![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 15 to 39 of 60. Go back in thread:
Posted by Monica L on November 28, 2009, at 19:18:47
In reply to Re: Add anything to help with the EMSAM wait.... » floatingbridge, posted by inanimate peanut on November 28, 2009, at 19:02:49
> It's just not working and I'm on the verge of going to the hospital. I don't know whether to keep giving it a chance or to go back on Wellbutrin and Pristiq (which I was horribly depressed on but not this bad), but that requires a wash out, or to try Nardil, or to try ECT. I just know I need to feel better soon before I go completely crazy.
That's so weird that you just posted to my thread. I'm looking up hospitals on the internet right now. I don't know what's making me feel this way, is it the holidays or what? I've been off EMSAM for almost a week now, cause I dont' have what it takes to give it time unless I'm in the hospital. I'm tired of having my kids see me like this and having my husband take over everything. I'm so thankful that he's so supportive of me and has been for the past 5 yrs that Ive been through this. I've tried ECT and felt that it did help, but I still struggle with low dopamine. It's too the point that because of the low dopamine and inability to function is making me depressed. I dont' know where to turn anymore, I took some ritalin earlier and I felt better for about 4 hrs and then of course it wears off. I'm sorry you are struggling too, I know how you feel.
Posted by Monica L on November 28, 2009, at 19:27:03
In reply to Re: Add anything to help with the EMSAM wait.... » Monica L, posted by floatingbridge on November 28, 2009, at 18:56:52
> Monica,
>
> I'm sorry the emsam seems to be a bust. How are you doing? Will you withdraw? I thought the washout was two weeks, but what do I know? I hope it is only one.
>
> best wishes,
>
> fbI'm not doing to good, I spent all week trying to get in touch with my pdoc, he never returned my call. I left messages with the patient coordinator that I wanted off the emsam and wanted to try something else. I don't understand how he puts me on 6 mg emsam and suggests he sees me in a month to see how I'm doing. One month is a long time when to follow up when you start a new med, with no increase in the dosage and during that month just hope it works. So I stopped the emsam on my own and so far no withdrawls except maybe just feeling worse. I'm think I',m going to see my reg dr on monday, explain whats been going on and see if she will prescribe the parnate. At this point though I'm afraid to try anything because I feel nothing will work. I'm willing to give it two weeks in PILL form, the patch drove me crazy, it never stuck completely.
Anyways, sorry I wrote so much....
Posted by Monica L on November 28, 2009, at 19:29:02
In reply to Re: Add anything to help with the EMSAM wait...., posted by emmanuel98 on November 22, 2009, at 17:04:56
> I tried Emsam last summer, first 6mg then up to 12. It didn't do a thing for me. However parnate worked wonders. Have you tried parnate? Unfortunately, once you're on Ensam, you need a 10-day washout to try anything else.
How long did it take for the parnate to kick in?
Thanks
Posted by floatingbridge on November 28, 2009, at 20:50:52
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 28, 2009, at 19:27:03
> I'm not doing to good, I spent all week trying to get in touch with my pdoc, he never returned my call. I left messages with the patient coordinator that I wanted off the emsam and wanted to try something else. I don't understand how he puts me on 6 mg emsam and suggests he sees me in a month to see how I'm doing. One month is a long time when to follow up when you start a new med, with no increase in the dosage and during that month just hope it works. So I stopped the emsam on my own and so far no withdrawls except maybe just feeling worse. I'm think I',m going to see my reg dr on monday, explain whats been going on and see if she will prescribe the parnate. At this point though I'm afraid to try anything because I feel nothing will work. I'm willing to give it two weeks in PILL form, the patch drove me crazy, it never stuck completely.
>
> Anyways, sorry I wrote so much....Monica, I'm glad you posted. Frankly, that your pdoc just left you on your own, esp. given your history, is irresponsible and bad medicine--I'm really sorry. Will you try segeline in pill, or just go for the parnate? Whichever, I hope you achieve some success. And I hope your gp will give you the parnate if that's what you decide. Sound very rough, Monica. Keep us posted. Many experienced people here w/ parnate to draw advice from.
my best wishes for you,fb
>
>
Posted by emmanuel98 on November 29, 2009, at 0:33:26
In reply to Re: Add anything to help with the EMSAM wait.... » emmanuel98, posted by Monica L on November 28, 2009, at 19:29:02
Parnate worked within a couple of days. I mean I literally went from severe, in the hospital, suidical depression to fine within 48 hours of starting parnate. Emsam did nothing for me.
But this is my experience and everyone responds differently.
> > I tried Emsam last summer, first 6mg then up to 12. It didn't do a thing for me. However parnate worked wonders. Have you tried parnate? Unfortunately, once you're on Ensam, you need a 10-day washout to try anything else.
>
> How long did it take for the parnate to kick in?
>
> Thanks
Posted by Monica L on November 29, 2009, at 8:46:26
In reply to Re: Add anything to help with the EMSAM wait.... » Monica L, posted by emmanuel98 on November 29, 2009, at 0:33:26
> Parnate worked within a couple of days. I mean I literally went from severe, in the hospital, suidical depression to fine within 48 hours of starting parnate. Emsam did nothing for me.
>
> But this is my experience and everyone responds differently.
>
>
> > > I tried Emsam last summer, first 6mg then up to 12. It didn't do a thing for me. However parnate worked wonders. Have you tried parnate? Unfortunately, once you're on Ensam, you need a 10-day washout to try anything else.
> >
> > How long did it take for the parnate to kick in?
> >
> > Thanks
>
>Thanks for the response, one more question if you don't mind, do you know if you take the generic parnate or the brand name?
Thanks Again
Posted by inanimate peanut on November 29, 2009, at 12:46:57
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 28, 2009, at 19:18:47
It's horrible to feel like this. I'm glad your husband is supportive. I had a supportive boyfriend but he left last time I was like this so now I'm all alone trying to deal with this. I have family but they live 2 hours away. I feel so alone and don't know what to do. I'm sorry you're feeling so bad too. I just wish there was something to help us. Do you know what you're going to try next?
Posted by Monica L on November 29, 2009, at 14:29:26
In reply to Re: Add anything to help with the EMSAM wait.... » Monica L, posted by inanimate peanut on November 29, 2009, at 12:46:57
> It's horrible to feel like this. I'm glad your husband is supportive. I had a supportive boyfriend but he left last time I was like this so now I'm all alone trying to deal with this. I have family but they live 2 hours away. I feel so alone and don't know what to do. I'm sorry you're feeling so bad too. I just wish there was something to help us. Do you know what you're going to try next?
Well first thing tomorrow morning I'm going to try and get an appointment with my regular Dr. My next appointment with the Pdoc isn't until the 14 of Dec., which I think is ridiculous, I cannot wait that long. I'm going to tell her that the emsam isn't working out for me and that I want to try parnate. I've been taking 40 mg of ritalin though, I don't know if that would prevent me from trying the parnate right away. If she does prescribe it, I'm going to start it regardless. I dont' know what else to do. My husband and I were talking about whether or not I should admit myself to the hospital and wait everything out there, for the medication to work basically. I'm sorry that you have to go through this alone and away from family. Do you work during the day, or have something to keep your mind busy during the day? It's hard for me because I stay home, and I really need something to keep me busy during the day. Being like this and being a homemaker do not mix well. Are you still on the emsam? The washout to start another maoi is 10 days or a week, I'm not sure but I'm going with the 10 days. Well, let me know how you're doing and hang in there..
Posted by inanimate peanut on November 29, 2009, at 14:53:46
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 29, 2009, at 14:29:26
I hope it works out for you to switch to Parnate. I too am wondering whether I should go in the hospital. I'm just not sure. I have a job but am too sick to work right now so I'm home alone all day. This is really too horrible for words. I'm just trying to get through each minute...
Posted by emmanuel98 on November 29, 2009, at 16:04:08
In reply to Re: Add anything to help with the EMSAM wait.... » emmanuel98, posted by Monica L on November 29, 2009, at 8:46:26
I take generic tranylcypromine.
> Thanks for the response, one more question if you don't mind, do you know if you take the generic parnate or the brand name?
>
> Thanks Again
Posted by ColoradoSnowflake on November 30, 2009, at 21:40:43
In reply to Re: Add anything to help with the EMSAM wait...., posted by emmanuel98 on November 29, 2009, at 16:04:08
I take generic Parnate, also. Gayle
Posted by floatingbridge on November 30, 2009, at 22:56:41
In reply to Add anything to help with the EMSAM wait...., posted by Monica L on November 22, 2009, at 16:16:39
Monica, my thoughts are with you.
fb
Posted by Kingston on December 2, 2009, at 4:24:05
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on November 28, 2009, at 18:55:23
To be honest, EMSAM is pretty good stuff but it does have the nasty habit of lowering my already low Blood Pressure (98/33) and I'm a 180 lb male. Thus it requires stimulant augmentation; I just can't afford EMSAM--plain and simple so I'm looking to alternatives--Parnate being my final alternative b/f up and moving to Bolivia where I can legally chew coca leaves on a perpetual basis. Apparently you can buy coca leaves on Amazon.com now though so maybe I'll stay.
As for EMSAM, you can safely add a stimulant to MAOIs(see discussion below). A low dose of Desoxyn or Dexedrine to the patch should suffice if it is Dopamine or and increase in BP that you are after. I would go with Desoxyn if you can get a script of it. It can be filled at any local Target pharmacy with a 1-2 day response time. It is the best medication on the market, 70 year efficacy record and quite possibly responsible for World War I. It does tend to make you feel like GOD but it blows all MAOIs out of the pharmaceutical abyss in regards to depression. Side effects are benign: increased narcissism, delusions of grandeur, increased strength, stamina and perceived intellect, propensity towards God Complex: all good things if you are someone suffering from Major Depression/Social Phobia.
Problem is, it's pure methamphetamine HCL(as are all the metabolites of the MAOIs: little known secret but the driving force behind these puppies) but Desoxyn has no guise to hide behind. It's very difficult to get and when you do get it, getting a script for the necessary 30+mg/day to knock out depression with an Ike Turner on Tina-uppercut is virtually impossible. It's not like Adderall or Dex in terms of the 'anxious space cadet effect' that comes with. It doesn't make you shaky or socially awkward. This is largely b/c it brushes your serotonin and opiate receptors. Feels sort of like happiness in a pill and you become supremely confident by defacto. Social Phobia, agoraphobia, depression quickly dissipate into thin smog after minutes of ingestion. Withdrawal?...i've never experienced it from Stims. You want to discuss withdrawal, try weaning off Klonopin; it's a nightmare on Elm street; wish i had never been introduced to this demotivating med that works all to well for just about everything but intellectual function/productivity/motivation. I feel like i'm permanently stoned inside a comfortably numb womb of Novicaine for the brain. They say it's more difficult to kick Klonopin than heroine.
I personally can't take Desoxyn anymore b/c like EMSAM, I can longer afford the exorbitant 500 dollar monthly fee(lost all my money in the stock market last year). I currently take the 6mg EMSAM patch with a 15mg Dexedrine Spansule, 30mg of Lamictal & 1mg of Klonopin(couldn't kick it). The cocktail works decently but I actually came on this site to hear people's thoughts about Parnate.
Rather than increasing my EMSAM dose to 12mg, I'm considering a batch of Parnate. I've been toggling Parnate for about five years now but haven't had the courage to succumb to this beast of a drug which is supposed to be the best when tolerated. Is it really that bad in terms of side effects? I've taken almost every drug known to man and have never once had any 'real' side effects. I think this is b/c I exercise daily and eat healthy by default of having Celiac's disease and having to be on a gluten, casein, lactose free diet. The MAOi diet is nothing compared to what i'm forced to eat. Broccoli and Chicken and that's about it. So yeah, not worried about weight gain. Can't see how an amphetamine based drug like Parnate would cause weight gain anyhow, and if it did, I would welcome it. EMSAM has turned me into a toothpick, albeit a ripped tooth pic. Sexual side effects, ACNE and cognition are my major concerns. One positive effect from EMSAM has been that my libido has skyrocketed and I no longer need Viagra to get it up. I know that Nardil is notorious for phallic Down Syndrome but what about Parnate?
Concerning EMSAM, you have to give this drug time. At least 1 month before passing final judgment. At 6mg, it is pretty much just targeting dopamine(it's major metabolite being methamphetamine). If you have severely low dopamine levels already, than you will need to up the dose. And at higher doses, you get some serotonergic and norepinephrinergic effects that are the hallmarks of Parnate and Nardil.
And as for Parnate, it is KING b/c it is essentially a high dose of amphetamine which is why it helps with depression. Parnate is about as close as you'll will get to street methamphetamine/cocaine which is another reason I think doctors tend to stay away from it; highly addictive and tolerance builds rapidly. Parnate does however, have the added benefits of serotonin and some GABA release(not sure about GABA? although I know Nardil releases GABA in megaton quantities) to quell excessive dopaminergic stimulation. This is what EMSAM lacks and why so many people can't tolerate it. If you get anxious on ESAM, contrary to what seems logical, increasing the dose will actually decrease anxiety due to the onset of both MAO-b and MAO-a effect. At 6mg, you are only getting MAO-b. Why they didn't make a Nardil or Parnate patch boggles the mind?? Probably b/c it would work too well and put the SSRI machine that is raking in billions, out of business.
I can imagine that tolerance with Parnate is the same as it would be with any stimulant: you get used to it after a while which makes augmenting with Namenda to abate amphetamine tolerance a possibility. Augmentation with Aricept would also boost the effects of any amphetamine based drug in my experience.
Not sure if Parnate will be any cheaper since my insurance isn't covering anything brand name(tapped out at 2000 max) till January and I refuse to take anything but brand; especially with a drug such as Parnate. For ex: I switched from GSK Lamictal that i was getting from overseas for a ridiculously cheap price to generic Lamictal. It felt like i'd been roofied with sugar pills so I was forced to switch back. Generics are just plain garbage and full of fillers that cause more problems than the intended med cures. I try to avoid anything in pill form and instead ask for either liquid, sub-lingual or transdermal. Pills are primitive and for ex: if you have a bowl of fiber, the pill will get absorbed with the fiber and you will defecate it out a-la-stool without it ever getting absorbed. This is the problem with pills and the major reason why I try to stay away from them. Here's another example of why generics are a waste of money: I take a 15mg GSK Dexedrine Spansule and watch my BP go from 110 to 130 in a matter of minutes. I feel it kick after about 15 minutes. If I take 30 mg of Barr (generic) Dex, there is no BP elevation and the cerebral effect is mild. It all has to do with asorbtion which is why I was hoping that my insurance would cover a new form of liquid Dexedrine called Procentra but nope. Without insurance, that has a 1000 dollar price tag. Ridiculous and I certainly can't afford it.
In long winded conclusion, I can imagine that if you're used to a much more potent drug like Parnate or have low dopamine levels, ESMAM would seem like the difference between caffeine and crystal meth; nothing basically; your dopamine threshold levels have habituated to a very high level so you are going to need a more potent drug or combo. Ask your doc about augmenting the patch with a stimulant. Read below. It was once common practice, even with Parnate.
FOUND THIS THREAD ON THE WEB AND THOUGHT IT MIGHT BE APPLICABLE TO EMSAM AS WELL.The commonest reason people do not respond to tranylcypromine (Parnate) is an inadequate dose. When using an MAOI I follow platelet MAO levels and keep increasing the dose is sufficient to reduce those levels almost to zero. This often takes > 60 mg/day of tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant improvement, the next thing I usually do is to add a psychostimulant such as methylphenidate or dextroamphetamine to the cocktail. Starting with small doses, the dose is gradually increased until the patient is taking about 30 mg/day of dextroamphetamine, or twice as much methylphenidate.
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: MAOIs in high doses and with stimulantsThere are recently been a number of warnings posted there that MAOIs should not be prescribed together with psychostimulants. While that is the conventional wisdom, if universally implemented, it would deprive many severely and intractably depressed people from relief.
In the olden days, the early 1960s, we used to treat some patients with resistant depressions with up to 200 mg/day of tranylcypromine and if that was not effective potentiate it with dextroamphetamine, starting with 2.5 mg once a day and gradually increasing to 15 or 20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine was only able to continue in his professional work by taking 170 mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since the isocarboxazid became unavailable, he has been doing almost as well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is often necessary to use combinations [and doses] of medication that are conventionally considered to be contraindicated.
From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
From: Donald Franklin Klein <dfk2@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine. Very useful for orthostatic hypotension.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder.
From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regimen, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulantsBy the way, I do not get signed consent. I do not think that that holds up very well anyway. Well documented clear chart notes indicating the clinical rationale and including what is told to the patient should always be standard practice and especially with atypical treatment modalities such as this.
Posted by Kingston on December 2, 2009, at 4:33:56
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on November 28, 2009, at 18:55:23
To be honest, EMSAM is pretty good stuff but it does have the nasty habit of lowering my already low Blood Pressure (98/33) and I'm a 180 lb male. Thus it requires stimulant augmentation; I just can't afford EMSAM--plain and simple so I'm looking to alternatives--Parnate being my final alternative b/f up and moving to Bolivia where I can legally chew coca leaves on a perpetual basis. Apparently you can buy coca leaves on Amazon.com now though so maybe I'll stay.
As for EMSAM, you can safely add a stimulant to MAOIs(see discussion below). A low dose of Desoxyn or Dexedrine to the patch should suffice if it is Dopamine or an increase in BP that you are after. I would go with Desoxyn if you can get a script of it. It can be filled at any local Target pharmacy with a 1-2 day response time. It is the best medication on the market, 70 year efficacy record and quite possibly responsible for World War I. It does tend to make you feel like GOD but it blows all MAOIs out of the pharmaceutical abyss in regards to depression. Side effects are benign: increased narcissism, delusions of grandeur, increased strength, stamina and perceived intellect, propensity towards God Complex: all good things if you are someone suffering from Major Depression/Social Phobia.
Problem is, it's pure methamphetamine HCL(as are all the metabolites of the MAOIs: little known secret but the driving force behind these puppies) but Desoxyn has no guise to hide behind. It's very difficult to get and when you do get it, getting a script for the necessary 30+mg/day to knock out depression with an Ike Turner on Tina-uppercut is virtually impossible. It's not like Adderall or Dex in terms of the 'anxious space cadet effect' that comes with. It doesn't make you shaky or socially awkward. This is largely b/c it brushes your serotonin and opiate receptors. Feels sort of like happiness in a pill and you become supremely confident by defacto. Social Phobia, agoraphobia, depression quickly dissipate into thin smog after minutes of ingestion. Withdrawal?...i've never experienced it from Stims. You want to discuss withdrawal, try weaning off Klonopin; it's a nightmare on Elm street; wish i had never been introduced to this demotivating med that works all to well for just about everything but intellectual function/productivity/motivation. I feel like i'm permanently stoned inside a comfortably numb womb of Novicaine for the brain. They say it's more difficult to kick Klonopin than heroine.
I personally can't take Desoxyn anymore b/c like EMSAM, I can longer afford the exorbitant 500 dollar monthly fee(lost all my money in the stock market last year). I currently take the 6mg EMSAM patch with a 15mg Dexedrine Spansule, 30mg of Lamictal & 1mg of Klonopin(couldn't kick it). The cocktail works decently but I actually came on this site to hear people's thoughts about Parnate.
Rather than increasing my EMSAM dose to 12mg, I'm considering a batch of Parnate. I've been toggling Parnate for about five years now but haven't had the courage to succumb to this beast of a drug which is supposed to be the best when tolerated. Is it really that bad in terms of side effects? I've taken almost every drug known to man and have never once had any 'real' side effects. I think this is b/c I exercise daily and eat healthy by default of having Celiac's disease and having to be on a gluten, casein, lactose free diet. The MAOi diet is nothing compared to what i'm forced to eat. Broccoli and Chicken and that's about it. So yeah, not worried about weight gain. Can't see how an amphetamine based drug like Parnate would cause weight gain anyhow, and if it did, I would welcome it. EMSAM has turned me into a toothpick, albeit a ripped tooth pic. Sexual side effects, ACNE and cognition are my major concerns. One positive effect from EMSAM has been that my libido has skyrocketed and I no longer need Viagra to get it up. I know that Nardil is notorious for phallic Down Syndrome but what about Parnate?
Concerning EMSAM, you have to give this drug time. At least 1 month before passing final judgment. At 6mg, it is pretty much just targeting dopamine(it's major metabolite being methamphetamine). If you have severely low dopamine levels already, than you will need to up the dose. And at higher doses, you get some serotonergic and norepinephrinergic effects that are the hallmarks of Parnate and Nardil.
And as for Parnate, it is KING b/c it is essentially a high dose of amphetamine which is why it helps with depression. Parnate is about as close as you'll will get to street methamphetamine/cocaine which is another reason I think doctors tend to stay away from it; highly addictive and tolerance builds rapidly. Parnate does however, have the added benefits of serotonin and some GABA release(not sure about GABA? although I know Nardil releases GABA in megaton quantities) to quell excessive dopaminergic stimulation. This is what EMSAM lacks and why so many people can't tolerate it. If you get anxious on ESAM, contrary to what seems logical, increasing the dose will actually decrease anxiety due to the onset of both MAO-b and MAO-a effect. At 6mg, you are only getting MAO-b. Why they didn't make a Nardil or Parnate patch boggles the mind?? Probably b/c it would work too well and put the SSRI machine that is raking in billions, out of business.
I can imagine that tolerance with Parnate is the same as it would be with any stimulant: you get used to it after a while which makes augmenting with Namenda to abate amphetamine tolerance a possibility. Augmentation with Aricept would also boost the effects of any amphetamine based drug in my experience.
Not sure if Parnate will be any cheaper since my insurance isn't covering anything brand name(tapped out at 2000 max) till January and I refuse to take anything but brand; especially with a drug such as Parnate. For ex: I switched from GSK Lamictal that i was getting from overseas for a ridiculously cheap price to generic Lamictal. It felt like i'd been roofied with sugar pills so I was forced to switch back. Generics are just plain garbage and full of fillers that cause more problems than the intended med cures. I try to avoid anything in pill form and instead ask for either liquid, sub-lingual or transdermal. Pills are primitive and for ex: if you have a bowl of fiber, the pill will get absorbed with the fiber and you will defecate it out a-la-stool without it ever getting absorbed. This is the problem with pills and the major reason why I try to stay away from them. Here's another example of why generics are a waste of money: I take a 15mg GSK Dexedrine Spansule and watch my BP go from 110 to 130 in a matter of minutes. I feel it kick after about 15 minutes. If I take 30 mg of Barr (generic) Dex, there is no BP elevation and the cerebral effect is mild. It all has to do with absorption which is why I was hoping that my insurance would cover a new form of liquid Dexedrine called Procentra but nope. Without insurance, that has a 1000 dollar price tag. Ridiculous and I certainly can't afford it.
In long winded conclusion, I can imagine that if you're used to a much more potent drug like Parnate or have low dopamine levels, EMSAM would seem like the difference between caffeine and crystal meth; nothing basically; your dopamine threshold levels have habituated to a very high level so you are going to need a more potent drug or combo. Ask your doc about augmenting the patch with a stimulant. Read below. It was once common practice, even with Parnate.
FOUND THIS THREAD ON THE WEB AND THOUGHT IT MIGHT BE APPLICABLE TO EMSAM AS WELL.The commonest reason people do not respond to tranylcypromine (Parnate) is an inadequate dose. When using an MAOI I follow platelet MAO levels and keep increasing the dose is sufficient to reduce those levels almost to zero. This often takes > 60 mg/day of tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant improvement, the next thing I usually do is to add a psychostimulant such as methylphenidate or dextroamphetamine to the cocktail. Starting with small doses, the dose is gradually increased until the patient is taking about 30 mg/day of dextroamphetamine, or twice as much methylphenidate.
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: MAOIs in high doses and with stimulantsThere are recently been a number of warnings posted there that MAOIs should not be prescribed together with psychostimulants. While that is the conventional wisdom, if universally implemented, it would deprive many severely and intractably depressed people from relief.
In the olden days, the early 1960s, we used to treat some patients with resistant depressions with up to 200 mg/day of tranylcypromine and if that was not effective potentiate it with dextroamphetamine, starting with 2.5 mg once a day and gradually increasing to 15 or 20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine was only able to continue in his professional work by taking 170 mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since the isocarboxazid became unavailable, he has been doing almost as well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is often necessary to use combinations [and doses] of medication that are conventionally considered to be contraindicated.
From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
From: Donald Franklin Klein <dfk2@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine. Very useful for orthostatic hypotension.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder.
From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regimen, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulantsBy the way, I do not get signed consent. I do not think that that holds up very well anyway. Well documented clear chart notes indicating the clinical rationale and including what is told to the patient should always be standard practice and especially with atypical treatment modalities such as this.
Posted by meltingpot on December 2, 2009, at 12:45:10
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on November 28, 2009, at 18:53:11
Hi,
I feel like you do right now and the only thing that has worked for me in the past when I feel so bad is 10mg of Zyprexa once every 7 days.
I'm taking one tomorrow because the way I feel now feels unbearable. I can't even concentrate on the television in the evening. I promise you that if you react to Zyprexa like I do you will feel a lot better and it will make sticking the Emsam trial out a hell of a lot easier.
Denise
Posted by Kingston on December 2, 2009, at 14:38:56
In reply to Re: Add anything to help with the EMSAM wait...., posted by meltingpot on December 2, 2009, at 12:45:10
Be weary of some of the advice given throughout these forums. I admit that my advice can seem a bit extreme and novel in approach (ie. prescribing desoxyn to someone with depression) but I only give sound advice that has been backed up by some of the top psychiatrists in the country. Recommending Zyprexa to someone as a quick fix for feeling down is, well i'll be blunt, not good advice to be giving. People need to stay as far away from Zyprexa and it's brotherhood as possible if possible. There is a great deal of pressure from the suits to push this drug on America. Much money to be made.
Some pdocs like to prescribe it b/c it works by effect of turning you into a zombie..thereby preventing you from hurting yourself and keeping the psychiatrist lawsuit free. I made the mistake of listening to an uneducated psychiatrist a few years back and experimented with 2.5 mg of zyprexa when I was feeling down. It took my brain 2 weeks to recover to a normal state and my jaw and hand twitched for a year straight. I also became rabidly hungry immediately after ingestion and raided six jars of peanut butter and three tubs of Haggen-Dazz. Food never tasted so good on Zyprexa and I'm not one to overeat..ever. I also enjoyed staring at the television screen and zoning out to American Idol and watching reruns of Sponge Bog Square Pants for about a week straight.
This drug, Zyprexa, will fry your brain in the end. But no one seems to care. BigPharma Lilly is now trying to pawn it off as an anti-Alzy med, claiming it prevents the break down of grey matter: as if grey matter actually matters and has anything to do with Alzheimer's(no one really knows the cause)...the suits don't care as long as it sounds good in a commercial and makes them money.
Don't listen to me, listen to this guy's experience:
"Zyprexa should be taken off the market. Lilly has made a fortune on this drug and Prozac. Both are very dangerous medications. I developed Tardive Dyskinesia from Zyprexa and only took it for 2 months. I was misdiagnosed and will have to live with this awful neurological disorder until I die and I am 30 years old. I hurt constantly in my face and hands. I take 4 drugs to try to control the Tardive Dyskinesia from Zyprexa. I also developed an addiction to Xanax because the Zyprexa made me have panic attacks. Could have lost my license to practice medicine except for the Addictionologist I knew got me off these awful meds and saved my life (yes, my blood sugar was elevated also), but I have been left with irreversible brain damage from Zyprexa. It destroys some of the function of your brain called your "basal ganglia" that controls motor (muscle) movement. Tardive Dyskinesia is a tortuous nightmare. Lilly could give me $100 million and the pain would never go away."Another drug that I see people popping off label is Abilify. You have to be joking??? Abilify, Zyprexa, Seroquel, these are all extremely potent drugs with little known about their long term side effect profile. These drugs are intended as anti-psychotics and the fact that people are using them off label for 'anything short of straight jacket psychosis' is insane. I'm not at all against off label use. For ex. I think Lamictal, Provigil and better yet Nuvigil and better yet high doses of Namenda are brilliant anti-depressants that need to become rapidly accepted as the new AD b/c SSRIs are just garbage and MAOis--while extremely effective--will never be accepted mainstream.
If you are feeling low, best remedy hands down is to go for a jog. I know that's going to get an "oh please, go piss off somewhere else" response and asking a bit much when you're really depressed and set on scarfing cookie dough, but trust me, that's exactly when you should exercise and you can do it even if it feels impossible. Ask yourself this, 'If a naked man walked into your home and began fondling his meat puppet before your eyes, would you stay and let him jostle it in your face or would you get up off the couch and start running?' Unless your a phallic fiend, you'd probably run away as fast as possible. Point being, unless handicapped, you are able to get out an jog if you so desire. Walking is ok but jogging or better yet running full force is the best solution to knocking the wind out of depression. You will not only clear your mind upon doing so with euphoric endorphins and excess oxygen but you will feel good about yourself for having gone for that jog..alleviating your depression further.
If you can't motivate to exercise, then I would recommend some Klonopin to stop suicidal/negatvie thinking. Klonopin is one of those drugs that is a terrible drug but god, what would we do without it. It has way too many positives to even warrant complaining about the negatives or to suggest ever banning it or to suggest that it is an evil drug. It's just addictive and cognitively dulling but there are plenty of ways around the latter at least. Addiction..um...not so much. I've tried and Lithium low dose does seem to help with withdrawl but I end up returning upon realizing just how beneficial Klonopin is. Granted, the five senses aren't as sharp but whatever. Nothing wrong with being addicted to Klonopin as long as you plan on being on it for the rest of your life and there is nothing wrong with that. It's harmless in terms of physical side effects and much safer than alcohol. The detrimental effects of high cortisol levels from high stress and anxiety are far more worrisome.
I would never reccomend stimulants in a down state to someone who is bipolar but I have found that chewing coca leaves(nothing like cocaine which I can't tolerate)to be amazing for lifting suicidal/depressed thoughts(and i'm bipolar by the way)-even if you are bipolar. Coca leaves can be purchased online and it's a crime that they're not readily available to everyone on planet earth. Not a believer in legalizing marijuana but legalizing coca, I strongly advocate. I mean caffeine is more dangerous than coca in so many ways.
But when it comes to anti-psychotics ...yeah...you just don't want to start messing around with anti-psychotics like Zyprexa unless you are forced to. They are intended for people with SEVERE, SEVERE mental disturbance ie. schizophrenia and even then, I could make an argument against there usage.
Apologies if people find this post upsetting as i'm sure many people in this forum are currently taking some the meds i mentioned and downplayed. I'm just stating the truth about a terrible group of medications that have some how finagled there way into mainstream psychiatry. Granted, they have their uses for the insane but I would strongly consider an alternative for everyone else that is coherent enough to post on this message board. I mean how depressed can you be if you're posting on the web? I know when I become suicidal or depressed, the last thing I want to do is to go on the web and start babbling about my problems. Support is good but a truly depressed person wouldn't have the energy to type some of messages i've read on here from people claiming to be in dire straights.-Kingston
Posted by RocketMan on December 2, 2009, at 15:15:19
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 14:38:56
Interesting post Kingston. Even though I disagree with pretty much all of what you wrote, it is your right to express your opinions.
PS.... I like zyprexa
Posted by Monica L on December 2, 2009, at 16:52:30
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 14:38:56
I've stopped the emsam about a week ago, and want to start Parnate. I see my pdoc tomorrow and hope we would agree that would be best to try next. One problem, I've been taking my ritilan for the past 3 days, 40 mgs. Say I do get prescribed the parnate tomorrow, because I've been taking the ritilan, do you think I can I start the parnate as soon as tomorrow or the next day? Or am I going to have to go through another washout before the parnate is started because of the ritilan I've been taking for the past 3 days?
Thanks
Monica
Posted by Kingston on December 2, 2009, at 18:20:52
In reply to Re: Add anything to help with the EMSAM wait.... » Kingston, posted by Monica L on December 2, 2009, at 16:52:30
Monica,
Are you stopping the Ritalin all together? If not, actually adding an MAOi to a patient who has been taking a stimulant is the safer route rather than a stimulant to MAOi."I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later."
The above is an excerpt from my post 2 posts ago towards the bottom and I'll re-post below. This is a convo between some docs in 1995, discussing the use of Ritalin and Dexedrine with Parnate. They all say the same thing: although the combo is considered taboo, they believe it to be safe and extremely beneficial in many cases.
If I were a doctor and you were my patient, I would ask how you responded to the EMSAM to get an idea of how you respond to MAOis? Did you feel tired on it? Difficulty walking up a flight of stairs? Did your blood pressure drop(hypotension)? If so, then I would say you're a prime candidate for stimulant + MAOi therapy and have little to worry about in regards to stopping the Ritilan you are currently taking. I would only recommend that you discuss this all with your doctor and that you lower the stimulant dosage appropriately until you understand how your body reacts to Parnate and whether or not you even need the Ritalin. It may be good to just stop the Ritilan for a while since Parnate is supposed to be stimulating so you may not need a stim unless you are prone to hypotension. Read the following below and show this discussion to your doctor so that he doesn't think you're insane if you do decide to ask to combine Parnate and Ritalin (I would suggest Desoxyn over Ritalin if your BP is normal and you still want the stimulant boost. Desoxyn has little effect on the peripheral nervous system and little effect on blood pressure. It's the safest of all the stimulants aside from having the associated stigma of society's most misunderstood and taboo name-methamphetamine.)
"From: Donald Franklin Klein
dfk2@columbia.edu
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine. Very useful for orthostatic hypotension."
"From: "David A. Kahn" kahndav@cpmc3.cpmc.columbia.edu
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regiment, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone."
From: "Steven L. Dubovsky"
Steven.Dubovsky@UCHSC.edu
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell
75112.1676@compuserve.com
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller MillerKB@wpogate.slu.edu
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder."
> I've stopped the emsam about a week ago, and want to start Parnate. I see my pdoc tomorrow and hope we would agree that would be best to try next. One problem, I've been taking my ritilan for the past 3 days, 40 mgs. Say I do get prescribed the parnate tomorrow, because I've been taking the ritilan, do you think I can I start the parnate as soon as tomorrow or the next day? Or am I going to have to go through another washout before the parnate is started because of the ritilan I've been taking for the past 3 days?
>
> Thanks
>
> Monica
>
Posted by Kingston on December 2, 2009, at 19:37:01
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 18:20:52
Monica,
Thought I'd ask why you are switching from the EMSAM patch? and why have you chosen Parnate over Nardil when Nardil is considered the safer and more efficacious of the two? I really want to believe in Parnate but i've yet to run into anyone that will explain why it is any better than EMSAM. So far, all i keep reading is that Parnate makes you feel good, eliminates depression but insomnia is a hallmark. Why isn't everyone taking Parnate if it is so great. There must be some downside to it? Someone be honest please and give me the low down on their long term experience with this drug? Can you or can't you sleep on it and if not, have you continued use and what did you do to resolve the sleep issue? Most importantly, how does it effect sex drive? Can you take Viagra with Parnate? How does Parnate effect your cognition? I just don't wan't to start taking something that makes me feel great(i have no doubt that Parnate will do wonders in that regard) but comes with a library's worth of side effects. Cocaine makes you feel good but that doesn't mean you should take it on a daily basis. Although I know plenty of people that actually do mini-bumps of cocaine all day long as a means of self-medicating(many of which are high functioning individuals), cocaine is not practical for most; particularly someone such as myself with biopolar spectrum issues.The only reason i'm even switching to 'possibly parnate', maybe even Nardil, is because of cost; Otherwise I would stick with EMSAM. The attraction of ESAM is that it should theoretically work like the other MAOis but with fewer side effects. Even at 12mg where dietary restrictions come into play, Selegeline just has fewer side effects in general. It's apparently the fountain of youth and will actually slow down the aging process when taken chronically(at least it does in rats but who knows if the effect is the same in humans. The idea of it sounds nice and was motivation enough for me to stick with EMSAM long enough for it to pay out. And that's all i suggest to anyone that reacts poorly to EMSAM. Give it a chance. It took a month of heightened anxiety and mood swings and another 2 months of nothing before EMSAM started working like I theorized and I think that's partially b/c the 6mg dose I started off at was the wrong starting dose. I found that starting at 3mg(cutting the patch in half) worked best, mainly targeting dopamine. After three weeks at 3mg, I went straight to 9mg, bypassing the 6mg patch. There isn't enough balance between MAO-a and MAO-b at 6mg. MAO-b is getting hit big time, releasing tons of dopamine which is overstimulating for most but MAO-b is only being brushed slightly. Serotonin and NE release is not enough to combat the dopamine shakes/ irritability(unless you are just someone who is severely deprived of dopamine).
I actually noticed that I became calmer, less anxious at 9mg EMSAM then at 3 and 6 mg. The true efficacy of the patch wasn't fully revealed until a 12 mg dose was reached. My blood pressure dropped drastically though so I augmented with two 15 mg Dex spansule to set my BP back to normal 115/76. Without the Dex, I would actually hate EMSAM as you do and would find myself hating life, very lethargic. Bp was at 86/31. However, the stim-MAOi combo is superior to anything i've ever tried. I've actually strapped on two 12 mg patches , 24mg total and found this to be Pandora; what I assume Parnate or Nardil must feel like. The current EMSAM doses are just too low for most people with years of major depression on their side; especially rapid acetylaters such as myself and a good portion of the Caucasian population. I also augment with 30-50mg of Lamictal which is another amazing find with zero side effects and 1mg of Klonopin which takes care of the GABA that both Parnate and EMSAM lack that Nardil targets.
Unfortunately, my insurance will only cover a 6mg patch( and they only cover 50% of the cost) and now that i'm tapped out($2000max), i can't even afford that. I'm actually thinking of using Zelepar until my insurance kicks in at the beginning of Jan...but then there's Parnate. I mean what if it works? I thinking from a purely financial perspective here. If Parnate works like EMSAM, well, obviously I'll take the Parnate given that it is about 490 dollars cheaper/ month. It sickens me when I think what cool stuff i could buy with a month's supply of EMSAM.
If finances weren't an issue, 12mg EMSAM, alow dose of stimulant, low dose Lamictal and low dose of Klonopin with either Namenda or Aricept or both would be my ideal cocktail. I like this for several reasons: the main being the lack of side effects. Other than low blood pressure and some initial acne, there haven't been any side effects. 2)cognition isn't dulled; if anything this combo boosts your IQ a few domains on the Richter scale. 3)enhanced athletic performance. LAMICTAL and Klonopin block the sensation of pain while EMSAM and a Stimulant increase stamina and strength.
What worries me about Parnate is just that it's going to come at a cost: liver damage and sexual dysfunction as well as insomia. Anyways Monica, sorry for the diatribe. I just start writing and well, don't have time to edit. Stream of conscious is what you get I suppose. Keep me updated on your progress with Parnate b/c i may follow your path if you find that it is working.
Posted by Monica L on December 2, 2009, at 19:58:39
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 19:37:01
I'm switching from the emsam patch because I just dont like how it won't stick good and I thought it was suppose to work quicker. I've tried every medication out there and they all have seem to work right away, that's why I was so discouraged with the emsam not working quickly. The first time I ever took a medication for depression, which was prozac, it changed my life within 20 min. No one ever believes me but it's true. I took the prozac for a while, but had to keep increasing the dosage and it eventually just stopped. Do you know how long the parnate takes to kick in? I'm willing to wait for the parnate to kick in because it's in pill form and not a patch that you dont know if it's on right or what. I was told the parnate would be faster. I went to a reg doc to see if they would by some chance switch me to the parnate, but of course they didnt. My next appt with the pdoc wasnt until the 14th of dec, no way could I wait that long. But she did prescribe me xanax, which has been helping along with the ritalin I already had. I am going to stop the ritalin tomorrow and hopefully I can start the parnate, if I get it, tomorrow. I'm almost scared to ask this, but is there a difference in the generic and brand name parnate? Well, thanks for the response and I'll keep you posted!
Posted by Kingston on December 2, 2009, at 21:37:44
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on December 2, 2009, at 19:58:39
Monica,
Yeah...I believe your Prozac story. Are you bipolar? A lot of the initial success stories and books such as 'Listening to Prozac' were written about patients like us; people who rapidly responded to prozac within days, taking on superhuman tasks as if born again with the energy of ten men. Naturally, this is what psychiatrists trying to sell books are going to write about. You don't hear about these patients five years down the road. And all the Prozac hype and the books that came with was before people understood bipolar spectrum disorder: patients who showed no signs of bipolar beofre SSRI treatment would show all the symptoms shortly after. They don't know what to call this so they just call Bipolar Spectrum Disorder. Off SSRIs, i'm completely normal and entirely boring.I react almost instantly to all of the SSRIs. My favorite was Zoloft. I wrote a 500 page novel in under a month the first time I took Zoloft; a novel which clearly wasn't garbage b/c it's sitting in Barnes and Nobles right now. I wasn't delusional. Just energized and on task. Zoloft changed my life.
We both have what is called SSRI induced hypomania. Sounds to good to be true and it is. The hypomania that allowed me to write a novel turned sour after ten months solid before dumping down the SSRI sewer pipes and into the fire-breathing cesspits of hell.
I never had suicidal thoughts until I went on Zoloft. Jumping from one SSRI to the next, my brain was fried when I finally met up with Prozac. Prozac rejuvenated me though and sent me on another hypomanic surge and I polished off book number two in a week flat.
Two months later, I was standing on a chair in my garage with a rope wrapped around my neck. SSRIs nearly destroyed my life but i'll spare you the lengthy tale and trail of mass chaos that me and my SSRIs left behind.
As for Parnate, it won't work immediately but it is one of the fastest acting anti-depressants. If it does boost you into a euphoria right away, be weary. I too have a chemical romance with euphoric states of mind, hypomanic, seemingly superhuman states where everything seems possible and it literally is(b/c in the end, doubt is what prevents people from achieving their goals). Take away doubt as Zoloft and Prozac once did for me and what do I do? I write two books. Been trying to get back to that state of mind ever since for book three but so far, no cigar. I am now forever caught in a torturous search, desperately trying to find true pharmaceutical love again, "the holy grail of pharmaceutical weaponry that will make me feel invincible again".
But yeah...if you've been on EMSAM for two weeks or more, you've already done most of the leg work by deactivating a lot of monamine oxidase in your body. Since EMSAM is irreversible in it's effect, it will take another two weeks for the monamine oxidase to reactivate. You've only been off the EMSAM a week right? so you might get still have some deactive MAO and get an instant reaction to Parnate. Parnate will likely be stronger and deactivate much more MAO too.
As for brand v generic....if i were going out of my way to take something like Parnate, I would want the best and unfortunately there will always be a difference between generic and brand. Here's a good explanation of why:
"a generic must have between 80 percent and 125 percent bioequivalency to its name-brand producta window of 20 percent less or 25 percent greater potency. Generally, that kind of variation is not going to make a difference in terms of efficacy or toxicity. But imagine a large pharmacy that negotiates with different generic manufacturers and buys a generic formulation from one manufacturer that has 80 percent bioequivalency to the name brand. Then imagine the pharmacy switches manufacturers to one that markets a generic that has 125 percent bioequivalency. That's a 45 percent difference in bioequivalency that theoretically can make a significant difference for the patient. If it's a downward shift, it could affect efficacy; if it's an upward shift, it could affect toxicity. It is also not impossible for particularly sensitive individuals to have variable reactions to the inert materials in a compound. Individuals can sometimes be allergic and react differently to whatever substance goes into making up the capsule or the tablet."
So my advice would be get brand name if you can. Fortunately i've discovered a very reliable pharmacy in Canada called Jan's Drugs if you aren't covered for brand or don't have insurance. I'd post a link but i'm sure i'll get in trouble for soliciting. Do a google search. You can get a month supply of 100x(10mg) brand Parnate pills for 60 dollars if you take 30 mg/day. Or 200x(10mg) for $100 dollars if you take 60mg/day. That price is not bad considering that it is brand name Parnate(Glaxo- my favorite pharm company). Now if your insurance will cover brand then you're good and no need to order from Canada. If you choose the brand when a generic is available, you will be responsible for the difference in cost between the brand and the generic in addition to your generic copay for most plans. Drugstore.com is selling 100 tabs of 10mg brand Parnate for 151 dollars and generic for 112. That means 10 dollar copay + 151-112 = 50 dollars. Actually, that's not bad considering my copay for brand is 35 dollars. So go with brand if you can afford between 50-60 dollars out of pocket for a 30 day supply of 30 mg and 80-100 for 60mg supply.
Posted by Phillipa on December 2, 2009, at 23:03:52
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 21:37:44
Kingston did anyone welcome you to babble? If not I'm welcoming you. Would love to hear from you. If so click on my name in blue and voila a screen appears you type a private e-mail go to bottom of that screen and click send babblemail no one but me can read it. You might also wish to turn your's on by going back to registration and merely clicking yes turn my babblemail on. Love Phillipa. Bet those novels are great reads!!!!
Posted by inanimate peanut on December 3, 2009, at 15:14:25
In reply to Re: Add anything to help with the EMSAM wait...., posted by Kingston on December 2, 2009, at 19:37:01
I just chose to switch from EMSAM to Parnate this morning. All I've been reading about on this site for days is about how wonderful Parnate is and how well it's working for people. I've been on EMSAM for 2 weeks with little results and I was ready for something different. Maybe I made the wrong choice but i needed to try something.
Posted by floatingbridge on December 3, 2009, at 15:56:39
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on December 3, 2009, at 15:14:25
Hey, so your pdoc agreed to the switch--. Drug trials can be so trying. Hope you're hanging in there, that your washout is (very) brief and you are feeling more relief soon(er!). We're pulling for you!
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> I just chose to switch from EMSAM to Parnate this morning. All I've been reading about on this site for days is about how wonderful Parnate is and how well it's working for people. I've been on EMSAM for 2 weeks with little results and I was ready for something different. Maybe I made the wrong choice but i needed to try something.
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