Shown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by SFY on June 16, 2006, at 13:04:10
After trying Requip to supplement my Nortriptyline failed to have any effect, good or bad, my next preferred option was to try Emsam. (I have dysthymia, anhedonia, amotivation, and social anxiety.)
Usually this would mean going off the Nortriptyline as it is clearly contraindicated with Emsam. However, right now I'm dealing with some difficult emotional upheaval in my life and don't want to go off meds especially one that seems to be providing some support against depression.
Despite the combination being clearly contraindicated in both meds' inserts, there are studies showing that adverse reactions are rare. This is especially true when one is already taking a Tricyclic and adds an MAOI to it.
I went into my pdoc's office with 5 pages of abstracts on these studies all set for his initial opposition to my plan. But he didn't even blink an eye - it turns out that years ago when he was in the UK (my pdoc is British), he and his colleagues would occasionally add an MAOI to a Tricyclic for treatment-resistant depression without any adverse effects. He just advised me to check my blood pressure at times (specifically by just stopping into a pharmacy with one of those free blood pressure testers) to make sure it wasn't elevated.
He also said he could give me some Emsam samples (I am his first patient to try it) which he had at his other office. I was a little wary when I picked up the samples the next day and he had me sign a waiver saying that I knew of the risks involved and taking him off the hook. Totally unexpected and it freaked me out a little but I knew there was a risk involved so I got over it.
I'm planning to start the Emsam on Sunday. I'm waiting because I have a party to go to on Saturday which will have a high tyramine menu. Plus on Sunday I'll be spending the day with my parents so just in case anything does go awry I won't be alone. (And then on Monday I'm scheduled to give blood so I'll get a blood pressure check).
I'll keep you all posted on my progress once I've been on it a few days (or when I first feel its effects, good or bad).
Posted by Phillipa on June 16, 2006, at 20:15:37
In reply to Emsam + Nortriptyline: Day T - 2, posted by SFY on June 16, 2006, at 13:04:10
I wouldn't do it if it were me. The fact he had your sign a waiver is bad enough. But he has no experience with EMSAM. Hope some others pop up. Love Phillipa
Posted by SFY on June 17, 2006, at 9:32:01
In reply to Re: Emsam + Nortriptyline: Day T - 2 » SFY, posted by Phillipa on June 16, 2006, at 20:15:37
I'm still leaning towards doing it despite the waiver. My pdoc has experience with MAOI/TCA combos and there is literature supporting using selegiline and TCAs without incident.
Ann Clin Psychiatry. 1997 Mar;9(1):7-13. Related Articles, Links
Retrospective study of selegiline-antidepressant drug interactions and a review of the literature.
Ritter JL, Alexander B.
University of Washington Medical Center, Seattle 98105, USA.
Selegiline is a selective monoamine oxidase inhibitor used in the treatment of Parkinson's disease. It is estimated that approximately one-half of Parkinsonian patients will develop depression requiring antidepressant drug treatment. Recently, selegiline's package insert was revised to reflect the potential risk of adverse effects when it is used in combination with selective serotonin reuptake inhibitors and tricyclic antidepressants. The objective of our study is to assess the safety of combining selegiline with antidepressants. A retrospective chart review was performed on all 28 patients with Parkinson's disease receiving selegiline and antidepressants concurrently to identify possible drug interactions. Compliance was assessed according to prescription refill records. Suspected adverse reactions with combination therapy were documented. There was a total of 40 selegiline-antidepressant drug combinations involving tricyclic antidepressants (n = 25), selective serotonin reuptake inhibitors (n = 7), trazodone (n = 5), and bupropion (n = 3). One patient receiving fluoxetine developed a reaction consistent with the serotonin syndrome; however, it was never documented as such. No other selegiline drug interactions were found. Adverse effects noted were typical of antidepressant monotherapy. Although no selegiline drug interactions were documented in our study, the concurrent administration of selegiline and selective serotonin reuptake inhibitors should be avoided because of literature-reported interactions. We believe that bupropion, tricyclic antidepressants, and trazodone are reasonable choices in combination with selegiline, although tricyclic antidepressants and trazodone may be reserved as second-line treatments.
Posted by crazy777girl on June 19, 2006, at 5:14:19
In reply to Re: Emsam + Nortriptyline: Day T - 2, posted by SFY on June 17, 2006, at 9:32:01
Greetings, I am also on EMSAM & Nortriptyline. My pdoc explained all the hype regarding the conflicts thought to exist. I am treatment resistant, trying this was another way to possibly see results. He has another pt who saw results on this mix.
My pharmacist still calls the mix to my attention & the insurance co still blocks payment till the Dr is phoned for confirmation, every time I get my refills at CVS, but I appreciate the thoroughness of concern on the part of the pharmacy techs.
A.>
I'm still leaning towards doing it despite the waiver. My pdoc has experience with MAOI/TCA combos and there is literature supporting using selegiline and TCAs without incident.
>
> Ann Clin Psychiatry. 1997 Mar;9(1):7-13. Related Articles, Links
>
> Retrospective study of selegiline-antidepressant drug interactions and a review of the literature.
>
> Ritter JL, Alexander B.
>
> University of Washington Medical Center, Seattle 98105, USA.
>
> Selegiline is a selective monoamine oxidase inhibitor used in the treatment of Parkinson's disease. It is estimated that approximately one-half of Parkinsonian patients will develop depression requiring antidepressant drug treatment. Recently, selegiline's package insert was revised to reflect the potential risk of adverse effects when it is used in combination with selective serotonin reuptake inhibitors and tricyclic antidepressants. The objective of our study is to assess the safety of combining selegiline with antidepressants. A retrospective chart review was performed on all 28 patients with Parkinson's disease receiving selegiline and antidepressants concurrently to identify possible drug interactions. Compliance was assessed according to prescription refill records. Suspected adverse reactions with combination therapy were documented. There was a total of 40 selegiline-antidepressant drug combinations involving tricyclic antidepressants (n = 25), selective serotonin reuptake inhibitors (n = 7), trazodone (n = 5), and bupropion (n = 3). One patient receiving fluoxetine developed a reaction consistent with the serotonin syndrome; however, it was never documented as such. No other selegiline drug interactions were found. Adverse effects noted were typical of antidepressant monotherapy. Although no selegiline drug interactions were documented in our study, the concurrent administration of selegiline and selective serotonin reuptake inhibitors should be avoided because of literature-reported interactions. We believe that bupropion, tricyclic antidepressants, and trazodone are reasonable choices in combination with selegiline, although tricyclic antidepressants and trazodone may be reserved as second-line treatments.
>
Posted by SFY on June 19, 2006, at 12:16:49
In reply to Re: Emsam + Nortriptyline: Day T - 2, posted by crazy777girl on June 19, 2006, at 5:14:19
> Greetings, I am also on EMSAM & Nortriptyline. My pdoc explained all the hype regarding the conflicts thought to exist. I am treatment resistant, trying this was another way to possibly see results. He has another pt who saw results on this mix.
>
> My pharmacist still calls the mix to my attention & the insurance co still blocks payment till the Dr is phoned for confirmation, every time I get my refills at CVS, but I appreciate the thoroughness of concern on the part of the pharmacy techs.
> A.How long have you been taking this combo? Have you seen any noticeable results?
I've put off adding the Emsam until later in the week for non-med related reasons.
Posted by crazy777girl on June 19, 2006, at 15:08:56
In reply to Re: Emsam + Nortriptyline: Day T - 2 » crazy777girl, posted by SFY on June 19, 2006, at 12:16:49
I've been on 50 mg of Nortriptyline w/ the lowest dose patch (6mg/24hrs) for about 6 weeks. I had to decrease my Nortriptilyne to 50 mg, as higher doses were making me zombie-like. Higher patch dose was producing swelling in my neck. This combination seems to produce neither bad side effects nor remarkably good results, for me. I am not convinced EMSAM is doing anything for me, and I think I've given it a fair shake, at this point in time. I'm happy to see others here on the board who've seen positive results, though, as not everyone will experience as much resistance to meds. I am also on Topamax, Lamictal, Clonazepam, and Methylphinidate.
Best of Luck - A.> > Greetings, I am also on EMSAM & Nortriptyline. My pdoc explained all the hype regarding the conflicts thought to exist. I am treatment resistant, trying this was another way to possibly see results. He has another pt who saw results on this mix.
> >
> > My pharmacist still calls the mix to my attention & the insurance co still blocks payment till the Dr is phoned for confirmation, every time I get my refills at CVS, but I appreciate the thoroughness of concern on the part of the pharmacy techs.
> > A.
>
> How long have you been taking this combo? Have you seen any noticeable results?
>
> I've put off adding the Emsam until later in the week for non-med related reasons.
Posted by Donna Louise on June 21, 2006, at 8:44:00
In reply to Re: Emsam + Nortriptyline: Day T - 2, posted by SFY on June 17, 2006, at 9:32:01
> I'm still leaning towards doing it despite the waiver. My pdoc has experience with MAOI/TCA combos and there is literature supporting using selegiline and TCAs without incident.
>
> Ann Clin Psychiatry. 1997 Mar;9(1):7-13. Related Articles, Links
>
> Retrospective study of selegiline-antidepressant drug interactions and a review of the literature.
>
> Ritter JL, Alexander B.
>
> University of Washington Medical Center, Seattle 98105, USA.
>
> Selegiline is a selective monoamine oxidase inhibitor used in the treatment of Parkinson's disease. It is estimated that approximately one-half of Parkinsonian patients will develop depression requiring antidepressant drug treatment. Recently, selegiline's package insert was revised to reflect the potential risk of adverse effects when it is used in combination with selective serotonin reuptake inhibitors and tricyclic antidepressants. The objective of our study is to assess the safety of combining selegiline with antidepressants. A retrospective chart review was performed on all 28 patients with Parkinson's disease receiving selegiline and antidepressants concurrently to identify possible drug interactions. Compliance was assessed according to prescription refill records. Suspected adverse reactions with combination therapy were documented. There was a total of 40 selegiline-antidepressant drug combinations involving tricyclic antidepressants (n = 25), selective serotonin reuptake inhibitors (n = 7), trazodone (n = 5), and bupropion (n = 3). One patient receiving fluoxetine developed a reaction consistent with the serotonin syndrome; however, it was never documented as such. No other selegiline drug interactions were found. Adverse effects noted were typical of antidepressant monotherapy. Although no selegiline drug interactions were documented in our study, the concurrent administration of selegiline and selective serotonin reuptake inhibitors should be avoided because of literature-reported interactions. We believe that bupropion, tricyclic antidepressants, and trazodone are reasonable choices in combination with selegiline, although tricyclic antidepressants and trazodone may be reserved as second-line treatments.
>I am so glad that you are not having any conflict with this combination. I just wanted to point out that the study referenced here refers to selegiline used in a dosage that is selective. Which is the usual oral dose given to parkinsonian patients. EMSAM however, is non selective and does effect levels of serotonin. So maybe it has to do with with TCA which is used in combination as to whether there is a problem or not. I believe nortriptyline does not effect serotonin.
donna
Posted by SFY on June 22, 2006, at 14:58:49
In reply to Re: Emsam + Nortriptyline: Day T - 2 » SFY, posted by Donna Louise on June 21, 2006, at 8:44:00
Added Emsam 6 mg patch yesterday to my nightly 75 mg of Nort. So far, so good. I noticed a slight bit of racing heart (but that could have come from my anxiety over the combo) but it soon faded and when I got up too quickly my usual Nort orthostatic hypotension seemed a bit more evident than usual.
Other than that, not much else to report. My sleep, while not perfect, seemed no worse than usual. I have yet to check my blood pressure but haven't noticed any signs of hypertensive crisis.
I may have been a bit more irritable than usual yesterday but I had a good external reason for this so not necessarily Emsam induced.
I'll keep posting as events warrant.
Posted by Donna Louise on June 22, 2006, at 15:37:51
In reply to Re: Emsam + Nortriptyline: Day T - 2 » SFY, posted by Donna Louise on June 21, 2006, at 8:44:00
I was afraid I said something wrong when I said that nortrip did not effect serotonin. I went to crazy meds, which is easy to read , and found there that it is a mild serotonin reuptake inhibitor and a moderate one for norepinephrine. It is like a newer version of Elavil (still it has been around since 1964) and has fewer hits at the histamine receptor so not as bad side effects. Also, "less likely to mess with your heart than other TCA's." Also "regular blood tests are needed for doses greater than 100mg a day." It didn't say why though. I guess I need more info about that.
Anyway, I wanted to correct that it does have a mild effect on serotonin reuptake.donna
Posted by SFY on June 22, 2006, at 23:39:07
In reply to correcting myself, posted by Donna Louise on June 22, 2006, at 15:37:51
> I was afraid I said something wrong when I said that nortrip did not effect serotonin. I went to crazy meds, which is easy to read , and found there that it is a mild serotonin reuptake inhibitor and a moderate one for norepinephrine. It is like a newer version of Elavil (still it has been around since 1964) and has fewer hits at the histamine receptor so not as bad side effects. Also, "less likely to mess with your heart than other TCA's." Also "regular blood tests are needed for doses greater than 100mg a day." It didn't say why though. I guess I need more info about that.
> Anyway, I wanted to correct that it does have a mild effect on serotonin reuptake.
>
> donnaThere might be some dosage issues calling for regular blood tests for high Nort dosing but I don't recall seeing a specific requirement. However, because Nort has a narrow therapeutic window, if you're on a high dose you want to get a blood test to make sure that your blood levels don't exceed the upper limit of that window. When your blood level gets too high, Nort loses its efficacy.
Posted by Donna Louise on June 23, 2006, at 6:25:05
In reply to Re: correcting myself » Donna Louise, posted by SFY on June 22, 2006, at 23:39:07
> > I was afraid I said something wrong when I said that nortrip did not effect serotonin. I went to crazy meds, which is easy to read , and found there that it is a mild serotonin reuptake inhibitor and a moderate one for norepinephrine. It is like a newer version of Elavil (still it has been around since 1964) and has fewer hits at the histamine receptor so not as bad side effects. Also, "less likely to mess with your heart than other TCA's." Also "regular blood tests are needed for doses greater than 100mg a day." It didn't say why though. I guess I need more info about that.
> > Anyway, I wanted to correct that it does have a mild effect on serotonin reuptake.
> >
> > donna
>
> There might be some dosage issues calling for regular blood tests for high Nort dosing but I don't recall seeing a specific requirement. However, because Nort has a narrow therapeutic window, if you're on a high dose you want to get a blood test to make sure that your blood levels don't exceed the upper limit of that window. When your blood level gets too high, Nort loses its efficacy.
>
I believe it said that 150 was a toxic dose, and if that is the case, maybe it is a way too to check to make sure that level is not being reached due to liver metabolism being sluggish.donna
Posted by SFY on June 25, 2006, at 12:05:03
In reply to Emsam + Nortriptyline: Day 1, posted by SFY on June 22, 2006, at 14:58:49
I'm on day 5 of 6 mg. Emsam & 75 mg. Nortriptyline. I've had some sleep disturbance and stomach upset but I'm not sure if these are directly related to Emsam. Even with just the Nort, I've had occasional episodes of early morning awakenings. If it continues then I'll try taking off the patch at night and see if things change. The GI issues are minor and aren't anything I didn't sometimes get before Emsam.
The other night I had a couple of alcoholic drinks in less than an hour and began to notice a headache coming on. It faded pretty quickly but I'm going to keep watch on this in case it's indicative of a possible hypertensive episode. (The rainy humid weather with low pressure also may have played a role.)
Other than that, not much to report. No skin irritation at all - I can't even tell where the patch was after I pull it off. I also haven't had any apparent positive changes. But as long as the side effects remain mild, I'm going to give this at least a six week trial.
This is the end of the thread.
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