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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by Jost on September 19, 2006, at 20:21:32
There's been discussion here about the dose of Emsam available in each patch, in general, and, more specifically, the effect of heat on amount of Emsam absorbed.
My experience indicates that the application of heat, such as in a hot tub, hot bath, heating pad, or even during vigorous exercise, can greatly increase the amount of selegeline absorbed in a short period of time.
This can lead to troublesome side effects, in my case tachycardia and an irregular heartbeat of a kind that would not be sustainable over time.
I've also noticed very negative mood and general physical tension effects after using emsam with heat.
I've had at least five (and possibly more) incidents when this has happened: once with a hot tub, once with use of a heating pad, and several times with aerobic exercise.
In the last week, I began more regular aerobic exercise. On the third or fourth day in a row, I noticed that my heart rate was varying widely (my exercise bike has a heart monitor), and heart palpitations strong enough to cause me to take my blood pressure, and record my pulse.
My heart rate was about 130 and the beat was quite irregular, coming in fast bursts. This continues on and off for five or more hours, and recurred the next day. It also recurred again when I exercised. At this point I consulted my Pdoc, who advised me to take off the patch, and was convinced that the reaction was to too high a dose of selegiline.
I reduced the dose, but yesterday, because of a muscle tightness, was using a heating pad, which happened to cover the area where I had placed the patch. Later, I again had the problem.
I also had a similar experience about a month ago with a hot tub, as well as the very uncomfortable overall mood and somatic sensations.
This overabsoption is due, I believe, to the fact that only a small percentage of the selegeline in the patch is generally absorbed (about 20%). However, under conditons of heat, it is possible that much greater amounts can be absorbed in a very short period of time, greatly increasing one's exposure to the drug. Therefore, under such conditions, side effects can occur that would not normally.
So I would caution anyone taking selegeline to check pulse rate and note other unusual reactions after application of any type of heat, or even exercise.
My Pdoc strongly recommends taking the patch off when exercising, if this problem should occur. Possibly timing the exercise so that the patch can be taken off before and replaced after exercise would be the recommended course.
Jost
Posted by Phillipa on September 19, 2006, at 22:07:05
In reply to Important Info Re: Emsam Dose and Heat, posted by Jost on September 19, 2006, at 20:21:32
Wow excercise. Thanks Jost. If I do go on it I have to remember that. Love Phillipa
Posted by Jost on September 19, 2006, at 23:11:13
In reply to Re: Important Info Re: Emsam Dose and Heat » Jost, posted by Phillipa on September 19, 2006, at 22:07:05
Hi, Phllipa. It's a good thing to keep in mind.
My pdoc thinks, now, that other people he sees have had some of the same reaction, esp. if they put the patch near the hip. People who had done well were having less good reactions, and then as it got cooler, or they moved it to their arm, they did much better. Of the recommended places the hip gets the least ventilation.
My pdoc couldn't make sense of it, but now thinks it's because the dose was probably too high because of irregular delivery of the drug esp in summer and in that location. Some people probably have a type of skin that absorbs the drug more easily, too.
The delivery system doesn't give the drug equally at all times, so it's possible to get more at times. It's nothing to be alarmed about. Just something to watch for.
So maybe when you do use the patch, you can put it on your arm, back, or upper chest.
I do hope you're able to go through the wash-out of luvox, and try the ensam. My pdoc is impressed based on his experience so far. I know it's hard for you to contemplate starting a new med, but maybe it would work for you. That would make it worthwhile to have gone through the difficulty of the switch.
Jost
Posted by Phillipa on September 20, 2006, at 19:37:47
In reply to Re: Important Info Re: Emsam Dose and Heat » Phillipa, posted by Jost on September 19, 2006, at 23:11:13
Jost I made a list with EMSAM at the top for my pdoc next week. As I can't understand how a med that has methamphetamines can help an anxious person. One who can't even be alone in the house or write a check in front of someone. Or shop alone. Thanks for the advise. Love Phillipa
Posted by Jost on September 20, 2006, at 20:31:36
In reply to Re: Important Info Re: Emsam Dose and Heat » Jost, posted by Phillipa on September 20, 2006, at 19:37:47
It seems like a paradox, Phillipa, but amphetamine-like substances can help with anxiety and states of agitation. That's why that work with ADHD. They seem to produce a calmer, more focussed state of mind, where people can concentrate and not be so jumpy and easily distracted.
Selegeline, in general, at the right dose seems to reduce anxiety, although at too high a dose, it can reintroduce it.
That's why sticking with it for a while until you get used to the dose is important. At first, it might make you a little more anxious, or irritable.. As you get used to it, that fades and more positive feelings, and better concentration and energy predominate.
When you do try it, I'm sure we can give you lots of support with some of the worries you have---even if, as may not happen-- there are a few rough spots.
It's not a sure thing-- nothing is-- but emsam is really worth a try.
Jost
Posted by Phillipa on September 20, 2006, at 21:43:17
In reply to Re: Important Info Re: Emsam Dose and Heat » Phillipa, posted by Jost on September 20, 2006, at 20:31:36
Jost seems hard to believe. So if I were to take 1/4 patch as my pdoc suggested and maybe took a higher benzo for a while it might help I might get a life and not dread each day while feeling anxious and my thoughts being I don't want to wake up just sleep. And then when up afraid to go anywhere, afraid to stay home, afraid to do everything? Love Phillipa
Posted by laima on September 20, 2006, at 21:46:28
In reply to Re: Important Info Re: Emsam Dose and Heat » Phillipa, posted by Jost on September 20, 2006, at 20:31:36
Well wow, did I ever have a weird high blood pressure issue, or I should call it "crisis", for several days while using Emsam during a severe heat wave in July!!! I was extremely agitated, panicked, "odd" that week and a half- no other variables changed.
Posted by Jost on September 21, 2006, at 0:31:10
In reply to Re: Important Info Re: Emsam Dose and Heat, posted by laima on September 20, 2006, at 21:46:28
Laima, I wouldn't want to say anything definitive. But it's certainly possible that you experienced the same heat-related dosage problem.
One of the most noticeable side-effects that I felt, and that he mentioned, was unexplained irritability, agitation, and discomfort. He said a number of other people had reported this, to his surprise, after very good responses-- and that now, in cooler weather, etc, they were reporting feeling much better again.
My blood pressure is also high now-- so it does fit, too, with what I'm seeing.
My pdoc is taking it quite seriously. He was very concerned that the manufacturer might hurt the acceptance of a good drug.
If it happens again, you might want to remove the patch, and wait until the next day. He says it's not good to put another one on right away, because there's good chance that the highest dose can be at the begenning. The drug company doesn't claim that the dose is delivered regularly-- only that you'll get about a certain amount in any 24 hours.
So, if it happens give that a try. And at least avoid baths, saunas, heating pads, etc-- or at least be careful if you use one.
Jost
Posted by Jost on September 21, 2006, at 0:43:58
In reply to Re: Important Info Re: Emsam Dose and Heat » Jost, posted by Phillipa on September 20, 2006, at 21:43:17
Phillipa, I really want to answer more tomorrow, because it's late.
But I didn't want to go leave without saying how much I agree with what Scott said above.
I'm hopeful that a small dose of Emsam--like a quarter patch-- may ease your starting, and that Emsam could be beneficial to you.
When my mood changes-- people have told me I look like a totally different person-- and that my age even looks remarkably different!-- Maybe the same is true for you! More importantly, people will feel who you are-- and not just a line on your forehead-- that won't be what matters to them, in the least--they won't even see that--
Because who you are is such a great person--
Jost
Posted by SFY on September 21, 2006, at 14:50:40
In reply to Important Info Re: Emsam Dose and Heat, posted by Jost on September 19, 2006, at 20:21:32
> There's been discussion here about the dose of Emsam available in each patch, in general, and, more specifically, the effect of heat on amount of Emsam absorbed.
>
> My experience indicates that the application of heat, such as in a hot tub, hot bath, heating pad, or even during vigorous exercise, can greatly increase the amount of selegeline absorbed in a short period of time.BMS and Somerset are not unaware of the possible negative effects of heat on EMSAM.
The included medication guide insert clearly states:
"Avoid exposing the EMSAM application site to external sources of direct heat, such as heating pads or electric blankets, heat lamps, saunas, hot tubs, heated water beds, and prolonged direct sunlight."
Posted by Jost on September 21, 2006, at 19:05:14
In reply to Re: Important Info Re: Emsam Dose and Heat » Jost, posted by SFY on September 21, 2006, at 14:50:40
>
> BMS and Somerset are not unaware of the possible negative effects of heat on EMSAM.
>
> The included medication guide insert clearly states:
>
> "Avoid exposing the EMSAM application site to external sources of direct heat, such as heating pads or electric blankets, heat lamps, saunas, hot tubs, heated water beds, and prolonged direct sunlight."It actually says:
"The effect of direct heat applied directly to the emsam patch on the bioavailability of selegiline HAS NOT BEEN STUDIED. However, IN THEORY, heat may result in an increase in the amount of selegiline absorbed...and produce elevated serum levels of selegiline. Patients should be advise to avoid exposing the Emsam application site to external sources of direct heat...such as .....PROLONGED DIRECT SUNLIGHT."
The full passage produces a significantly less clear warning than the part of it that you quoted.
By the way, I was not so advised. While I noticed the mention of this issue, I was by no means aware of its importance.
Also, "prolonged direct sunlight" (the last item in a long list of otherwise more similar items) is not, in my mind, external heat applied "directly" to the patch. It raises a whole other set of issues than saunas, heating pads, etc.
Plus subject was discussed on this board when I started taking emsam. Most people seemed to conclude that baths etc were probably safe. This is apparently very possibly or very likely not the case.
Third, my reactions, and those of other patients of my pdoc, were not produced by saunas, etc. They were produced by normal activities, in the summer-- and attaching the patch to a suggested area of the body.
So the problem may be more significant than one would conclude from the Emsam insert or PDR description.
Jost
Posted by Phillipa on September 21, 2006, at 20:40:03
In reply to Re: Important Info Re: Emsam Dose and Heat » Phillipa, posted by Jost on September 21, 2006, at 0:43:58
Thanks Jost I appreciated that. I have a list for the pdoc of various meds I've tried or want to and Emsam is at the top. Love Phillipa
Posted by SFY on September 22, 2006, at 11:29:50
In reply to Re: Important Info Re: Emsam Dose and Heat, posted by Jost on September 21, 2006, at 19:05:14
> >
> > BMS and Somerset are not unaware of the possible negative effects of heat on EMSAM.
> >
> > The included medication guide insert clearly states:
> >
> > "Avoid exposing the EMSAM application site to external sources of direct heat, such as heating pads or electric blankets, heat lamps, saunas, hot tubs, heated water beds, and prolonged direct sunlight."
>
> It actually says:
>
> "The effect of direct heat applied directly to the emsam patch on the bioavailability of selegiline HAS NOT BEEN STUDIED. However, IN THEORY, heat may result in an increase in the amount of selegiline absorbed...and produce elevated serum levels of selegiline. Patients should be advise to avoid exposing the Emsam application site to external sources of direct heat...such as .....PROLONGED DIRECT SUNLIGHT."Actually, we're both right.
You're quoting the officially required full prescribing information insert which is attached to sample boxes but is not included with prescription packages.
I'm referring to the briefer, much more readable medication guide which is inside every EMSAM box, sample and prescription.
You can download both as PDFs from the official EMSAM site, www.emsam.com
> The full passage produces a significantly less clear warning than the part of it that you quoted.
Again, the clear warning is in the medication guide.
> By the way, I was not so advised. While I noticed the mention of this issue, I was by no means aware of its importance.I'm probably stating the obvious, and I mean no offense, but wouldn't one read an enclosed medication guide before beginning any medication? (And the EMSAM Medication Guide is written in a readable fashion for the consumer with helpful information including a clear description of the dietary restrictions for the 9 mg and 12 mg patches.)
Posted by Jost on September 22, 2006, at 14:26:06
In reply to Re: Important Info Re: Emsam Dose and Heat » Jost, posted by SFY on September 22, 2006, at 11:29:50
> > >
>
> I'm probably stating the obvious, and I mean no offense, but wouldn't one read an enclosed medication guide before beginning any medication? (And the EMSAM Medication Guide is written in a readable fashion for the consumer with helpful information including a clear description of the dietary restrictions for the 9 mg and 12 mg patches.)
No, not really--not if I've done significant reading online of the full information--which as I mentioned, I'd done in this case.Also, I just opened my latest package, which was inside the stapled-closed drugstore bag, and there wasn't any insert in it, so I'm not sure I got an insert.
Plus these are several pages of miniscule type, so I tend to rely on my doctor's advise about which precautions are most important and which need to be followed, and which are less important.
As I, and his other patients, seem to be among the few who do well on this drug, maybe it doesn't matter. However, I"m not sure what your objection is--
That I'm telling everyone that I, as a fairly careful and responsible user of meds, came across an unexpected problem?
What's your objection to this?
My pdoc, who prescribes a lot of Maois, was really surprised about what I told him, and esp. with how it fit with reports from other patients-- and plans to contact the manufacturer to inform them. So I don't think I was in the least negligent in perusing available information about use of Emsam.
Jost
Posted by laima on September 22, 2006, at 20:35:23
In reply to Re: Important Info Re: Emsam Dose and Heat » laima, posted by Jost on September 21, 2006, at 0:31:10
This:>The drug company doesn't claim that the dose is delivered regularly-- only that you'll get about a certain amount in any 24 hours.
...is very interesting. I suspected such. Thanks for your input.
Posted by SFY on September 26, 2006, at 11:20:59
In reply to Re: Important Info Re: Emsam Dose and Heat, posted by Jost on September 22, 2006, at 14:26:06
> No, not really--not if I've done significant reading online of the full information--which as I mentioned, I'd done in this case.
>
> Also, I just opened my latest package, which was inside the stapled-closed drugstore bag, and there wasn't any insert in it, so I'm not sure I got an insert.
>
> Plus these are several pages of miniscule type, so I tend to rely on my doctor's advise about which precautions are most important and which need to be followed, and which are less important.
>
> As I, and his other patients, seem to be among the few who do well on this drug, maybe it doesn't matter. However, I"m not sure what your objection is--
>
> That I'm telling everyone that I, as a fairly careful and responsible user of meds, came across an unexpected problem?
>
> What's your objection to this?I don't have any objection at all. You and your pdoc are obviously well-informed (although unaware of the clearly described heat issue). However, many others who may be considering taking EMSAM may not be so inclined and may be dealing with pdocs or gps whose knowledge is limited. Thus it is critical that they read the Medication Guide.
I'm surprised that the Medication Guide wasn't included with your prescription. The EMSAM box clearly informs the pharmacist that it is to be dispensed with the Medication Guide, which clearly lays out the warnings, contraindications, and dietary restrictions.
Unlike the full prescription insert you refer to, the Medication Guide is fairly brief (only 3 pages long as a PDF), clearly written, and printed in a readable type size. For those who are considering EMSAM, as well as those for whom it was not included with their prescription, the Medication Guide can be found here: http://emsam.com/pdf/medguide.pdf
This is the end of the thread.
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