (I took 50 mg Zoloft on the first day and just about dropped to my knees with chest pain and threw the bottle out). I'm only 28. I think I'm just supersensitive to the adrenergic stimulation. I have to admit, I've never heard of SSRI's causing chest pain--even my 88 year old grandmother tolerates them, so I often wonder what the heck is wrong with my physiology.
The few months that I took Ritalin were amazing...yes I hate to be dramatic but it was like an awakening...and although I only took Adderall and Dex for a few days each, I was able to focus for the first time in my life. Unfortunately I just cannot tolerate these drugs. Without them I have no physical problems -- I'm actually quite an avid runner and stay in good shape.
I'm just so frustrated that the few drugs that actually work on the symptoms that have so long plagued me I simply cannot tolerate.
That's why I'm thinking about Strattera, but I'm really not sure if I want to try it...I'm quite gunshy at this point. Anyhow, sorry for the long-winded response but I hope I answered your question.
Posted by mike99 on January 8, 2006, at 17:17:00
In reply to Re: Cardiovascular Stimulation-Strattera vs Stimul, posted by vbAgent on January 8, 2006, at 15:41:49
> hi mike99, many people are hypersensitive to stimulants. This doesn't necessarily mean you can't benefit or that it's the wrong medication.
>
> Have you considered using a beta blocker? Beta blockers, like Toprol or atenolol, are commonly combined with a stimulant to dull the cardiovascular activation. The (p)doc will want to aim for a beta blocker that has minimal impact on the CNS (central nervous system) in the brain; one that doesn't readily cross the blood-brain barrier.
>
> About Strattera, I have tried it, but with little success. I experienced nausea and dizziness from it. This is NOT to say you will also exerience these adverse effects. Your mileage may vary.
>
> I think staying on a low dose of a stimulant or non-stimulant, like Strattera, is a good idea in your case. Strattera *may* increase blood pressure. So, if you give it a trial run start with a low dose.Hi and thanks for the input, vbAgent. I have long considered adding a beta-blocker or alpha/beta blocker (like labetalol) to a stim. Not to be dismissive of this suggestion, but if regular doses of stims were to cause me mild symptoms I would consider this.
However, given the severe reaction I've had to even miniscule doses of stimulants (please see previous post) AND the fact that even an SSRI and L-Tyrosine have caused me chest pain/tachycardia/high blood pressure (which I still can't figure out-- and I have never taken an SSRI at the same time as a stimulant), I will never again touch a stimulant.
I'm sorry to hear Strattera did not work for you. I get the general impression it's really not that great of a treatment and actually don't hold out much hope for it. Nonetheless it seems to help some people and I'd be grateful if it could give me just have the benefits that stimulants do-- if I could tolerate it. In such a case I'd consider taking a beta-blocer w/ Strattera, but I'm quite gunshy about trying anything with adrenergic properties at this point.
Again, thanks for your reply and input. I really hope I can find something that works.
Posted by vbAgent on January 8, 2006, at 18:30:40
In reply to Re: Cardiovascular Stimulation-Strattera vs Stimul, posted by mike99 on January 8, 2006, at 17:17:00
>> "...and the ER doc said not to take any more stimulants (not that I needed him to tell me that). The EKG read "incomplete right bundle branch block"...which scared me to death but he and at least 2 other cardiologists said my EKG was of no concern and just to stay away from the stims."
hello again, I'm also 28, and I have a mild case of hypertension, insomnia and ADHD - all which I take medication for. Thankfully, my BP is under control. The rest is variable...
Anyhow, I definitely relate to your frustration! Do NOT give up hope. Many people who are ADHD also have anxiety, depression &/or insomnia mixed in that complicates the clinical picture. Treating one problem can tip the scale by aggravating a preexisting problem. Like I said in an unrelated post, your health care becomes a trial and error chemistry experiment.
You are on the right track by being careful and following the advice of the ER docs.
-------
p.s. Have you heard of Focalin? If not, look it up at http://www.drugs.com/
You always have the option of taking a low dose stimulant w/ a beta blocker. The decision is yours to make and there's certainly no rush.
Peace...
Posted by mike99 on January 9, 2006, at 10:54:55
In reply to Re: Cardiovascular Stimulation-Strattera vs Stimul, posted by vbAgent on January 8, 2006, at 18:30:40
> >> "...and the ER doc said not to take any more stimulants (not that I needed him to tell me that). The EKG read "incomplete right bundle branch block"...which scared me to death but he and at least 2 other cardiologists said my EKG was of no concern and just to stay away from the stims."
>
> hello again, I'm also 28, and I have a mild case of hypertension, insomnia and ADHD - all which I take medication for. Thankfully, my BP is under control. The rest is variable...
>
> Anyhow, I definitely relate to your frustration! Do NOT give up hope. Many people who are ADHD also have anxiety, depression &/or insomnia mixed in that complicates the clinical picture. Treating one problem can tip the scale by aggravating a preexisting problem. Like I said in an unrelated post, your health care becomes a trial and error chemistry experiment.
>
> You are on the right track by being careful and following the advice of the ER docs.
>
> -------
>
> p.s. Have you heard of Focalin? If not, look it up at http://www.drugs.com/
>
> You always have the option of taking a low dose stimulant w/ a beta blocker. The decision is yours to make and there's certainly no rush.
>
> Peace...
Thanks again for the encouragement and info...And yes, I'm familiar with Focalin, although I've never tried it. I too have insomnia and can definitely relate to your "trial and error chemistry experiment" point.I'm still unsure of what I want to do at this point... I guess I always have the option of doing nothing, but I will take my time to think it over. Thanks again...peace
Posted by ed_uk on January 9, 2006, at 15:07:36
In reply to Cardiovascular Stimulation-Strattera vs Stimulants, posted by mike99 on January 6, 2006, at 19:07:46
Hi Mike
Strattera certainly sounds like it might be a risky option for you :(
>MVP, so Provigil is out of the question....
Mitral valve prolapse? The manufacturer (of Provigil) suggests that this may be a contra-indication. I'm not sure it's based on good evidence though.
Ed
Posted by mike99 on January 9, 2006, at 17:06:54
In reply to Re: Cardiovascular Stimulation-Strattera vs Stimulants » mike99, posted by ed_uk on January 9, 2006, at 15:07:36
Thanks Ed,Yeah, I'm aware of the MVP contraindication with Provigil. I seriously doubt I'd try Strattera either. Also, I know in theory an alpha/beta blocker could be combined with a stimulant, but in reality I'm afraid I just may have to go without.
Posted by alohashirt on January 10, 2006, at 4:09:10
In reply to Re: Cardiovascular Stimulation-Strattera vs Stimulants, posted by mike99 on January 9, 2006, at 17:06:54
Mike,
Here's one experience of stimulant + beta blocker:
I was on 72mg Concerta with mild BP elevation
(123/70 --> 132/78) and wanted to try dexedrine or Adderall
My pdoc suggested starting with 30mg Adderall and monitoring
BP.
Day1:
30mg Adderall 138/83 and symptoms suggested 30mg was too low
Day 2
30mg Adderall 140/110 headaches, called pdoc who insisted I stop Adderall immediatelyfew months later I spoke to my internist who suggested "If you get substantively better symptom relief (such that work is more succesful) you could *consider* combining with BP treatment) I began with small dose of dexedrine and ended up with:
54mg dexedrine
100mg Toprol XR, BP 130/80
No side effects from Toprol aside from less sweating in nervous situations.
When Focalin XR was released I tried it and am now on
50mg Focalin XR, no Toprol, 128/78.When I did my dexedrine+Toprol experiment I worked at a place that had an onsite nurse so I could do daily BP monitoring.
It may be worth considering Focalin in that it's a single isomer
which means (in theory) 50% of side effects.Its worth doing this with your internist - remember everyone responds differently both to beta blockers and stimulants in terms of both side effects and symptom reduction. I'm a big fan of careful titration and individual experimentation
>
> Thanks Ed,
>
> Yeah, I'm aware of the MVP contraindication with Provigil. I seriously doubt I'd try Strattera either. Also, I know in theory an alpha/beta blocker could be combined with a stimulant, but in reality I'm afraid I just may have to go without.
Posted by mike99 on January 10, 2006, at 11:00:16
In reply to Beta Blocker (Re: Cardiovascular Stimulation » mike99, posted by alohashirt on January 10, 2006, at 4:09:10
> Mike,
>
> Here's one experience of stimulant + beta blocker:
>
> I was on 72mg Concerta with mild BP elevation
> (123/70 --> 132/78) and wanted to try dexedrine or Adderall
> My pdoc suggested starting with 30mg Adderall and monitoring
> BP.
> Day1:
> 30mg Adderall 138/83 and symptoms suggested 30mg was too low
> Day 2
> 30mg Adderall 140/110 headaches, called pdoc who insisted I stop Adderall immediately
>
> few months later I spoke to my internist who suggested "If you get substantively better symptom relief (such that work is more succesful) you could *consider* combining with BP treatment) I began with small dose of dexedrine and ended up with:
> 54mg dexedrine
> 100mg Toprol XR, BP 130/80
> No side effects from Toprol aside from less sweating in nervous situations.
>
>
> When Focalin XR was released I tried it and am now on
> 50mg Focalin XR, no Toprol, 128/78.
>
> When I did my dexedrine+Toprol experiment I worked at a place that had an onsite nurse so I could do daily BP monitoring.
>
> It may be worth considering Focalin in that it's a single isomer
> which means (in theory) 50% of side effects.
>
> Its worth doing this with your internist - remember everyone responds differently both to beta blockers and stimulants in terms of both side effects and symptom reduction. I'm a big fan of careful titration and individual experimentation
Alohashirt,Thanks for sharing that. Do you mind if I ask how often you took the Toprol XL w/Dexedrine (once daily?) and if you had any tachycardia or angina while on Dex stimulant alone?
I think Focalin would be the only stimulant I'd consider at this point (probably with a beta blocker), because it should have the least peripheral effects of all the stims theoretically.
Thanks again.
Posted by mike99 on January 10, 2006, at 11:13:20
In reply to Re: Beta Blocker (Re: Cardiovascular Stimulation, posted by mike99 on January 10, 2006, at 11:00:16
I've heard of many people taking beta-blockers to counter the cardiovascular activation of stimulants.However, in a prior post a babbler strongly recommended against this as it could lead to "unopposed beta-blockade"-- meaning that the alpha receptors would be overstimulated in relation to the beta receptors (beta blocked but not alpha)-- leading to tachycardia, high-blood pressure...and so that a mixed alpha/beta antagonist such as labetalol or carvedilol should be used to counter a stimulant.
I believe I recall hearing this in a pharmacology class also. Can anyone provide more information on this?
Posted by vbAgent on January 10, 2006, at 15:16:13
In reply to Re: Beta Blocker (Re: Cardiovascular Stimulation, posted by alohashirt on January 10, 2006, at 11:34:42
Hey Mike,
If you haven't stumbled accross it yet, check out my thread further down titled "Treatment-resistant insomnia and I'm sick of it!", particularly the last couple that I added moments ago under the heading "Result of doctor's appt..." Some if it pertains to what's going on here. Good luck. Peace...
Posted by mike99 on January 10, 2006, at 18:25:10
In reply to Re: Beta Blocker (Re: Cardiovascular Stimulation, posted by vbAgent on January 10, 2006, at 15:16:13
Thanks vbAgent...It wouldn't be a bad idea to have a home bp monitoring kit.
I also saw that you mentioned about trying a light box...would that be for your insomnia?
I saw a sleep specialist who said I likely have "delayed phase sleep syndrome"--a form of insomnia where my mind is goofed up on whether it's day or night...He told me to use a light-box (along w/Ambien and Rozerem).
I've been using a light-box I bought on mercola.com (I bought the cheap version) for a few months...It's hard to tell if it's really helped because I (re)started Ambien at the same time, but I don't think it's hurt at all.
Anyhow, thanks for the reference and peace...
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.