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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 RetiredYoung on March 6, 2006, at 9:38:33
Hello - With the newly approved EMSAM, I understand that the dietary restrictions are less strenuous, particularly at lower dosages. However, does it share the same trait as the MAOIs in that one must completely wean off of their current anti-depressant cocktail before even beginning use of the new patch? Thanks in advance..
Jim
Posted by SLS on March 6, 2006, at 11:18:28
In reply to EMSAM/new MAOI patch question about when to start, posted by RetiredYoung on March 6, 2006, at 9:38:33
Hi Jim.
> Hello - With the newly approved EMSAM, I understand that the dietary restrictions are less strenuous, particularly at lower dosages. However, does it share the same trait as the MAOIs in that one must completely wean off of their current anti-depressant cocktail before even beginning use of the new patch? Thanks in advance..
That very much depends on what drugs you are currently taking. You might want to list them here for others to comment on.
For the sake of safety, I think it would be prudent to treat EmSam like any other MAOI.
- Scott
Posted by RetiredYoung on March 6, 2006, at 12:44:32
In reply to Re: EMSAM/new MAOI patch question about when to st, posted by SLS on March 6, 2006, at 11:18:28
Hi Scott -
I'm currently transitioning from Prozac to Paxil, augmented with 10mg Zyprexa. It's giving me "fair at best" results. If the switch to Paxil doesn't help much, I'll be shopping for a new drug/drug combo.
I've always wanted to try MAOIs because I have many of the symptoms of atypical depression, but I've been on some antidepressant regimine for 18 years now and know that completely going off any medication long enough to start an MAOI would be too hellish to endure (I've tried several times in the past).
That's why I'm hoping that the new MAOI patch is less restrictive in its drug-drug interactions, and would let me start using it while transitioning off my current stuff.
Regards,
Jim
Posted by gibber on March 6, 2006, at 20:38:27
In reply to Re: EMSAM/new MAOI patch question about when to st » SLS, posted by RetiredYoung on March 6, 2006, at 12:44:32
When I transitioned from Prozac to Nardil I had to wait four weeks. All the SSRIs I believe are contraindicated with MAOIs so they need to be out of the system. Fortunately I didn't have any withdrawal symptoms from the prozac, but after the four week withdrawal I was really ready for a new med. I'd guess you would need to washout of Paxil before taking the patch.
Posted by DavidLA on March 6, 2006, at 23:02:48
In reply to Re: EMSAM/new MAOI patch question about when to st, posted by gibber on March 6, 2006, at 20:38:27
I'm taking Nardil now -- how would I transition to EMSAM?
-David
Posted by rvanson on March 7, 2006, at 7:42:55
In reply to EMSAM/new MAOI patch question about when to start, posted by RetiredYoung on March 6, 2006, at 9:38:33
> Hello - With the newly approved EMSAM, I understand that the dietary restrictions are less strenuous, particularly at lower dosages. However, does it share the same trait as the MAOIs in that one must completely wean off of their current anti-depressant cocktail before even beginning use of the new patch? Thanks in advance..
>
> JimYes, if your doctor is careful, he/she will or should want you off the SSRI's and other such A/D's before starting a new, untested in the general population med like Emsam.
If you are using a longer lasting A/D, like Prozac, you would be needing to cut down on it soon in order to give EmSam a fair trial when it comes out on the shelves in April.
Posted by Chairman_MAO on March 7, 2006, at 10:28:33
In reply to EMSAM/new MAOI patch question about when to start, posted by RetiredYoung on March 6, 2006, at 9:38:33
A more aggressive strategy would be to start on oral selegiline up to 15mg/day (with food!) during the washout and then switch to the patch.
FWIW, I used to take 15mg/day sublingually or orally along with an SSRI and never had an interaction. The inhibition of brain MAO-A from the lowest dose of the patch is probably significantly greater than 20mg+ oral selegiline, though.
Posted by cecilia on March 8, 2006, at 0:39:27
In reply to Re: EMSAM/new MAOI patch question about when to st » RetiredYoung, posted by Chairman_MAO on March 7, 2006, at 10:28:33
I've been thinking about Emsam and how they claim it has practically no side effects. I just can't believe it won't cause anxiety and insomnia. I finally figured out why they probably got such good results in their studies. In real life most people have both anxiety and depression and often other problems as well, but in studies, if they're trying to get approval for something for depression they have to find subjects who have ONLY depression and no anxiety, and vise versa. Now I'm discouraged. I bet there will be lots of side effects in the real world. Cecilia
Posted by rvanson on March 8, 2006, at 7:42:31
In reply to Emsam-Anxiety, posted by cecilia on March 8, 2006, at 0:39:27
> I've been thinking about Emsam and how they claim it has practically no side effects. I just can't believe it won't cause anxiety and insomnia. I finally figured out why they probably got such good results in their studies. In real life most people have both anxiety and depression and often other problems as well, but in studies, if they're trying to get approval for something for depression they have to find subjects who have ONLY depression and no anxiety, and vise versa. Now I'm discouraged. I bet there will be lots of side effects in the real world. Cecilia
There will be side-effects that are not mentioned in the studies.
Being as Emsam will probably be affecting the Dopamine reward system more so then the Serotonin or even worse, Norepinepherine systems it _could_ help with anxiety in _some_ people.
I just hope the FDA doesnt pull another Survector ban or Merital recall and put lots of needy people right back on the road to hell, i.e depression by pulling Emsam off the market after a few months.
Posted by Last Chance on March 8, 2006, at 10:04:04
In reply to Emsam-Anxiety, posted by cecilia on March 8, 2006, at 0:39:27
> I've been thinking about Emsam and how they claim it has practically no side effects. I just can't believe it won't cause anxiety and insomnia. I finally figured out why they probably got such good results in their studies. In real life most people have both anxiety and depression and often other problems as well, but in studies, if they're trying to get approval for something for depression they have to find subjects who have ONLY depression and no anxiety, and vise versa. Now I'm discouraged. I bet there will be lots of side effects in the real world. Cecilia
Cecelia - try and be a little more optimistic - let's just wait and see how it works - occasionally something good does happen. You are probably right about the criteria for clinical trials, but don't be discouraged, YET. Richard
Posted by willyee on March 8, 2006, at 14:44:25
In reply to Re: Emsam-Anxiety, posted by rvanson on March 8, 2006, at 7:42:31
At the higher doses it will come,i dont believe deprenyl EMSAM is gonna be so selective on dopamine,now it wont be like Nardil cause nardil is unique in its metabolites actualy increase OVERALL brain gaba,HOWEVER unlike low doses of deprenyl,im expecting it to instead prob feel like parnate,only when parnate first is used,minus the tolerance.
Once it reaches the inhibition it should,except the entrance into the body,yay yay,it should be similiar to parnate.
Nardil is always gonna be a unique maoi.
Posted by cecilia on March 8, 2006, at 21:57:19
In reply to Re: Emsam-Anxiety, posted by willyee on March 8, 2006, at 14:44:25
That's what I'm afraid of -that it'll be similar to Parnate. Parnate was like drinking 20 gallons of coffee a day. Cecilia
Posted by Chairman_MAO on March 8, 2006, at 22:12:39
In reply to Re: Emsam-Anxiety, posted by willyee on March 8, 2006, at 14:44:25
Actually, tranylcypromine is more atypical of an MAOI than the hydrazines or selegiline. Its mechanism of inhibition is not that of a suicide substrate. The exact mechanics of it are beyond the scope of my knowledge, and I am not sure if they've even been fully elucidated. However, it is a "semi-reversible" inhibitor, i.e. MAO activity returns to normal sooner upon withdrawal of tranylcypromine.
The antidepressant effect of tranylcypromine is more robust than that of oral selegiline (even at up to 80mg/day)--even in the patch, most likely. Tranylcypromine is a vastly more potent DA releaser, and in doses of 1.5mg/kg+ (90-200mg/day) its active metabolites block monoamine uptake (SE, DA, NE) and also perhaps cause amphetamine-like K+-stimulated DA release as well. This is not surprising given it is trans-2-phenylcyclopropylamine (cyclicized amphetamine). Amphetamine can also be called phenylisocyclopropylamine.
Selegiline does act as a "catecholamine activity enhancer" (see articles by Jozef Knoll) and is a good antidepressant, especially for those with marked vegitative symptoms/psychomotor retardation. Tranylcypromine is probably suprior for social phobia.
Unless you throw on two or more patches at once, I would be surprised if the patch would be as robust as 1.5mg/kg tranylcypromine. :)Note that tranylcypromine is an excellent antidepressant for those suffering from Parkinson's disease as well. Selegiline is used more frequently because it has substantially less toxicity, especially at low doses.
If you have an anxiety disorder and are willing to tolerate MAO drug/dietary restrictions, then I'd say tranylcypromine is probably a better choice than selegiline (assuming monotherapy). What you describe as "tolerance" is actually the first-run MAOI effects waning and a growing sensitization to the psychostimulant effect of tranylcypromine and its metabolites. Due to its short half-life, you are constantly reminded of this, unfortunately. I had to dose 150-200mg/day to sustain full benefits all day.
For anxiety, I would try d-amphetamine with a hydrazine MAOI, d-amphetamine with 0.7mg/kg tranylcypromine + benzodiazepine, or d-amphetamine with low-dose selegiline patch + benzo.
Posted by willyee on March 9, 2006, at 19:32:03
In reply to Re: tranylcypromine vs. selegiline » willyee, posted by Chairman_MAO on March 8, 2006, at 22:12:39
I have worried that,being on such a parnate dose
the patch would not be effective,but i dont truly dont believe my doc feels this way because of the knowledge u just spoke of,i believe simply she wants to be difficult.I went literaly crazy on amphetmaine and ended in ER,it caught up to me,out of no where,so i dont wanna mess with that,but i do think about possably waiting on the patch,i know u dident agree with the reasoning,but when i added medium dose liq deprenyl to parnate i had much more improvment,im doing a lot better now,upon xyrem in low doses and depakote,not perfect but a LOT better,im gratefull we have such knowledagble people here,and again many may not agree but seeing many many docs i feel a good number of people here can run circles around them.
Posted by Chairman_MAO on March 11, 2006, at 17:57:01
In reply to Re: tranylcypromine vs. selegiline, posted by willyee on March 9, 2006, at 19:32:03
Oh, I'm sure selegiline had a noticeable effect when you added it to Parnate--probably a lot more than if you took it alone. I'm just saying that I strongly suspect you aren't going to get what you're looking for out of the patch unless you wear four of them. :)
Worth a try, though. I'm glad I don't have your doctor. Mine is being difficult about amphetamine+MAOIs, but other than that he has been refreshingly non-dogmatic and ocmpetent. It took me a long time to find this guy; I have had some utterly incompetent psychiatrists before. The worst guy I had would not Rx an MAOI despite god knows how many treatment failures. I am also sure beyond any doubt that I knew vastly more pharmacology than he did.
This is the end of the thread.
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